INTERVIEW

Creating a WellCare Ecosystem Craig Samitt, MD, MBA Blue Cross Blue Shield of Minnesota

As a payer, you have a fairly unique perspective on the pandemic. What are some of the most surprising things you have seen that you can share with physicians?

In our professional lifetime, we have not seen, or been taught, how to deal with one crisis − let alone many simultaneous ones. A pleasant surprise for me, both as a physician and payer, has been how much the local care delivery and business communities have rallied and worked in lockstep to care for the sick and needy, to keep employees safe, and to work hard to preserve jobs and protect livelihoods.

The explosion of telehealth has been a major byproduct of the pandemic. What can you share about your plans around ongoing reimbursement for these services as well as experiences with your own Doctor on Demand program?

I’ve long hoped that virtual care would become more of a mainstream option for care delivery, but would not have wanted that transformation to be fueled by a pandemic. In 2019, we paid about 65,000 telehealth claims, and through the first three quarters of 2020, we saw more than 2 million telehealth claims. Patient response to no-cost access for services offered by Doctor On Demand was tremendous. We will continue offering expanded virtual care benefits for members and pay parity with in-person visits for providers into 2021. Before extending the program further out into the future, we first want to assure that telehealth delivers all that patients hope and expect − more convenient, high quality, and over lower cost healthcare. Through telehealth and other improvements that are needed in our industry, we have an opportunity to pivot to value in response to this pandemic. We should not squander that chance.

Some of the current thinking at BC/BS MN involves the idea of the health care ecosystem. Please tell us about this.

While we currently reference our industry as a Healthcare System, I’d prefer that we aspire

Our industry cannot be “...” the barrier to progress. “...”

to be something better. Let me call it a Wellcare Ecosystem. What if our industry truly lived the expression “an ounce of prevention is worth a pound of cure?” What if we rewarded prevention, avoidance, social health, mental health, wellness, eliminating systemic racism − everything we can argue is in the “ounce?”

Similar to a rainforest, health care has a complex ecosystem with interdependent stakeholders that don’t all need to work in lockstep at the same time. Healthcare stakeholders need to be aligned around the same goals and incentives, with everything focused on delivering better care at a lower cost for patients and better health for our community. I believe our current system is unsustainable if left on its current course. The fewer that can afford health care, the fewer in our community that benefit. The more that industry stakeholders work in opposition, the more patients are caught in the middle. My hope is that a transition to an ecosystem centered on wellness will put our industry back on track.

Many people say the employer-sponsored health insurance model is unsustainable. What evolution do you see in this field?

I’m a strong advocate for universal coverage, and believe that all Minnesotans should have access to high quality, affordable healthcare. To achieve this goal, and to preserve consumer choice, I’m hoping that we can adopt a “no wrong door” approach that offers high-value care options for all that want and need it. 180 million Americans are insured by employersponsored coverage today. While that amount may erode over time, many employers enjoy this model and view it as a key tool in attracting and retaining top talent. That said, the primary reason employer-sponsored health insurance is unsustainable is the rising cost of care. As such, I envision that we will see employers become more aggressive in working with plans and providers to use price transparency, innovation, technology, virtual care, selective networks, and other means to improve quality and drive down costs.

Another problem involves hospital costs. How will the role of the hospital change, both in the metro and outstate?

From the start of the pandemic, we have witnessed the critical role that hospitals play in providing emergent and intensive care. Postpandemic, I predict we will see the role of hospitals in our ecosystem continue to change. As the population ages, there will be increasing demand for complex and emergent care and appropriate elective inpatient care. In the future, hospitals will likely address this growing demand not through additional bed capacity, but by safely and effectively shifting lower acuity, non-emergent, non-intensive care delivery to other venues, such as ASCs, doctor offices, patient homes and telehealth. As we have seen at Blue Cross via our growing partnerships with North, Allina, Mayo, Minnesota Oncology, Minnesota Healthcare Network and others, I envision that high-performing hospitals will

increasingly become population health companies − with an intensified focus on ambulatory, social and behavioral health as a complement to inpatient care.

What work is BC/BS MN undertaking to address cultural diversity and systemic racism?

One of the challenges in our industry is we’ve been asked to − or forced to − stay in our lanes. As I mentioned previously, I believe systemic racism and cultural bias is part of the “ounce of prevention.” If we are to play a role in transforming healthcare, organizations like Blue Cross and Blue Shield of Minnesota need to be more than just a claims company, a sickness management company, and a payment company. Given that our strategic plan is all about reinventing our industry by reinventing ourselves, we are undertaking a bold and comprehensive portfolio of racial and health equity and diversity equity and inclusion efforts. In doing so, we are getting into the equity business, social determinants of health business, and racial justice business. While I don’t have the space here to add all that we’re doing, I’d be happy to fully share all that we’re doing for those that are interested. Needless to say, we aren’t being shy, remaining silent, or avoiding risks in this space. We are taking bold action to advance true racial and health equity for our team, for those that we serve, and for our community at large.

You have said that the biggest problem facing health care is the resistance to change. What can you tell us about this?

My hope is that all that we’ve been through in 2020 will lead to a fundamental reinvention of our industry. How is it possible that we can cost so much as an industry and yet preserve the gaps we’ve seen through this crisis? I’m referring to coverage gaps, care delivery gaps, equity gaps and others. If we come out of this crisis and see premiums rise, ongoing inequities, worsening coverage, or a return to a fee-for-service payment chassis, that would only compound the tragedy. Our industry cannot be the barrier to progress. We must be the drivers of reinvention of our own industry.

Another concept you have put forth is the idea of becoming the “un-health plan”. What does this mean?

At a recent meeting, I heard someone appropriately point out that “if the healthcare industry doesn’t propose change, change will likely be imposed.” I’ve long advocated for reinvention of our industry from the inside-out rather than awaiting disruptive innovators or regulations driving change from the outside-in. For me, reinvention isn’t incremental change. It requires transformation. So becoming an un-health plan isn’t about becoming modestly better. It’s about leading a paradigm shift that drives material improvement in patient satisfaction, access, quality and affordability.

Are there any final thoughts you would like to share with physicians as we move into 2021?

In addition to my heartfelt thanks and gratitude, I wish our physician colleagues much health, safety, rest and healing heading into the New Year.

Craig Samitt, MD, MBA is the President and CEO of Blue Cross Blue Shield of Minnesota. Since 2018 he has been responsible for overseeing the strategy and operations of the state’s first and largest health plan.

Your trusted imaging partner

Your patients look to you for answers. You look to us.

Get the best quality images and expert interpretations from top local radiologists you know and trust in the safety and convenience of outpatient centers.

i

MORE

INFO

myCDI.com

SERVICES

MRI (3T, 1.5T, High-field open MRI, and Open Upright MRI) CT Diagnostic & therapeutic injections 3D mammography Nuclear medicine PET/CT Ultrasound X-ray CDI Pain Care CDI Vascular Care Regenerative medicine

3Corporate Culture in Health Care from cover Culture in organizations of professionals is inextricably linked with the and perplex health system boards. Why? In part it’s performance of the organization at all levels. the health system’s governing board. The physician services organization is, by definition, an extension of a community health system’s mission and Defining Corporate Culture strategy, and is the legal responsibility of the governing board. Before going deeper into the rationale for health system governing boards’

The physician services organization provides a level of their physician organization in their health system, of mission and business complexity that can challenge let’s start with a definition of culture. responsibility to understand and care for the culture because the physician organization often has no “Culture is the foundation of intrinsic beliefs defined and articulated purpose in the organization. In fact for some organizations growth and development Physicians are the economic, financial and clinical care that bind and inspire the behaviors of people in organizations to pursue a mission with unity of the physician organization has been kept sub- flywheel of the organization. and purpose.” The culture of an organization is rosa. It’s there, but it may lack formal organization, a made manifest in its performance; its clinical care distinct brand identity, there is no formal leadership performance, the quality of the patient experience, structure with physicians in leadership positions, and its approach to mission responsibilities, how it treats the physicians of the organization have no defined its employees and how it ranks in comparison with institutional standing. By extension, the physician other, similar, community health services providers. organization has no defined mission, strategy, business How does this definition apply to physician organizations in health plan or intentionally defined and led culture. systems, and why does it matter to governing boards? The effective practice of

It is this last point that should give health system governing boards medicine, as a component of health care delivery, is a “team sport”. The very pause and reason to ask the question of health system senior leadership practical rationale for why it should matter to governing boards is physicians “what is the state and status of the culture of our employed physician are the economic, financial and clinical care flywheel of the organization. organization and what role does it play in our mission, strategy and Their decisions, behaviors, and attitudes influence performance at multiple overall success?” But why? There are very practical and sound mission levels. They move freely through and across the organization daily. They and business reasons for the question. The short answer is, “it matters”. interact with, direct, and influence the behaviors and attitudes of multiples of staff who provide and support patient care, and they are seen as formal and informal leaders of the organization. For many patients they are the face of the brand of the organization, and they exert considerable influence

CELEBRATING 30 YEARS OF PROVIDING on the patient experience. Simply stated, the culture of the organization is

CREATIVE PLANNING & DESIGN affected and reflected by physicians employed by the health system.

SOLUTIONS FOR EFFICIENT, PATIENT- A practical example may help illustrate the point and importance.

CENTERED HEALTHCARE ENVIRONMENTS During a speech to a group of physicians employed by a health system, a heart surgeon, who was into his first year of employment, raised his hand to provide his perspective on the importance of culture. He shared; “When I came to join the physician group of the health system, I had visions of becoming a member of a unified, high-performing team. What I discovered is I joined a loose confederation of physicians practicing independently together. We are not a cohesive group with a shared vision and mission. As such, I decided that if I stayed I had to become comfortable with being a cog in a big machine; show up, do my work and go home.”

Hennepin Cty: 1800 Chicago Avenue Triage Center | Minneapolis, MN

CONTACT: Mark L. Hansen, AIA, NCARB, LEED AP mhansen@mohagenhansen.com | 952.426.7400

mohagenhansen.com

It is important for members of governing boards to understand that physician organizations in health systems are not composed solely of physicians. Depending upon the size and clinical specialty composition of the organization, the number of non-physician employees, in the physician services organization will be multiples of the that of the employed physicians. The perspective for boards to internalize here is the physician organization will touch and influence the performance of hundreds, and perhaps thousands, of people in the organization. The culture of the physician services organization will have profound implications for the culture of the whole, and that culture will affect the performance of the organization.

The Psychology of Physician Service Organizations

Physicians make their way to the employ of health systems by multiple paths. Some come with the acquisition of a local medical practice. Local physicians

may join as individuals, leaving a private practice for the employ of the health system. Physicians with years of experience are recruited to the health system from other external environments, domestic and foreign. Physicians fresh out of training programs, residencies and fellowships, will be recruited to the health system. Each shows up with varied histories, impressions, expectations and hopes related to the culture of the organization they’re joining.

Those who are local, and join as a group by a practice acquisition, will bring their own expectations of culture, said and unsaid, ranging from “we have our own culture, leave us alone” to “the principal reason we wanted to join is we have a dysfunctional culture and we need someone to fix it”. At times, the physicians of the practice acquired will endure varying levels of responses from their own independent practice colleagues, ranging from dismissiveness, benign neglect, or even disdain for colleagues who “sell out”. In certain instances the independent physicians will lobby members of governing boards for “equal treatment” ensuring that the employed physicians are not unduly advantaged. The point here is that given how physician organizations in health systems begin and evolve, letting the culture “take care of itself “ is a leadership mistake. The first lesson of leading culture is every organization will have a culture, by design of default. The culture of the organization is the leaders’ choice.

The need for understandings of culture goes to the level of the individual professional. Boards need to appreciate the employed physician as a highly trained, skilled and practiced professional. Physicians are, at once, members of teams, and are expected to be the at the tip of the accountability spear. An illustration of this complexity is in order here. When facing professional liability exposures, the physician organizations with the under-developed cultures will run from their colleague facing the threat, those with the wellled and developed cultures will run to their colleague to provide support, counsel and the benefit of their own experience and advice.

The individual physician requires a culture that supports the value of the team, while according the physician sufficient freedoms to exercise their professional judgement, along with reasonable sufficiencies of personal control over how they craft and development their personal practice style, within guidelines established by leadership of the group. Likewise, the system of rewards must meet a set of complex needs, wants and expectancies. Here the meaning of “rewards” goes far beyond the mundane; e.g., money and time off, to rewards derivative of affiliation with a strong culture, including the pride that comes with being a member of a respected organization with high community standards and status. In one study conducted by our team, the factor that most affected physicians’ evaluation of the state of the culture of the organization was “all physicians are held to the same quality standards”.

Governance and the Culture of the Physician Organization

Our research shows that the people of the organization believe the culture of the organization is what the leadership wants it to be; for better or worse. While “leadership” may be defined variously, and for some it is an amorphous concept, there is no doubt that the governing board of a healthcare organization is defined legally and morally as the leadership body “in charge” of the organization, and while it may delegate the attending of culture to senior management, it is not in a position to abdicate

Corporate Culture in Health Care to page 344

We’re here for adults, for kids, and best of all... for relief.

Just as your patients trust you, you can trust MNGI for the best adult and pediatric GI care possible. Our dedicated, caring team of specialists are uniquely qualified to meet the special GI needs of all your patients–big and small. With clinics throughout the metro and telehealth visits, MNGI offers the appointment access your patients deserve. MNGI–the smartest choice in GI care.

Refer your patients using our secure referral site at referrals.mngi.com or call 612-870-5400.

3Administrative Overload from cover Patients are likely to experience most of their interactions with in the nation by the average cost per procedure, largely burdened by the range from medical receptionists, schedulers, patient accounts staff and more. administrative overload that is not mitigated by an economy of scale. While some of these models can help create more efficiencies for physicians,

Discussions about healthcare reform, most often the processes that administrative staff streamlining our systems, creating a single-party support are driven by a response to external forces payer, and many other means to simplify access to opposed to an improvement in patient care. These care are constant. All the while the administrative outside forces include such things as changes in overload of our health systems continues to increase. Most health care administrators are driven by compassion and desire to help people, Nearly 95% of job growth in healthcare is in administrative jobs. regulations, increased compliance expectations, revenue cycle requirements, technology and more. Analyzing Non-Clinical Support but quickly find themselves lost in the minutiae The Medical Group Management Association of rote tasks that seem worlds away from patient (MGMA) was founded in 1947 to help identify care. This overload primarily comes in the form and promote best-practices in clinic management. of indirect processes and paperwork, usually The MGMA currently has more than 55,000 required by regulatory agencies and insurance members and their advocacy and resources have companies, not driven by administrator’s desire to control a hospital, been core to the functioning of many medical practices. Only a generation clinic or health system. The added layers of administrative duties continue ago the concept of a clinic administrator was seen as a threat to the fidelity to drive job growth, but not necessarily wages. A writer for the Harvard of patient care but today nearly 95% of job growth in healthcare is in Business Review estimated that over half of costs of healthcare are wages administrative jobs. for workers, while productivity has historically been worsening. While administrative staff who are supporting the care delivery processes. This will most people envision hospitals being run by doctors and nurses, and Despite administrative efforts to create efficiencies, health care delivery maybe a few administrators behind the scenes, the opposite may be true. is fragmented and there are increasing numbers of layers of work. The result More than 60% of labor is non-clinical, and those jobs are fragmented is a system that is not well-engineered for our patients in terms of caring across organizations, payer systems and delivery models. for their whole self, throughout their needed cycle of care and conditions. The main issues shown in epidemiological data that contribute to the rising costs of U.S. healthcare stem from our aging population, obesity, and the management of chronic diseases. Americans visit their doctors less often and are not as diligent about preventative measures such as lifestyle habits and regular screenings.

The reality is that in order to support one physician, there is an everincreasing requirement of additional indirect duties that need to be performed by administrators. In some cases, these requirements even limit how much the physician can do (such as scheduling appointments, ordering labs and more). There are also increasing needs to support back-end operations such as supply-chain management and facilities maintenance. To help curb some of these costs, most clinic and hospital systems are members of group purchasing organizations (GPOs) designed to get greater discounts when ordering in bulk, through exclusive agreements. Discounts can be offered up front and savings can also be realized through confusing “shareback” programs. Oftentimes these GPOs are owned and managed by larger health systems as a separate business. While they are designed to save costs and create efficiencies, participation requires fees, sometimes exclusivity, and even then they require close administrative monitoring. It is not uncommon for members of the same GPO to receive different pricing and perks due to the constantly shifting and archaic way they are designed.

Administrative burden can largely be attributed to the following areas:

Technology

Our health systems utilize expensive technologies such as MRIs and specialized procedures more often than our peers in other countries. In addition to medical device technology, our systems are incredibly reliant on expensive electronic health information and practice management systems. Expenses to implement an electronic health record (EHR) systems can easily

reach into the millions for a single hospital, and even into the billions for the use and dissemination of health care information. In practice, compliance large multi-hospital systems. The indirect costs and administrative burden with HIPAA requires incredible costs in technology and staffing. beyond implementation is staggering. This includes training, security, maintenance, upgrades and more. By 2014 the federal investment into the Accreditation and Compliance Health Information Technology for Economic Almost all major health systems work with an accrediting organization and Clinical Health (HITECH) Act had like The Joint Commission, National Committee already reached $25 billion. The EHR industry for Quality Assurance, or DNV GL Healthcare. now generates over $16 billion a year and offers These organizations have CMS deeming authority providers a baffling range of over 700 products. which means earning their seal of approval also The vision of easy and secure data-sharing Compliance with HIPAA subsumes the CMS Conditions of Participation, between systems and interoperability remains requires incredible costs in and most other insurance companies. Surveys elusive for most providers. EHRs are also the most technology and staffing. can be exhaustive and have direct costs associated prominent contributor to provider burnout. Many with participating in their programs, paying for practice management systems aim to assist in staff travel, and even for ongoing consultation. meeting compliance standards, but the inevitable The indirect costs far exceed the survey itself with need for ongoing integration and development is hospital teams that support and implement the surprisingly complicated and in many cases even accreditation standards, educate staff, perform cost-prohibitive. This means practices often compromise on true efficiency mock audits and more. While in general receiving formal accreditation and quality process, for the sake of affordability. Therefore, the impact of fundamentally aligns a health system with top standards, many areas of changes in standards elsewhere in healthcare can create a dependence on compliance seem overly bureaucratic or redundant, and in some cases even technology, and subsequent costs of development. unnecessary. A major complaint from many systems is the authority given Billing and Insurance Related (BIR) between surveys. A health systems preparedness will likely still require This includes things like prior authorizations, claims submission and visits and audits from other insurance companies and local officials, such payment processing. While the Affordable Care Act (ACA) has helped extend insurance to millions more Americans, many are now experiencing Administrative Overload to page 324 the pains of being underinsured. Even for those who have insurance, there are high-deductible plans, copays, co-insurance, confusing networks – all of which have increased the financial burden and stress for patients. This has had the same impact on health systems who are responsible for checking benefits, gaining tedious authorizations, submitting, processing and reprocessing claims. It is estimated that nearly 1 in 5 claims need to be reprocessed. According to a 2019 McKinsey & Company report, the U.S. could reduce administrative spending by 30 percent by automating and streamlining BIR processes.

The revenue cycle process in healthcare has become increasingly more complicated and prone to errors that can leave guarantors with unnecessary financial responsibilities, and leave providers going unpaid entirely. Health systems must employ and train specialists to deal with all of these disparities within the revenue cycle including managing complex software with rulesengines that vary by payer, ensuring ongoing authorizations for hospital services, and keeping up to date on frequent regulatory changes.

One of the most popularized examples of overload in this area are the compliance requirements of the Health Insurance Portability and Accountability Act (HIPAA). For the most part, people misunderstand the fundamental purpose of HIPAA – which is to help make the exchange of private health information easy and safe to help in the delivery of highquality care, while mitigating fraud and abuse. In reality, an immense amount of time and energy of both providers and administrators goes into managing consents, disclosures, releases, and security. Most people have HIPAA backwards as this formidable law results in significant administrative burden and the threat of penalties. Ironically, Title II of HIPAA contains the Administrative Simplification provisions which are largely aimed at increasing the efficiency of the health care system by creating standards for to the individual surveyors to interpret standards, which may feel different

Physician Coaching That Works!

Just as top professional golfers improve by hiring a swing coach, physicians can improve by hiring a professional coach.

- Physician in Crisis? - Provider Suffering from Burnout? - Practice Partnership Challenges? - Develop Physician Leaders - Need to Improve Metrics?

24 years of experience have proven our evidence-based coaching consistently produces positive outcomes. Coaching Works! Even in the most challenging situations.

Call for a FREE consult.

Timothy R. McClernon, Ph.D. CEO, Managing Partner 612.321.8066 (cell)

Learn more: PeopleArchitects.com

Physician Coaching Leadership Coaching Clinical Team Building