November 5, 2025 • 49 mins
Join host Chad Mulvany as he shares the latest healthcare policy and legislative updates for the week of November 2, 2025. Later in the episode, Chad is joined by Randy Biernat, partner in the Healthcare Consulting practice at Forvis Mazars. They discuss the role of the physician enterprise in improving access and explore innovative strategies and operating models to help improve performance and physician alignment.
- Washington Watch (0:48)
- Randy Biernat Interview (17:55)
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Related content:
- Key Questions for Evaluating the Physician Enterprise
- Improving Medicare Advantage Provider Performance: An Integrated Approach
- Value-Based Physician Compensation: A New Era of Healthcare
- A Guide to Value-Based Enterprises for Health System Executives
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:01):
On today's episode of Achieving Health,
I've got the latest policy and legislativeupdates from Washington, D.C.
for the week of November 2nd, 2025.
Then I'll be joined by my colleagueRandy Biernat,
partner in the healthcareconsulting practice at Forvis Mazars.
We'll explore innovative strategiesand operating models that help
health systems better manage and aligntheir physician enterprises.
(00:23):
Stay tuned for a fascinating discussion.
This is AchievingHealth, a podcast from Forvis Mazars,
where we delve into the topicsthat matter most to healthcare
organizationsacross the continuum of care.
Our goal is to help younavigate the dynamic healthcare landscape
and achieve health at your organization.
(00:44):
Here's your host, Chad Mulvany.
Welcome to Achieving Health.
I'm Chad Mulvany, director inthe healthcare practice at Forvis Mazars.
Thank you for joining me.
We'll begin today with our WashingtonWatch segment, where I share updates
on the most recent actionsof federal policymakers and their
anticipated impact on healthcare providersand payers.
(01:05):
Today's WashingtonWatch reflects information as of 11:00
Eastern Time on Friday, October 31st.
My comments on these discussions are basedon what's being reported by the D.C.
trade pressat the time of the conversation, mixed
with a lot of judgment about where thingsmay go, based on my experience in D.C.
(01:27):
So, today's remarks reflect informationas of this moment and will change.
As far as our agenda is concerned today,
we are still in the middleof a partial federal government shutdown.
The Senate failed to pass the HouseCR for the 13th time this week.
While it has adjourned for this week,meaning that we will likely set
a record for federal governmentshutdowns or partial shutdowns,
(01:49):
there may be some movementtowards a resolution.
And speaking of shutdowns,
if the enhanced ACA subsidieswere to expire, analysis projects
that between three and four million peoplecould be affected, with young adults
facing the steepest rise in uninsurancerates, up to 25% among those aged
(02:09):
19 to 34.
The Urban Institute estimatesthat the expiration of the enhanced
subsidies would increaseuncompensated care by $7.7 billion.
And so we'll dig into those numbersin the episode.
Moving to 340B, on Thursday last week,the Senate Health,
Education, Labor and PensionsCommittee held a hearing on the program.
(02:30):
Senators from both parties voicedfrustration over the lack of progress
on reforming 340Band then earlier this week,
we saw HRSA release, or announce,
the participants in the rebate model,and we'll cover both of those items.
President
Trump last week also told GOP senatorshe, quote unquote, “got
(02:51):
everything he wanted” in the OneBig Beautiful Bill Act
and is uninterestedin another reconciliation bill.
While this could temporarily reducethe threat of additional significant
legislative cuts to providers,there could possibly be something
in the works from Republicans to attemptto make healthcare costs more affordable.
(03:11):
And then finally, we'll close outby talking
about challenging payer-providerrelations.
Public contract disputes between healthplans and providers are rising
sharply as both sides grapplewith mounting medical cost pressures.
As providers enter into thesemore challenging negotiations,
they'll want to use the plantransparency files
to support their requestfor increased rates.
(03:32):
So with that, let's get into it.
In terms of our shutdown update,the Senate failed to pass the House C.R.
for the 13th time this week.
While, again,it has adjourned for the week,
there may be some movementtowards resolution.
It seems this is driven in partby increasing delays
at airports due to air traffic controllerscalling out.
And I'll note that ReaganNational on Thursday,
(03:54):
as senators were trying to flyout, was delayed by 90 minutes due to air
traffic controller workforce issues.
Also, you've got the pending lapsein SNAP, Supplemental Nutrition Assistance
Program, funding, which could affect upto 40 million Americans
and the economic impacts of federalworkers missing yet another paycheck.
There is thought that this may be resolvedeither
(04:16):
late next week, November 3rd,or the week of November 10th,
although that is preliminaryand certainly subject to change.
Given that the current House-passedCR only extends government
funding for fed fiscal ‘26through November 21st,
there are rumorsthe House may be back in session
next week to pass a CRwith a longer duration,
(04:39):
possibly punting the need to finalizea federal budget into next year.
Further concerns about the SNAP impacton beneficiaries and the broader economy
may drive Senate Dems to providethe necessary votes then later next week,
or I guess now this week,if you're listening to this,
to pass a continuing resolutionthat reopens the government in exchange
(05:00):
for potentially a promise to voteon the enhanced exchange subsidies.
Although, again, this is allvery tentative and somewhat rumored.
And one of the questions that I have is,if the CR that is passed expires early
next year, it's unclear to mewhat the forcing mechanism
is to extend the enhancedexchange subsidies,
unless there are other changesto the program,
(05:22):
like extending the open enrollment windowfor the federally facilitated exchanges.
In terms of a
couple of items that we continueto watch: the extenders.
So, reports related to the newCR suggest that the healthcare extenders
that providers care aboutwill be included in the package.
So therefore, I'm optimisticthat again, we'll see
an extension of the delay of the ACAMedicaid DSH cuts,
(05:45):
an extension of the Medicare dependent
hospital and low volume adjustmentprograms, the COVID-era
telehealth waivers, community healthcenter funding, the rural ambulance add-on
and the Rural Geographic Practicecost index floor and the hospital at home.
So thinking that all of these thingswill be extended as we've expected.
And with the shutdown,there was some question
(06:06):
whether or not we'dget the CMS calendar year rules on time.
So physician fee schedule,
outpatient prospective paymentsystem, home health and ESRD.
We got the
physician fee schedule rule on Friday
the 31st,anticipating that the other three rules
will come out later this week,the week of November 3rd.
(06:31):
And so we will unpack all of those rulesin our next episode once
we've had time to do a deep dive on themand understand them better.
As we think about kind of the impactof the enhanced exchange subsidies
and what happensif they expire, analysis projects
that between three and four million peoplecould be affected.
(06:54):
Young adults would face the steepest risein uninsurance rates,
up to 25% among those aged 19 to 34.
Obviously, children would be less impacteddue to Medicaid and CHIP eligibility.
Not surprisingly,income is the driving factor in this.
Those earning between 250and 400% of the federal poverty
level could see a 26% rise in uninsured,while higher
(07:17):
income individuals would lose coveragealtogether.
States that have not expanded Medicaidare expected to feel the sharpest effects,
as the enhanced creditscurrently fill that gap.
The ripple effects of this,obviously would extend through consumers
into the healthcare system.
Hospitals alreadystrained by Medicaid cuts in some states
and increasing uncompensated careas a result of a slowing economy in
(07:41):
some areas, are expected to face greaterfinancial pressure as more patients
lose coverage.
This impact will be especially pronouncedin states with high ACA enrollment.
It's likely that some of thosewho lose coverage
will turn to unregulated alternatives,such as short-term limited-duration
insurance plans,exposing them to increased financial risk
(08:01):
given the coverage limitationsof those types of policies.
The Urban Institute estimatesthat the expiration of the enhanced
exchange subsidies would increaseuncompensated care by $7.7 billion,
so 12%,relative to the baseline of $66.7 billion.
The burden of the additional $7.7billion in uncapped
care would fall on all provider types.
(08:24):
Hospitals would absorbapproximately $2.2 billion.
A billion for physician offices,$3.1 billion on other services,
and $1.5 billion on prescription drugs.
Not surprisingly, the increase in uncapped
care is greater in non-expansion states.
The Urban Institute projectsa 26% increase
in Mississippi, SouthCarolina and Tennessee.
(08:46):
In contrast, uncompensated caredemand would increase by only 5% in less
than 15 statesand less than 1% in Connecticut,
the District of Columbia, Hawaii,Minnesota, and Vermont.
Many of the revenue cycle strategiesthat were discussed in the third
installment of Forvis Mazars OBBBA
Tuesday series are applicablefor organizations looking to mitigate
(09:10):
the impact of increased uninsuredif the subsidies do expire,
and we’llinclude a link in the show notes,
and would certainly encourage youto check that webinar out.
Switching to
340B, October 30th, HRSA approved the 340B
rebate model for nine of the 10 drugsselected for Medicare price negotiations,
with Novartis Entrestobeing the only one excluded.
(09:35):
Beginning January 1st, 2026,these rebate models will apply
to all covered entity typesand include expanded medical claims
data requirements which were not includedin the initial announcement.
The nine approved drugs will operatethrough the Beacon
Channel Management System,which is a platform tied to 340B ESP.
(09:56):
While HRSA initially allowed manufacturersto limit participation to certain
entities,the final approval notice posted on HRSA’s
website mandatesinclusion of all covered entities.
When the pilot was announced,it only required covered entities
to submit the 11 pharmacy claimsdata elements.
The HRSA announcement nowrequires covered entities to also submit
(10:18):
11 medical claims data elements,which include plan ID and plan name.
Assuming the participating manufacturersare able to notify
covered entities by November 2nd,that would provide 60 days notice,
and then they'll be ableto launch the pilot on January 1st.
The 11th hour inclusion of medical claimsdata is certainly concerning.
(10:39):
It's going to be difficultfor organizations
to gather that data into a formatthat can be submitted to the platform,
and so that may complicate covered
entities efforts to prepare for the model.
Beyond the operational issues,certainly providing the plan name and ID
will give manufacturers more insight intowho will be getting the discount.
(11:01):
So we can certainly anticipatethat that data will be used
in their advocacyefforts related to the program.
Staying with 340B, want to
focus on the Senate Health, Education,Pensions and Labor hearing from last week.
Last Thursday, senators from both partiesvoiced frustration
over the lack of progress onreforming the 340B drug pricing program.
(11:23):
Efforts to reform the programhave been stalled for years
due to clashes between hospitaland pharmaceutical interests.
Draft legislation, the Sustain 340B Act,from a bipartisan Senate workgroup,
what's known as the Gang of Six, seeksto increase oversight and transparency.
The Gang of Six releaseda draft of the Sustain 340B
(11:45):
Act last spring that would have prohibitedpharmacy restrictions by drug companies,
tightened requirementsfor offsite facilities,
and had a placeholderthat would have redefined
what an eligible patientis potentially narrowing that definition.
The draft was released with a requestfor information related to the bill.
However, a final version of that billhas still not been introduced,
(12:08):
and so a final version obviously wouldinclude, if that section was still there,
a more specific definition of whata patient is.
Senate Health Committee Chair
Cassidy has also calledfor reforms to the program to ensure
that savings are passed on to patientsand to also address transparency issues.
He has indicated that he intends torelease his own 340B reform legislation.
(12:32):
Personally, I think it's unlikely,given the challenges
Congress is having passing a 2026 budget,
that legislationlimiting 340B or reforming
340B will pass this year.
And I'm somewhat doubtful that Congressis going to be able to take up and pass
anything that could potentiallybe this controversial in an election year.
(12:53):
However, even a chance of legislation
is certainly a concernfor covered entities
because anything that they pass,while it may provide some benefits,
will also likely take some things awayand potentially limit savings,
which would compound the margindegradation risk facing covered entities
as a result of the rebate model,which is now going into effect.
(13:15):
In terms of
additional potential sweepingfederal legislation,
President Donald Trump signaled Tuesdaythat Republicans
are unlikely to pursueanother reconciliation bill.
He told GOP senators recentlythat the Big Beautiful Bill already
included everything that he wanted,such as major tax cuts, defense and border
funding, and a repeal of the green energytax credits.
(13:38):
His remarks undercut Speaker
Johnson's earlier plansfor additional reconciliation measures
and cast doubt on the effort,given the narrow GOP majorities,
the heavy workload of fed fiscal ‘26appropriations,
and the political risksof another vote-a-rama, which is
associated with reconciliation billsin the Senate, before midterm elections.
(13:58):
It would be an opportunity,if they were to go for this again,
for Dems to put in a bunchof messaging amendments that could
potentially put GOP senatorswho are up for election in a tough spot.
While conservatives had pushedfor a second package to address
issues like Medicaid funding for statescovering undocumented immigrants,
skepticism was already highand the president's comments suggest
(14:20):
reconciliationis effectively off the table for now
unless Republicans can unite arounda new agenda and sell it to the president.
I think one of the things that made thisa longshot to start with is,
as was noted by the president,all of the quote unquote “goodies”
that might make Republican membersline up and take a hard vote
less than 12 monthsbefore a federal election.
(14:40):
So again, the tax cuts, defensespending, border
security were already done in OBBBA,
and unless they're able to includean issue that really animates
and engages the president,I think the odds were pretty low
that they could get himto rally around the package
and then leverage him to be the closerthat he was
in the OB3, or OBBBA, votes,
(15:02):
which really helpedget that piece of legislation
across the finish line in the Houseand the Senate.
If we do see another reconciliationbill, though, I do
or am concerned that it would includeadditional healthcare cuts.
So things like expansion of Medicareor site-neutral payments or changes
(15:22):
to Medicare Advantage risk adjustmentcoding to either pay for increased
spendingthat may be part of other packages, or
provide additional deficit reductionto placate fiscal conservatives
that are still concerned about the OB3’sdeficit impact.
The one place where I think
may be possible for an attemptat a reconciliation bill could be around
(15:46):
healthcare,given we're coming into the election
and healthcare costs certainly could befront and center at issue,
particularly if the enhanced exchangesubsidies are allowed to lapse.
And so the Republicans may feel the needto do something about it legislatively.
Again, something to monitor,not something that I would bet
a paycheck on yet,but definitely something to watch.
(16:09):
Last thing I want to coveris plan-provider negotiations.
We are seeing public contract
disputes between insurers and providersrising sharply.
So, spilling out into the public
as both sides grapplewith mounting medical cost pressures,
with at least 90 disputes becoming publicso far
compared to the 51 in 2022
(16:30):
and the 133 in 2024.
Providers are increasingly unwillingto compromise on reimbursement rates
and prior authorization ruleswhile insurers remain
firm in efforts to control costs,particularly for employers.
This trend comes amid growingcriticism of insurers for frequent care
denials and worsening public perceptionof the industry, as providers
(16:53):
need to shift the OB3 Medicaidcuts, the cost of those cuts,
and the increased uncompensated careas a result
of the growing uninsuredto commercial payers.
As providers enter into thesemore challenging negotiations,
they should use the plantransparency files to support their rate
increase requestsso that these are grounded in data.
(17:15):
As providers look to use this data,key questions they should ask include:
How does your organization's payer pricingcompare to peers?
Is our organization collectingthe negotiated rates they've established
today?
How do our organization services fitthe market?
Is our pricing justifiedbased on the services provided?
And how will consumers viewour organization's value?
(17:38):
This concludes today's Washington Watch.
Up next, I'll be joined by my colleagueRandy Biernat to talk about
innovative approaches to improvingphysician enterprise performance.
I'd like to welcome back
to the podcast, our guest for today'sepisode, Randy Biernat.
(18:00):
Randy is a partner in the healthcareconsulting practice at Forvis Mazars,
whose work focuses on physician services,including consulting for transactions
and compliance,
hospital and physician alignment, and fairmarket value compensation.
Randy,thank you again for being here today.
Great to be with you, Chad.
Happy to be back.
Randy,our listeners may remember you from back
(18:21):
on our second episode of Achieving Health,when we explored insights
from our annual Mindsetssurvey of healthcare executives.
And I’d encourage everyone to go backand give that episode a listen,
if you haven't already.
At the time,you shared some fascinating insights
on aligning the physician enterprisewith key priorities
for the healthcare organizationand for healthcare leaders,
(18:44):
including insightsrelated to the concept of aligned growth
and also the conceptof talent optimization.
And so wanted to have you back todayfor a deeper dive on those topics.
Let's start at a high level.
Why is an effective physician enterprisesuch an important
strategic assetfor healthcare organizations today?
(19:06):
So I'll focus on one area.
It's about access.
So the physician enterpriseis a high cost, hard to recruit,
generally aging employee cohort.
And so what you do withit becomes extremely important.
There's no
doctors, no hospital.
(19:27):
What that really means, at a strategic level, is access.
And so when your physician enterprisefunctions at a high level,
you're providing the right service
in the right care setting at the righttime in the right location.
So when you stack all that up and you'reefficiently allocating your human capital,
(19:48):
you're able to drive accesswhere it needs to be to be effective.
And there are hardchoices associated with that.
But when it's well done,you're meeting the needs of the community,
and you are drivingfinancial sustainability.
When that's unoptimized, right,the physician enterprise can be
(20:10):
a barrier to success
and really work with health systemsright now
trying to think throughwhat do we do with this problem?
And it's like,this is not the problem, right?
That we are not optimized.
You have this asset.
We need to turn it into one.
No, and I think your point about access iswell taken, because when you think about
(20:35):
you get access right,you improve outcomes, you get access right
where you're getting people with the rightsetting a care,
you're delivering carein a cost efficient manner.
You get access right,
you're improving patient satisfaction
because they're able to get inin a timely manner.
And that also, by the way, helps drivefinancial performance
for the health system.
So this to meseems like one of the key lynchpins
(20:55):
that organizations need to be thinkingabout.
Let's get into some of the details aroundwhen it comes
to improvingphysician enterprise performance.
How should physician enterprisesmanage physician subsidies?
I know that's somethingthat all organizations struggle with.
Yeah, another big question and a good one.
And so if you're part of a health systemthat has an integrated physician group,
(21:21):
or if you're working very closelywith independent groups
through professional servicesarrangements, you get to the same place.
And the core question is (21:29):
do we have alignment between the professional side
and the facility side and okay,so how do we evaluate that?
We go down one level,we start to think we think
a lot about service lineor service line rationalization.
So base threshold question (21:48):
Does
it make sense to be in the service line,yes or no?
Ten years ago, candidly,you could have an open-heart program
as a vanity project and it would be okay.
You can't do that now.
You truly have to evaluatewhat does it cost us to run this?
(22:08):
Should we be doing openhearts in our community, yes or no?
And it needs to reallymake financial sense
because the spend is so muchnot just on, you know, the proceduralist
doing the work, we think aboutis specialized anesthesiology.
And you think about the call coverageand things like that.
So, you know,is it really cool to be able to do
(22:30):
open hearts locallyand not have to drive 50 or 100 miles?
Yes. It is really neat.
But that stuff, from a decade agothat worked,
that doesn't work todaywith all the economic pressure. So,
you know, service line rationalizations,are we doing what we should?
Is it aligned?
And so there are going to be, you know,if you think about expanding circles,
(22:52):
there are going to be some core circlesthat we're going to say yes to no matter
what in our community.
The most obvious example is an obstetricsprogram, right?
Are we really a hospitalif we don't deliver babies?
If you ask boards, community boardsespecially, the answer is
no, we're not a hospitalif we don't deliver babies.
So are we,is it rational to be in this business?
No, it's mission.
(23:13):
Okay. And that's an okay answer.
Once.
Twice, three times.
It's not an okay answer 15 times. Right?
At some point, you start to have to say,no, it's not rational.
We're out of that first ring ofwe must do it
into things that we maybe could door we should do,
(23:33):
and sort of figuring outwhere to direct resources becomes more
and more financially orientedas it gets away from the core.
And so, we think about serviceline rationalization.
It has to
inform the target operating model,
(23:55):
to meet the community's needin the most efficient manner.
And if it's core, does it make sense to bein this productivity or access model?
Usually it's going to be the access modelfor your core programs
that are loser programs, net net.
And then if you go out a circle,it should be more of a productivity
(24:17):
orientation operating model,to fulfill patient demand.
And those should befinancially sustainable.
And it's in that second ring of,you know, cancer
care, orthopedic care, cardiac care.
That's where we're generating marginsto sustain the whole enterprise.
Right.
And having that balance between thethe money
(24:40):
moneymaker programs and a service linebasis and,
our community support payments,you know, community support programs
where we aren't, you know, standalone,financially sustainable.
Right.
Having the right portfolio balance to stayin the game is what you need to do.
And sometimes that means trimming thingslike the open-heart program I mentioned.
(25:02):
To get to the right answer.
And Randy, I like that model of
sort of thinking about
what's in the core, being disciplinedto limiting that to a number of factors.
Then everything else needs
to not only support itself,be able to support the core as well.
You started to touch on thisin your answer, particularly as it,
(25:25):
you know, across the things that are coreand also the things that are non-core.
But how can physician enterprise leadersdetermine
whether their workforce is structuredappropriately?
What should they be looking at?
Chad, I will tell you,I think, it's the same answer.
It first depends on whether or notit's access or productivity.
(25:46):
If it's an access model.
And we're really, again, trying to delivercare to the community.
It's absolutely about the cost of careand that visit as cost per metric.
And this does tie into accountable care.
And it does tie into sustainabilityand those other things.
(26:08):
But we need to be managing costs
per visit and our access modelsand managing that down.
We still want to maximize reimbursementby all acceptable means,
but from an operations standpointthat that's not in their control,
whether or not we're a rural health clinic
or we're providerbased or participating in 340B,
(26:29):
it is cost per visit in the clinicfor access models.
Now, if we think about productivity models
that are really the key driversof financial sustainability
in our organization, cost pervisit is still a good metric to look at.
But we're really gonna flipto margin per visit,
(26:50):
and we cannot pay our doctorsfor margin that we earn.
But we can make investment decisions,whether it's technology.
Should we buy this robot?
Should we get
ambient AI to help us, you know, manage, the physician's time better?
So charts pre-populated where we maketechnology investments, how we staff.
(27:14):
Right.
So, we can get a physicianto be more productive
by adding human resourcesor technological resources.
We should do that in a productivity model
if it's accretive to margin.
For an access model,that's the wrong decision.
I mean, it's the wrong framework.
And so again,I like to bucket things into,
(27:36):
hey, it's core service access focus.
Well,we're going to focus on cost per visit.
I'm trying to fulfillthe community need at the lowest,
you know, cost per visit.
And then if it's a driver of growth,it really is about net margin,
which is why the service linerationalization becomes important.
(27:58):
It helps us know what investments
we should make to allowfor financial sustainability.
As you start to think
about operating models,what does a more efficient one look like?
When we think
about a more efficient operating model,
what's happening in in healthcare,almost a surprise.
(28:18):
But it fits the demographic trends.
This is of course, it's to some degreeanecdotal,
but, employed medical staffs in a lot of
markets were the result of, primarily reimbursement pressure. And.
Okay, well, we'll employthis group of surgeons or oh, okay.
(28:40):
We'll bring in the hospitalist.
Or, oh okay, we'llbring in the OBs, right?
And so we brought these groups together.
There's been a lot of focusin the last 5 or 7 years
on one medical group
to supplement the demandand to sort of stitch things together.
There's been a big infusionof advanced practice providers.
(29:00):
So whether it's physicians assistantsor nurse practitioners, these advanced
practice providers or APPs for short,
they have flooded the workforce.
And so when we thinkabout a more efficient model,
like, you know, in our business,like accounting and consulting,
(29:21):
getting some human leverage from a billing
standpoint, is part of the answer.
So advanced practice providerscan get used in a lot of different ways.
I think we're in a phase of optimizingthe use of advanced
practice providers with himwithin employed medical groups.
(29:42):
And so when we talk aboutwhat's a more efficient operating model,
clearly it's figuring out
how to, especially by
specialty basis, make the most of advancedpractice providers.
But for the most part, the ability to get production,
even with the difference in licensure,even with the 15%
(30:05):
differential reimbursement,there is low cost,
reasonable quality serviceto be had out of the APRN group
to get your physicians to top of license
in those productivity models.
And there's a great opportunityfor access, with team-based care
(30:25):
led by a physician running with two
or three or four APRNs to provide access.
So kind of what it sounds likeyou're sketching out is if we're talking
about a proceduralist,making sure that we're keeping them in
the operatingsuite or the procedure suite,
(30:47):
and then having an APRN or two
back at the clinic doing consultsand kind of keeping
using the APRNs to make sure that,you know, they're doing the thing up
with their license.
And then anything that the proceduralistis touching is really worth their time
given what they're being compensated.
And, to your pointthat that is a different operating model
(31:08):
than what mostthe world is running on today,
which then sort of leads to thethought that, you know, change management
is going to be incredibly importantto get to this optimal model.
If you were a physician enterprise leader,
how would you plan for moving towardsthis different target operating model?
(31:30):
Yeah.
So when we talk with folks about targetoperating model and pay a lot, you know,
physician alignment and compensation plansand all the things
that are the ingredients to success to runa highly aligned physician enterprise,
a lot of timesthe immediate reaction is tactical.
(31:51):
Hey, I can't change everything tomorrow.
You know,that's going to be very disruptive.
And so, you know, the approachthat we like to use,
especially where we're, you know,dipping our toes into value based,
enterprise type physician alignment,where we are compensating
(32:11):
the physicians, in partbased on the shared success
of a service line, which directly tiesinto service line rationalization.
We don't want to force everybodyinto a model
to force people out or to force,and I'll say instead of people
say physicians,we don't want to force physicians out.
We don't want to force them to fail.
(32:31):
And we know that if we slam top downa new operating model, a new pay plan,
it's going to drive
some level of chaos,some level of turnover.
And filling in the gaps aroundcall coverage with locums
is incredibly expensive. Right?
So just because we have this belief thatwe need to do things differently doesn't
(32:53):
mean we can do all of it differently todayor tomorrow or next month.
And so we think about how
we want, a service lineor a set of service lines
to look and act and be modeledand how they we want them aligned.
We do need to think about a multiyear timehorizon.
And typically we can get
(33:16):
a third to half of providers on board
with a new pay plan, right?
Because they want to be heard.
They want the opportunityto perform better.
They do want to be aligned.
So there's a core group that you can leadtowards change that are open to it.
And a lot of timeswhat we want to do is allow for a pilot
(33:39):
and, or an opt in for something new.
And it's a reallythe old plan alone for a year or 2 or 3.
So, doctors,if this doesn't sound good to you,
you can just wait and see.
We're not going to give youa big raise, right?
But we are going to permit statusquo for a period of time.
(34:03):
And we're going to take the coalitionof the willing forward
into our target operating model.
And that's obviouslyfrom a change management
standpoint; we're going to provideincentives for the physicians
who are open to change or providefinancial incentives.
And if we're able to changethe cost of care,
those incentives pay for themselves.
(34:24):
And so if we think about, hey,what's our medical roster,
what's our team look like in three yearsor five years, what do we want it to be?
You know, that's a lot easier to manage.
Especially we're talking about somethinglike call coverage.
It's a lot easier to manageif we, permit different operating models.
(34:45):
But I do think it's usefulfrom an alignment standpoint to,
you know, current state, future state,timeline out what we want it to look like,
what's the amount of changethat we can tolerate
over a period oftime, and plan accordingly?
No, I think
I think that makes senseas a model, particularly,
(35:06):
you know, I'm not trying to forceanything down, but really allowing those
who want to move forward to do soand giving those who maybe aren't
as immediately as excited an opportunityto either become a customer
or think about something else.
You know, over the last several years,
we've seen more and more care,in particular primary care,
be delivered by advanced practiceproviders.
(35:29):
What kind of governance modeldo organizations or should organizations
set up to set up APPs for success?
I love this question, Chad.
So, thank you.
Organizationally, we need to
match skills to roles,
and we've got to support thatwith training and development.
(35:52):
So it's a big enough employee cohortthat in my mind,
the APRNs or the PAs
need a place to go for training,
education, mentorship that isn't justthe collaborating physician
or the docs in that officeor on the floor or whatever.
So having, you know, even at amaybe a VP level, an APRN
(36:16):
that is helping with training, leadershipdevelopment,
how to work with physicians
who aren't always the easiestto work with folks.
And so I do think that the workforcein, in so many organizations is big enough
that having a counterpart to the VP
(36:39):
or the CMO or other
clinical leadership,that's a physician having,
someone who's walked in their shoes,
you know, with that backgroundand leadership would be very helpful.
And so that is somethingthat makes a ton of sense to me
is as they become a bigger and biggerpart of the employee provider workforce.
(37:04):
What else
can physician enterprise leadersdo to set APPs up for success?
Right.
You talked about the training,
but obviously maybe it's not a one sizefits all training model.
Yeah.
So again, if half of your workforce,provider workforce, is APRNs and PAs,
which is not uncommon right now,
(37:24):
that's still expensive talent to acquire.
So do they cost much less than physicians.
Yes. Are they still expensive
workforce or highly paid workforce.
Yes. And so, what we want to start to do
is to manage turnover,you know, to screen better for fit.
(37:45):
And one of the most importantthings is skills-based evaluation.
If you're hiring a physician,you know, who's board
certified in urology,you know what you're getting.
You can do background check and understandthe kind of procedures
that the physician is skilled and doingand so forth.
(38:06):
And licensure is a pretty good indicatorof their clinical capabilities.
For APRN, licensure is not nearly as goodof an indicator of clinical capabilities.
So, it really is about skills.
So, skills-basedevaluation, training, development,
helping the APRNswe're bringing in land in the right place,
(38:26):
giving them runway to be successful,helping them with engagement.
If they are paired with a physician who,and they're sort of forced into that
and there's not a greatfit, that can drive turnover.
That's so counter to what we want to doto be efficient and sustainable.
So, bringing them in in a waythat they're supported,
(38:50):
setting the expectationswith collaborating physicians,
moving into a team-based care modelwhere the physician success
is linked to the APP success,you know, is a way to help this.
But there are, APPs rendera lot of patient care in this country.
It's increasing every yearin every setting,
(39:10):
setting them up for better success.
You know, as they comein, as they develop and grow
and sustain with your organization,is incredibly valuable work.
No, I think I think what you've laid outmakes a lot of sense, particularly as it’s
sort of figuring outonce you've hired them, meeting them
where they are and their skill sets,figuring out how to develop them, and also
(39:33):
how to deploy them in rolesthat they can be most effective in.
You know, going back to kind of thisnew model that you're talking about,
you know, it's predicated on
physicians leading a panel of APPs.
If you were running a physician enterprisetoday,
(39:53):
how would you changethe physician comp model
to reward or encourage physiciansto step into that leadership role?
Yeah.
So I mentioned team-basedcare a couple of times.
Team based careexists in places and pockets.
How I viewit, Chad, is just how you describe it.
You have a physician leading a paneland really having dedicated time
(40:17):
with a group, you know, ledby the physician with two, three, four,
mid-level providers or advanced practiceproviders, rather
having them really focus on
executing the care plans,working through the visits,
working through the follow ups,working through the messages in a team
(40:38):
setting is a little differentthan what's happening in most places.
Lots of physicians get paid for
nurse practitioner
collaboration,or they're getting paid to review charts.
They're getting $500 a monthto be available and do some chart review.
And then, over-read some charts, do some sign-off things like that.
(41:02):
That's not team based care.
Team based care really is a programmatic,and by programmatic
I mean operational, approachwhere a patient understands
they are being seenby a team of providers.
They may never see the physician,but they understand
that the physician is involvedin their care, through oversight
(41:23):
and through planning and execution.
It’s done in that team setting.
We want to think about how much,
access that creates, how
that influences cost of care,how much that saves us,
financially, we want to rewardthe physician to do that,
which isn't $500 per monthper nurse practitioner.
(41:46):
That is not enough
to compensate for the
time it takes to lead the team.
And so we want to,and over-reward is the wrong term, but
we want to appropriately reward the levelof commitment to that type of program.
And in my mind, that is worth more
than the physician seeing patients
(42:09):
on their own.
And so, this is not to get intonecessarily opportunity costs,
but a physician can producethree RVUs per hour, four RVUs per hour.
Or they can lead a team that's producing
15 RVUs per hour.
The latter is more valuable,
(42:30):
on an apples-to-apples basis.
And so pay plans that rewardthat, are going to far outstrip
the stipend model,like I said, $500 or $1,000 per month.
And so does that look like two timesor three times
or four times as remunerativeas traditional APP collaboration?
(42:52):
Yes. And the economics are there for it.
It promotes financial sustainability and really recognizes the value of that work.
No, I know, but I think that makes sense.
And, you know, want to just, you know,the model where you're providing a stipend
and that, I guessgoes back to kind of the distinction
(43:13):
between being a leaderand being a manager. Right?
We've all worked for peoplethat basically managed us versus
those who led and certainly, at least inmy experience, working for those who led
it had always been more fulfilling
and I was always more productivein those models.
And so you kind of think about itfrom the stipend model,
which kind of is more of a managementmodel versus
(43:34):
that greater level of engagementthat gets a physician
to be more of a leaderinto that leadership role.
Seems to make a lot of sense.
I totally agree.
And so Randy, last question before we
wrap up.
What are you seeing in the market in termsof interesting use cases of telehealth?
So we work with facilitiesall over the country
(43:58):
and access to specialists,especially expensive specialists.
So, think a urologist, really hard,
really hard in some marketsto get critical mass.
But there's a clear need.
Again, urology is a really good example.
So, you know,a patient has a need to drive 50
(44:21):
or 75 miles to see a urologist.
You know,
if we can't get a physician in place,but it's hard to just get a founder.
It's almost even harderto get the second physician in.
But then for call, you really needthree physicians, maybe four.
So there are a lot of facilitiesare just struggling to get enough
(44:43):
physician staff to really have a program.
But there's a clear community need,and so one of the interesting things
with telehealth,I'll get around to telehealth in a minute.
One of the interesting thingsabout telehealth is the idea that instead
of having a local groupof three fill in the blank,
but we'll just go with urologist,instead of a local group of three,
(45:07):
that we may not be able to clinicallykeep busy.
So again,going back to my earlier example,
we would like to have proceduralistslike urologists in a productivity model.
But we may only be able to keep
one and a half busy, but we need threefor call coverage purposes.
So there are these marketsthat are sort of in-between
(45:29):
enough local patientdemand that there's real work to do,
not enough to have a big enough panelto provide call
to meet the level three trauma designationor whatever for that section.
And so what is interesting is I'm
seeing a couple of my clients
get into agreements where they are
(45:51):
accepting a physician parachuting
in just to sit in the hospitaland do procedures at the hospital.
And that's being fed by
an advanced practice provider in a clinic,
working under the
support of a remote telemedicine physician
(46:14):
to do some of the team-based care stuffwe mentioned.
But, you know, planning for the day, chart
review, what tests have been ordered,what those tests might mean.
So, some true collaboration.
The nurse practitioner does the visits.
Where a procedure's indicated,the physician again
zooms in on a telehealth visit and talksabout the procedure with the patient.
(46:39):
The patient then gets scheduledfor a procedure at the hospital.
The on-call physician,that sort of just sitting in the hospital,
again, they've got coverage now
and it's just not that hardto slot in a handful of procedures.
And so we're able to get the accessin the community through telehealth.
(47:02):
We're able to get the procedures donein the community and the call coverage
accomplished.
And honestly, the price point versuskeeping three in the community
ends up being less.
So, even though you're payingfor restricted call coverage,
you're able to set that modelup to be financially viable.
(47:26):
Couldn't happen without telehealth.
So that's something I'm seeing right nowthat's pretty cool.
And I expect to see more just like that.
Randy, thank you for sharing that.
That is a pretty creative model to check.
A lot of boxes,get the care delivered, improve
physician quality of life,and also sort of pencils out financially.
(47:46):
Yeah, mileage may vary. Right.
You know reimbursement matters.
The market matters.You know, there's different things.
I'm not sure it's a universal approach.
But in the right setting.
And for a couple of my clients, it'sbeen a great set.
Well, Randy,thank you again for joining us today.
Always an insightful conversation.
I also want to thank our listenersfor tuning in.
(48:08):
If you're looking for more insightson physician enterprise
strategies, we have links to relatedcontent in the show notes.
I hope you'll join me in two weeksfor the next episode of Achieving Health.
You can follow
Achieving Healthon your favorite podcast platform or visit
forvismazars.us/AchievingHealthPodcastto learn more.
(48:30):
New episodes are released the firstand third Wednesday of each month.
Achieving Health is produced by ForvisMazars LLP, an independent member
of Forvis Mazars global, a leading globalprofessional services network.
Ranked among the largest publicaccounting firms in the United States,
the firm's 7,000 dedicated team membersprovide an Unmatched Client Experience
(48:53):
through the delivery of assurance, taxand consulting services for clients
in all 50 states and internationallythrough the Global Network.
The information set forth in this podcastcontains the analysis and conclusions
of the panelists based upon his, her,or their research
and analysis of industryinformation and legal authorities.
Such analysis and conclusionsshould not be deemed opinions
(49:16):
or conclusions by Forvis Mazars,or the panelists
as to any individual situationas situations are fact-specific.
The listener should performtheir own analysis and form
their own conclusionsregarding any specific situation.
Further, the panelists’ conclusionsmay be revised without notice,
with or without changes in industryinformation and legal authorities.
On today's episode of Achieving Health,
I've got the latest policy and legislativeupdates from Washington, D.C.
for the week of November 2nd, 2025.
Then I'll be joined by my colleagueRandy Biernat,
partner in the healthcareconsulting practice at Forvis Mazars.
We'll explore innovative strategiesand operating models that help
health systems better manage and aligntheir physician enterprises.
(00:23):
Stay tuned for a fascinating discussion.
This is AchievingHealth, a podcast from Forvis Mazars,
where we delve into the topicsthat matter most to healthcare
organizationsacross the continuum of care.
Our goal is to help younavigate the dynamic healthcare landscape
and achieve health at your organization.
(00:44):
Here's your host, Chad Mulvany.
Welcome to Achieving Health.
I'm Chad Mulvany, director inthe healthcare practice at Forvis Mazars.
Thank you for joining me.
We'll begin today with our WashingtonWatch segment, where I share updates
on the most recent actionsof federal policymakers and their
anticipated impact on healthcare providersand payers.
(01:05):
Today's WashingtonWatch reflects information as of 11:00
Eastern Time on Friday, October 31st.
My comments on these discussions are basedon what's being reported by the D.C.
trade pressat the time of the conversation, mixed
with a lot of judgment about where thingsmay go, based on my experience in D.C.
(01:27):
So, today's remarks reflect informationas of this moment and will change.
As far as our agenda is concerned today,
we are still in the middleof a partial federal government shutdown.
The Senate failed to pass the HouseCR for the 13th time this week.
While it has adjourned for this week,meaning that we will likely set
a record for federal governmentshutdowns or partial shutdowns,
(01:49):
there may be some movementtowards a resolution.
And speaking of shutdowns,
if the enhanced ACA subsidieswere to expire, analysis projects
that between three and four million peoplecould be affected, with young adults
facing the steepest rise in uninsurancerates, up to 25% among those aged
(02:09):
19 to 34.
The Urban Institute estimatesthat the expiration of the enhanced
subsidies would increaseuncompensated care by $7.7 billion.
And so we'll dig into those numbersin the episode.
Moving to 340B, on Thursday last week,the Senate Health,
Education, Labor and PensionsCommittee held a hearing on the program.
(02:30):
Senators from both parties voicedfrustration over the lack of progress
on reforming 340Band then earlier this week,
we saw HRSA release, or announce,
the participants in the rebate model,and we'll cover both of those items.
President
Trump last week also told GOP senatorshe, quote unquote, “got
(02:51):
everything he wanted” in the OneBig Beautiful Bill Act
and is uninterestedin another reconciliation bill.
While this could temporarily reducethe threat of additional significant
legislative cuts to providers,there could possibly be something
in the works from Republicans to attemptto make healthcare costs more affordable.
(03:11):
And then finally, we'll close outby talking
about challenging payer-providerrelations.
Public contract disputes between healthplans and providers are rising
sharply as both sides grapplewith mounting medical cost pressures.
As providers enter into thesemore challenging negotiations,
they'll want to use the plantransparency files
to support their requestfor increased rates.
(03:32):
So with that, let's get into it.
In terms of our shutdown update,the Senate failed to pass the House C.R.
for the 13th time this week.
While, again,it has adjourned for the week,
there may be some movementtowards resolution.
It seems this is driven in partby increasing delays
at airports due to air traffic controllerscalling out.
And I'll note that ReaganNational on Thursday,
(03:54):
as senators were trying to flyout, was delayed by 90 minutes due to air
traffic controller workforce issues.
Also, you've got the pending lapsein SNAP, Supplemental Nutrition Assistance
Program, funding, which could affect upto 40 million Americans
and the economic impacts of federalworkers missing yet another paycheck.
There is thought that this may be resolvedeither
(04:16):
late next week, November 3rd,or the week of November 10th,
although that is preliminaryand certainly subject to change.
Given that the current House-passedCR only extends government
funding for fed fiscal ‘26through November 21st,
there are rumorsthe House may be back in session
next week to pass a CRwith a longer duration,
(04:39):
possibly punting the need to finalizea federal budget into next year.
Further concerns about the SNAP impacton beneficiaries and the broader economy
may drive Senate Dems to providethe necessary votes then later next week,
or I guess now this week,if you're listening to this,
to pass a continuing resolutionthat reopens the government in exchange
(05:00):
for potentially a promise to voteon the enhanced exchange subsidies.
Although, again, this is allvery tentative and somewhat rumored.
And one of the questions that I have is,if the CR that is passed expires early
next year, it's unclear to mewhat the forcing mechanism
is to extend the enhancedexchange subsidies,
unless there are other changesto the program,
(05:22):
like extending the open enrollment windowfor the federally facilitated exchanges.
In terms of a
couple of items that we continueto watch: the extenders.
So, reports related to the newCR suggest that the healthcare extenders
that providers care aboutwill be included in the package.
So therefore, I'm optimisticthat again, we'll see
an extension of the delay of the ACAMedicaid DSH cuts,
(05:45):
an extension of the Medicare dependent
hospital and low volume adjustmentprograms, the COVID-era
telehealth waivers, community healthcenter funding, the rural ambulance add-on
and the Rural Geographic Practicecost index floor and the hospital at home.
So thinking that all of these thingswill be extended as we've expected.
And with the shutdown,there was some question
(06:06):
whether or not we'dget the CMS calendar year rules on time.
So physician fee schedule,
outpatient prospective paymentsystem, home health and ESRD.
We got the
physician fee schedule rule on Friday
the 31st,anticipating that the other three rules
will come out later this week,the week of November 3rd.
(06:31):
And so we will unpack all of those rulesin our next episode once
we've had time to do a deep dive on themand understand them better.
As we think about kind of the impactof the enhanced exchange subsidies
and what happensif they expire, analysis projects
that between three and four million peoplecould be affected.
(06:54):
Young adults would face the steepest risein uninsurance rates,
up to 25% among those aged 19 to 34.
Obviously, children would be less impacteddue to Medicaid and CHIP eligibility.
Not surprisingly,income is the driving factor in this.
Those earning between 250and 400% of the federal poverty
level could see a 26% rise in uninsured,while higher
(07:17):
income individuals would lose coveragealtogether.
States that have not expanded Medicaidare expected to feel the sharpest effects,
as the enhanced creditscurrently fill that gap.
The ripple effects of this,obviously would extend through consumers
into the healthcare system.
Hospitals alreadystrained by Medicaid cuts in some states
and increasing uncompensated careas a result of a slowing economy in
(07:41):
some areas, are expected to face greaterfinancial pressure as more patients
lose coverage.
This impact will be especially pronouncedin states with high ACA enrollment.
It's likely that some of thosewho lose coverage
will turn to unregulated alternatives,such as short-term limited-duration
insurance plans,exposing them to increased financial risk
(08:01):
given the coverage limitationsof those types of policies.
The Urban Institute estimatesthat the expiration of the enhanced
exchange subsidies would increaseuncompensated care by $7.7 billion,
so 12%,relative to the baseline of $66.7 billion.
The burden of the additional $7.7billion in uncapped
care would fall on all provider types.
(08:24):
Hospitals would absorbapproximately $2.2 billion.
A billion for physician offices,$3.1 billion on other services,
and $1.5 billion on prescription drugs.
Not surprisingly, the increase in uncapped
care is greater in non-expansion states.
The Urban Institute projectsa 26% increase
in Mississippi, SouthCarolina and Tennessee.
(08:46):
In contrast, uncompensated caredemand would increase by only 5% in less
than 15 statesand less than 1% in Connecticut,
the District of Columbia, Hawaii,Minnesota, and Vermont.
Many of the revenue cycle strategiesthat were discussed in the third
installment of Forvis Mazars OBBBA
Tuesday series are applicablefor organizations looking to mitigate
(09:10):
the impact of increased uninsuredif the subsidies do expire,
and we’llinclude a link in the show notes,
and would certainly encourage youto check that webinar out.
Switching to
340B, October 30th, HRSA approved the 340B
rebate model for nine of the 10 drugsselected for Medicare price negotiations,
with Novartis Entrestobeing the only one excluded.
(09:35):
Beginning January 1st, 2026,these rebate models will apply
to all covered entity typesand include expanded medical claims
data requirements which were not includedin the initial announcement.
The nine approved drugs will operatethrough the Beacon
Channel Management System,which is a platform tied to 340B ESP.
(09:56):
While HRSA initially allowed manufacturersto limit participation to certain
entities,the final approval notice posted on HRSA’s
website mandatesinclusion of all covered entities.
When the pilot was announced,it only required covered entities
to submit the 11 pharmacy claimsdata elements.
The HRSA announcement nowrequires covered entities to also submit
(10:18):
11 medical claims data elements,which include plan ID and plan name.
Assuming the participating manufacturersare able to notify
covered entities by November 2nd,that would provide 60 days notice,
and then they'll be ableto launch the pilot on January 1st.
The 11th hour inclusion of medical claimsdata is certainly concerning.
(10:39):
It's going to be difficultfor organizations
to gather that data into a formatthat can be submitted to the platform,
and so that may complicate covered
entities efforts to prepare for the model.
Beyond the operational issues,certainly providing the plan name and ID
will give manufacturers more insight intowho will be getting the discount.
(11:01):
So we can certainly anticipatethat that data will be used
in their advocacyefforts related to the program.
Staying with 340B, want to
focus on the Senate Health, Education,Pensions and Labor hearing from last week.
Last Thursday, senators from both partiesvoiced frustration
over the lack of progress onreforming the 340B drug pricing program.
(11:23):
Efforts to reform the programhave been stalled for years
due to clashes between hospitaland pharmaceutical interests.
Draft legislation, the Sustain 340B Act,from a bipartisan Senate workgroup,
what's known as the Gang of Six, seeksto increase oversight and transparency.
The Gang of Six releaseda draft of the Sustain 340B
(11:45):
Act last spring that would have prohibitedpharmacy restrictions by drug companies,
tightened requirementsfor offsite facilities,
and had a placeholderthat would have redefined
what an eligible patientis potentially narrowing that definition.
The draft was released with a requestfor information related to the bill.
However, a final version of that billhas still not been introduced,
(12:08):
and so a final version obviously wouldinclude, if that section was still there,
a more specific definition of whata patient is.
Senate Health Committee Chair
Cassidy has also calledfor reforms to the program to ensure
that savings are passed on to patientsand to also address transparency issues.
He has indicated that he intends torelease his own 340B reform legislation.
(12:32):
Personally, I think it's unlikely,given the challenges
Congress is having passing a 2026 budget,
that legislationlimiting 340B or reforming
340B will pass this year.
And I'm somewhat doubtful that Congressis going to be able to take up and pass
anything that could potentiallybe this controversial in an election year.
(12:53):
However, even a chance of legislation
is certainly a concernfor covered entities
because anything that they pass,while it may provide some benefits,
will also likely take some things awayand potentially limit savings,
which would compound the margindegradation risk facing covered entities
as a result of the rebate model,which is now going into effect.
(13:15):
In terms of
additional potential sweepingfederal legislation,
President Donald Trump signaled Tuesdaythat Republicans
are unlikely to pursueanother reconciliation bill.
He told GOP senators recentlythat the Big Beautiful Bill already
included everything that he wanted,such as major tax cuts, defense and border
funding, and a repeal of the green energytax credits.
(13:38):
His remarks undercut Speaker
Johnson's earlier plansfor additional reconciliation measures
and cast doubt on the effort,given the narrow GOP majorities,
the heavy workload of fed fiscal ‘26appropriations,
and the political risksof another vote-a-rama, which is
associated with reconciliation billsin the Senate, before midterm elections.
(13:58):
It would be an opportunity,if they were to go for this again,
for Dems to put in a bunchof messaging amendments that could
potentially put GOP senatorswho are up for election in a tough spot.
While conservatives had pushedfor a second package to address
issues like Medicaid funding for statescovering undocumented immigrants,
skepticism was already highand the president's comments suggest
(14:20):
reconciliationis effectively off the table for now
unless Republicans can unite arounda new agenda and sell it to the president.
I think one of the things that made thisa longshot to start with is,
as was noted by the president,all of the quote unquote “goodies”
that might make Republican membersline up and take a hard vote
less than 12 monthsbefore a federal election.
(14:40):
So again, the tax cuts, defensespending, border
security were already done in OBBBA,
and unless they're able to includean issue that really animates
and engages the president,I think the odds were pretty low
that they could get himto rally around the package
and then leverage him to be the closerthat he was
in the OB3, or OBBBA, votes,
(15:02):
which really helpedget that piece of legislation
across the finish line in the Houseand the Senate.
If we do see another reconciliationbill, though, I do
or am concerned that it would includeadditional healthcare cuts.
So things like expansion of Medicareor site-neutral payments or changes
(15:22):
to Medicare Advantage risk adjustmentcoding to either pay for increased
spendingthat may be part of other packages, or
provide additional deficit reductionto placate fiscal conservatives
that are still concerned about the OB3’sdeficit impact.
The one place where I think
may be possible for an attemptat a reconciliation bill could be around
(15:46):
healthcare,given we're coming into the election
and healthcare costs certainly could befront and center at issue,
particularly if the enhanced exchangesubsidies are allowed to lapse.
And so the Republicans may feel the needto do something about it legislatively.
Again, something to monitor,not something that I would bet
a paycheck on yet,but definitely something to watch.
(16:09):
Last thing I want to coveris plan-provider negotiations.
We are seeing public contract
disputes between insurers and providersrising sharply.
So, spilling out into the public
as both sides grapplewith mounting medical cost pressures,
with at least 90 disputes becoming publicso far
compared to the 51 in 2022
(16:30):
and the 133 in 2024.
Providers are increasingly unwillingto compromise on reimbursement rates
and prior authorization ruleswhile insurers remain
firm in efforts to control costs,particularly for employers.
This trend comes amid growingcriticism of insurers for frequent care
denials and worsening public perceptionof the industry, as providers
(16:53):
need to shift the OB3 Medicaidcuts, the cost of those cuts,
and the increased uncompensated careas a result
of the growing uninsuredto commercial payers.
As providers enter into thesemore challenging negotiations,
they should use the plantransparency files to support their rate
increase requestsso that these are grounded in data.
(17:15):
As providers look to use this data,key questions they should ask include:
How does your organization's payer pricingcompare to peers?
Is our organization collectingthe negotiated rates they've established
today?
How do our organization services fitthe market?
Is our pricing justifiedbased on the services provided?
And how will consumers viewour organization's value?
(17:38):
This concludes today's Washington Watch.
Up next, I'll be joined by my colleagueRandy Biernat to talk about
innovative approaches to improvingphysician enterprise performance.
I'd like to welcome back
to the podcast, our guest for today'sepisode, Randy Biernat.
(18:00):
Randy is a partner in the healthcareconsulting practice at Forvis Mazars,
whose work focuses on physician services,including consulting for transactions
and compliance,
hospital and physician alignment, and fairmarket value compensation.
Randy,thank you again for being here today.
Great to be with you, Chad.
Happy to be back.
Randy,our listeners may remember you from back
(18:21):
on our second episode of Achieving Health,when we explored insights
from our annual Mindsetssurvey of healthcare executives.
And I’d encourage everyone to go backand give that episode a listen,
if you haven't already.
At the time,you shared some fascinating insights
on aligning the physician enterprisewith key priorities
for the healthcare organizationand for healthcare leaders,
(18:44):
including insightsrelated to the concept of aligned growth
and also the conceptof talent optimization.
And so wanted to have you back todayfor a deeper dive on those topics.
Let's start at a high level.
Why is an effective physician enterprisesuch an important
strategic assetfor healthcare organizations today?
(19:06):
So I'll focus on one area.
It's about access.
So the physician enterpriseis a high cost, hard to recruit,
generally aging employee cohort.
And so what you do withit becomes extremely important.
There's no
doctors, no hospital.
(19:27):
What that really means, at a strategic level, is access.
And so when your physician enterprisefunctions at a high level,
you're providing the right service
in the right care setting at the righttime in the right location.
So when you stack all that up and you'reefficiently allocating your human capital,
(19:48):
you're able to drive accesswhere it needs to be to be effective.
And there are hardchoices associated with that.
But when it's well done,you're meeting the needs of the community,
and you are drivingfinancial sustainability.
When that's unoptimized, right,the physician enterprise can be
(20:10):
a barrier to success
and really work with health systemsright now
trying to think throughwhat do we do with this problem?
And it's like,this is not the problem, right?
That we are not optimized.
You have this asset.
We need to turn it into one.
No, and I think your point about access iswell taken, because when you think about
(20:35):
you get access right,you improve outcomes, you get access right
where you're getting people with the rightsetting a care,
you're delivering carein a cost efficient manner.
You get access right,
you're improving patient satisfaction
because they're able to get inin a timely manner.
And that also, by the way, helps drivefinancial performance
for the health system.
So this to meseems like one of the key lynchpins
(20:55):
that organizations need to be thinkingabout.
Let's get into some of the details aroundwhen it comes
to improvingphysician enterprise performance.
How should physician enterprisesmanage physician subsidies?
I know that's somethingthat all organizations struggle with.
Yeah, another big question and a good one.
And so if you're part of a health systemthat has an integrated physician group,
(21:21):
or if you're working very closelywith independent groups
through professional servicesarrangements, you get to the same place.
And the core question is (21:29):
do we have alignment between the professional side
and the facility side and okay,so how do we evaluate that?
We go down one level,we start to think we think
a lot about service lineor service line rationalization.
So base threshold question (21:48):
Does
it make sense to be in the service line,yes or no?
Ten years ago, candidly,you could have an open-heart program
as a vanity project and it would be okay.
You can't do that now.
You truly have to evaluatewhat does it cost us to run this?
(22:08):
Should we be doing openhearts in our community, yes or no?
And it needs to reallymake financial sense
because the spend is so muchnot just on, you know, the proceduralist
doing the work, we think aboutis specialized anesthesiology.
And you think about the call coverageand things like that.
So, you know,is it really cool to be able to do
(22:30):
open hearts locallyand not have to drive 50 or 100 miles?
Yes. It is really neat.
But that stuff, from a decade agothat worked,
that doesn't work todaywith all the economic pressure. So,
you know, service line rationalizations,are we doing what we should?
Is it aligned?
And so there are going to be, you know,if you think about expanding circles,
(22:52):
there are going to be some core circlesthat we're going to say yes to no matter
what in our community.
The most obvious example is an obstetricsprogram, right?
Are we really a hospitalif we don't deliver babies?
If you ask boards, community boardsespecially, the answer is
no, we're not a hospitalif we don't deliver babies.
So are we,is it rational to be in this business?
No, it's mission.
(23:13):
Okay. And that's an okay answer.
Once.
Twice, three times.
It's not an okay answer 15 times. Right?
At some point, you start to have to say,no, it's not rational.
We're out of that first ring ofwe must do it
into things that we maybe could door we should do,
(23:33):
and sort of figuring outwhere to direct resources becomes more
and more financially orientedas it gets away from the core.
And so, we think about serviceline rationalization.
It has to
inform the target operating model,
(23:55):
to meet the community's needin the most efficient manner.
And if it's core, does it make sense to bein this productivity or access model?
Usually it's going to be the access modelfor your core programs
that are loser programs, net net.
And then if you go out a circle,it should be more of a productivity
(24:17):
orientation operating model,to fulfill patient demand.
And those should befinancially sustainable.
And it's in that second ring of,you know, cancer
care, orthopedic care, cardiac care.
That's where we're generating marginsto sustain the whole enterprise.
Right.
And having that balance between thethe money
(24:40):
moneymaker programs and a service linebasis and,
our community support payments,you know, community support programs
where we aren't, you know, standalone,financially sustainable.
Right.
Having the right portfolio balance to stayin the game is what you need to do.
And sometimes that means trimming thingslike the open-heart program I mentioned.
(25:02):
To get to the right answer.
And Randy, I like that model of
sort of thinking about
what's in the core, being disciplinedto limiting that to a number of factors.
Then everything else needs
to not only support itself,be able to support the core as well.
You started to touch on thisin your answer, particularly as it,
(25:25):
you know, across the things that are coreand also the things that are non-core.
But how can physician enterprise leadersdetermine
whether their workforce is structuredappropriately?
What should they be looking at?
Chad, I will tell you,I think, it's the same answer.
It first depends on whether or notit's access or productivity.
(25:46):
If it's an access model.
And we're really, again, trying to delivercare to the community.
It's absolutely about the cost of careand that visit as cost per metric.
And this does tie into accountable care.
And it does tie into sustainabilityand those other things.
(26:08):
But we need to be managing costs
per visit and our access modelsand managing that down.
We still want to maximize reimbursementby all acceptable means,
but from an operations standpointthat that's not in their control,
whether or not we're a rural health clinic
or we're providerbased or participating in 340B,
(26:29):
it is cost per visit in the clinicfor access models.
Now, if we think about productivity models
that are really the key driversof financial sustainability
in our organization, cost pervisit is still a good metric to look at.
But we're really gonna flipto margin per visit,
(26:50):
and we cannot pay our doctorsfor margin that we earn.
But we can make investment decisions,whether it's technology.
Should we buy this robot?
Should we get
ambient AI to help us, you know, manage, the physician's time better?
So charts pre-populated where we maketechnology investments, how we staff.
(27:14):
Right.
So, we can get a physicianto be more productive
by adding human resourcesor technological resources.
We should do that in a productivity model
if it's accretive to margin.
For an access model,that's the wrong decision.
I mean, it's the wrong framework.
And so again,I like to bucket things into,
(27:36):
hey, it's core service access focus.
Well,we're going to focus on cost per visit.
I'm trying to fulfillthe community need at the lowest,
you know, cost per visit.
And then if it's a driver of growth,it really is about net margin,
which is why the service linerationalization becomes important.
(27:58):
It helps us know what investments
we should make to allowfor financial sustainability.
As you start to think
about operating models,what does a more efficient one look like?
When we think
about a more efficient operating model,
what's happening in in healthcare,almost a surprise.
(28:18):
But it fits the demographic trends.
This is of course, it's to some degreeanecdotal,
but, employed medical staffs in a lot of
markets were the result of, primarily reimbursement pressure. And.
Okay, well, we'll employthis group of surgeons or oh, okay.
(28:40):
We'll bring in the hospitalist.
Or, oh okay, we'llbring in the OBs, right?
And so we brought these groups together.
There's been a lot of focusin the last 5 or 7 years
on one medical group
to supplement the demandand to sort of stitch things together.
There's been a big infusionof advanced practice providers.
(29:00):
So whether it's physicians assistantsor nurse practitioners, these advanced
practice providers or APPs for short,
they have flooded the workforce.
And so when we thinkabout a more efficient model,
like, you know, in our business,like accounting and consulting,
(29:21):
getting some human leverage from a billing
standpoint, is part of the answer.
So advanced practice providerscan get used in a lot of different ways.
I think we're in a phase of optimizingthe use of advanced
practice providers with himwithin employed medical groups.
(29:42):
And so when we talk aboutwhat's a more efficient operating model,
clearly it's figuring out
how to, especially by
specialty basis, make the most of advancedpractice providers.
But for the most part, the ability to get production,
even with the difference in licensure,even with the 15%
(30:05):
differential reimbursement,there is low cost,
reasonable quality serviceto be had out of the APRN group
to get your physicians to top of license
in those productivity models.
And there's a great opportunityfor access, with team-based care
(30:25):
led by a physician running with two
or three or four APRNs to provide access.
So kind of what it sounds likeyou're sketching out is if we're talking
about a proceduralist,making sure that we're keeping them in
the operatingsuite or the procedure suite,
(30:47):
and then having an APRN or two
back at the clinic doing consultsand kind of keeping
using the APRNs to make sure that,you know, they're doing the thing up
with their license.
And then anything that the proceduralistis touching is really worth their time
given what they're being compensated.
And, to your pointthat that is a different operating model
(31:08):
than what mostthe world is running on today,
which then sort of leads to thethought that, you know, change management
is going to be incredibly importantto get to this optimal model.
If you were a physician enterprise leader,
how would you plan for moving towardsthis different target operating model?
(31:30):
Yeah.
So when we talk with folks about targetoperating model and pay a lot, you know,
physician alignment and compensation plansand all the things
that are the ingredients to success to runa highly aligned physician enterprise,
a lot of timesthe immediate reaction is tactical.
(31:51):
Hey, I can't change everything tomorrow.
You know,that's going to be very disruptive.
And so, you know, the approachthat we like to use,
especially where we're, you know,dipping our toes into value based,
enterprise type physician alignment,where we are compensating
(32:11):
the physicians, in partbased on the shared success
of a service line, which directly tiesinto service line rationalization.
We don't want to force everybodyinto a model
to force people out or to force,and I'll say instead of people
say physicians,we don't want to force physicians out.
We don't want to force them to fail.
(32:31):
And we know that if we slam top downa new operating model, a new pay plan,
it's going to drive
some level of chaos,some level of turnover.
And filling in the gaps aroundcall coverage with locums
is incredibly expensive. Right?
So just because we have this belief thatwe need to do things differently doesn't
(32:53):
mean we can do all of it differently todayor tomorrow or next month.
And so we think about how
we want, a service lineor a set of service lines
to look and act and be modeledand how they we want them aligned.
We do need to think about a multiyear timehorizon.
And typically we can get
(33:16):
a third to half of providers on board
with a new pay plan, right?
Because they want to be heard.
They want the opportunityto perform better.
They do want to be aligned.
So there's a core group that you can leadtowards change that are open to it.
And a lot of timeswhat we want to do is allow for a pilot
(33:39):
and, or an opt in for something new.
And it's a reallythe old plan alone for a year or 2 or 3.
So, doctors,if this doesn't sound good to you,
you can just wait and see.
We're not going to give youa big raise, right?
But we are going to permit statusquo for a period of time.
(34:03):
And we're going to take the coalitionof the willing forward
into our target operating model.
And that's obviouslyfrom a change management
standpoint; we're going to provideincentives for the physicians
who are open to change or providefinancial incentives.
And if we're able to changethe cost of care,
those incentives pay for themselves.
(34:24):
And so if we think about, hey,what's our medical roster,
what's our team look like in three yearsor five years, what do we want it to be?
You know, that's a lot easier to manage.
Especially we're talking about somethinglike call coverage.
It's a lot easier to manageif we, permit different operating models.
(34:45):
But I do think it's usefulfrom an alignment standpoint to,
you know, current state, future state,timeline out what we want it to look like,
what's the amount of changethat we can tolerate
over a period oftime, and plan accordingly?
No, I think
I think that makes senseas a model, particularly,
(35:06):
you know, I'm not trying to forceanything down, but really allowing those
who want to move forward to do soand giving those who maybe aren't
as immediately as excited an opportunityto either become a customer
or think about something else.
You know, over the last several years,
we've seen more and more care,in particular primary care,
be delivered by advanced practiceproviders.
(35:29):
What kind of governance modeldo organizations or should organizations
set up to set up APPs for success?
I love this question, Chad.
So, thank you.
Organizationally, we need to
match skills to roles,
and we've got to support thatwith training and development.
(35:52):
So it's a big enough employee cohortthat in my mind,
the APRNs or the PAs
need a place to go for training,
education, mentorship that isn't justthe collaborating physician
or the docs in that officeor on the floor or whatever.
So having, you know, even at amaybe a VP level, an APRN
(36:16):
that is helping with training, leadershipdevelopment,
how to work with physicians
who aren't always the easiestto work with folks.
And so I do think that the workforcein, in so many organizations is big enough
that having a counterpart to the VP
(36:39):
or the CMO or other
clinical leadership,that's a physician having,
someone who's walked in their shoes,
you know, with that backgroundand leadership would be very helpful.
And so that is somethingthat makes a ton of sense to me
is as they become a bigger and biggerpart of the employee provider workforce.
(37:04):
What else
can physician enterprise leadersdo to set APPs up for success?
Right.
You talked about the training,
but obviously maybe it's not a one sizefits all training model.
Yeah.
So again, if half of your workforce,provider workforce, is APRNs and PAs,
which is not uncommon right now,
(37:24):
that's still expensive talent to acquire.
So do they cost much less than physicians.
Yes. Are they still expensive
workforce or highly paid workforce.
Yes. And so, what we want to start to do
is to manage turnover,you know, to screen better for fit.
(37:45):
And one of the most importantthings is skills-based evaluation.
If you're hiring a physician,you know, who's board
certified in urology,you know what you're getting.
You can do background check and understandthe kind of procedures
that the physician is skilled and doingand so forth.
(38:06):
And licensure is a pretty good indicatorof their clinical capabilities.
For APRN, licensure is not nearly as goodof an indicator of clinical capabilities.
So, it really is about skills.
So, skills-basedevaluation, training, development,
helping the APRNswe're bringing in land in the right place,
(38:26):
giving them runway to be successful,helping them with engagement.
If they are paired with a physician who,and they're sort of forced into that
and there's not a greatfit, that can drive turnover.
That's so counter to what we want to doto be efficient and sustainable.
So, bringing them in in a waythat they're supported,
(38:50):
setting the expectationswith collaborating physicians,
moving into a team-based care modelwhere the physician success
is linked to the APP success,you know, is a way to help this.
But there are, APPs rendera lot of patient care in this country.
It's increasing every yearin every setting,
(39:10):
setting them up for better success.
You know, as they comein, as they develop and grow
and sustain with your organization,is incredibly valuable work.
No, I think I think what you've laid outmakes a lot of sense, particularly as it’s
sort of figuring outonce you've hired them, meeting them
where they are and their skill sets,figuring out how to develop them, and also
(39:33):
how to deploy them in rolesthat they can be most effective in.
You know, going back to kind of thisnew model that you're talking about,
you know, it's predicated on
physicians leading a panel of APPs.
If you were running a physician enterprisetoday,
(39:53):
how would you changethe physician comp model
to reward or encourage physiciansto step into that leadership role?
Yeah.
So I mentioned team-basedcare a couple of times.
Team based careexists in places and pockets.
How I viewit, Chad, is just how you describe it.
You have a physician leading a paneland really having dedicated time
(40:17):
with a group, you know, ledby the physician with two, three, four,
mid-level providers or advanced practiceproviders, rather
having them really focus on
executing the care plans,working through the visits,
working through the follow ups,working through the messages in a team
(40:38):
setting is a little differentthan what's happening in most places.
Lots of physicians get paid for
nurse practitioner
collaboration,or they're getting paid to review charts.
They're getting $500 a monthto be available and do some chart review.
And then, over-read some charts, do some sign-off things like that.
(41:02):
That's not team based care.
Team based care really is a programmatic,and by programmatic
I mean operational, approachwhere a patient understands
they are being seenby a team of providers.
They may never see the physician,but they understand
that the physician is involvedin their care, through oversight
(41:23):
and through planning and execution.
It’s done in that team setting.
We want to think about how much,
access that creates, how
that influences cost of care,how much that saves us,
financially, we want to rewardthe physician to do that,
which isn't $500 per monthper nurse practitioner.
(41:46):
That is not enough
to compensate for the
time it takes to lead the team.
And so we want to,and over-reward is the wrong term, but
we want to appropriately reward the levelof commitment to that type of program.
And in my mind, that is worth more
than the physician seeing patients
(42:09):
on their own.
And so, this is not to get intonecessarily opportunity costs,
but a physician can producethree RVUs per hour, four RVUs per hour.
Or they can lead a team that's producing
15 RVUs per hour.
The latter is more valuable,
(42:30):
on an apples-to-apples basis.
And so pay plans that rewardthat, are going to far outstrip
the stipend model,like I said, $500 or $1,000 per month.
And so does that look like two timesor three times
or four times as remunerativeas traditional APP collaboration?
(42:52):
Yes. And the economics are there for it.
It promotes financial sustainability and really recognizes the value of that work.
No, I know, but I think that makes sense.
And, you know, want to just, you know,the model where you're providing a stipend
and that, I guessgoes back to kind of the distinction
(43:13):
between being a leaderand being a manager. Right?
We've all worked for peoplethat basically managed us versus
those who led and certainly, at least inmy experience, working for those who led
it had always been more fulfilling
and I was always more productivein those models.
And so you kind of think about itfrom the stipend model,
which kind of is more of a managementmodel versus
(43:34):
that greater level of engagementthat gets a physician
to be more of a leaderinto that leadership role.
Seems to make a lot of sense.
I totally agree.
And so Randy, last question before we
wrap up.
What are you seeing in the market in termsof interesting use cases of telehealth?
So we work with facilitiesall over the country
(43:58):
and access to specialists,especially expensive specialists.
So, think a urologist, really hard,
really hard in some marketsto get critical mass.
But there's a clear need.
Again, urology is a really good example.
So, you know,a patient has a need to drive 50
(44:21):
or 75 miles to see a urologist.
You know,
if we can't get a physician in place,but it's hard to just get a founder.
It's almost even harderto get the second physician in.
But then for call, you really needthree physicians, maybe four.
So there are a lot of facilitiesare just struggling to get enough
(44:43):
physician staff to really have a program.
But there's a clear community need,and so one of the interesting things
with telehealth,I'll get around to telehealth in a minute.
One of the interesting thingsabout telehealth is the idea that instead
of having a local groupof three fill in the blank,
but we'll just go with urologist,instead of a local group of three,
(45:07):
that we may not be able to clinicallykeep busy.
So again,going back to my earlier example,
we would like to have proceduralistslike urologists in a productivity model.
But we may only be able to keep
one and a half busy, but we need threefor call coverage purposes.
So there are these marketsthat are sort of in-between
(45:29):
enough local patientdemand that there's real work to do,
not enough to have a big enough panelto provide call
to meet the level three trauma designationor whatever for that section.
And so what is interesting is I'm
seeing a couple of my clients
get into agreements where they are
(45:51):
accepting a physician parachuting
in just to sit in the hospitaland do procedures at the hospital.
And that's being fed by
an advanced practice provider in a clinic,
working under the
support of a remote telemedicine physician
(46:14):
to do some of the team-based care stuffwe mentioned.
But, you know, planning for the day, chart
review, what tests have been ordered,what those tests might mean.
So, some true collaboration.
The nurse practitioner does the visits.
Where a procedure's indicated,the physician again
zooms in on a telehealth visit and talksabout the procedure with the patient.
(46:39):
The patient then gets scheduledfor a procedure at the hospital.
The on-call physician,that sort of just sitting in the hospital,
again, they've got coverage now
and it's just not that hardto slot in a handful of procedures.
And so we're able to get the accessin the community through telehealth.
(47:02):
We're able to get the procedures donein the community and the call coverage
accomplished.
And honestly, the price point versuskeeping three in the community
ends up being less.
So, even though you're payingfor restricted call coverage,
you're able to set that modelup to be financially viable.
(47:26):
Couldn't happen without telehealth.
So that's something I'm seeing right nowthat's pretty cool.
And I expect to see more just like that.
Randy, thank you for sharing that.
That is a pretty creative model to check.
A lot of boxes,get the care delivered, improve
physician quality of life,and also sort of pencils out financially.
(47:46):
Yeah, mileage may vary. Right.
You know reimbursement matters.
The market matters.You know, there's different things.
I'm not sure it's a universal approach.
But in the right setting.
And for a couple of my clients, it'sbeen a great set.
Well, Randy,thank you again for joining us today.
Always an insightful conversation.
I also want to thank our listenersfor tuning in.
(48:08):
If you're looking for more insightson physician enterprise
strategies, we have links to relatedcontent in the show notes.
I hope you'll join me in two weeksfor the next episode of Achieving Health.
You can follow
Achieving Healthon your favorite podcast platform or visit
forvismazars.us/AchievingHealthPodcastto learn more.
(48:30):
New episodes are released the firstand third Wednesday of each month.
Achieving Health is produced by ForvisMazars LLP, an independent member
of Forvis Mazars global, a leading globalprofessional services network.
Ranked among the largest publicaccounting firms in the United States,
the firm's 7,000 dedicated team membersprovide an Unmatched Client Experience
(48:53):
through the delivery of assurance, taxand consulting services for clients
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The information set forth in this podcastcontains the analysis and conclusions
of the panelists based upon his, her,or their research
and analysis of industryinformation and legal authorities.
Such analysis and conclusionsshould not be deemed opinions
(49:16):
or conclusions by Forvis Mazars,or the panelists
as to any individual situationas situations are fact-specific.
The listener should performtheir own analysis and form
their own conclusionsregarding any specific situation.
Further, the panelists’ conclusionsmay be revised without notice,
with or without changes in industryinformation and legal authorities.
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