In this solo episode of 'Relentless Health Value,' host Stacey Richter dives into the intricate relationship between increased emergency room (ER) visits and the lack of access to effective primary care. Discussing insights from recent episodes featuring experts like Matt McQuide, Dr. Christine Hale, and others, Stacey explores how inadequate primary care leads to skyrocketing ER costs, which now account for 6% of total healthcare spending.
Key points include the systemic issues driving this trend, the incentives misalignments within hospitals and insurance carriers, and the importance of establishing trust and relationships in primary care. The episode also discusses perspectives from healthcare professionals and thought leaders on potential solutions to realign healthcare incentives and improve patient outcomes.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP467
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe
🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe
🎤 Listen on Apple Podcasts
https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify
https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel
https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social/
✭ X https://twitter.com/relentleshealth/
02:16 Connecting the dots between the last six shows.
05:34 EP466 with Vivian Ho, PhD.
05:53 EP463 with Betsy Seals.
05
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Episode 467.
This is a recurring theme show.
"Connecting Sky High ER Spend toPrimary Care Access, Following the
Dollar Through Carriers and Hospitals".
(00:21):
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
Relentlessly Seeking Value.
Here's my new idea for an episode.
Welcome to it.
I want to talk about a majortheme running through the last few
episodes of Relentless Health Value.
(00:41):
And this theme is, heads up,going to continue through a
few upcoming shows as well.
We have Matt McQuide, coming up,talking about patient engagement and
Christine Hale, Dr. Christine Hale,talking about high cost claimants.
And we also have an encore coming up withDr. Kenny Cole, talking about a lot of
things, but patient trust is one of them.
(01:02):
But before I get to the maintheme to ponder here, let me talk
about what gets selected to talkabout on Relentless Health Value.
I will freely admit, how topics for showsget picked, it's not exactly a linear
sort of affair, and furthermore, evenif it were, I can't always get the stars
(01:23):
to align to get a specific cluster ofguests to all come on like one after the
other, so for sure, it might be less thanobvious at times, where my head is at, and
sometimes, admittedly, I don't even know.
This may sound incredibly scattershotand it probably is, but in my defense,
this whole healthcare thing, in case youdidn't know, it's really complicated.
(01:46):
Every time I get a chance to chatwith an expert, I learn something new.
I feel like it's almost impossibleto sit in a vacuum and mastermind
some kind of grand insight.
Very, very fortunately, I don'tneed to sit in a cave and do all
this heavy thinking all by myself.
We got ourselves a tribe here.
Of like minded, really smartfolks between the guests and you
(02:10):
lot, all of you in the tribe oflisteners who are here every week.
Yeah, you rock and I can alwayscount on you to start teasing out
the themes and the through lines andthe really key actionable points.
You email me, you write great postsand comments on LinkedIn and elsewhere.
Even if I am a little bit behindthe eight ball, translating my
instinct into an actual trend line,it doesn't slow this bus down.
(02:34):
It's you who keeps it moving, which iswhy I can confidently say it's you all
who are to blame for this new idea I cameup with the other day after the podcast
with Al Lewis triggered so much amazingand really deep insight and dot connecting
back and forth that hooked together thepast six, I'm going to say, or so shows.
(02:56):
Let's just start at the beginning.
Let's start with the topics thathave been discussed in the past
several episodes of the pod.
Here I go.
Emergency room visits are nowcosting about 6 percent of total
plan sponsor spend on average.
That was the holy crap momentfrom the episode with Al Lewis.
Emergency room volume isup and also prices are up.
(03:20):
In that show with Al Lewis, Idid quote Dr. John Lee, who is an
emergency room doctor, by the way.
I quoted him because he told a storyabout a patient who came into the ER,
winds up getting a big workup in his ER.
Dr. Lee says he sees this situationa lot where the patient comes in,
(03:40):
they've had something going on fora while, they've tried to make an
appointment with their PCP or evenurgent care, they could not get in.
It's also really hard to coordinateand get all the blood work or the
scans and have that all looked at.
That's needed for theworkup to even happen.
I've spoken with multiple ERdoctors at this point, and they
all say pretty much the same thing.
They see the same scenario happen oftenenough, maybe even multiple times a day.
(04:04):
Patient comes in with something thatmay or may not be emergent, and they
are now in the ER because they've beenworried about it for weeks or months.
And the ER is like the only placewhere they can get to the bottom of
what is going on with their body.
And then the patient, you know,they spend the whole day in the ER
getting what amounts to weeks worthof outpatient workup accomplished
and scans and imaging and labs.
(04:25):
And there's no priorauthing anything down.
It's also incredibly expensive.
Moving on from the Al Lewis showearlier than that I had had on Rushika
Fernandopulle MD, and then also ScottConard, MD, both are PCPs, both talking
about primary care, and what makes goodprimary care, and what makes bad primary
(04:45):
care, and how our current, in air quotes,healthcare marketplace, as Dr. Conard
puts it, incentivizes either no primarycare and or primary care where volume
driven throughput is the name of the game.
You know, like seeing 25 patientsa day, these visits or episodes of
care are often pretty transactional.
If relationships are formed,it's because the doctor and or
(05:07):
the patient are rising above thesystem, not the other way around.
And none of that is good for primarycare doctors, nurses or other clinicians.
It's also not good for patients andit's not good for plan sponsors or
any of the ultimate purchasers here,taxpayers, patients themselves.
Because, while all of this isgoing on, those patients getting
no or not good primary care aresomebody's next high cost claimant.
(05:30):
Okay, so those were the shows withRushika Fernandopulle, and Scott Conard.
Then this past week was the show withVivian Ho, who discusses the incentives
that hospital leadership often has.
And these incentives may actually soundgreat on paper, but IRL, they wind up
actually jacking up prices and set upsome weird incentives to increase the
number of beds and the heads in them.
(05:53):
There was also two shows, one of themwith Betsy Seals and then another one
with Wendell Potter about MedicareAdvantage and what payers are up to.
All right, so let's dig in.
What's the big theme?
What's the big through line here?
Let's take it from the top.
Theme one is largely this.
And Scott Conard actually saidthis flat out in his show.
(06:13):
Primary care, good primarycare I mean, is an investment.
Everything else is a cost.
And those skyrocketing ER costsare pure evidence of this.
Again, listen to that show withAl Lewis earlier for a lot of
details about this, but total plancosts 6 percent are ER visits.
(06:34):
Tim Denman from Premise Health wrote,"That is an insane number, anything
over 2 percent warrants concern".
But yeah, these days we have onaverage across the country, 200 plan
members out of a thousand every singleyear, dip it into their local ER.
That number, by the way, willrise and fall depending on the
access and availability of primarycare and or good urgent cares.
(06:59):
Here's from a website entitled ERVisit Statistics, Facts, and Trends
and I'm gonna read what they say here.
"In the United States, emergencyroom visits often highlight gaps
in healthcare accessibility.
Many individuals turn to ERs forconditions that could have been managed
through preventative or primary care.
This indicates that inadequate accessto healthcare often leads to increased
(07:22):
reliance on emergency departments.
ED visits can entail significantcosts, particularly when a
considerable portion of these visitsis classified as non urgent visits,
not requiring immediate medicalintervention, often lead to unnecessary
expenditures that could be betterallocated in primary care settings."
And by the way, if you look atthe total cost across the country
(07:44):
of ER visits, it's billions andbillions and billions of dollars.
In 2017, ED visits, I don't have astat right in front of me, but in
2017, ED visits were 76.3 billiondollars in the United States.
Alright, so, the Al Lewis show comesout, I see that, what I just read,
and then, like a bolt of lightning,Francois de Brantes enters the chat.
(08:05):
Francois de Brantes was on RelentlessHealth Value several years ago,
I should have him come back on.
But Francois de Brantes cemented withmortar the connectivity between runaway
ER costs and the lack of primary care.
He started out talking actually about anew study from the Milbank Memorial Fund.
Only like 5 percent of our spend goingto primary care is way lower than any
(08:26):
other developed country in the world.
All of whom, of course, have farhigher life expectancies than us.
So yeah, they might be onto something.
Francois de Brantes wrote, and I'm goingto read what he wrote with probably
some light editing because apparentlyI can't read and talk at the same time.
He wrote, "Setting aside the impotenceof policies, the real question we
(08:46):
should ask ourselves is whether we'relooking at the right numbers. The short
answer is No, with all due respectto the researchers that crunched
the numbers, that's probably becausethe lens they're using is incredibly
narrow and misses everything else".
And he's talking now about,is that 5 percent primary
care number actually accurate?
Francois de Brantes continues,"Consider for example, that in
(09:09):
commercially insured plans, the totalspend on EDs is 6 percent or more."
And then he says, "Check out StaceyRichter's podcast on the subject.
But 6 percent is essentially whatresearchers say is spent on, you
know, in air quotes, primary care.
Except they don't countthose costs, the ER costs.
They don't count many other costs thatare for primary care, meaning for the
(09:29):
treatment of routine preventative and sickcare, all the things that family practices
used to manage but don't anymore.
They don't count them because thoseservices are rendered by clinicians other
than those in primary care practice.
Francois concludes and he wrotea great article, which I will
certainly link to in the show notes.
He concludes that if you add upall the dollars that are spent on
things that amount to primary care,but just didn't happen in a primary
(09:51):
care office, it's conservativelyaround 17 percent of total dollars.
So yeah, it's not like anyone issaving money by not making sure
that every plan member or patientacross the country has a relationship
with an actual primary care team.
You know, a doctor or a nurse who theycan get on the phone with who knows them.
Listen to the show comingup with Matt McQuide.
This theme will continue.
But any plan not making sure thatprimary care happens in primary care
(10:16):
offices is shelling out for the mostexpensive primary care money can
buy, you know, because it's going tohappen either in the ER or elsewhere.
Jeff Charles Goldsmithput this really well.
He wrote, "As others have said, this surgein ER dollars is a direct consequence
of a worsening primary care shortage".
Then Dr. John Lee turned up.
(10:36):
He, I had quoted on the Al Lewisshow, but he wrote a great post on
LinkedIn that again, I will link to.
And part of it was this.
"Toward a systemic solution, we gottado some unsqueezing of the balloon.
Stacey and Al likens our system to asqueezed balloon with pressure forcing
patients into the emergency room.
The true solution is to unsqueezethe system by improving access to
(11:00):
care outside the emergency room.
Addressing these upstream issuescould prevent patients from
ending up in the emergency room.
While the necessary changes are staringus in the face, unsqueezing the balloon
is far more challenging than it sounds."
And speaking of ER docs weighing in, thenwe had Dr. Mick Connors, who left a banger
of a comment with a bunch of suggestionsto untangle some of these challenges that
(11:22):
are more challenging than they may soundat first glance that Dr. Lee mentions.
And as I said, he's a 30 year pediatricemergency physician, so I'm inclined
to take his suggestions seriously.
You can find them on LinkedIn.
But yeah, I can see why some communitiesare paying 40 bucks a month or something
for patients without access to primarycare to get it just like they pay fire
(11:43):
departments or police departments.
There's a link in the show notes toPrimary Care For All Americans who
are trying to help local communitiesget their citizens primary care.
And Dr. Conard talked about thisa little bit in that episode.
I can also see why plan sponsorshave every incentive to change the
incentives such that primary care teamscan be all in on doing what they do.
(12:06):
Dr. Fernandopulle hits on this.
This is truly vital, making sure thatthe incentives are right, because
we can't forget, as Rob Andrewshas said repeatedly, organizations
do what you pay them to do.
And unless a plan sponsor gets intothe mix, it is super rare to encounter
anybody paying anybody for amazing primarycare in an actual primary care setting.
At that point, Dr. Alex Summersarrived on the scene and he
(12:29):
wrote again with light editing.
Sorry, I can't read.
"This one is in my wheelhouse.
There is a ton that could be done here.
There just has to bestrategy in any given market.
It's a function of access, resources, andlike minded employers willing to invest
in a direct relationship with providers.
But not just any providers, providers whoare willing to solve a big X in this case.
(12:52):
You certainly don't need atrauma team on standby to remove
a splinter or take off a wart.
A great advanced primary carerelationship is one way, but another
thing is just access to care offhours with the resources to make
a difference in a cost plus model.
You can't help everybody at once.
But you can help a lot of people ifthere is a collaborative opportunity."
And then Dr. Alex Summers continues.
(13:13):
He says, "We already have EKG,most procedures and supplies, xray,
ultrasounds, and MRI in our clinics.
All that's missing is a CT scanner.
It just takes a feasible criticalmass to invest in a given geography
for that type of alternative caremodel to alter the course here.
6 percent of plans been going to the ER.
My goodness."
So then we have Ann Lewandowski who justgets to the heart of the matter and the
(13:38):
rate critical for primary care to becomethe investment that it could be, trust.
Anne Lewandowski says, "I 100 percentagree with all of this basically.
I think strong primary care thatpromotes trust before things get so
bad people think they need to go tothe emergency room is the way to go".
This whole human concept of trust isa gigantic requirement for clinical
(14:03):
and probably financial success.
We need primary care to be an investment,but for it to be an investment,
there's got to be relationshipsand there has to be trust between
patients and their care teams.
Now, neither relationships or trustare super measurable constructs, so
it's really easy for some financepro to do things in the name of
(14:24):
efficiency or optimization thatundermine the entire spirit of the
endeavor without even realizing it.
Then we have a lot of primary care thatdoesn't happen in primary care offices,
it happens in care settings like the ER.
So let's tug this theme along to theshows that concern carriers, meaning
the shows with Wendell Potter on howshareholders influence carrier behavior
(14:47):
and with Betsy Seals on MedicareAdvantage plans and what they're up to.
Here's where the primarycare slash ER through line
starts to connect to carriers.
I'm going to read a LinkedIn post bythe indomitable Dr. Steve Schutzer.
Dr. Schutzer wrote about theBetsy Seals conversation.
And he said, "Stacey, you made a commentduring this fabulous episode with Betsy
(15:10):
that I really believe should be amplifiedfrom north to south, coast to coast.
Something that unfortunately is nottop of mind for many in this industry.
And that was, focus on the valuethat accrues to the patient, period.
End of story.
That is the North Star of the valuebased care movement lest we forget.
(15:31):
Financial outcome measures areimportant in the value equation, but
the numerator must be about the patient.
As always, grateful for yourinsights and ongoing leadership."
Oh, thank you so much.
And same to you.
Grateful for yours.
Betsy Seals in that podcast, though, shereminded carrier listeners about this.
Think about the value accruingto the patient in that episode.
(15:52):
And in the Wendell Potter encore thatcame out right before the show with
Betsy, yeah, what Wendell said kindof made me realize why Betsy felt it
important to remind carriers to thinkabout the value accruing to patients.
Wall Street rewards profitmaximization in the short term.
It does not reward valueaccruing to the patient.
However, and here's me agreeing withDr. Steve Schutzer, because I think
(16:15):
this is what underlies his comment.
If what we're doing gets so far removedfrom what is of value to the patient,
then yeah, we're getting so removedfrom the human beings we're allegedly
serving, that smart people can make smartdecisions in theoretical model world.
But what's being done lacks afundamental grounding in actual reality.
(16:39):
And that's dangerous for plan members,but it's also pretty treacherous from
a business and legal perspective,as I think we're seeing here.
Okay, so back to our theme of brokenprimary care and accelerating ER costs.
Are carriers getting in thereand putting a stop to it?
I mean, as aforementioned about 8to 10 times, if you have a broken
primary care system, you're gonnapay for primary care, all right?
(17:01):
It's just gonna be in reallyexpensive care settings.
You gotta figure carriers are wiseto this and they're the ones that
are supposed to be keeping healthcarecosts under control for all America.
Well, relative to keeping ER costs undercontrol, link in the show notes to a study
Vivian Ho, PhD sent from Health Affairs,showing how much ER prices have gone up.
(17:24):
ER prices are way higherthan they used to be.
So you'd think that carriers wouldhave a huge incentive to get members
primary care and do lots and lots ofthings to ensure that not only would
members have access to primary care,but it'd be amazing primary care with
doctors and nurses that were trustedand relationships that would be built.
It'd be salad days for value.
(17:46):
Except, they're not doing a wholelot at any scale that I could find.
We have Iora and ChenMedand a few others aside.
These are advanced primary care groupsthat are deployed by carriers and these
organizations can do great things.
But I also think they serve, andthis came up in the Dr. Fernandopulle
show, they serve like 1 percentof overall patient populations.
(18:06):
Dr. Fernandopulle talked about this inthe context of why these advanced primary
care disruptors may have great impact onindividual patients, but they have very
little overall impact at a national scale.
They're just not scaledand they're not nationwide.
But why not?
I mean, why aren't carriersall over this stuff?
Well, first of all, and again, kindof like back to the Wendell show now.
(18:30):
If we're thinking short term, as acarrier, like Wall Street encourages,
you know, quarter by quarter, andif only the outlier, mission driven
folks, the Knights, in any givencarrier organization are checking
what's going on actually with plans,members and patients like Betsy advised.
Keep in mind, it's a whole lot cheaperand it's easier to just deny care.
(18:51):
And you can do that at scale if youget yourself an AI engine and press go.
Or you can come up with, I don'tknow, exciting new ways to maximize
your risk adjustment and upcoding.
There's a article that was written bySergei Polevikov called "The 80 percent
error rate diagnostic device at theheart of United Health's upcoding fraud".
Right?
So you definitely have some carriers whoare trying to take a shortcut, which might
(19:14):
not wind up being much of a shortcut.
Now, that's not to say thateverybody has the same strategy.
I read in Kevin O'Leary's Health TechNerds newsletter the other day, Kevin
wrote "On Wednesday, Humana announcedit will expand its primary care
footprint in 11 states and four newmarkets. Between Centerwell, Conviva,
and its Walmart partnership, Humanawill add 2230, DeNovo, and Acquired
(19:36):
Clinics in 2025, 11 Walmart locationsare scheduled to open up this year".
Dr. Vivek Garg, by the way, fromHumana, was on the pod a few years ago
talking about Humana's PCP strategy.
Humana also, let's keep in mind, has a bigfootprint in Medicare Advantage, where the
carrier itself is at risk and is going tofoot that bill for the emergency rooms.
(19:57):
So, from an incentivestandpoint, theirs is strong.
Here's my point, exceptions aside,despite the fact that carriers should
have a vested interest to keep patientsout of the ER by ensuring that they
have access to great primary care,given the challenges that Dr. John
Lee alluded to, we all know how trustand relationships have eroded over the
(20:20):
years, and Dr. Mick Connors and Dr.Alex Summers talked about this too.
Despite the obvious incentive, thecarriers, most of them, look at
spreadsheets and decide to take a moreexpedient path to greater profitability,
which is great until I guess theyget sued or investigated by the DOJ.
Lastly, lastly, because the showis getting a little long in the
(20:41):
tooth, let me bring up the podwith Vivian Ho, PhD, it's the next
place that this through line heads.
The show with Vivian Ho digs in ona whole bunch of things, but the
part that's relevant to this primarycare theme is how hospital boards
of directors are usually rich folks,mostly with finance backgrounds.
And that whole thing came up onthe show with Dr. Suhas Gondi
(21:03):
specifically about hospital boardsof directors and who is on them.
But these boards of directors havea bit of a personal goal here and
that personal goal, at least one ofthem, is to not have to travel to
get the fancy scans or treatments.
They do not want to have to go to NewYork City or Cleveland or Minnesota.
So yeah, budgets are set and incentivesare set for hospital leadership and
(21:25):
money that is available is divertedfrom primary care, which is boring and
so very basic, to this fancy stuff.
It's a zero sum game, and if boards ofdirectors are creating incentives and
strategic imperatives and annual goals tostand up, you know, fancy schmancy suites
of really specific machinery or somethingfor really specific diseases, then primary
(21:46):
care is like, hey guys, what about me?
There's lots of other things goingon at hospitals too, like how ERs
have become big profit centers.
This comes up slightly actually inthe show with Matt McQuide, which is
coming up and it is a reality thatplan sponsors need to be aware of.
Okay, so there you go.
That is the through line.
Primary care is an investment if it's goodprimary care, everything else is a cost.
(22:09):
And the thing about this whole thingis that if you don't fund primary
care in a primary setting, it's notlike people don't need primary care.
They will go get it and they willgo get it in the most expensive
place that they possibly can getit, which is the emergency room.
And we've got carriers who are doing alot of other things, but not stemming
the root cause of this ER trend.
(22:30):
And then we also have hospitals whoactually have a vested interest for
this trend to continue again at thec-suite hospital leadership level.
I am certainly not talking about probablymost people that work at a hospital now.
My name is Stacey Richter.
This podcast is sponsored by AventriaHealth Group, and I am super interested
in what you think about this idea thatI had to do this through line show.
(22:51):
Hi, this is Tom Nash, oneof the RHV team members.
You might recognize my voicefrom the podcast intro.
If you love the show and you want toshow us your support, please follow us
on your favorite podcast app, sign upfor the newsletter, or maybe consider
making a small donation in the tip jar.
Thanks so much for listening.
Episode 467.
This is a recurring theme show.
"Connecting Sky High ER Spend toPrimary Care Access, Following the
Dollar Through Carriers and Hospitals".
(00:21):
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
Relentlessly Seeking Value.
Here's my new idea for an episode.
Welcome to it.
I want to talk about a majortheme running through the last few
episodes of Relentless Health Value.
(00:41):
And this theme is, heads up,going to continue through a
few upcoming shows as well.
We have Matt McQuide, coming up,talking about patient engagement and
Christine Hale, Dr. Christine Hale,talking about high cost claimants.
And we also have an encore coming up withDr. Kenny Cole, talking about a lot of
things, but patient trust is one of them.
(01:02):
But before I get to the maintheme to ponder here, let me talk
about what gets selected to talkabout on Relentless Health Value.
I will freely admit, how topics for showsget picked, it's not exactly a linear
sort of affair, and furthermore, evenif it were, I can't always get the stars
(01:23):
to align to get a specific cluster ofguests to all come on like one after the
other, so for sure, it might be less thanobvious at times, where my head is at, and
sometimes, admittedly, I don't even know.
This may sound incredibly scattershotand it probably is, but in my defense,
this whole healthcare thing, in case youdidn't know, it's really complicated.
(01:46):
Every time I get a chance to chatwith an expert, I learn something new.
I feel like it's almost impossibleto sit in a vacuum and mastermind
some kind of grand insight.
Very, very fortunately, I don'tneed to sit in a cave and do all
this heavy thinking all by myself.
We got ourselves a tribe here.
Of like minded, really smartfolks between the guests and you
(02:10):
lot, all of you in the tribe oflisteners who are here every week.
Yeah, you rock and I can alwayscount on you to start teasing out
the themes and the through lines andthe really key actionable points.
You email me, you write great postsand comments on LinkedIn and elsewhere.
Even if I am a little bit behindthe eight ball, translating my
instinct into an actual trend line,it doesn't slow this bus down.
(02:34):
It's you who keeps it moving, which iswhy I can confidently say it's you all
who are to blame for this new idea I cameup with the other day after the podcast
with Al Lewis triggered so much amazingand really deep insight and dot connecting
back and forth that hooked together thepast six, I'm going to say, or so shows.
(02:56):
Let's just start at the beginning.
Let's start with the topics thathave been discussed in the past
several episodes of the pod.
Here I go.
Emergency room visits are nowcosting about 6 percent of total
plan sponsor spend on average.
That was the holy crap momentfrom the episode with Al Lewis.
Emergency room volume isup and also prices are up.
(03:20):
In that show with Al Lewis, Idid quote Dr. John Lee, who is an
emergency room doctor, by the way.
I quoted him because he told a storyabout a patient who came into the ER,
winds up getting a big workup in his ER.
Dr. Lee says he sees this situationa lot where the patient comes in,
(03:40):
they've had something going on fora while, they've tried to make an
appointment with their PCP or evenurgent care, they could not get in.
It's also really hard to coordinateand get all the blood work or the
scans and have that all looked at.
That's needed for theworkup to even happen.
I've spoken with multiple ERdoctors at this point, and they
all say pretty much the same thing.
They see the same scenario happen oftenenough, maybe even multiple times a day.
(04:04):
Patient comes in with something thatmay or may not be emergent, and they
are now in the ER because they've beenworried about it for weeks or months.
And the ER is like the only placewhere they can get to the bottom of
what is going on with their body.
And then the patient, you know,they spend the whole day in the ER
getting what amounts to weeks worthof outpatient workup accomplished
and scans and imaging and labs.
(04:25):
And there's no priorauthing anything down.
It's also incredibly expensive.
Moving on from the Al Lewis showearlier than that I had had on Rushika
Fernandopulle MD, and then also ScottConard, MD, both are PCPs, both talking
about primary care, and what makes goodprimary care, and what makes bad primary
(04:45):
care, and how our current, in air quotes,healthcare marketplace, as Dr. Conard
puts it, incentivizes either no primarycare and or primary care where volume
driven throughput is the name of the game.
You know, like seeing 25 patientsa day, these visits or episodes of
care are often pretty transactional.
If relationships are formed,it's because the doctor and or
(05:07):
the patient are rising above thesystem, not the other way around.
And none of that is good for primarycare doctors, nurses or other clinicians.
It's also not good for patients andit's not good for plan sponsors or
any of the ultimate purchasers here,taxpayers, patients themselves.
Because, while all of this isgoing on, those patients getting
no or not good primary care aresomebody's next high cost claimant.
(05:30):
Okay, so those were the shows withRushika Fernandopulle, and Scott Conard.
Then this past week was the show withVivian Ho, who discusses the incentives
that hospital leadership often has.
And these incentives may actually soundgreat on paper, but IRL, they wind up
actually jacking up prices and set upsome weird incentives to increase the
number of beds and the heads in them.
(05:53):
There was also two shows, one of themwith Betsy Seals and then another one
with Wendell Potter about MedicareAdvantage and what payers are up to.
All right, so let's dig in.
What's the big theme?
What's the big through line here?
Let's take it from the top.
Theme one is largely this.
And Scott Conard actually saidthis flat out in his show.
(06:13):
Primary care, good primarycare I mean, is an investment.
Everything else is a cost.
And those skyrocketing ER costsare pure evidence of this.
Again, listen to that show withAl Lewis earlier for a lot of
details about this, but total plancosts 6 percent are ER visits.
(06:34):
Tim Denman from Premise Health wrote,"That is an insane number, anything
over 2 percent warrants concern".
But yeah, these days we have onaverage across the country, 200 plan
members out of a thousand every singleyear, dip it into their local ER.
That number, by the way, willrise and fall depending on the
access and availability of primarycare and or good urgent cares.
(06:59):
Here's from a website entitled ERVisit Statistics, Facts, and Trends
and I'm gonna read what they say here.
"In the United States, emergencyroom visits often highlight gaps
in healthcare accessibility.
Many individuals turn to ERs forconditions that could have been managed
through preventative or primary care.
This indicates that inadequate accessto healthcare often leads to increased
(07:22):
reliance on emergency departments.
ED visits can entail significantcosts, particularly when a
considerable portion of these visitsis classified as non urgent visits,
not requiring immediate medicalintervention, often lead to unnecessary
expenditures that could be betterallocated in primary care settings."
And by the way, if you look atthe total cost across the country
(07:44):
of ER visits, it's billions andbillions and billions of dollars.
In 2017, ED visits, I don't have astat right in front of me, but in
2017, ED visits were 76.3 billiondollars in the United States.
Alright, so, the Al Lewis show comesout, I see that, what I just read,
and then, like a bolt of lightning,Francois de Brantes enters the chat.
(08:05):
Francois de Brantes was on RelentlessHealth Value several years ago,
I should have him come back on.
But Francois de Brantes cemented withmortar the connectivity between runaway
ER costs and the lack of primary care.
He started out talking actually about anew study from the Milbank Memorial Fund.
Only like 5 percent of our spend goingto primary care is way lower than any
(08:26):
other developed country in the world.
All of whom, of course, have farhigher life expectancies than us.
So yeah, they might be onto something.
Francois de Brantes wrote, and I'm goingto read what he wrote with probably
some light editing because apparentlyI can't read and talk at the same time.
He wrote, "Setting aside the impotenceof policies, the real question we
(08:46):
should ask ourselves is whether we'relooking at the right numbers. The short
answer is No, with all due respectto the researchers that crunched
the numbers, that's probably becausethe lens they're using is incredibly
narrow and misses everything else".
And he's talking now about,is that 5 percent primary
care number actually accurate?
Francois de Brantes continues,"Consider for example, that in
(09:09):
commercially insured plans, the totalspend on EDs is 6 percent or more."
And then he says, "Check out StaceyRichter's podcast on the subject.
But 6 percent is essentially whatresearchers say is spent on, you
know, in air quotes, primary care.
Except they don't countthose costs, the ER costs.
They don't count many other costs thatare for primary care, meaning for the
(09:29):
treatment of routine preventative and sickcare, all the things that family practices
used to manage but don't anymore.
They don't count them because thoseservices are rendered by clinicians other
than those in primary care practice.
Francois concludes and he wrotea great article, which I will
certainly link to in the show notes.
He concludes that if you add upall the dollars that are spent on
things that amount to primary care,but just didn't happen in a primary
(09:51):
care office, it's conservativelyaround 17 percent of total dollars.
So yeah, it's not like anyone issaving money by not making sure
that every plan member or patientacross the country has a relationship
with an actual primary care team.
You know, a doctor or a nurse who theycan get on the phone with who knows them.
Listen to the show comingup with Matt McQuide.
This theme will continue.
But any plan not making sure thatprimary care happens in primary care
(10:16):
offices is shelling out for the mostexpensive primary care money can
buy, you know, because it's going tohappen either in the ER or elsewhere.
Jeff Charles Goldsmithput this really well.
He wrote, "As others have said, this surgein ER dollars is a direct consequence
of a worsening primary care shortage".
Then Dr. John Lee turned up.
(10:36):
He, I had quoted on the Al Lewisshow, but he wrote a great post on
LinkedIn that again, I will link to.
And part of it was this.
"Toward a systemic solution, we gottado some unsqueezing of the balloon.
Stacey and Al likens our system to asqueezed balloon with pressure forcing
patients into the emergency room.
The true solution is to unsqueezethe system by improving access to
(11:00):
care outside the emergency room.
Addressing these upstream issuescould prevent patients from
ending up in the emergency room.
While the necessary changes are staringus in the face, unsqueezing the balloon
is far more challenging than it sounds."
And speaking of ER docs weighing in, thenwe had Dr. Mick Connors, who left a banger
of a comment with a bunch of suggestionsto untangle some of these challenges that
(11:22):
are more challenging than they may soundat first glance that Dr. Lee mentions.
And as I said, he's a 30 year pediatricemergency physician, so I'm inclined
to take his suggestions seriously.
You can find them on LinkedIn.
But yeah, I can see why some communitiesare paying 40 bucks a month or something
for patients without access to primarycare to get it just like they pay fire
(11:43):
departments or police departments.
There's a link in the show notes toPrimary Care For All Americans who
are trying to help local communitiesget their citizens primary care.
And Dr. Conard talked about thisa little bit in that episode.
I can also see why plan sponsorshave every incentive to change the
incentives such that primary care teamscan be all in on doing what they do.
(12:06):
Dr. Fernandopulle hits on this.
This is truly vital, making sure thatthe incentives are right, because
we can't forget, as Rob Andrewshas said repeatedly, organizations
do what you pay them to do.
And unless a plan sponsor gets intothe mix, it is super rare to encounter
anybody paying anybody for amazing primarycare in an actual primary care setting.
At that point, Dr. Alex Summersarrived on the scene and he
(12:29):
wrote again with light editing.
Sorry, I can't read.
"This one is in my wheelhouse.
There is a ton that could be done here.
There just has to bestrategy in any given market.
It's a function of access, resources, andlike minded employers willing to invest
in a direct relationship with providers.
But not just any providers, providers whoare willing to solve a big X in this case.
(12:52):
You certainly don't need atrauma team on standby to remove
a splinter or take off a wart.
A great advanced primary carerelationship is one way, but another
thing is just access to care offhours with the resources to make
a difference in a cost plus model.
You can't help everybody at once.
But you can help a lot of people ifthere is a collaborative opportunity."
And then Dr. Alex Summers continues.
(13:13):
He says, "We already have EKG,most procedures and supplies, xray,
ultrasounds, and MRI in our clinics.
All that's missing is a CT scanner.
It just takes a feasible criticalmass to invest in a given geography
for that type of alternative caremodel to alter the course here.
6 percent of plans been going to the ER.
My goodness."
So then we have Ann Lewandowski who justgets to the heart of the matter and the
(13:38):
rate critical for primary care to becomethe investment that it could be, trust.
Anne Lewandowski says, "I 100 percentagree with all of this basically.
I think strong primary care thatpromotes trust before things get so
bad people think they need to go tothe emergency room is the way to go".
This whole human concept of trust isa gigantic requirement for clinical
(14:03):
and probably financial success.
We need primary care to be an investment,but for it to be an investment,
there's got to be relationshipsand there has to be trust between
patients and their care teams.
Now, neither relationships or trustare super measurable constructs, so
it's really easy for some financepro to do things in the name of
(14:24):
efficiency or optimization thatundermine the entire spirit of the
endeavor without even realizing it.
Then we have a lot of primary care thatdoesn't happen in primary care offices,
it happens in care settings like the ER.
So let's tug this theme along to theshows that concern carriers, meaning
the shows with Wendell Potter on howshareholders influence carrier behavior
(14:47):
and with Betsy Seals on MedicareAdvantage plans and what they're up to.
Here's where the primarycare slash ER through line
starts to connect to carriers.
I'm going to read a LinkedIn post bythe indomitable Dr. Steve Schutzer.
Dr. Schutzer wrote about theBetsy Seals conversation.
And he said, "Stacey, you made a commentduring this fabulous episode with Betsy
(15:10):
that I really believe should be amplifiedfrom north to south, coast to coast.
Something that unfortunately is nottop of mind for many in this industry.
And that was, focus on the valuethat accrues to the patient, period.
End of story.
That is the North Star of the valuebased care movement lest we forget.
(15:31):
Financial outcome measures areimportant in the value equation, but
the numerator must be about the patient.
As always, grateful for yourinsights and ongoing leadership."
Oh, thank you so much.
And same to you.
Grateful for yours.
Betsy Seals in that podcast, though, shereminded carrier listeners about this.
Think about the value accruingto the patient in that episode.
(15:52):
And in the Wendell Potter encore thatcame out right before the show with
Betsy, yeah, what Wendell said kindof made me realize why Betsy felt it
important to remind carriers to thinkabout the value accruing to patients.
Wall Street rewards profitmaximization in the short term.
It does not reward valueaccruing to the patient.
However, and here's me agreeing withDr. Steve Schutzer, because I think
(16:15):
this is what underlies his comment.
If what we're doing gets so far removedfrom what is of value to the patient,
then yeah, we're getting so removedfrom the human beings we're allegedly
serving, that smart people can make smartdecisions in theoretical model world.
But what's being done lacks afundamental grounding in actual reality.
(16:39):
And that's dangerous for plan members,but it's also pretty treacherous from
a business and legal perspective,as I think we're seeing here.
Okay, so back to our theme of brokenprimary care and accelerating ER costs.
Are carriers getting in thereand putting a stop to it?
I mean, as aforementioned about 8to 10 times, if you have a broken
primary care system, you're gonnapay for primary care, all right?
(17:01):
It's just gonna be in reallyexpensive care settings.
You gotta figure carriers are wiseto this and they're the ones that
are supposed to be keeping healthcarecosts under control for all America.
Well, relative to keeping ER costs undercontrol, link in the show notes to a study
Vivian Ho, PhD sent from Health Affairs,showing how much ER prices have gone up.
(17:24):
ER prices are way higherthan they used to be.
So you'd think that carriers wouldhave a huge incentive to get members
primary care and do lots and lots ofthings to ensure that not only would
members have access to primary care,but it'd be amazing primary care with
doctors and nurses that were trustedand relationships that would be built.
It'd be salad days for value.
(17:46):
Except, they're not doing a wholelot at any scale that I could find.
We have Iora and ChenMedand a few others aside.
These are advanced primary care groupsthat are deployed by carriers and these
organizations can do great things.
But I also think they serve, andthis came up in the Dr. Fernandopulle
show, they serve like 1 percentof overall patient populations.
(18:06):
Dr. Fernandopulle talked about this inthe context of why these advanced primary
care disruptors may have great impact onindividual patients, but they have very
little overall impact at a national scale.
They're just not scaledand they're not nationwide.
But why not?
I mean, why aren't carriersall over this stuff?
Well, first of all, and again, kindof like back to the Wendell show now.
(18:30):
If we're thinking short term, as acarrier, like Wall Street encourages,
you know, quarter by quarter, andif only the outlier, mission driven
folks, the Knights, in any givencarrier organization are checking
what's going on actually with plans,members and patients like Betsy advised.
Keep in mind, it's a whole lot cheaperand it's easier to just deny care.
(18:51):
And you can do that at scale if youget yourself an AI engine and press go.
Or you can come up with, I don'tknow, exciting new ways to maximize
your risk adjustment and upcoding.
There's a article that was written bySergei Polevikov called "The 80 percent
error rate diagnostic device at theheart of United Health's upcoding fraud".
Right?
So you definitely have some carriers whoare trying to take a shortcut, which might
(19:14):
not wind up being much of a shortcut.
Now, that's not to say thateverybody has the same strategy.
I read in Kevin O'Leary's Health TechNerds newsletter the other day, Kevin
wrote "On Wednesday, Humana announcedit will expand its primary care
footprint in 11 states and four newmarkets. Between Centerwell, Conviva,
and its Walmart partnership, Humanawill add 2230, DeNovo, and Acquired
(19:36):
Clinics in 2025, 11 Walmart locationsare scheduled to open up this year".
Dr. Vivek Garg, by the way, fromHumana, was on the pod a few years ago
talking about Humana's PCP strategy.
Humana also, let's keep in mind, has a bigfootprint in Medicare Advantage, where the
carrier itself is at risk and is going tofoot that bill for the emergency rooms.
(19:57):
So, from an incentivestandpoint, theirs is strong.
Here's my point, exceptions aside,despite the fact that carriers should
have a vested interest to keep patientsout of the ER by ensuring that they
have access to great primary care,given the challenges that Dr. John
Lee alluded to, we all know how trustand relationships have eroded over the
(20:20):
years, and Dr. Mick Connors and Dr.Alex Summers talked about this too.
Despite the obvious incentive, thecarriers, most of them, look at
spreadsheets and decide to take a moreexpedient path to greater profitability,
which is great until I guess theyget sued or investigated by the DOJ.
Lastly, lastly, because the showis getting a little long in the
(20:41):
tooth, let me bring up the podwith Vivian Ho, PhD, it's the next
place that this through line heads.
The show with Vivian Ho digs in ona whole bunch of things, but the
part that's relevant to this primarycare theme is how hospital boards
of directors are usually rich folks,mostly with finance backgrounds.
And that whole thing came up onthe show with Dr. Suhas Gondi
(21:03):
specifically about hospital boardsof directors and who is on them.
But these boards of directors havea bit of a personal goal here and
that personal goal, at least one ofthem, is to not have to travel to
get the fancy scans or treatments.
They do not want to have to go to NewYork City or Cleveland or Minnesota.
So yeah, budgets are set and incentivesare set for hospital leadership and
(21:25):
money that is available is divertedfrom primary care, which is boring and
so very basic, to this fancy stuff.
It's a zero sum game, and if boards ofdirectors are creating incentives and
strategic imperatives and annual goals tostand up, you know, fancy schmancy suites
of really specific machinery or somethingfor really specific diseases, then primary
(21:46):
care is like, hey guys, what about me?
There's lots of other things goingon at hospitals too, like how ERs
have become big profit centers.
This comes up slightly actually inthe show with Matt McQuide, which is
coming up and it is a reality thatplan sponsors need to be aware of.
Okay, so there you go.
That is the through line.
Primary care is an investment if it's goodprimary care, everything else is a cost.
(22:09):
And the thing about this whole thingis that if you don't fund primary
care in a primary setting, it's notlike people don't need primary care.
They will go get it and they willgo get it in the most expensive
place that they possibly can getit, which is the emergency room.
And we've got carriers who are doing alot of other things, but not stemming
the root cause of this ER trend.
(22:30):
And then we also have hospitals whoactually have a vested interest for
this trend to continue again at thec-suite hospital leadership level.
I am certainly not talking about probablymost people that work at a hospital now.
My name is Stacey Richter.
This podcast is sponsored by AventriaHealth Group, and I am super interested
in what you think about this idea thatI had to do this through line show.
(22:51):
Hi, this is Tom Nash, oneof the RHV team members.
You might recognize my voicefrom the podcast intro.
If you love the show and you want toshow us your support, please follow us
on your favorite podcast app, sign upfor the newsletter, or maybe consider
making a small donation in the tip jar.
Thanks so much for listening.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com