December 26, 2024 • 25 mins
In this Inbetweenisode titled 'End of Year Wrap Up and My Personal Charter Encore,' Stacey Richter extends heartfelt thanks to listeners and healthcare workers for their dedication.
She reflects on the challenges of maintaining personal integrity in a profit-driven healthcare system and introduces her personal charter. This charter, focused on ensuring net positive outcomes for patients, acknowledges that achieving transformational change in healthcare requires a collective effort.
Stacey discusses the complexities of balancing ethical decisions, financial constraints, and the broader impact on patient care, urging others to reflect on their own guiding principles.
Here's her manifesto which she is now calling her Personal Charter below which she breaks down in this podcast episode:
"If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients."
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06:52 “It’s a zero-sum game.”
07:02 Is the amount of profit fair?
07:13 What is an inescapable fact of the healthcare industry?
07:30 What does the financialization of healthcare mean?
07:55 Why does the self-interest in healthcare matter?
09:54 “It’s basically up to us as individuals to do the right thing.”
13:39 What is the first part of Stacey’s personal charter?
13:54 How does Stacey calculate the net positive of an impact?
14:17 What are two major upsides/downsides that Stacey contemplates?
17:08 Why are incremental change and disruptive change not mutually exclusive?
21:16 “I always try to keep in mind that it will take a village.”
22:55 Why finger pointing is killing innovation in healthcare.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Stacey Richter (00:00):
Inbetweenisode.
"End of Your Wrap Up and MyPersonal Charter Encore, Where
the Rubber Hits the Road."
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
(00:21):
Relentlessly Seeking Value.
Okay, so, we're gonna gowith Personal Charter.
Just, yeah, given everythinggoing on right now, yeah.
It is a charter, not a manifesto.
Because of the end of the yearstatus of this episode, I just want
to kick this off by giving a bigthank you to everyone listening.
But this isn't a thank you for listening.
(00:41):
We covered that in the Thanksgiving show.
This is a thank you for doing what you do.
Doing what you do for patients, formembers, for anyone financially on
the hook for any of what's going on.
And I can say that fullthroatedly because I know you.
I know the tribe who listens to this pod.
This show is not a showfor casual bystanders.
(01:01):
The Relentless Health Value Tribeis interested in topics that are
not anybody's whimsical hobby
and none of it is comedy gold.
Hilarity rarely ensues.
So, I can, with great confidence, thankeveryone for listening, for doing what
you do on behalf of patients, and forhaving a personal charter of your own,
even if that charter at this point issimply to be well informed enough by
(01:25):
listening to this and or other pods orreading enough to make good decisions day
by day on behalf of patients or membersbecause you see the forest for the trees.
So here's a round of applause for you,a heartfelt thank you, and I mean that.
It's hard as a bag of rocks rightnow to do work that is aligned with
personal values or aligned with thepersonal charter we set for ourselves.
(01:46):
It's hard.
It's hard to feel responsible andaccountability when patients or members
are not helped or maybe even harmed.
So from the bottom of my heart, pleasehave my gratitude for all you can manage
to accomplish, even if it's not as much asyou may have hoped to have accomplished.
You're doing the best you can.
We all are.
Goals need to be realistic.
Ted Denman wrote somethingrelevant to this whole conversation
(02:09):
the other day, and it's a gem.
He wrote, "Being a fiduciary issomewhat like being a parent.
The good ones are constantly worriedabout actually doing the job well.
The bad ones never even stopto ponder the question."
Interchange any other healthcare job title with the word
fiduciary, same rules apply.
They apply to us individually, andI'm going to state the obvious here,
(02:32):
but it probably has to be said.
If too many individuals at a companyput profits over patients, then the
company writ large not going to do inthe halls what's written on the walls or
is said during the heartfelt speeches.
Now, I'm not saying this right nowto be a downer, I'm saying this with
the intention of throwing my supportto any of you listening right now
who are trying to act and be part ofthings that are in accordance with your
(02:55):
own values and finding misalignmentwith your workplace that you have
to navigate day in and day out.
Now look, if you happen to work ata place like this, I'm gonna be your
biggest cheerleader to keep goingbecause it's gonna be people like you
who have a lot of ability to influencethe lives of so many by changing a
gigantic vector by like even 0.05%.
(03:17):
But this is a really real placeof sometimes real despair.
And I have heard from so many ofyou who feel like you're pushing
a rock up a hill because look.
Any for-profit company at its corporatelevel has a fiduciary obligation to
maximize profits for shareholders.
The end.
At the corporate level, thatcorporation has no mandate or
(03:38):
feelings or duty to serve patients.
They have no mandate to live up to apress release, but they do have a very,
very well documented fiduciary personalobligation to serve shareholders.
I mean, also, there's funny stuffgoing on at plenty of non-profits
as well, it's crazy how many boardsof directors mostly have finance
degrees listen to the show with Dr.
Suhas Gondi.
So, yeah, I guess it's not allthat surprising, some of the
(04:00):
stuff that's happening today.
I say all this to say, for anybody whoworks somewhere where the organization
is a riptide yanking you into placesyou don't want to go, call me your
biggest cheerleader to resist and steerwithin your sphere of influence in
directions that you believe are right.
This is me musing right now, butthere's a reason why I've heard more
and more that small, independent,and locally owned is a bulwark that
(04:24):
protects the interests of patients,members, plan sponsors, and communities.
So maybe an extra thank you to all of youwho wade into those waters because they
are also shark infested trying to figureout how to stay afloat and not get eaten.
So yeah, the good ones are constantlyworried about actually doing the job well.
The bad ones never evenstop to ponder the question.
(04:45):
Thanks for being a good one.
It's so much easier to justearmuffs and believe the press
releases and drink the Kool-Aid.
And there are so manywho are happy to do so.
This, for sure, is notthe podcast for them.
None of them are here right now.
But you are.
Thanks for even considering havinga personal charter to begin with
or listening to mine, even though,yeah, the ones who really need
(05:06):
a charter are the exact oneswho don't realize they need one.
The irony is palpable.
Okay, with that, here is your encore.
Just everywhere you hear me say manifestoin your mind, insert personal charter.
This is a low budget operation, folks.
And I'm up to my eyeballs trying tomake a living at my day job so I can
continue to put this show out next year.
(05:26):
And with that, here is your encore.
And once again, Thanks so much for beinghere and for doing all that you do.
This whole endeavor to create amanifesto is born out of me struggling
personally to figure out what havingpersonal integrity in this business
actually means when it comes todeciding what to do and what not to do.
(05:48):
When it comes to deciding who orwhat to try to help or support
or who or what to step away fromeither passively or actively.
I mean, how this podcast getsfunded is my business partner and
I pay for it with money from ourconsulting business and from some
tech products that we have on offer.
Who do we choose to take on asclients and what are we willing
(06:09):
to do for them or help them with?
These are questions thatliterally keep me up at night.
And this is what this episode,part two, is all about.
It's about my struggle and how Iattempt to navigate my own path forward.
And holy shnikes!
It's tough to find a path,especially when you have the sort of
perspective that I've wound up withover these past however many years.
(06:33):
It can feel like no matter whatI do, there's negatives as it
relates to the quadruple aim.
You raise one of the quadrantsand something else for somebody
else certainly has the potentialto be negatively impacted.
We cannot forget here in the shortterm, but for sure, often in the longer
term as well, it's a zero sum game.
(06:53):
Every dollar someone takes inprofit under the banner of improving
health or even saving money is adollar that someone else paid for.
Is the amount of profit fair?
Where'd that money come from?
Is there COI, conflict of interest?
And if so, what's the impact?
I think hard about things like this.
An inescapable fact is that therehas been a financialization of
(07:18):
the healthcare industry and thatincludes everybody who also gets
sucked into the healthcare industry,whether they want to be or not, i.e.
patients, members, and plansponsors, and oftentimes physicians
and other clinicians too.
But the financialization ofhealthcare means that most
everybody at the healthcare industryparty has a self interest to
(07:38):
either make money or save money.
And sometimes the saving money meanssaving money for themselves, not
necessarily anything that is evergoing to accrue to patients or members.
Now let's say I'm trying to determineif I want to take on a new client
or decide if I personally want topromote or do something or other.
This self interest, that aboundsall around, matters here because
(08:00):
it means it is often very tough tofind some kind of in air quotes pure
initiative to hitch your wagon to.
The crushing reality that we allface is you gotta earn a living.
The other reality is that oftenthe person that benefits from
the thing you want to do, i.e.
the patient, is not going to pay for it.
And frequently physicianorganizations won't either.
(08:22):
If everybody was lining up to payto get something fixed, the problem
would not be a problem, after all.
But the only way your moral compassis the only moral compass in play is
if you're doing whatever you're doingfor free, really, or by yourself.
And thus you're not encumbered byanybody else or any self interest beyond
your own, and your own motives arethe only motives that you can control.
(08:44):
I hear all the time initiatives andcoalitions and advocacy organizations
and even research fuded by grants.
These things also get bashed as suspectsbecause who'd that money come from
and whose side are the funders on?
Nikhil Krishnan wrote on LinkedInthe other day, and I'm going to do
a little bit of editing, but yeah.
He wrote, "Patients have low trustin healthcare because they think
(09:08):
every stakeholder is incentivizednot in their best interest.
Many patients think the hospitalswant to keep them sick, the carriers
and plan sponsors don't want to paytheir claims, the drug companies
want to keep them on their meds, etc.
And we can't pretendlike this isn't true."
Every party, every stakeholderhas some measure of self interest.
They have to.
(09:29):
Otherwise they'd be out of business.
It's all a matter of degrees.
No big group, no entire categorygets to stand on the high ground
here when you think like a patient.
There's great hospitals and greatpeople who work at hospitals and
then there's people doing things thatcause a strikingly large percentage of
patients to fear going to the hospitalfor clinical and or financial reasons.
(09:50):
Pick any other stakeholder andI'd tell you the same thing.
Any other stakeholder.
It's basically up to us asindividuals to do the right thing.
In every sector of the healthcareindustry, there's good eggs and there's
bad eggs and there's eggs in the middlejust doing their day jobs as instructed.
Personally I want to be a good egg andthat's what my manifesto is all about.
Let me dig into this a bit furtherfor just a sec and then I'll continue
(10:12):
with my personal manifesto for howI find my own path of integrity
through all of this confusion.
Here's another anecdote, stuff likethis I make myself crazy thinking about.
I was listening to a podcast and one ofthe guests said, I wanted to get my MPH,
Master of Public Health, because I felta personal calling to be altruistic.
Then, 120 seconds later, he sayssomething like, So then, when it came
(10:35):
time to pick my internship, I huntedaround to find the one that paid the
most money, and that's how I woundup working for an HMO in the 90s.
Consider how that strikes you.
How do you feel about that guy rightnow, who, by the way, has gone on
to support some very interestingand probably impactful initiatives?
There's this commonly used phrase,let's do well by doing good.
(10:58):
So back to that HMO intern, let'sjust say we all agree that these HMOs
were not unconflicted organizations.
We all know they had a reputationfor putting profits over members and
a reason they went out of businesswas because they denied care.
They refused to pay claimsfor patients who had AIDS.
(11:18):
And it turns out that the friendsand families of people with AIDS
are incredibly well organized andsued the crap out of the HMOs, which
may have expedited their demise.
You know what the internwas doing at the HMO?
He was helping them with data analytics.
And his personal goal was to use thatdata to improve patient outcomes.
So, okay, here's the thought experiment.
(11:39):
Do we want this HMO taking money thatthey're gonna take anyway, and then not
adding the value that they potentiallycould add with their data because they
don't have any smart, dedicated, highlycompensated, interns working there to keep
the ship pointed in a decent direction.
I mean, I guess if I know I'm gonna spenda dollar as a member of that plan, I'd
(12:00):
prefer to get as much as possible formy dollar that is already being spent.
Maybe from that perspective, thisguy is doing well by doing good.
You see how this gets messy whenyou take a theoretical statement
and then apply everyone's real worldprejudices and predilections to it?
Here's the last point to ponder,and this is another thought
experiment, so just heads up andthen I'll get to the point here.
(12:22):
Say you are asked to help with a programrun by a Medicare Advantage plan to
provide those in need of transportationa ride to their annual wellness exam.
Do you help?
Those who listen to the show will fullyunderstand there's a lot of self interest
involved in getting patients to the annualwellness exam because risk adjustment.
Also, Star Ratings.
(12:42):
Listen to the show with Betsy Sealsif you need the full story here.
Short version is, MA plans, MedicareAdvantage plans, can't upcode, either
fairly or aggressively if they areso inclined, if the patients don't
show up for their annual physical.
So there's a lot ofmoney for them at stake.
But then again, are physicalsimportant for patients?
Do they improve patient care and health?
(13:04):
If we think yes, then again, is thisdoing well by doing good to help
patients get to their appointments?
After literally years of asking myselfquestions like this, and most of them were
not thought experiments, I came up withmy manifesto and there are three parts
to it and I will go through each of them.
But here's my manifesto in full.
If the thing results in a net positivefor patients, then I will do it.
(13:29):
The time frame is short term ormedium term, and the assumption is
that it will take a village and I amnot alone in my efforts to transform
healthcare or do right by patients.
Here's how I think about thefirst part of my manifesto.
If the thing results in a net positivefor patients, then I'll do it.
And keep in mind, I could talk aboutthis for seven hours, so everything
I'm saying is oversimplified tosome degree and has as many nuances
(13:52):
as there are stars in the sky.
So to calculate the net positive impact,I think through what good the thing could
do and weigh that against the negatives.
And there are always negatives becausemost of the time, the work that I do
anyway has to get paid for by somebody.
And that somebody has some self interest.
That self interest means that thatthey are attaining something that
(14:15):
furthers their business goals.
So let me list two major upsideslash downside contemplations.
One contemplation.
How much good does the thingactually do for patients?
I think about this.
What's the value here?
Is that a little?
Is it a lot?
Will this thing be adistraction for clinicians?
Because time is often themost precious currency.
(14:36):
If we're talking about some kindof navigation or utilization
management, what's the reasonsomeone wants to do this?
Is the reason clinically andfor reals evidence driven?
Or are we predominantly doing this toenrich shareholders or save plan sponsors
money in ways that are not a win win forpatients in the clinic right now trying
to get cancer treatments for their kid?
(14:57):
I try to think like a patientand be as impartial as possible.
Number two thing I contemplatewhen assessing whether something
is a net positive for patients.
Money.
Where's the money forthis thing coming from?
And who wins in thisparticular initiative?
i.e.
is it a win win and patientswin something worthwhile?
Now, the company doing the fundinghas got to win too, otherwise
(15:21):
they wouldn't fund the thing.
That's where it gets subjective and asaforementioned, do I care if the company
in question wins, if the patient wins too?
Or is this company so damn evil at itscore that I am willing to sacrifice
the opportunity to do a good thing forpatients in order to not have anything
to do with said possible funding entity?
Or am I cutting off my nose tospite my face because this is a
(15:46):
really important thing for patientsand this particular company is
the only one that's gonna fund it.
Because tragedy of thecommons or whatever else.
Again, this gets dicey really fast.
Let me poorly paraphrase a littleexchange I saw on LinkedIn the other
day that had me completely preoccupiedduring my work from home midday walk
around the block for at least three days.
(16:07):
Somebody wrote, maybe that Masterof Public Health intern, somebody
wrote, given how intractable it feelsto me to try to reduce healthcare
spend, I think I'm going to try tohelp patients get more value out of
the dollars that are currently beingspent by them or on their behalf.
Do you think that's a worthy goal?
Well, not everyone does.
Somebody, in t-minus 8 seconds,responded, That's a toxic way of thinking.
(16:33):
Everyone who is not activelyworking to reduce healthcare spend
by putting patients in cash paymodels is part of the problem.
This is a good segue into thesecond part of my manifesto.
So the first part is, if thething results in a net positive
for patients, then I'll do it.
Here's the second part.
The time frame is short term or mediumterm and here's what I mean by that.
(16:54):
My main focus is helpingpatients right now.
This is what this has to do with theaforementioned exchange on LinkedIn
wherein someone was trying to figureout how to get more out of the dollars
we're currently spending and someone elsesaid that's toxic because we should rip
it all down and build a better model.
There's incremental change, andthen there's disruptive change.
These two things arenot mutually exclusive.
(17:15):
Apparently, Mr.
This is Toxic doesn't agree with me,but as I said in the last episode,
there's that Buckminster Fullerquote, "You never change things
by fighting the existing reality.
To change something builds a new modelthat makes the existing model obsolete."
And sure, I like to aspire tothat as much as the next person.
But does aspiring to a big hairygoal mean completely forgoing any
(17:38):
incremental ways that patients can behelped immediately, like right now?
If you ask me, and you're listeningto this, so you de facto asked me,
incremental change will probably actuallysupport and beget disruptive change.
So incremental versus disruptionis not a battle royale.
These things are notdiametrically opposed.
(17:58):
They're probably actually aligned.
I could go on a tangent here toexplain why, but I'm not going
to, except to say tipping points.
But forget about that for a sec.
Here's the more basic question.
If all parties are interested intransforming healthcare, legit, how does
someone trying to do it incrementallyor improve value for patients right
(18:18):
now in any way negatively impactsomeone trying to be disruptive and
or trying to change financial models?
Keep all this in mind.
And now let me get back to my manifesto.
I'm worried about patients and I'mworried about them largely right
now, short term to medium term.
So if I have the opportunity to helpa patient, and I think about my two
grandmothers, God rest their soulshere, but both of them would have
(18:40):
died in the healthcare system multipletimes in avoidable ways had my family
not been there advocating for them.
If I have the opportunity to helpa patient, I will do so, as long
as I believe that the impact is anet positive in the shorter term.
Disruption is a longer term operation.
Some have said it's a generational change.
When I see stuff like Toxicity Guy wroteon LinkedIn, I really try to understand
(19:04):
what his point is, as I always try tounderstand what people's points are.
Could he be arguing that no one shouldwork to improve care right now, or try
to maximize what we get for the bucksthat we've already been shelling out?
And if so, for what reason?
Like, so that what happens?
So that resentment about poorquality care builds up to a boiling
(19:26):
point such that everybody shuns thestatus quo and moves to a new care
model and financial models faster?
Is that the aim of Toxicity Guy?
To force a let them eat cakemoment for the purposes of
triggering a faster revolution?
I've probably thought about thisguy's motives and his potential
impact harder than he has.
In my manifesto, in my worldview, Idon't let grandmas suffer right now
(19:49):
so that someone else has a betternarrative, even if I am in full support
of what that person is trying to doand the mission that they are on,
which by the way, is a longer term one.
And this gets me to thethird part of my manifesto.
The assumption is that transformingthe healthcare industry will take
a village and I am not alone.
When I state this outright, it's goingto seem self evident, but sometimes it's
(20:12):
hard to not push blame here, like ToxicityGuy, so I say this sort of in his defense.
Here's the point of contemplation.
There's maybe four big parts of thehealthcare industry at a minimum.
We have those trying to fix SDOH, SocialDeterminants or Drivers of Health.
We have those trying tofix medical morbidity, i.e.
(20:35):
our patients on evidence based pathwaysand taking meds appropriately, limiting
polypharmacy side effects, cascades.
Like, once a patient is in thehealthcare system, what happens then?
Then we have those working hard toimprove behavioral slash mental health.
And lastly, everything going onwith what I'm going to call FDOH,
Financial Determinants of Health.
(20:56):
Patients making decisions orhaving decisions made for them
due to financial implicationsfor them or for somebody else.
Lots of stuff rolls up under thesecategories, but even just listing out
these four things, we got a hell of alot of work to do to improve the lot
of patients and taxpayers and make iteasier to do business in this country.
I always try to keep in mindthat it will take a village.
(21:21):
Just because someone is working on gettingpatients housing or eating better does not
imply that they don't care about employersstruggling to curb claims billing
waste, fraud and abuse and vice versa.
It's just not everybody can do everything.
For me personally, I tend to focusmy attention on helping as many
patients as possible get on whatwould be for them the optimal
(21:43):
treatment plan or best care pathway.
That does not mean I'm antisomeone working on getting more
competition in the payer space.
Nor does it mean I'm against trying tocurb the price of overpriced as per ICER
pharmaceutical products or legislateto rein in hospitals doing stuff that
in my book they should not be doing.
I am all for getting all of thesethings done, I just do not have
(22:05):
the bandwidth or the depth ofexpertise to do everything myself.
I would suspect that no one does.
As my grandma used to say, andanyone who attended a slumber
party seance in 8th grade mightknow, "Many hands make light work".
You get 15 girls each holding out, but twofingers and you can lift up your friend?
No problem.
What I keep in mind,that it takes a village.
(22:26):
It helps me curtail the tendency to becomeparalyzed in my quest to help patients
because I can see a potential problemit might create somewhere else in the
industry or somewhere else down the line.
I have to trust that one ofmy fellow villagers is holting
down that end of the fort.
Here's a quote from Dr.
J.
Michael Connors that hewrote in his newsletter.
(22:47):
"When you point one finger,three are pointing back at you.
It's like everything you learned inkindergarten seems to be so applicable
to our approach in healthcare.
Sadly, the game of finger pointingand pushing blame on others is killing
real innovation in healthcare."
This is so real, which is why, inherentin my manifesto here, is my efforts to
remember we're all on the same team.
(23:09):
All the good eggs, anyway.
That it takes a village, that there willbe some things that some people are doing
that I maybe don't fully agree with.
There might be groups whodon't accomplish much.
There are certain people doing well, i.e.
doing self interested things,but at the same time creating
a better place for patients.
As long as, in general, we areall following the same North
(23:30):
Star, we'll achieve much morespending our time focused on our
own missions and not worryingabout what other people are doing.
And when I say not worrying aboutwhat other people are doing, I mean
people in the good egg village.
I do not mean I intend to stopcalling out conflicted and
negative self interested behavior.
Because this is what some people inthe village should hopefully have their
(23:51):
eyes on and get busy working against.
The village here, it's a Venn diagram.
At the point where other people'scircles intersect with my mission
or what I think would be better forpatients, these are the people I
can work with and collaborate with.
These are the people that I take theirbusiness or I try to help them if I can.
My manifesto is to determine whensomething is a positive for patients
(24:12):
and then to find others who will winas a result of that thing happening.
Then I can study why this is a winfor those others, which is always
going to be some self interested why.
And then I can think throughwhat the negatives are if their
self interest comes to fruition.
Is it still a net positive?
If yes, proceed.
Look, this making it better forpatients, this transforming healthcare,
(24:33):
it is hard dispiriting work.
It's a long slog.
I'd like to suggest weencourage each other.
Can we be the wind beneath each other'swings when we find a kindred spirit?
Can we focus on the points ofintersection and spend our energy
deepening what's going on there?
So again, here's my manifesto.
If the thing results in a net positivefor patients, then I'll do it.
(24:56):
The time frame I'm concernedabout, short term, medium term.
The assumption is that it willtake a village to transform
healthcare and I am not alone.
I feel kind of exhaustedhaving finished that.
But let me ask you this.
What is your manifesto?
If you have one or a few thoughts onthis, go to our website and click on the
orange button to leave a voice message.
My hope is to do an upcomingshow sharing what you think.
(25:18):
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.
So let's talk about going over to ourwebsite and typing your email address
in the box to get the weekly emailabout the show that has come out.
Sometimes people don't do that becausethey have subscribed on Apple Podcasts or
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(25:39):
What you get in that email is the wholeintroduction of the show transcribed.
There's also show notes withtimestamps just apprising you of
the options that are available.
Thanks so much for listening.
Inbetweenisode.
"End of Your Wrap Up and MyPersonal Charter Encore, Where
the Rubber Hits the Road."
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
(00:21):
Relentlessly Seeking Value.
Okay, so, we're gonna gowith Personal Charter.
Just, yeah, given everythinggoing on right now, yeah.
It is a charter, not a manifesto.
Because of the end of the yearstatus of this episode, I just want
to kick this off by giving a bigthank you to everyone listening.
But this isn't a thank you for listening.
(00:41):
We covered that in the Thanksgiving show.
This is a thank you for doing what you do.
Doing what you do for patients, formembers, for anyone financially on
the hook for any of what's going on.
And I can say that fullthroatedly because I know you.
I know the tribe who listens to this pod.
This show is not a showfor casual bystanders.
(01:01):
The Relentless Health Value Tribeis interested in topics that are
not anybody's whimsical hobby
and none of it is comedy gold.
Hilarity rarely ensues.
So, I can, with great confidence, thankeveryone for listening, for doing what
you do on behalf of patients, and forhaving a personal charter of your own,
even if that charter at this point issimply to be well informed enough by
(01:25):
listening to this and or other pods orreading enough to make good decisions day
by day on behalf of patients or membersbecause you see the forest for the trees.
So here's a round of applause for you,a heartfelt thank you, and I mean that.
It's hard as a bag of rocks rightnow to do work that is aligned with
personal values or aligned with thepersonal charter we set for ourselves.
(01:46):
It's hard.
It's hard to feel responsible andaccountability when patients or members
are not helped or maybe even harmed.
So from the bottom of my heart, pleasehave my gratitude for all you can manage
to accomplish, even if it's not as much asyou may have hoped to have accomplished.
You're doing the best you can.
We all are.
Goals need to be realistic.
Ted Denman wrote somethingrelevant to this whole conversation
(02:09):
the other day, and it's a gem.
He wrote, "Being a fiduciary issomewhat like being a parent.
The good ones are constantly worriedabout actually doing the job well.
The bad ones never even stopto ponder the question."
Interchange any other healthcare job title with the word
fiduciary, same rules apply.
They apply to us individually, andI'm going to state the obvious here,
(02:32):
but it probably has to be said.
If too many individuals at a companyput profits over patients, then the
company writ large not going to do inthe halls what's written on the walls or
is said during the heartfelt speeches.
Now, I'm not saying this right nowto be a downer, I'm saying this with
the intention of throwing my supportto any of you listening right now
who are trying to act and be part ofthings that are in accordance with your
(02:55):
own values and finding misalignmentwith your workplace that you have
to navigate day in and day out.
Now look, if you happen to work ata place like this, I'm gonna be your
biggest cheerleader to keep goingbecause it's gonna be people like you
who have a lot of ability to influencethe lives of so many by changing a
gigantic vector by like even 0.05%.
(03:17):
But this is a really real placeof sometimes real despair.
And I have heard from so many ofyou who feel like you're pushing
a rock up a hill because look.
Any for-profit company at its corporatelevel has a fiduciary obligation to
maximize profits for shareholders.
The end.
At the corporate level, thatcorporation has no mandate or
(03:38):
feelings or duty to serve patients.
They have no mandate to live up to apress release, but they do have a very,
very well documented fiduciary personalobligation to serve shareholders.
I mean, also, there's funny stuffgoing on at plenty of non-profits
as well, it's crazy how many boardsof directors mostly have finance
degrees listen to the show with Dr.
Suhas Gondi.
So, yeah, I guess it's not allthat surprising, some of the
(04:00):
stuff that's happening today.
I say all this to say, for anybody whoworks somewhere where the organization
is a riptide yanking you into placesyou don't want to go, call me your
biggest cheerleader to resist and steerwithin your sphere of influence in
directions that you believe are right.
This is me musing right now, butthere's a reason why I've heard more
and more that small, independent,and locally owned is a bulwark that
(04:24):
protects the interests of patients,members, plan sponsors, and communities.
So maybe an extra thank you to all of youwho wade into those waters because they
are also shark infested trying to figureout how to stay afloat and not get eaten.
So yeah, the good ones are constantlyworried about actually doing the job well.
The bad ones never evenstop to ponder the question.
(04:45):
Thanks for being a good one.
It's so much easier to justearmuffs and believe the press
releases and drink the Kool-Aid.
And there are so manywho are happy to do so.
This, for sure, is notthe podcast for them.
None of them are here right now.
But you are.
Thanks for even considering havinga personal charter to begin with
or listening to mine, even though,yeah, the ones who really need
(05:06):
a charter are the exact oneswho don't realize they need one.
The irony is palpable.
Okay, with that, here is your encore.
Just everywhere you hear me say manifestoin your mind, insert personal charter.
This is a low budget operation, folks.
And I'm up to my eyeballs trying tomake a living at my day job so I can
continue to put this show out next year.
(05:26):
And with that, here is your encore.
And once again, Thanks so much for beinghere and for doing all that you do.
This whole endeavor to create amanifesto is born out of me struggling
personally to figure out what havingpersonal integrity in this business
actually means when it comes todeciding what to do and what not to do.
(05:48):
When it comes to deciding who orwhat to try to help or support
or who or what to step away fromeither passively or actively.
I mean, how this podcast getsfunded is my business partner and
I pay for it with money from ourconsulting business and from some
tech products that we have on offer.
Who do we choose to take on asclients and what are we willing
(06:09):
to do for them or help them with?
These are questions thatliterally keep me up at night.
And this is what this episode,part two, is all about.
It's about my struggle and how Iattempt to navigate my own path forward.
And holy shnikes!
It's tough to find a path,especially when you have the sort of
perspective that I've wound up withover these past however many years.
(06:33):
It can feel like no matter whatI do, there's negatives as it
relates to the quadruple aim.
You raise one of the quadrantsand something else for somebody
else certainly has the potentialto be negatively impacted.
We cannot forget here in the shortterm, but for sure, often in the longer
term as well, it's a zero sum game.
(06:53):
Every dollar someone takes inprofit under the banner of improving
health or even saving money is adollar that someone else paid for.
Is the amount of profit fair?
Where'd that money come from?
Is there COI, conflict of interest?
And if so, what's the impact?
I think hard about things like this.
An inescapable fact is that therehas been a financialization of
(07:18):
the healthcare industry and thatincludes everybody who also gets
sucked into the healthcare industry,whether they want to be or not, i.e.
patients, members, and plansponsors, and oftentimes physicians
and other clinicians too.
But the financialization ofhealthcare means that most
everybody at the healthcare industryparty has a self interest to
(07:38):
either make money or save money.
And sometimes the saving money meanssaving money for themselves, not
necessarily anything that is evergoing to accrue to patients or members.
Now let's say I'm trying to determineif I want to take on a new client
or decide if I personally want topromote or do something or other.
This self interest, that aboundsall around, matters here because
(08:00):
it means it is often very tough tofind some kind of in air quotes pure
initiative to hitch your wagon to.
The crushing reality that we allface is you gotta earn a living.
The other reality is that oftenthe person that benefits from
the thing you want to do, i.e.
the patient, is not going to pay for it.
And frequently physicianorganizations won't either.
(08:22):
If everybody was lining up to payto get something fixed, the problem
would not be a problem, after all.
But the only way your moral compassis the only moral compass in play is
if you're doing whatever you're doingfor free, really, or by yourself.
And thus you're not encumbered byanybody else or any self interest beyond
your own, and your own motives arethe only motives that you can control.
(08:44):
I hear all the time initiatives andcoalitions and advocacy organizations
and even research fuded by grants.
These things also get bashed as suspectsbecause who'd that money come from
and whose side are the funders on?
Nikhil Krishnan wrote on LinkedInthe other day, and I'm going to do
a little bit of editing, but yeah.
He wrote, "Patients have low trustin healthcare because they think
(09:08):
every stakeholder is incentivizednot in their best interest.
Many patients think the hospitalswant to keep them sick, the carriers
and plan sponsors don't want to paytheir claims, the drug companies
want to keep them on their meds, etc.
And we can't pretendlike this isn't true."
Every party, every stakeholderhas some measure of self interest.
They have to.
(09:29):
Otherwise they'd be out of business.
It's all a matter of degrees.
No big group, no entire categorygets to stand on the high ground
here when you think like a patient.
There's great hospitals and greatpeople who work at hospitals and
then there's people doing things thatcause a strikingly large percentage of
patients to fear going to the hospitalfor clinical and or financial reasons.
(09:50):
Pick any other stakeholder andI'd tell you the same thing.
Any other stakeholder.
It's basically up to us asindividuals to do the right thing.
In every sector of the healthcareindustry, there's good eggs and there's
bad eggs and there's eggs in the middlejust doing their day jobs as instructed.
Personally I want to be a good egg andthat's what my manifesto is all about.
Let me dig into this a bit furtherfor just a sec and then I'll continue
(10:12):
with my personal manifesto for howI find my own path of integrity
through all of this confusion.
Here's another anecdote, stuff likethis I make myself crazy thinking about.
I was listening to a podcast and one ofthe guests said, I wanted to get my MPH,
Master of Public Health, because I felta personal calling to be altruistic.
Then, 120 seconds later, he sayssomething like, So then, when it came
(10:35):
time to pick my internship, I huntedaround to find the one that paid the
most money, and that's how I woundup working for an HMO in the 90s.
Consider how that strikes you.
How do you feel about that guy rightnow, who, by the way, has gone on
to support some very interestingand probably impactful initiatives?
There's this commonly used phrase,let's do well by doing good.
(10:58):
So back to that HMO intern, let'sjust say we all agree that these HMOs
were not unconflicted organizations.
We all know they had a reputationfor putting profits over members and
a reason they went out of businesswas because they denied care.
They refused to pay claimsfor patients who had AIDS.
(11:18):
And it turns out that the friendsand families of people with AIDS
are incredibly well organized andsued the crap out of the HMOs, which
may have expedited their demise.
You know what the internwas doing at the HMO?
He was helping them with data analytics.
And his personal goal was to use thatdata to improve patient outcomes.
So, okay, here's the thought experiment.
(11:39):
Do we want this HMO taking money thatthey're gonna take anyway, and then not
adding the value that they potentiallycould add with their data because they
don't have any smart, dedicated, highlycompensated, interns working there to keep
the ship pointed in a decent direction.
I mean, I guess if I know I'm gonna spenda dollar as a member of that plan, I'd
(12:00):
prefer to get as much as possible formy dollar that is already being spent.
Maybe from that perspective, thisguy is doing well by doing good.
You see how this gets messy whenyou take a theoretical statement
and then apply everyone's real worldprejudices and predilections to it?
Here's the last point to ponder,and this is another thought
experiment, so just heads up andthen I'll get to the point here.
(12:22):
Say you are asked to help with a programrun by a Medicare Advantage plan to
provide those in need of transportationa ride to their annual wellness exam.
Do you help?
Those who listen to the show will fullyunderstand there's a lot of self interest
involved in getting patients to the annualwellness exam because risk adjustment.
Also, Star Ratings.
(12:42):
Listen to the show with Betsy Sealsif you need the full story here.
Short version is, MA plans, MedicareAdvantage plans, can't upcode, either
fairly or aggressively if they areso inclined, if the patients don't
show up for their annual physical.
So there's a lot ofmoney for them at stake.
But then again, are physicalsimportant for patients?
Do they improve patient care and health?
(13:04):
If we think yes, then again, is thisdoing well by doing good to help
patients get to their appointments?
After literally years of asking myselfquestions like this, and most of them were
not thought experiments, I came up withmy manifesto and there are three parts
to it and I will go through each of them.
But here's my manifesto in full.
If the thing results in a net positivefor patients, then I will do it.
(13:29):
The time frame is short term ormedium term, and the assumption is
that it will take a village and I amnot alone in my efforts to transform
healthcare or do right by patients.
Here's how I think about thefirst part of my manifesto.
If the thing results in a net positivefor patients, then I'll do it.
And keep in mind, I could talk aboutthis for seven hours, so everything
I'm saying is oversimplified tosome degree and has as many nuances
(13:52):
as there are stars in the sky.
So to calculate the net positive impact,I think through what good the thing could
do and weigh that against the negatives.
And there are always negatives becausemost of the time, the work that I do
anyway has to get paid for by somebody.
And that somebody has some self interest.
That self interest means that thatthey are attaining something that
(14:15):
furthers their business goals.
So let me list two major upsideslash downside contemplations.
One contemplation.
How much good does the thingactually do for patients?
I think about this.
What's the value here?
Is that a little?
Is it a lot?
Will this thing be adistraction for clinicians?
Because time is often themost precious currency.
(14:36):
If we're talking about some kindof navigation or utilization
management, what's the reasonsomeone wants to do this?
Is the reason clinically andfor reals evidence driven?
Or are we predominantly doing this toenrich shareholders or save plan sponsors
money in ways that are not a win win forpatients in the clinic right now trying
to get cancer treatments for their kid?
(14:57):
I try to think like a patientand be as impartial as possible.
Number two thing I contemplatewhen assessing whether something
is a net positive for patients.
Money.
Where's the money forthis thing coming from?
And who wins in thisparticular initiative?
i.e.
is it a win win and patientswin something worthwhile?
Now, the company doing the fundinghas got to win too, otherwise
(15:21):
they wouldn't fund the thing.
That's where it gets subjective and asaforementioned, do I care if the company
in question wins, if the patient wins too?
Or is this company so damn evil at itscore that I am willing to sacrifice
the opportunity to do a good thing forpatients in order to not have anything
to do with said possible funding entity?
Or am I cutting off my nose tospite my face because this is a
(15:46):
really important thing for patientsand this particular company is
the only one that's gonna fund it.
Because tragedy of thecommons or whatever else.
Again, this gets dicey really fast.
Let me poorly paraphrase a littleexchange I saw on LinkedIn the other
day that had me completely preoccupiedduring my work from home midday walk
around the block for at least three days.
(16:07):
Somebody wrote, maybe that Masterof Public Health intern, somebody
wrote, given how intractable it feelsto me to try to reduce healthcare
spend, I think I'm going to try tohelp patients get more value out of
the dollars that are currently beingspent by them or on their behalf.
Do you think that's a worthy goal?
Well, not everyone does.
Somebody, in t-minus 8 seconds,responded, That's a toxic way of thinking.
(16:33):
Everyone who is not activelyworking to reduce healthcare spend
by putting patients in cash paymodels is part of the problem.
This is a good segue into thesecond part of my manifesto.
So the first part is, if thething results in a net positive
for patients, then I'll do it.
Here's the second part.
The time frame is short term or mediumterm and here's what I mean by that.
(16:54):
My main focus is helpingpatients right now.
This is what this has to do with theaforementioned exchange on LinkedIn
wherein someone was trying to figureout how to get more out of the dollars
we're currently spending and someone elsesaid that's toxic because we should rip
it all down and build a better model.
There's incremental change, andthen there's disruptive change.
These two things arenot mutually exclusive.
(17:15):
Apparently, Mr.
This is Toxic doesn't agree with me,but as I said in the last episode,
there's that Buckminster Fullerquote, "You never change things
by fighting the existing reality.
To change something builds a new modelthat makes the existing model obsolete."
And sure, I like to aspire tothat as much as the next person.
But does aspiring to a big hairygoal mean completely forgoing any
(17:38):
incremental ways that patients can behelped immediately, like right now?
If you ask me, and you're listeningto this, so you de facto asked me,
incremental change will probably actuallysupport and beget disruptive change.
So incremental versus disruptionis not a battle royale.
These things are notdiametrically opposed.
(17:58):
They're probably actually aligned.
I could go on a tangent here toexplain why, but I'm not going
to, except to say tipping points.
But forget about that for a sec.
Here's the more basic question.
If all parties are interested intransforming healthcare, legit, how does
someone trying to do it incrementallyor improve value for patients right
(18:18):
now in any way negatively impactsomeone trying to be disruptive and
or trying to change financial models?
Keep all this in mind.
And now let me get back to my manifesto.
I'm worried about patients and I'mworried about them largely right
now, short term to medium term.
So if I have the opportunity to helpa patient, and I think about my two
grandmothers, God rest their soulshere, but both of them would have
(18:40):
died in the healthcare system multipletimes in avoidable ways had my family
not been there advocating for them.
If I have the opportunity to helpa patient, I will do so, as long
as I believe that the impact is anet positive in the shorter term.
Disruption is a longer term operation.
Some have said it's a generational change.
When I see stuff like Toxicity Guy wroteon LinkedIn, I really try to understand
(19:04):
what his point is, as I always try tounderstand what people's points are.
Could he be arguing that no one shouldwork to improve care right now, or try
to maximize what we get for the bucksthat we've already been shelling out?
And if so, for what reason?
Like, so that what happens?
So that resentment about poorquality care builds up to a boiling
(19:26):
point such that everybody shuns thestatus quo and moves to a new care
model and financial models faster?
Is that the aim of Toxicity Guy?
To force a let them eat cakemoment for the purposes of
triggering a faster revolution?
I've probably thought about thisguy's motives and his potential
impact harder than he has.
In my manifesto, in my worldview, Idon't let grandmas suffer right now
(19:49):
so that someone else has a betternarrative, even if I am in full support
of what that person is trying to doand the mission that they are on,
which by the way, is a longer term one.
And this gets me to thethird part of my manifesto.
The assumption is that transformingthe healthcare industry will take
a village and I am not alone.
When I state this outright, it's goingto seem self evident, but sometimes it's
(20:12):
hard to not push blame here, like ToxicityGuy, so I say this sort of in his defense.
Here's the point of contemplation.
There's maybe four big parts of thehealthcare industry at a minimum.
We have those trying to fix SDOH, SocialDeterminants or Drivers of Health.
We have those trying tofix medical morbidity, i.e.
(20:35):
our patients on evidence based pathwaysand taking meds appropriately, limiting
polypharmacy side effects, cascades.
Like, once a patient is in thehealthcare system, what happens then?
Then we have those working hard toimprove behavioral slash mental health.
And lastly, everything going onwith what I'm going to call FDOH,
Financial Determinants of Health.
(20:56):
Patients making decisions orhaving decisions made for them
due to financial implicationsfor them or for somebody else.
Lots of stuff rolls up under thesecategories, but even just listing out
these four things, we got a hell of alot of work to do to improve the lot
of patients and taxpayers and make iteasier to do business in this country.
I always try to keep in mindthat it will take a village.
(21:21):
Just because someone is working on gettingpatients housing or eating better does not
imply that they don't care about employersstruggling to curb claims billing
waste, fraud and abuse and vice versa.
It's just not everybody can do everything.
For me personally, I tend to focusmy attention on helping as many
patients as possible get on whatwould be for them the optimal
(21:43):
treatment plan or best care pathway.
That does not mean I'm antisomeone working on getting more
competition in the payer space.
Nor does it mean I'm against trying tocurb the price of overpriced as per ICER
pharmaceutical products or legislateto rein in hospitals doing stuff that
in my book they should not be doing.
I am all for getting all of thesethings done, I just do not have
(22:05):
the bandwidth or the depth ofexpertise to do everything myself.
I would suspect that no one does.
As my grandma used to say, andanyone who attended a slumber
party seance in 8th grade mightknow, "Many hands make light work".
You get 15 girls each holding out, but twofingers and you can lift up your friend?
No problem.
What I keep in mind,that it takes a village.
(22:26):
It helps me curtail the tendency to becomeparalyzed in my quest to help patients
because I can see a potential problemit might create somewhere else in the
industry or somewhere else down the line.
I have to trust that one ofmy fellow villagers is holting
down that end of the fort.
Here's a quote from Dr.
J.
Michael Connors that hewrote in his newsletter.
(22:47):
"When you point one finger,three are pointing back at you.
It's like everything you learned inkindergarten seems to be so applicable
to our approach in healthcare.
Sadly, the game of finger pointingand pushing blame on others is killing
real innovation in healthcare."
This is so real, which is why, inherentin my manifesto here, is my efforts to
remember we're all on the same team.
(23:09):
All the good eggs, anyway.
That it takes a village, that there willbe some things that some people are doing
that I maybe don't fully agree with.
There might be groups whodon't accomplish much.
There are certain people doing well, i.e.
doing self interested things,but at the same time creating
a better place for patients.
As long as, in general, we areall following the same North
(23:30):
Star, we'll achieve much morespending our time focused on our
own missions and not worryingabout what other people are doing.
And when I say not worrying aboutwhat other people are doing, I mean
people in the good egg village.
I do not mean I intend to stopcalling out conflicted and
negative self interested behavior.
Because this is what some people inthe village should hopefully have their
(23:51):
eyes on and get busy working against.
The village here, it's a Venn diagram.
At the point where other people'scircles intersect with my mission
or what I think would be better forpatients, these are the people I
can work with and collaborate with.
These are the people that I take theirbusiness or I try to help them if I can.
My manifesto is to determine whensomething is a positive for patients
(24:12):
and then to find others who will winas a result of that thing happening.
Then I can study why this is a winfor those others, which is always
going to be some self interested why.
And then I can think throughwhat the negatives are if their
self interest comes to fruition.
Is it still a net positive?
If yes, proceed.
Look, this making it better forpatients, this transforming healthcare,
(24:33):
it is hard dispiriting work.
It's a long slog.
I'd like to suggest weencourage each other.
Can we be the wind beneath each other'swings when we find a kindred spirit?
Can we focus on the points ofintersection and spend our energy
deepening what's going on there?
So again, here's my manifesto.
If the thing results in a net positivefor patients, then I'll do it.
(24:56):
The time frame I'm concernedabout, short term, medium term.
The assumption is that it willtake a village to transform
healthcare and I am not alone.
I feel kind of exhaustedhaving finished that.
But let me ask you this.
What is your manifesto?
If you have one or a few thoughts onthis, go to our website and click on the
orange button to leave a voice message.
My hope is to do an upcomingshow sharing what you think.
(25:18):
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.
So let's talk about going over to ourwebsite and typing your email address
in the box to get the weekly emailabout the show that has come out.
Sometimes people don't do that becausethey have subscribed on Apple Podcasts or
Spotify and or we're friends on LinkedIn.
(25:39):
What you get in that email is the wholeintroduction of the show transcribed.
There's also show notes withtimestamps just apprising you of
the options that are available.
Thanks so much for listening.
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