Rae Woods (00:02):
From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. This podcast serves as your weekly download on how to untangle health care's most pressing challenges. By now, you know that we do that through literal decades of Advisory Board research and experience.

(00:25):
In this last year, the health care industry faced more challenges than perhaps ever before. But here's the thing, that's not necessarily going to change in 2023, and sometimes it can feel like we have more questions than answers. On this episode, I want to give you a peak at the future of exactly what Advisory Board is going to be focusing our attention on in the new year.

(00:51):
You're going to hear from nine different Advisory Board experts, and we're going to talk about things like what's the new phase of value-based care? What would it really take to address the behavioral health crisis in America? How do you balance the need for clinical innovation with actually making that accessible? What is a technologically enabled workforce? How could organizations actually compete on women's health and in what ways can we actually forecast the impact of an industry that is rapidly diversifying? I'll let my colleagues take it from here.

Yulan Egan (01:31):
Hi, I'm Yulan Egan.

Miriam Sznycer-Taub (01:44):
Hi, I'm Miriam Sznycer-Taub.

Yulan Egan (01:48):
We are here to talk about the future of value-based care. Now, Miriam, I want to start by saying it feels to me like we're approaching a key turning point for the value-based care movement. We've obviously been at this transition for years at this point over a decade by most measures, and progress has been steady, but also a lot slower than we would've originally thought. Medicare has really led the charge so far, but with CMS distracted by so many other things, it sort of feels like value-based care has taken a bit of a backseat. It feels to me like we're approaching this moment of are we getting serious about risk or are we getting out of the game entirely?

Miriam Sznycer-Taub (02:28):
Yeah, I think the one thing that's clear is that the next era of risk is going to be decided by players in the private sector, and that's employers, Medicare Advantage plans and the providers and suppliers that partner with them. Probably some combination of all of those stakeholders, and that's really different from the past 15 years, where we were looking to the federal government and traditional Medicare to lead the charge on value-based care.

Yulan Egan (02:50):
Yeah, I would agree with that. I think my hypothesis is that if we're going to get to meaningful risk, if the next decade is going to look different, the private sector is going to have to step up. I at least am particularly intrigued by the role that employers will play. I think commercial risk is going to be the deciding factor here and the big question in my mind is, can we do anything to address the structural challenges with employer sponsored insurance that make embracing risk so difficult? For example, what do we do about the fact that people tend to switch employers relatively often?

Miriam Sznycer-Taub (03:26):
You're right, private payers are going to have to step up. I might argue that it's MA plans that could really change the game when it comes to value-based care for the Medicare eligible population, the focus really has been on Medicare advantage to foster the innovation on how we care for seniors. We've seen some really interesting changes to care models as Medicare Advantage has grown. Everything from special needs plans that work with specific segments of the population and also care models that focus on primary care, care coordination. A lot of innovation happening in the Medicare advantage space.

Yulan Egan (04:01):
It's definitely true that we're approaching a key turning point for the Medicare program. If I'm remembering correctly, it's within the next year, maybe two, that more people will be enrolled in MA plans than in traditional Medicare. Definitely makes sense that MA is going to have a much, much larger role to play when it comes to BBC adoption in the future.

Miriam Sznycer-Taub (04:22):
That's right. If you look across all the different types of payers, MA has really led the way in value-based care. I think it's about 50% of payments right now for MA are in shared savings or some kind of population model. That population-based payment model is really interesting to watch. It's seen a huge jump over the past couple of years.

Yulan Egan (04:42):
I have to say though, because MA has typically had more of its payments funneled through those types of risk based models, I think a lot of people tend to assume that more MA equals more value-based care. But I for one tend to be a little bit skeptical of that argument.

Miriam Sznycer-Taub (04:58):
Oh, there's a lot of understandable skepticism of MA. Everything from the marketing and coding practices to the really big question, which is, does Medicare Advantage actually accomplish the goal of providing quality care to seniors at lower cost? As MA grows, I think that scrutiny and skepticism is only going to grow as well. At the end of the day, I'm really going to be watching if those Medicare Advantage plans that do embrace value-based care are ultimately the ones that are more successful.

Yulan Egan (05:31):
Well, I think it's obvious that there are a lot of interesting open questions when it comes to the future of value-based care. Going to be an interesting year for research and I think we're both excited to dive more into both MA and the employer space.

Darby Sullivan (05:52):
My name is Darby Sullivan and I am the director of Health Equity Research for Advisory Board. The biggest question that me and my team are grappling with, as we look to 2023 is how and honestly whether our industry is going to come together to address the behavioral health care crisis today. We have a theory on what that's going to look like and what it would take to address that. That would be truly integrating behavioral health into our broader health care system.

(06:20):
I know we always say crisis, we throw that word around a lot. I think it's actually warranted in this case, and the listeners of this podcast would agree. Nothing new that our behavioral health care system is broken, that outcomes are worse than ever, especially for people of color, for low income people, for people with serious mental illness. But it is different today, and that's because needs have increased across all populations.

(06:44):
Whereas before, if you were in a historically powerful group of people, so if you were wealthy, if you were a child with wealthy parents, you could kind of get around the problems and the dysfunction in behavioral health by just paying out of pocket for high quality care. But the demand is so high right now that you can't do that anymore. That's my hypothesis as to why we have this newfound urgency and unprecedented investment in addressing the problems in behavioral health.

(07:13):
The investment has been received really well with the leaders across our industry that we work with, providers and health plans and purchasers, because they're all coming to us saying, "Hey, we have a problem. We have worse outcomes overall and higher costs overall because of this behavioral health care crisis. The problem though, is that a lot of the folks we work with are heads down just kind of trying to make it to the next day. They're fixes have been largely surface level.

(07:39):
What my team has set up to discover this year, is what would it take to actually prevent this from happening in the first place. We've come to a conclusion and I don't think everyone's going to be happy about it. In fact, that's that's our insight, which is that in order to make significant progress in behavioral health, every single sector of our industry has to make some difficult compromises. Every single piece will have a tough pill to swallow, and the leaders we work with might say, "Hey, what you're asking me to do is too difficult for my business to accommodate."

(08:11):
That's a principle decision that that's one that anyone could make if that were true. But our push is that if that's true for you, if you're not willing to make these compromises, we have to accept that the fundamental forces driving our behavioral health care crisis will continue. Ultimately, the conclusion we've come to in our research is that we have to integrate behavioral health into a broader health care system if we want to make things better, but at the same time, we have to make sure we're not replicating the very inequities and lack of affordability and dysfunction that we already have in the rest of the health care system.

Solomon Banjo (08:56):
Hi, I'm Solomon Banjo and I study topics about and for life science companies here at Advisory Board.

Gina Lohr (09:03):
I'm Gina Lohr. I collaborate with Solomon on a lot of that research, and specifically I focus on pharmacies, diagnostic services and their related benefit managers.

Solomon Banjo (09:13):
Now, across the past few years, we've been spending a ton of time understanding the coming wave of clinical innovations, and we've realized that as transformative as these products can be, including potentially curing life limiting diseases, the big question out there is how do we actually make sure these devices and drugs are actually accessible to patients?

Gina Lohr (09:35):
Looking at the price tags for some of these drugs, it's hard to even comprehend what those numbers mean for an individual, let alone multiplied out at the societal level. This is a huge problem. We've been kicking the can down the road as far as solutions are concerned, and that is not really a sustainable solution.

Solomon Banjo (09:55):
To prepare for this, we first have to understand which innovations will have the biggest impact. Yes, there's a coming wave. If you listen to the previous live recording, you heard a little bit about that, but what's going to hit first and how could that change over time? Now, if you've heard other Radio Advisory episodes with me, you know that I'm going to be pushing leaders on how these innovations are dispersed to address not exacerbate health care inequities.

Gina Lohr (10:21):
Then this is where my research comes in around how health plans employers and the government should think about providing access to these products and paying for them. They probably can't do it alone. What could partnership look like and what critical questions do stakeholders need to consider to enable access to these innovations?

Solomon Banjo (10:43):
Let's get more practical and less theoretical. Let's talk about gene and cell therapies. These are therapies that manipulate a patient's genes at the cellular level to treat inherited diseases. There's been a lot of criticism and concern about these new drugs hitting the market with multimillion dollar price tags. Just this November, a new gene therapy for hemophilia B was announced, it's called Hemgenix, and it will cost three and a half million dollars for a single use treatment. Now, while some people criticize that price, industry analysts like ICER who are normally tough on prices actually said that's pretty close to fair value. Now, these patients would otherwise be requiring up to $20 million in lifetime care.

Gina Lohr (11:31):
But the thing with Hemgenix is that there's only about 8,000 patients in the US that have hemophilia B. It's still pretty rare, but a gene therapy is in the pipeline that shows promise to sustainably lower high cholesterol. One in four people worldwide have high cholesterol. So, now what?

Solomon Banjo (11:48):
That's really the question, right? Our research aims to develop a framework for how to think about these things. What do we need to be watching out for as far as innovations are concerned, and what do we need to be thinking about and actually figuring out? No more of that, kicking the can Gina was talking about, as our society looks for ways to incorporate these game changing innovations into our systems for providing and paying for care.

Gina Lohr (12:13):
We're definitely looking to engage with people like you. If you have a perspective on these topics, consider this your invitation to spam our inboxes, if you'd like to talk.

Solomon Banjo (12:22):
Please, not mine.

Gina Lohr (12:24):
For those of you who are trying to figure out all of us along with us, I know there are a lot of unanswered questions and you can expect to hear more from us.

Monica Westhead (13:39):
Monica Westhead, managing Director research. You hear me talking a lot about nursing and the workforce, but in 2023, I'm going to be partnering with another researcher, John League, who is also a familiar voice to those of you who listen to Radio Advisory. The biggest question on our minds going into next year, is what role should technology play in supporting or potentially supplanting clinical staff?

(14:06):
Health systems are investing a ton of money in technology that is aimed at supporting the clinical workforce or even replacing the need for specific staff members. Things like telehealth services, like virtual visits and remote patient monitoring to expand the reach of the clinician, AI and clinical decision support to improve decision making and patient safety, ambient listening to reduce documentation time, predictive analytics to increase patient flow efficiency.

(14:37):
But what concerns me, is that I don't think systems are asking the right questions about what technology makes sense and what it can and can't do. I think a lot of systems are investing in the next big thing. They are buying technology and trying to fit it into a human workflow or asking humans to live in a technological framework that doesn't necessarily make sense for them, versus redesigning the workflow to accommodate the needs of both the technology and the human workers.

(15:11):
Now, there's one big caveat here. As someone who has spent a lot of time on clinical workforce issues, I've noticed that the focus on technology also tends to be very physician-centric. This leaves out the biggest cohort of staff and the role with the biggest shortage, nurses. I've got a lot of questions here. To what degree will technology be able to alleviate the staffing shortages that we're seeing? How much are we, by introducing technology, changing the pain that our clinicians are feeling versus alleviating that pain, asking clinicians to do things that are different but are still problematic for them?

(15:50):
If you think about something like EMR implementation, anyone who went through that, anyone who sells technology, anyone who works with technology has a horror story of sometimes technology makes things harder. How do we move forward with figuring out the right technology and implementing it without burning everyone out? Finally, does any of this even work? Is this the right way to spend money or should we just shelve it and invest differently in our staff?

(16:20):
There's the potential for health systems to make some very expensive mistakes here. I'm not just talking about money, but I'm also talking about staff goodwill, at a time that you really can't afford to lose it. Our goal in 2023 is to help health systems figure out the right tech investments to make and where to spend better.

Gaby Marmolejos (16:49):
Hi, I'm Gabby Marmolejos and I'm a women's health researcher at Advisory Board. Many of us in the health industry know we need to devote more resources to women's health. Over the next year, I'll be researching the most pressing challenges we need to resolve in the women's health space today. One of our nation's biggest challenges right now is navigating through the shifting landscape of abortion access across the country.

(17:17):
I expect new state abortion bans and restrictions will impact the delivery of care for anyone capable of getting pregnant in those states, and they will likely disproportionately restrict abortion access among historically marginalized communities. I'm currently thinking about the impacts of abortion bans and restrictions on health inequity and income inequality across the country. I'm also thinking about another related challenge facing our country today surrounding maternal health. I want to look into the best way for health industry stakeholders to combat the US's ongoing maternal health crisis, with a focus on improving care for black and indigenous women who face the starkest maternal health disparities.

(18:02):
I also want to identify opportunities to reverse the growing trend of OB unit closures that contribute to maternal care deserts across the country. But there are a lot of other questions worth researching in women's health. After all, women aren't just the majority of the US population. We are the ones who are driving the majority of health care decisions as well. When people think of women's health, they immediately think of obstetrics and gynecology. Women have needs beyond pregnancy and childbirth though, and US fertility is dropping.

(18:38):
Even if it wasn't the demand for primary oncology, cardiovascular, and osteoarthritis care, far outpaces obstetric volumes and all of those specialties have differential impacts for women. I'd love to research care for women and honestly any one of those specialties, but to narrow the scope, I'm turning it back to you all. I'm asking leaders across the health industry to share the challenges they're facing in the delivering the full spectrum of care for women.

(19:06):
So far, I've heard questions on how to compete for women as health care consumers of comprehensive services. Women are driving the majority of health care decisions. What factors drive women's loyalty to providers? Is it still true that positive birthing experiences drives loyalty to health systems? Did this change after covid? Women are more likely than men to use telehealth, so how might this disrupt or enhance loyalty to traditional health care systems? Speaking of telehealth, there has been a rise in fem tech startups over the last few years, and this raises the question of where are opportunities for disruption in women's health care delivery? I'm looking forward to diving into these topics and providing solutions to the most pressing women's health challenges facing the industry today.

Vidal Seegobin (19:57):
Vidal Seegobin, and I lead our research on hospitals and health systems.

Paul Trigonoplos (20:09):
My name is Paul Trigonoplos and I'm the director of International Health Care.

Vidal Seegobin (20:13):
If you've been following any of the headlines across 2022, you know that most large health systems have not been staying in their lane.

Paul Trigonoplos (20:23):
There's of course some high profile stories that we can point to, Amazon buying One Medical, CVS and Signify, UHG and Change Health Care, Village MD adding Summit Health to its portfolio. All these are multi-billion dollar deals, and all of them are expanding reach and capabilities.

Vidal Seegobin (20:40):
The thing I'd underscore about that, is it's not just the giants that are playing here. In our conversations with members, we're hearing regional health systems, health plans, tech vendors, physician groups, and even life sciences firms, all trying to diversify the business lines and areas that they compete and operate in.

Paul Trigonoplos (20:59):
Today's environment often feels like a frenzy of FOMO. It's driving acquisitions by all of those companies that are afraid of missing out. Everyone wants to be a part of the deal activity. Some players out there are probably moving too fast, others are probably being too cautious. But regardless of how aggressive you're being, we think it's time to zoom out from one story or headline at a time.

Vidal Seegobin (21:22):
It's been really important to keep in mind, because these things are not happening in a vacuum. You have to think about what it means for an entire industry where players are trying to diversify and change what they do going forward. The consequence that we're going to be tracking is how that exerts real force on a market. These are things that are going to happen far beyond the headlines that come to your inbox. There's a couple things that we're going to be tracking across 2023 for listers of the podcast.

Paul Trigonoplos (21:52):
First, what capabilities are actually important in the health care business of the future? Organizations right now are all making bets on what functions they think they're going to need that are essential to perform and control. The capabilities that different stakeholders are assembling are really interesting and thinking into our 2023 research, the big one we're already seeing is a focus on all players in the industry looking to gain some control over primary care.

(22:19):
For some, the goal is to do as much upstream preventive treatment as possible. For others, it's about being in charge and steering patients to acute care services. For some, they want to do both, but primary care is only one of these capabilities. Indexing the market this way is going to be a critical research stream for us next year.

Vidal Seegobin (22:40):
The second question is, what does it really mean to meaningfully diversify? I think there's a lot of players that are going to think to themselves acquiring a lot of assets are going to be what diversification means for them, but I'm really curious on how people are going to make the pieces work together and for lack of a better term, integrate. Additionally, I think it's fair to say that for some players, diversification is not the right angle for them. They should instead be thinking about how to specialize and focus and become differentiated, so that they can't be knocked out of their lane or substituted by something else.

Paul Trigonoplos (23:18):
Next, how much competitive freedom will actually remain? As more organizations start to build out more functions and get bigger and more expansive, they're often finding themselves in a sort of frenemy relationship with a number of other stakeholders. We see this, especially with the vertically integrated systems, where one part of the business actively serves a fierce competitor of another part of their business.

(23:41):
There's three questions here for us next year. One, how long is this sustainable internally at the organizations that are getting this big? Two, for niche players, is there going to be an entangling of alliances or different drawing of battle lines, or will they be able to work this all out with each other? Of course, there's a regulatory question about how the FTC is going to look at these deals and respond, which we're eagerly watching and see how it plays out.

Vidal Seegobin (24:09):
Finally, I think there's a question worth asking, even if it sounds very sophisticated, is this really just a war over market share and dominance over the key business lines that are going to control the future of health care delivery? Now, seemingly the stable status quo for how money flows across the health system disguises very contradictory business models from suppliers to providers to plans. As diversification plays out and some organizations prioritize an overarching business goal, we'll be looking to see how these plans or these strategies come to a head.

Paul Trigonoplos (24:47):
These diversified giants are going to continue to try and actively dismantle those who are getting in their way. One of the big targets that I think is going to come to a head in 2023 is hospitals, largely because of the challenge of how costly they are to operate. For health systems, they're going to have to be careful about making principled diversification choices that aren't just aimed at subsidizing their hospital business even more, but actually make choices instead that can advance a more sustainable business model in the future.

Vidal Seegobin (25:18):
Last takeaway I would just include here, is that while there might be an inclination to feel FOMO by missing out on acquiring assets, the real FOMO that we want to keep in mind is whether or not people are missing the boat on experimenting on their current business lines to ensure that they are actually non substitutable and are going to maintain success and progress in health care going forward.

Rae Woods (25:48):
I want to thank everyone for sharing their insights on Radio Advisory, and I'm not just talking about the people who shared their insights on this episode. A ton of people participated in this podcast, came on episodes, shared their insights, gave their hypotheses, asked important questions, and we have a whole library of episodes that you can access as you move into your holidays. If you like Radio Advisory, please share this podcast with your networks, subscribe wherever you get your podcasts and leave a rating and a review.

(26:22):
Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Katie Anderson and Kristin Myers. This episode was edited by Dan Tayag with technical support by Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston, Alice Lee, and Nicole Addy. I really wasn't kidding when I said so many people came on and supported Radio Advisory this year. To give them a little bit of a thank you and a little bit of a tease, we actually made a video to share our thanks and showcase all of the support that we've had this year. You can find that on social media and in the link in our show notes. As always, remember, we're here to help.