Breier: I think those of us who look at high costs, we know that a lot of the spend is coming later in life with late-stage care. There is however, a lack of transparency and coordination. And in our view, the way to take waste out of the system is to form partnerships.
How do you deal with issues of control?
Dean: The first thing we do is assess if our missions are aligned. That's half of the equation to success. We've also learned that just because we may be the larger of the two entities, we don't have to control the partnership, there is a lot of talent and companies that have expertise that we can use for the betterment of our communities.
Breier: I'll give you a perfect example with Lloyd sitting here next to me. We have a joint venture in Phoenix. We are happy to have Dignity's name all over this beautiful rehabilitation hospital, and Lloyd and his team are happy to allow our expertise in managing the facility. Those are the kinds of partnerships that work, because everybody can't be everywhere all at once.
Mostashari: We are in a joint venture for Medicare Advantage, and the question was: If they have a service that goes to people's homes and does an assessment—who is in control of calling that service for a patient? Is it the plan or the primary-care doc? We've had contracts where the payer was like, "No, this is just what we do. You'll be lucky if we tell you we went there." But in this case they said, "You're in charge of the clinical interactions with the patient, so you should call," and that worked because from the beginning we were crystal clear on who's accountable for what.
Dean: We find that culture issues are very difficult to overcome. When I first came to what was then called Catholic Healthcare West, one of our attitudes was that if we didn't build it—we didn't own it—we didn't control it—it just couldn't be good. So, part of our leadership journey was to check our egos at the door. When it comes to value, we need the expertise, the innovation, the creativity of others.
How do you split the dollar?
Mostashari: One way is try to get to some understanding of who brought what value to the table. The other is who's got more power in the relationship? And all too often, particularly when you're dealing with lack of competition, it becomes the latter. So, the cure for, "I'm bigger, therefore you take my terms," is, "Well, I'll go work with someone else." There was one payer who we spent 18 months negotiating with and they said, "Well, take it or leave it," and we said, "OK, bye," and they were shocked. But we knew we had other options.
Breier: How many years ago did we start talking about value-based care and population health and taking bundles and taking risk? We've made a lot of progress, but we still have a lot of work ahead of us. We still live in a predominantly fee-for-service environment. And I would argue that the big, large-scale national payers are not yet willing to give up the ghost, if you will. They like the control.
Dean: We can prevent some of the control issues with due diligence upfront. We've found that by setting up transparency and honesty in the beginning that it allows for more room to operate. In some cases we determined that no matter what we said at the beginning, we were just not aligned and we walked away. And sometimes we've decided that when we look at what we're trying to achieve for the community, what our ultimate goals are, that we might take a 49% stake. But that has to be when a lot of other things are in place to ensure that our value proposition for the community is stronger under that scenario. But to be clear, we don't make a practice of taking the lesser position.
How are you creating partnerships that pass the regulatory sniff test?
Mostashari: I used to be a regulator. And what I like to say is, if the final rule comes out and everyone says, "It's exactly what we thought it was going to be," then we won. You have to listen to the stakeholders in a very public way, not requiring people to have very expensive lobbyists. Now, I'm looking at the regulators and I'm thinking, "What do they want? What are they worried about?" So it's incumbent on you to offer regulators ways they can achieve their goals, because they know what they want but they don't have perfect knowledge, particularly knowledge from the field.
Dean: Regulations can lead to standardization of best practices. But even if there is regulation that on paper looks good, real world dynamics necessitate change and that can be, as we have all experienced, a long and tedious processes. In the meantime, patients are still coming through our doors. My growing concern is that policy and regulations are becoming more driven by interests outside of health care. I think the more we can do to address regulation policy on behalf of our patients, the stronger we will be as a nation and the more we will ultimately be able to achieve in the healthcare sector for our communities.
Is there really a return on investment on value-based care, and can the push come from the private sector?
Breier: Yes, but I don't believe, quite frankly, that you can get there through the government telling you what you have to do. I thought maybe a hybrid of showing us the path and letting the private sector try to get it right was probably more the right way. That has obviously shifted with the changes in the Center for Medicare and Medicaid Innovation, but I think, yes, and it has to.
Dean: Yes, I agree with my colleagues because right now we are servicing, collectively in this room, millions of individuals. We don't have the luxury of taking a timeout. I think that we have to continue to talk to each other, whether it's providers to payers or vice versa, we're in it now. We have to make it work.
Mostashari: I think that the way out of the uncertainty around the details is to think about the low-regret actions. It's unlikely that there's going to be a future where being able to deliver genuinely better care at genuinely lower cost isn't going to be good for your organization.
Modern Healthcare's Leadership Symposium is an invitation-only event. To request an invitation for 2018, visit: ModernHealthcare.com/2018LeadershipSymposium.
