INBW35: Collaboration Between Healthcare Providers, Payers, and Others Is Required to Improve Chronic Care Patient Outcomes

Late in May of this year, three-ish months ago, I did an inbetweenisode that explores the “why with the no collaboration” amongst healthcare stakeholders and what the lack of collaboration signifies. That episode got a lot of traction and engagement.  

This episode that follows is a pretty good approximation of a presentation that I made at the MTVA (Moving to Value Alliance) symposium that happened in Connecticut this past June. If you listened to the earlier show about collaboration, this one is slightly different, shorter, and more to the point.

So, let’s start here: When you listen to any patient with a chronic condition talk about their challenges with the healthcare industry—and yes, if a patient has a chronic condition, more often than not, that is what they will talk about, their challenges …

I went on Twitter just now, and it took me literally 13 minutes to collect what I’m going to say are 300+ Tweets written by patients and their caregivers complaining about their chronic care journey. That’s the sad part. I don’t mean to kick this off talking about problems; however, if you’re gonna solve for something, it is important to understand what problem you are solving for. You do not want to be a solution looking around for a problem.

So, let’s fix this, this rampant problem problem that chronic care patients seem to have.

Many of the patient challenges in the 300 Tweets that I just collected can be grouped into two major categories. And these two major challenge groups can really only be solved for with collaboration amongst healthcare stakeholders. So, let’s dig in here.

The first major patient challenge is what I’m gonna call the care gap problem.

I was talking to someone at a provider organization the other day, and she had 8000 known care gaps with patients and [insert overwhelm here]. And these were just the care gaps that showed up on somebody’s radar because they added up to a quality metric, which is sometimes the definition people use for what is a care gap.

But if we think about all the other holes in patient care, the typical care gaps that are identified probably come not even close to the total number of actual care gaps: patients who can’t see their specialist because they can’t get ahold of their records from the local health system or no coordination of care. Coordination is probably another synonym for collaboration. This is a huge deal. People literally die because their clinician cannot get their biopsy results or whatever from somebody else. That’s a care gap as deep as a grave.

Or patients who keep showing up in the ER because they aren’t getting the help or the meds or the accurate diagnoses or the treatment plan that they need to stay out of the ER ... My grandfather had heart failure. At the end of his life, he was probably in the ER once a month. It was sad and painful and expensive and totally unnecessary. But his PCP didn’t seem to be collaborating with the specialists, and the ER I don’t think was telling anybody what was going on. Right? Or patients who can’t get a drug they need approved by their insurance, so they wind up in crisis. Crappy prior auth processes create care gaps. All of these things are gaps in care.

Carly Eckert, MD (EP361), was on the podcast; and she made a crucial point for me. In fact, I tried to get her to come on the podcast originally to talk about care gaps and closing care gaps; but she categorically refused. Chronic care management, she said, should not be a game of whack-a-mole. It may be better than nothing, a game of whack-a-mole; but it is certainly not ideal.  

Chronic care management by care gap is like cooking with a fire extinguisher. If we want to eliminate care gaps for reals, let’s just not have care gaps.

So, how do you go about not having care gaps, then? The goal should be to craft a non-fragmented patient journey. Let’s figure out what a great care journey looks like ahead of time and then try to keep the patient on it. That is the best way to eliminate care gaps: proactively. You don’t have them.

Immediately, because I am a person of action, I went into my filing cabinet; and I actually found an example of a patient journey map amongst my papers that I had worked on years ago. You have probably seen one of these and may have some of your own patient journey maps tucked away in a binder in your office somewhere. Most people have them. There are a few things that they all have in common, irrespective of the disease state or the organization or anything. The things that they have in common are they are complicated flowcharts with a lot going on. Besides just being complicated, the other thing that patient journey maps all have in common is that there are multiple parties mentioned with roles in that patient journey. You’re gonna have a PCP, a specialist or two, a hospital, a payer, a pharma company more than likely, a PBM maybe, maybe a community organization …

Here’s a quote that kinda sums that up from Dr. William Bestermann: “Improving chronic disease management is an enormous problem that requires multiple stakeholders coming together to combine new science, new systems, and new payment models in a comprehensive solution. No one person or organization can make progress that matters. The problem is too big.”  

Is this obvious? I think it’s pretty obvious. But yet, collaboration in general at the organizational level is less than common. With uncommon exceptions, you not only don’t have multiple providers working together but—heaven forbid!—you have payers and providers or other entities working together.

But just taking this back to the thrust of this conversation, the first major patient challenge can only be solved for with collaboration to create a non-fragmented patient journey, which reduces care gaps by avoiding care gaps in the first place. So, collaboration is a rate critical for a non-fragmented patient journey to eliminate care gaps that patients have big issues with.

So now, let’s move on now to the second big problem category that chronic care patients were Tweeting about in those Tweets that I collected: They can’t afford their care. This crisis of affordability is a huge patient challenge that, it’s not the only thing, but we can’t solve for it without being collaborative, without having collaborative relationships along the patient journey.

I don’t really want to get into how much healthcare prices have skyrocketed, but healthcare prices have been inflating at 4x the cost of everything else. This causes mental health issues; it causes stress. There’s a show with Wayne Jenkins from Centivo where we dig into this deeply. Listen to EP358.  

It is inarguable at this point that financial toxicity is clinical toxicity. I have a folder on my computer where I chuck references for this statement, and at this point, I probably have 400 studies and articles that all say the same thing in different ways with different patient populations. Most of these patients are insured. By the way, just because you have insurance doesn’t mean that you can afford to use it. And patients who cannot afford their care have worse clinical outcomes. Period. End of sentence.

Minor sidebar because I was really like head exploding emoji this morning: I saw somebody in a forum today lashing out at patients suffering with crippling medical debt saying that these people really should take some personal responsibility for the financial choices that they have made. WTH? The entity not taking responsibility for people losing their life savings and their homes simply because they had the fortune of getting sick or injured, the entity that should be taking some responsibility here is a broken, profit-driven healthcare industry.

Let me just add some fidelity to what I mean when I say “the healthcare industry,” which really should take some responsibility here for the financial toxicity that they themselves are creating. Consider that a lot of medical debt is of a balance bill nature and the people being pursued generally signed a contract which they did not understand the consequences of, because most of them had “insurance” and they certainly weren’t given a quote up-front so that they could make a rational economic choice.

So, let’s add some fidelity: How do we make healthcare more affordable? Or how do we make the charges not a complete surprise at a minimum? How do we do that?

Lots of ways, big and small, are required; but let’s talk about one of them: Navigate patients to high-quality providers charging a fair price. Navigate patients to providers who do not do low-value things and who have practice patterns that are aligned with evidence-based medicine (ie, get employers and providers to direct contract, especially in non-FFS ways, especially as it relates to primary care where there are measurable outcomes or quality). ACOs or CINs (clinically integrated networks) who know how to refer to high-value specialists or hospitals is another example of a collaboration that can help with affordability. Some health plans and TPAs (third-party administrators) are starting to get really data-driven about how they go about this. Point being, to coordinate care to or amongst high-value providers, multiple parties have to be involved (ie, collaboration).

So, in sum, we talked about two common and major patient problems, which are probably not a surprise to anyone listening. The two are a lack of coordinated care (patients falling into gigantic care gaps) and then also a lack of affordability.

We know how to solve for both of these issues. Defragment care and steer patients to high-quality provider organizations/hospitals/CoEs with competitive prices. Collaborate in these two ways. So, why are so few doing it, then?

You can always count on me to say the quiet part out loud, so here we go: The business model of most, many, lots of healthcare organizations, both for-profit and tax-exempt, is revenue maximization. As Kevin Schulman, MD, said on the podcast (EP366), it’s not A or B; we have a dysfunctional healthcare benefits system in this country.  

But nonetheless, if we want to identify a root cause for why with the no interoperability, why with the info blocking to prevent network leakage, why with the no collaboration … it’s not a technical problem at its core. It’s not a HIPAA concern, really, at its core. It’s a business case problem.

And I don’t say this as any sort of castigation. I say this because it’s actionable information. Tiptoeing around a thing that we all know just clutters our ability to come up with a solution that is actually going to work. Really understanding a pretty big root cause behind why needed collaborations don’t happen is necessary. This level of introspection is required for those who are mission driven to find others who are similarly mission driven to get a collaboration over the line.

But the good news is success stories abound. It’s my belief the healthcare industry won’t be transformed in one giant turn of some flywheel. It’s gonna be transformed one local market at a time. And there’s a lot of great stuff happening in local markets. Listen to the show with Dave Chase (EP374) for a bunch of examples. There’s a show with Cora Opsahl (EP372) that has some great examples of this. There’s the one with Doug Hetherington (EP367). We also have a show coming up in October with Nick Stefanizzi from Northwell Direct.  

All of these great examples are stakeholders harnessing the power of collaboration to defragment patient journeys and get patients into high-value care settings so that the overall cost of care is in range for employers, taxpayers, patients, and American families. I’m so excited, honestly, about that because the healthcare industry is a legacy that we will leave behind to children and grandchildren. I have a vision in my head about what I want the healthcare industry to look like in 25 years. Maybe you do, too. Listen to the show with David Muhlestein, PhD, JD (EP364), for more on that.

But the point is, if this vision is going to come true, we need to—like, right now—start building the roadmap to get to that goal. And a lot of this involves facilitating collaboration. Actually collaborating, for reals. There’s real momentum behind that in organizations such as the Moving to Value Alliance in Connecticut, where I originally gave a version of this same talk.

Thanks, by the way, to Steve Schutzer, MD, for moderating the collaboration panel that I was a part of at aforementioned MTVA symposium. Not only is he a great moderator, but he also has done a great service for patients through his ability to get a whole bunch of surgeons—who are pretty competitive as a general rule—to collaborate and form a Center of Excellence.

For more information, go to aventriahealth.com.  

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.

01:41 What are the two major patient challenges in chronic patient care that can only be solved by collaboration?
01:56 What is the “care gap” problem?
03:19 “Crappy prior auth processes create care gaps.”
03:25 EP361 with Carly Eckert, MD.  
04:00 How do you eliminate care gaps proactively?
06:46 EP358 with Wayne Jenkins.  
08:21 What is one way to make healthcare more affordable?
09:49 Why aren’t more healthcare entities collaborating?
10:04 EP366 with Kevin Schulman, MD.  
11:13 EP374 with Dave Chase. 
11:18 EP372 with Cora Opsahl.  
11:22 EP367 with Doug Hetherington.  
11:25 Upcoming episode with Nick Stefanizzi.
12:00 EP364 with David Muhlestein, PhD, JD.  

For more information, go to aventriahealth.com.