On today’s episode, Jason shares an article about how Mark Cuban is expanding his low-cost pharmacy project. And Aron shares about how charging for digital messages may be on shaky ground.

Jason sits down with our guest Steve Adams. A Certified Professional Coder Instructor with InGauge Healthcare Solutions with more than 20 years-experience with training others how to code in all arenas of care. Steve dissects the coding changes for 2023 in the Final Rule, including E&M, new G-codes, and screening reimbursements.

Aaron’s news: https://www.beckerspayer.com/policy-updates/mychart-message-fees-live-on-unstable-ground.html

Jason’s news: https://www.beckershospitalreview.com/pharmacy/mark-cuban-cost-plus-partners-with-2nd-pbm-hints-at-insulin-market-entry.html

Credits

Production Assistance & Editing: Nyla Wiebe

Scripting by: Aaron C Higgins

Show Notes & Transcription: Aaron C Higgins

Social Media Management: Jeremy Miller & Nyla Wiebe

News Co-Hosts: Aaron C Higgins & Jason Crosby

Interview hosts: Jason Crosby

Executive Producers: Mike Scribner & John Crew

Transcript

Jason Crosby
All right, today our guest is Steve Adams, senior consultant with inHealth professional services.
OK, he is a certified professional coder with over 20 years experience of various settings including many, many guest speaking engagement. Steve, thanks for joining us today and welcome to the podcast.
Steve Adams
This it’s my pleasure. This is my first one, so I’m excited.
Jason Crosby
Alright, well, good deal. We’ll tell you what, what the timing of the the podcast we got about a month left just for the listeners month left in the 2022. So obviously the last couple of months.
Lots of changes, final ruling AMA and their coding changes. Let’s let’s dive right in. Can you give us a quick overview of the E&M changes you’re expecting or what you’re seeing for 2023 for the audience?
Steve Adams
Yeah, it’s really it’s really pretty easy. The biggest change that you’re gonna notice in your CPT books this year is there were about 393 changes in the CPT book, but nearly half of those were just revisions and deletions in the evaluation and management section. And you know, when I look at this, I’ve seen a new one, looks like they have about one new code, 49 have been revised and 25 were deleted. And we’re also busy that a lot of times people are missing out.
On all these revisions, and then Medicare just published their Federal Register about three weeks ago, when they came out with a lot of new G codes, they changing the time requirements for depression screens and for alcohol use screening. So there’s a lot of things going on regardless of what specialty you’re in. It would be, it’s worth taking a look at some of these changes that we’re going to go over today.
Jason Crosby
Fantastic. Let’s jump right on then. There which which are some of the key ones that you’re seeing as far as on the deletion side in any revisions that you had mentioned?
Steve Adams
Yeah. I think the biggest thing to kind of realize is that in 2021 CMS and AMA changed the way that we documented our evaluation and management services in the outpatient setting and they did that just to kind of see how it was going to work and it worked so well that now they’ve incorporated those changes into facility based coding. So now what you’re going to see is the opportunity to build total daytime on almost every visit still except the emergency room visits. But we are seeing all that time change we’re seeing now that you just have to have a medically appropriate history and a medically approx.
For an exam for all code. So if you’re used to doing auditing, you no longer will have to download a doctor for an initial hospital visit. If they don’t have 10 review of systems or an 8 organ system exam, I think probably the biggest thing that’s gonna be a change for a lot of people is CMS has done away with the observation codes. So we’ve seen the observation codes, deleted the initial ones, the subsequent the annual nursing facility code has been deleted.
They’ve changed all the domiciliary and rest home as well as home visit code, so they’ve deleted all those and again revised just about everything else. So even if you’re in the emergency room, you know they’ve revised those codes. They’ve revised the consultation codes, nursing home, home health. They’ve made some nice changes to the transitional care management codes that if you’re doing that, I’ll make it a little bit easier to explain to your physicians what’s happening. But those are some of the things that I want to kind of look at today is how they’ve incorporated those.
Observation codes. Now that you might be familiar with 992189921999220 and they’ve just incorporated those into the old initial hospital codes like 99221 used to read initial.
You know, initial hospital visit and now it just says initial hospital or observation service, so you no longer have the discharge code for observation and there’s a couple other little things that are important in there, especially if you do hospital coding.
Jason Crosby
Yeah, it it definitely looks like different settings have some variables that have been tossed in the some of the codes might have gone away, descriptions altered, that sort of thing. So what should folks be looking for that are there on the front lines every day in the coding world?
Steve Adams
I think the biggest thing that you can do is if you do in hospital coding, remember that.
The history and exam is all going to be medically necessary when it’s stressed to your providers about that. You also kind of want to be cognizant of the fact that CMS has dropped the conversion factor this year and some of the codes that we used to do really well on like your initial hospital code used to pay about $200.00. Now it’s down to about 170. The only code that’s really increased are some of your subsequent hospital visit codes and that’s because they’ve really stuck it to us on.
The time components. So if you do hospital coding a lot of times, doctors would do 99233 based on what we call unit 4 floor time. So if you spent greater than 50% of your time on the floor and that time was 35 minutes, you were able to build like a 99233. Now in the hospital nursing home everywhere else they’ve transitioned to total daytime. So it’s gonna be really important for you to update your physicians that the New Times are substantially more.
Then they used to be. So for example a 99233 that used to be 35 minutes greater than 50% was unit. Floor time is now up to 50 minutes unit floor time, so that changes the dynamics a lot on your Level 3 visits and one of the reasons that they went up on those codes, 232 used to be 25. Now it’s 35 minutes. So what you used to be able to Bill is A33 is now A32 and they’ve also taken out of the CPT book and this is important. The disclaimers that used to be under those codes. So it used to be AT233, which everybody wanted to bill, used to have to be 35 minutes greater than 50% unit floor time, or the patient had to have a such a significant problem. They weren’t responding at all to treatment, major complications. So I think that we’re going to see some reductions in the number of 9923 threes. And I mean, I think that when I’m teaching physicians this week and next week on all these changes, that’s the thing. I’m really driving home because at the end of the day, you actually have to document less.
Then you did in the past. The only thing that’s really shifted is the amount of time, and it’s no more greater than 50%. It’s total daytime and in your CPT book they have a section on that and they kind of go over with you. The nine things that count as total daytime. So I would definitely take a look at that, just open up the front of that CPT book and you’ll see all of these changes in the front where you’re and requirements are.
Jason Crosby
So some of the feedback I’ve been reading up on these changes, would you agree that the the process itself is more simple and flexible? What do you think there’s gonna be some natural give and take us folks learn what these changes are?
Steve Adams
I think the changes are the documentation. Requirements are so much easier. I I think that the thing about it is and honestly I’m.
I I work with several hospitalist groups and I think the one thing that’s gonna kill a lot of doctors is this time this additional time required for the 99233. I mean, if you think about a typical hospitalist working a 12 hour shift and they used to be able to build 9923 threes, you know three or four every couple hours and now they’re not able to do that. So I think once you start delving into it is really funny. Before we started talking, you know, I even brought up the fact that I’ve went back to school to get a third degree.
So that just because this stuff is getting a little bit more easy, I have a Plan B myself to back out of this system because this when I started in 92, this stuff was so difficult and it was so just redundant and there was no medicine being practiced. Now that they’re shifting to billing based on the complexity of the patient, that makes everything so much easier for your providers. And the thing that is really impressive is that the AMA has worked with CMS on this. And I mean, I’m really impressed with that. And I think it’s just.
And I think the future is gonna be a lot easier for doctors to support various levels of service.
Jason Crosby
Good feedback for sure. So with all that said, because every year there’s a lot to absorb with such changes.
For audience that’s listening that that is in there every day. What can they do to prepare for those changes here in the next few weeks?
Steve Adams
I think one of the things again that you do is you know you reach out to whoever you’re coding person is whether or not it’s a. If you work with the State Medical society. I know I do consulting for the Georgia Academy of Family Practice, Georgia, OBGYN Society, the American College of Physicians, and those are areas where if you’re part of those groups, you can they have webinars every year. I’m doing the OBGYN when this Friday and the Georgia Academy of Family Practice next week.
If you’re in plastic surgery, you can contact the Georgia Academy of Plastic Surgery, ophthalmology into whatever they should have some resources for you. Normally they have a consultant who works closely with them. Who does these kinds of E&M seminars that will get you ready and that way it’ll save you some money because the biggest thing that I see and I hate.
These companies who send you these emails that say, you know, did you know there were 373 coding changes and for $750, you know, we can explain it to you. And I always tell my private clients, you know, don’t do that unless it’s somewhere like in Las Vegas where you can fly out there or Miami this time of the year. But don’t get confused by the emails that you’re going to get. Contact your specialty societies, your national society. And again, they’re going to have some resources that will give you this information because.
I mean, if you look at Medicare, especially with prolong services, when we know that we had the 99417, when we went 15 minutes over for an outpatient facility code and then Medicare came up with their own code G2O12 and now we have these new prolong service codes for hospital. You know AMA came out with 99418, but now we also have Geo 3160317, go 318. There’s just so many little nuances.
In the coding world that you really, if you don’t want to pay a lot of money, reach out to your societies first. And I think that’s gonna be your best bet.
Jason Crosby
Yeah. So if if you’re a kind of keep going down that path.
If if you’re sort of new into the field or looking to to sort of take on this new skill set and maybe this is kind of OK Steve, go back to when you first got into the field.
How describe how best for that person to maybe expand on that if they’re just starting out aside from reaching out to the consultants, any other types of resources, education tracks or maybe highlight for us how you got into it as well?
Steve Adams
The hard thing about any kind of coding change is that they’re honestly just, there’s not a lot of people out there who specialize it anymore. I’d be just honest with you. It’s really hard. A lot of the hospital systems that I used to consult with have just decided, well, hey, listen, we’re going to go out and hire a guy full time to work in our facility. So what I would tell people to do because my neighbor, I helped her become certified and she’s worked for a great family practice here in Augusta.
For, you know, at least a decade and what I would tell her is just go to Google.
Umm, I mean, I have a wife and kids and dogs and cats and I love to make money, but I I’ve been in this business since 1992 because I wanna save people money and I would literally just go to Google and or YouTube and I would just type in 2023.
E&M coding changes or 2023 CPT. Coding changes and there are people who put out free information to kind of draw traffic to their website. So I would if your society doesn’t have anything and you want to learn more about coding, that’s a good place to start. Another fantastic place to start is your local aapc coding chapter. Now, if you’ve got an ink pen, I’ll tell you how to do this. I get calls at least once a week. Somebody who wants to enter this field.
Steve Adams
And when I tell him to do is coders on the on the whole are pretty introverted. We only like our own people and we get together usually every month that these local coding chapters and these local coding chapters, you get an opportunity to network with fellow nerds. And even if you’re not certified, you can do that. And the way that you do that is simple. You just, I’m going to give you a phone number. You’re going to call them or you can go on their website, you find a local coding chapter. You can join that local coding chapter and then they have guest speakers who come once a month, either virtually or in person.
And they talk about this and it’s so stupid to say this, but I mean, I’m a pretty big deal in this business and I have a a local chapter right here in Augusta, and they never ask me to speak anymore. I don’t know if it’s because they’re afraid I’m going to take their clients. I don’t know what it is, but I try to tune in every once in a while to a local chapter meeting and you’ll find good resources there. So here’s what you do. You call one 800-626-2633 and it’s easy to remember. That’s one 800-626-CODE.
Since a lot of us are on social media and etcetera, you can go also to the Internet and just go to Aapc American Academy of Professional coders.com. Apc.com has a lot of great resources and you can just call them and you can go to their website and just look for local coding chapters, call them up and just say, hey, listen, I live in the perimeter area of Atlanta. Do you have a coding chapter? They’ll tell you who the contact person is. You look them up, they’re going to have people come in and talk about.
Uh, talk about this. These coding changes and again, that’s a membership opportunity for you. And so that’s what I would say, yes. And I would say if you want to get into this field, I every time I talk to somebody, I’m like, yeah, you can come to one of my coding classes, but I can’t get you a job. You’re only going to get a job, usually through these local coding chapters. So I hope that wasn’t too long of an explanation, but use YouTube, Google, go to apc.com, join their organization. They send out newsletters, they have webinars that you can attend as well. And that’s how I would recommend it.
Jason Crosby
Fantastic. Fantastic. Very, very helpful. And it I I would add to that, it probably doesn’t matter what type of setting you’re in where you’re located there. There’s always an evolution to this part of the field that’s always going to have some sort of demand to it.
Steve Adams
And Jason, I don’t wanna interrupt you here, but I I’m going to because a lot of times people think well, I don’t want to be a certified professional coder. You know, I’ve been coding for 20 years. I don’t wanna be a CPC, the aapc of which I receive no money from. Trust me. God, I pay them probably $2500 a year just to teach their stuff and give their test. But they have credentialing for specialists. So, I mean, if you’re a GI coder, you don’t want to be a CPC, become a GI coder. You can take their certification test. Interventional radiology.
Again, you can do so many different things right now a big field is HCC and risk value based coding. You can take their online home study courses for that. There’s just so many opportunities. They’re on Facebook, they’re on Twitter. They have a campaign right now that just talks about how people have a three times better chance of passing their national exams. If you take their their online courses. So just don’t be constrained. And just think I want to be a CPC and know a little bit about everything, focus in on your specialty. That’s another opportunity for you to learn.
Jason Crosby
Great insight as we wrap up here to tell our listeners how can they get in touch with you if they need to request your services.
Steve Adams
It is so simple to reach out to me, the first thing I tell people is just my e-mail. So I have a I work for a firm called in health and that’s in Atlanta. I live in Augusta. A lot of people just send me emails because I’ve known in this industry as the King of coders. So really easy way that people reach out to me is just going to the king of coders@gmail.com and sending me an e-mail. I tried to make things simple. So the king of coders@gmail.com you can also go to my website. I’ve just updated it. A lot of that information that we’re talking about today I have.
The ICD 10 manual up there, I just have a lot of resources for 2023 and it’s easy to remember that too because I made coding consultant so my website isthecodingconsultant.com and you can go out there and take a look at some of my stuff and you can e-mail me from there. You can call me. There’s no secretary since 1992. It’s just been me, a rental car and a laptop and my number is simple, it’s 706-483-4728 and just in case my firm hears me, my company e-mail is steve.adams@inhealthps.com and that’s why I never give out that web because it’s a I don’t understand. When I worked at Mag Mutual, my e-mail was so cool. They used the first initial of your name and your last name at Mag Mutual. So I was saddams@magmutual.com. Now, if you’re, you know, I was involved in the first Gulf War, so it was really cool for me because older people remembered Saddam Hussein. So don’t send emails to saddams@magnitude.com I no longer work there. They sold us. So the kingofcoders@gmail.com is probably the best way to reach out to me or go to my website.
Jason Crosby
That’s awesome, Steve. That’s good. Alright, well, well, great information, Steve. We can certainly go on for hours, probably just diving into the details each time they’re it changes and we’ll have to certainly have you on again soon and really appreciate your time and joining us today.
Steve Adams
To my pleasure, half an hour out of my life is no problem. This is my first podcast. I can’t wait to tell everybody that I was officially on a podcast now, and I’ll be making millions of dollars and endorsement deals, and I’ll be pimping AMA stuff and ICD 10 products. I’ll have my own shirt line. It’ll be great. So thanks for giving me the opportunity to retire early. Guys. I really appreciate it.

In this episode, Jason shares a report that shows that hospital safety improved prior to the COVID-19 pandemic, but did the pandemic erase all our progress? And Aaron shares how workers in all sectors are taking more sick time, but not for the reasons you might think.

Then, we both sat down with Kristin Woodlock, CEO of Woodlock & Associates. For years, Kristin has worked with healthcare organizations as both an advocate and a champion for behavioral health. Kristin now helps organizations work through complex decision-making challenges and develop better methods of communication. We dive into the realm of leadership. In particular with regard to leading during a time of change and innovation.  We further discuss the art of feedback and how best to manage such and develop as a core skill set within your organization.

News:

Jason’s News

Aaron’s News

Kristin can be found on

Website: https://www.woodlockassociates.com/

LinkedIn: https://www.linkedin.com/in/kristin-woodlock-7272a179/

Credits

Production Assistance & Editing: Nyla Wiebe

Scripting by: Aaron C Higgins

Show Notes & Transcription: Aaron C Higgins

Social Media Management: Jeremy Miller & Nyla Wiebe

News Co-Hosts: Aaron C Higgins & Jason Crosby

Interview hosts: Jason Crosby & Aaron C Higgins

Executive Producers: Mike Scribner & John Crew

Transcript

Jason Crosby

Hey, everyone. I’m Jason Crosby. If strategic HealthCare Partners and your host along with Aaron Higgins, welcome to Beyond the Stethoscope Vital Conversations with SHP.

Jason Crosby

Today we are joined by Kristin Woodlock, CEO, Woodlock and Associates. Kristen, thank you for joining us today and welcome to the podcast.

Kristin Woodlock

Ohh thank you Jason and Aaron. It’s terrific to be with you. I’m really excited to join this effort.

Aaron Higgins

Yeah, Kristin, we’re really excited to have you here. A few months ago for the listening audience, SHP invited Kristen to come and speak to our organization. We were kind of facing a crossroads as we were determining some of our path going forward as a company. And Kristen really spoke to us and where we were at.

No, that’s terrific, right.

Aaron Higgins

Yeah. How to make some really difficult, complicated decisions in the process going into that and we got so much out of her, we had to share her with the rest of the world. So yeah, Kristin, thank you for joining us. So, let’s jump right in. Yeah, so.

Obviously, you talk to our company about change, and you know we’re in changing times, right? We we’re just coming out of the COVID pandemic, and the world is suddenly new.

Umm, so how can companies really understand the difference between the leading innovation in their space and then change ‘cuz we hear that all the time, leaders of innovation, what does that mean and how can a company understand that?

Kristin Woodlock

That’s a great questionnaire and I I think this is so important, I have to tell you, you know, I’ve been, I’ve been doing work in the field for well over 30 years in a variety of places. And I would tell you a year ago I would have said, well, there really isn’t a material difference between change and innovation. You need the same set of skills, maybe use them differently. And then I bumped into the work of Doctor Linda Hill from Harvard and she really changed my thinking on this and what she brings forth. I think this is just so important for teams right now and in any kind of organization is that.

Change when you’re doing change. You really have a clear sense of what you’re trying to do, so I think sort of for people who are in our space, the simplest example is like we’re going to have a new electronic health record or we’re going to have a new payment system, right? We know what it is. We know when it’s gonna work. We, you know, we know all of these various things. And what I’m trying to do as a leader in my organization is be clear on, you know, what it is we’re doing and create followership to that. But it’s pretty, you know, there’s a pathway for it. And I think most people will tell you if you used an electronic health record, it’s not always linear. But like, we know what it is. We know how we do that.

Innovation is just really different and I do think after the pandemic, this is where we are and so we don’t necessarily have that really clear vision and what but what we do have is a purpose. We have that that why statement. If you follow Simon Sinek, we have a you know that noble purpose. This is why we exist and this is what we’re doing and leaders who are doing innovation are really clear in that and are able to bring their teams forward to really think about a codesign process, right where it’s.

It’s rooted and shared understanding of our purpose and then a shared understanding of each of the various roles within the organization. And you’re really trying to inspire that team to do that differently. And I I think you know and I I know you both have, you know, have huge leadership roles thinking I don’t have a vision as a pretty scary thing. But I I think if we’re, if we’re honest and we reflect on where we are post pandemic, I think there’s so much opportunity for innovation, but we can’t necessarily have a blueprint that’s really specific.

And at the same level of specificity with our electronic health record. So you know, thinking about those two things differently, thinking about the code design of innovation and thinking about also being really clear on your purpose are our key strategies for leaders who are thinking about innovation.

Aaron Higgins

I would say that the most daunting thing a leader has is where to begin, and I think that’s where we were at earlier this spring when you met with us, we were looking at this mountain. We weren’t sure First off, we want we knew we wanted to get to the peak, but we didn’t even know where the trail began. So I guess tell me about what you do. How does your organization help people find that trailhead?

Kristin Woodlock

So the first thing is to really come up with that purpose. And you know what’s interesting is sometimes I’ll talk to groups and say, well, we have a mission statement and I have yet there. There may be somebody in the audience who’s had the benefit of this, but I have yet to go work with an organization where people can tell me their mission statement verbatim. You know, it’s on the website. It’s somewhere maybe they get a couple of words. I can’t tell you how many times people like, I don’t really know.

So that that to me is an artifact of the past, we really need to give our teams and our whole organization that noble purpose. Why do we exist and we shouldn’t be afraid of that. We should be able to dig deep on that and say, you know, look, maybe we don’t need to exist, right. What is it that really is special about us and just to illustrate that, I mean there are there are many wise statements that you can find by using Google and typing in why statements but two that really stick with me. One is Google’s.

Which is to organize the world’s information and make it universally accessible and useful. Like anybody at Google has a chance of repeating that right? And like that can be an organizing principle, whether you are the CEO or whether you’re the last person hired to say, like, that’s what I want you doing in your role when you’re thinking about what’s the little cute art, artistic rendition of Google that we’re gonna put on today, I want you thinking about that purpose statement, right. It just, it just creates some glue for organizations. Somebody in my space and in working in the mental health space.

Used a why statement of people get better with us and it was just phenomenally helpful for the organization during the the COVID pandemic this group was in New York City, epicenter of the pandemic. People were out all over the city and the one thing that they had when they didn’t have any other information on COVID was that my purpose at this organization is that people are gonna get better with us. So what do I have to do for that? OK, I’ve gotta. I’ve gotta make sure that we are washing our hands. I’ve got to make sure that they have milk. I’ve got to make sure it just creates the glue and the stickiness. So.

First up is really go through that process to come up with your purpose and it’s, you know, it’s not a mission statement, right? It’s something repeatable. It’s your essence of why you exist and it it really helps you to think about that, that innovation front that we were talking about before.

Aaron Higgins

OK, so let’s dial it in a little bit more. Obviously, there’s the big, the big vision statements, the corporate vision statements. What about me as a leader within the company? Maybe I’m starting a big project or something along those lines. How can we take those bigger idea principles and shrink them down to a more individual basis?

Kristin Woodlock

So what? What is different? I think if you were on this path of you, you know your purpose, your, your, you know you’re in the innovation, Layne. A couple of things you need as a project leader, not even just the CEO, but a project leader we need to socialize within our organization if we are taking the innovation path, we have to understand that that you know failures face plants, things don’t go as planned as part of the price of admission to doing innovation because we are we are experimenting, we’re learning, we’re figuring that out now that’s not.

I’m not talking catastrophic error but really saying in the spirit of innovation, we’re gonna make some mistakes. We’re gonna have to, you know, back the car up and go a different direction and know that going into it, that’s something that’s really important. I think for project leads. And I think different, right, that that may be another cultural element that you need to to really give to your teams. The other is really skilling up and having and having what could be tough conversations around the innovation, right. The innovation may mean we stop doing something.

The innovation may mean that our fiscal department has to support the physicians differently going forward, right? So they’re in this innovation. We need to make sure that we have actually skilled up our folks in how do you not tap out of conversations when they get hard? How do you help people through when they’re sort of stuck and we’ve always done it that way, you know, and how do we really, really follow this moniker of clear as kind, right that we are so often taught and told and raised to say that you know you just.

You just don’t say anything if it’s not nice, don’t say anything, right? We. I’m just so nice and polite. But the reality and in this in this business environment and in innovation, we have to be able to give each other feedback and we have to be able to really talk to people about what’s going right and what’s going wrong and what we oftentimes do is we tap out because it gets uncomfortable physiologically and we end up going to somebody else and talking about that person. Right. So clear as kind means as we’re as we’re on this innovation project, we are clear about what our roles are.

We’re clear about how we’re going to move forward and if you know, if we are drifting a bit, we want somebody to be able to come back to the project lead and say I’m not sure we’re on track. And let me tell you why.

Jason Crosby

Well, you, you hit on what probably was my favorite portion of your presentation to our firm, Kristin. Honestly clear is kind and it’s something we have actually talked about quite a bit, quite honestly since that presentation, so…

Aaron Higgins

Yeah, it’s come up multiple times.

Jason Crosby

It’s come up multiple times and from staff all the way up to our principal.

Kristin Woodlock

For who?

Jason Crosby

Because as you mentioned, sometimes with there’s hesitation And delivering a message that may sound confrontational of sorts, right? So if you don’t mind go a little bit more into. Clear as kind, unclear is unkind. What you would tell a new leader when they feel like it’s an obstacle to communicate in such a way? Dive a little bit deeper into there, if you will.

Kristin Woodlock

Sure, sure. So you know, I think when we think about this, so clear as kind does not mean you know Jason, that you and I are debriefing a meeting that we had, you know earlier today and I come in and I say like you were a real jerk in that meeting, right? You just talked over everybody. You didn’t give, you know, like man, you’re intrusive and it just it just killed the whole project, right. That might be clear, but it is not. It is not serving the work so. So clear is kind to me means.

As a as a good team member where regardless of my hierarchical position in an organization, is a good team member, I’m committed to serving the work and I’m committed to sharing feedback in a way that is that’s focused on that work because I want it to work. I want us to do well with that. So Jason, I may come in to you afterwards and say, you know, in that in that staff meeting today, as soon as you started talking about our project and then you linked it to the quarterly financials, everybody shut down. And I don’t know if you did you notice that.

And you may say no, Chris, I didn’t notice that at all. Ohh my gosh, that’s not my intent at all. Yeah, well, I think we lost people on that and you know, I think it just was perceived as being not mission driven and just bottom line driven. And I think we need to go back and repair that and Jason, you may say like well, what do you think might work with that and what might we do, right? So you know I know that’s those these feel a little bit artificial when you know they’re not something they’re not like the big you know problem with that staring at you. But I think that’s how you look at that, right. So I didn’t in any way diminish your role as an executive within the organization.

I’m just. I’m just sharing that when you link that project to finances, there was a real negative like dimming and the room and that’s not what we wanted. So how we gonna fix that? Right, so we keep it about what we’re trying to do with the project, you know, like another one that I’ve heard, you know, and I do work with the with the Brené Brown Group One is one of the ones I think she has. She has just communicated beautifully is if you have somebody on your team, your project team who just is always jumping in and answering, you know like before anybody has a chance.

The think about consequences and how things are gonna come. You’ve always got your sort of person who’s gonna answer, answer, answer. Clear is kind might pull that person aside and say, you know, we go into the operations meeting today. I really want you to sit back and let other people answer. Well, well, why? If I know I have the, you know, the right answer because I really want us as a team to work up some different, you know, different muscles. And I want to hear from some different voices. And one of the things I really, really would appreciate you helping is asking those really detailed great questions that I know you can ask Aaron.

And really try to pull information out of others within the meeting, right? So, you know I didn’t come and say you’re overly talkative. You’re getting in the way, you know. Shut up. Right. Like, that is not kind. That’s not gonna be helpful. But what I did was sort of talked about, you know, I want you to step back a little bit more. I want to hear from others. But one thing you can really help me with is asking questions. If you feel like, you know, the answer, ask some questions, it might help us get to that answer. Right. So you really have to come into it from the perspective of serving the work and by the way, you also got to be ready.

If somebody you know gets you know you, you could have somebody get ticked off at you. You could have somebody cry, you could have somebody say I’m done on this stupid project. So remember we are emotional beings. So when you’re doing this, you just have to be prepared for that. I. And I think coming back to, I just thought this feedback was really important. I want this project to be successful. I certainly didn’t intend to make you angry, to hurt your feelings. How can I fix that? That’s not. That’s not what I wanted to do. So let’s talk about it a little bit more.

Jason Crosby

Great point there. How now flip the table of that conversation. Communication being a two-way street, right. And we all have different personalities, you know, personality types, etcetera. What maybe advice would you give to the person on the other side of the table who maybe has difficulty receiving that what is perceived as unkind but is actually trying to be truthful? From someone else, any advice to give it to the person receiving the feedback?

Kristin Woodlock

So I do. I mean it was and it’s sort of I am totally reading between the lines and probably painting things, you know, Jason and Aaron with your team that may have not may not have happened, but I loved what you said about after we started to have the conversation about clear as kind and what that can do to really create innovation and good communication within a team.

You talked about how much you have talked about it, right? So I think it is very hard within a team or even between, you know, a supervisor and A and a colleague or a supervisor or somebody or supervising to just start in with this and not have had a conversation about, you know what I’ve heard this really great thing that I want us to think about. And that is clear as kind. And let me tell you what’s behind that. Let me tell you what that means. You know, it’s intended to serve the work, to give real feedback and real time to people and for us to gather, to come about, like, what’s going to happen next. And I think if you create that culture and expectation ahead of time.

It helps people when they tend to get defensive reactive, they feel like you’re criticizing me. And if I so I would socialize that with my team. I really want us to show up this way with each other. And if I see somebody struggling, I’m probably gonna reach out to that person one-on-one and say whether again, whether I’m just a colleague, I you don’t have to do this in a hierarchical way and just say I just, I I see a struggling when we’re really trying to deal with clear as kind. Is there something I can do? Can we talk it through? You know, I did not hear Jason and any way criticize.

The work that you did on that dashboard, what I what I heard him say is that the data and the dashboard was making people on the team really judge each other. And so he wanted to take a different route at it, but that had nothing to do with how you created the dashboard, right? So sometimes you can give people specific feedback on where you think they’re getting stuck and it can help them through it. Again, regardless of where you are in the organization.

Jason Crosby

Do you think you mentioned how the from the right? Very first question about innovation and how different that’s been just in the last year versus the your first thirty, would you would you say uh communication and difficulty in communication has also been a little bit more difficult post you know with pandemic people working from home you know there’s a lot of talk of turnover quiet quitting all these types of things. Do you feel that’s made things even more difficult whether you’re giving or receiving the message?

Kristin Woodlock

Yeah, it’s, it’s interesting. And I you know, I do think it’s important for your for your listeners to like remember that, you know, I’ve had a very long career in like running large health systems and doing, you know, even taking one large nonprofit into bankruptcy. And, you know, under a massive spotlight. So I’ve, I’ve actually run stuff. What’s been interesting to me as a consultant is, is in the first five or six years, did a lot of work, you know, and the demand that people would come to me with was I’m, you know, I’m restructuring my health system. I’m bringing in different affiliates. Can you help me with that structure with that process? It was.

Very much about the business of behavioral healthcare or healthcare in the last year or so, I, I just my phone rings off the hook or whatever the cool technology is of the day. I’m sure I have the latest technology. It’s not, it’s not, it’s not a landline. I’m not that I’m not that technologically backwards, but so. So my phone rings off the hook, I get the emails and it’s all about like I need you to come in because like, I feel like my staff is burnt out. I I feel like people are tired, you know.

It’s like all of my clinical staff wanna work from home, but I can’t make that work. You know, we aren’t having the tough conversations we’re irritable with like it is so much about, about the ability to communicate with each other. How are we going to set up new norms and really doing that? And what’s been funny? Jason, I think is, as I’ve started to work with some organizations, in particular using DARE to lead, which is just one sort of tool in my toolbox. What I found is that it creates enough conversation. But then people start saying, well.

Yeah. Well, we’re there to lead train. Well, I didn’t see Aaron show up that way.

You know, Jason shows up that way, but I didn’t see Aaron show up that way. So the there’s just so much to unpack and I think what I have really resonated and liked about Brené Browns work is that she gives us very concrete tools and language so that like clear is kind right that that can be pretty simple. But that a team can sort of have a shared commitment to have a shared understanding, you know, skill up about how to give each other feedback and what does really engage feedback look like, which is important.

Kristin Woodlock

And also like if we’re if if we’re starting a new project or I’m asking you to do something, this is another Brené Brown tool that I think is helpful on this on this emotional teamwork and she’ll say make sure you paint Don. So. So I don’t just go to Aaron and say get me get me the spreadsheet of all of our expenses that we’ve had with outside vendors for 2021 and Aaron’s going to do the best he can to figure out what the heck is in my mind and what I’m gonna do with it. Right so he’ll try he’s gonna spend a lot of time really trying to.

You know, buff and polish, something that looks really cool, but what I didn’t tell Aaron was that I was really looking at outside vendors that we could potentially consolidate and look to group in a different way. And so I wanted to see some affinity elements of that and I wanted to see who ordered them and I wanted to see more detail on the invoice about what we actually purchased from them. So when Aaron delivers that product to me, I’m going to be like, this is not what I wanted and Aaron’s going to feel bad. I’m gonna be mad ‘cuz I wanted to share it with you, Jason. Then two hours.

And and So what we really are trying to focus on this as well is me sitting down with Aaron and saying like I I’d like those invoices. And Aaron says like paint done for me, Kristin, if I don’t think to say it, I’m like, OK, here’s what I wanna do. Here’s why I wanna do it. And Aaron might say, you know what, I know you’re thinking and voices, but we actually have a better tool. I think if we look at our purchase offers and the then the purchasing system that we do, that’s going to give us the information you want. And I think if I pull that together, it’s really going to impress Jason in terms of, OK, great, right, let’s do this.

So really having that detailed communication and frankly like some people hate doing that, they hate spending the extra 15 seconds saying why you want it. I’ve even seen some leaders hate it because they don’t really know what they want.

Like they know what it’s like. I know when I see it and whatever you give me, Aaron, is not gonna be what I want, right, like, but. But if you can, if you can have that conversation ahead of time, it’s amazing how much that streamlines the work. It, you know, it gave Aaron a chance to, to show off a little bit to me about how he knows what’s going on in the system. And he’s like, yeah, alright, good. I really influenced this. Right. And his work was actually productive instead of needing to go back and do it two or three times. Right. So. So there are some little things that we can do as organizations or we can.

You know, we can take a, you know, a bigger, more holistic approach. I do work with some organizations who dare to lead, like across the whole organization. But you can do some little things that really help sort of tamp down some of the anxiety, angst, conflict and can really start the team working together with a with a fresh set of energy. And I think that’s what I heard you to describe sort of happened after I spent some time with your team.

Jason Crosby

1. Yes.

Kristin Woodlock

He said. I felt that lift, you know.

Jason Crosby

No question, no question. What? So lots of very good applicable tools for audience that that was able to listen to all that. What as we wrap this up, what are some of the quick hit type things? Would you advise to whether it’s a new manager, right, we’ve got practice administrators, we’ve got hospital administrators listening, it’s hectic quick environment.

Where can they go? Find some more information along the lines of what you just discussed and find you and maybe a couple things as to what they can take back and apply in the near term.

Kristin Woodlock

Sure, sure. So they can find me at uhwoodlockassociates.com. All the contact info is there. You know folks that I’m following right now. I I think the Dare Delete podcast that that Bernie does on Spotify is just fantastic whether you’re driving, walking, you know, hiding in your closet where whatever you’re trying to do, they’re about 45 Minute podcast. She brings in amazing people. That’s why I heard doctor Linda Hill talk about the difference between change and innovation.

I just think those are 45 amazing reenergizing informative minutes so that that’s a really good, good resource. Brené Brown does have a website and has a bunch of freeware activities, including a daring leader assessment that you can take if you’re just curious about sort of what some of your skills, you know, skill spots, soft spots are, I think Simon Sinek ‘Start with the Why’ is really amazing in terms of getting to the to the purpose part of things. So, you know, I think those are some, those are some quick lifts.

I think that are out there that that really would give you a lot give, give the listeners a lot of things to start working on.

Jason Crosby

Fantastic. I’ll tell you what I for those lessening, do yourself a favor.

Go to Kristin’s website, engage with her. The presentation you did for us. Of course, Kristen, whether it was the clearest unkind, the 5C’s there. July, we went through all those tools.

And as someone that you know, if you’re doubtful of if this is your fearful that there’s fluffiness to the discussion, I’m here to tell you no, this is one of those things where there’s not as applicable tools.

In in these applications that Kristen is talking about, so please, if I if you are looking for such an engagement, I would encourage you to do so, Kristin. I really, first of all appreciated the presentation and thankful for the information today as well.

Kristin Woodlock

Great to be with you both. Thank you so much.

Aaron Higgins

Yeah, thank you Kristin. My only regret is that we didn’t have more time, so we might wanna have you back sometime here in the near future. So.

Kristin Woodlock

Sure. Have to come back.

Aaron Higgins

Thank you for joining us and everyone. Thank you for listening to vital conversations with SHP. Again, our guest today was Kristin Woodlock. You can find herwoodlockassociates.com or Google her name. I did. I found plenty of ways to get a hold of her. If you want her to come talk to your organization, she’s available for that as well. Alrighty. Thank you. Kristen. Jason, you both have a wonderful day.

Jason Crosby

Thanks Aaron. Thank you.

Wound & Ostomy Care Gaps | Joe Ebberwein

In this episode, Jason Crosby and Aaron Higgins provide a quick overview of the PFS Final Rule that released at the end of October.

Then Jason talks with Joe Ebberwein. Joe is the Co-founder and Chief Financial Officer of Corstrata, a technology-enabled care management solution focused on improving outcomes for wound and ostomy patients. We gain data-oriented insight into this often-neglected area of care and how Corstrata is working on solving this care gap; then, they discuss how virtual care and telehealth are viable solutions for any provider to utilize.

News Item – PFS 2023 Final Rule 15 Takeaways

Register for the Nov 15th QPP Webinar

Credits

Production Assistance & Editing: Nyla Wiebe

Scripting by: Aaron C Higgins

Show Notes & Transcription: Aaron C Higgins

Social Media Management: Jeremy Miller & Nyla Wiebe

News Co-Hosts: Aaron C Higgins & Jason Crosby

Interview hosts: Jason Crosby

Executive Producers: Mike Scribner & John Crew

Transcript

Jason Crosby

Hey, everyone. I’m Jason Crosby with Strategic Healthcare Partners and your host for Beyond the Stethoscope: Vital Conversations with SHP. Today we are joined by Joe Ebberwein, who is cofounder and CFO for Corstrata, a tech enabled solution provider for the wound and ostomy care markets. Joe, thanks for joining us today and welcome to the podcast.

Joe Ebberwein

Yeah, great to be with you today.

Jason Crosby

We look forward to it. Well, we’ve got some questions lined up for you. But first, let’s start with just some background information on yourself and kind of your journey to healthcare industry.

Joe Ebberwein

Absolutely. Yeah. So my background is actually accounting and finance, got an undergraduate in accounting and the CPA route and worked for both and this’ll age me, but both Arthur Anderson and Price Waterhouse. And started working in healthcare in early in that career at doing CPA work auditing and what’s in Atlanta for a little while, and then moved back to Savannah and actually began work with Memorial Medical Center, now part of HCA, but worked primarily on the post-acute side and the for-profit entities, which back then were the area ambulance and MedStar the ground ambulance, and then all of the other ancillary in home services such as home health, DME, et cetera.

So I’ve really spent most of my career in that space just about anything that could be done in the home from nursing traditional home health, Hospice, private duty care. And then as the years went on back in the early 2000s, the agency that I was involved with, we got into telehealth in a big way. And the use of vital signs monitoring in the home. So we were one of the early adopters, really nationally, and kind of became known as national thought leaders around implementing that, that use of technology in the home health space.

And we saw some pretty amazing results. We saw improvement in clinical outcomes and improvement in financial outcomes. So we were much more equipped to manage patients with chronic conditions like CHF, COPD etcetera in the home using this equipment again back in the early 2000s, clunky, expensive equipment that, fast forward, that was really kind of the initial groundwork for what my business partner Kathy, paid and I ended up doing at Corstrata about seven years ago. And really what we did is we took that concept of how can you apply technology to a healthcare problem. And we had experienced a big problem in managing chronic wounds for patients that were in from health. So similar to the teleradiology model.

We thought kind of came up with a thesis that we could move images similar to radio graphic images to a distributed workforce and that that workforce happened to be board certified wound and ostomy nurses. So we started doing a lot of R&D into research around how could we come up with a technology solution to that problem. So that’s really kind of how Corstrata was born seven years ago, but that’s my background.

You know, finance, accounting, but a whole lot of other hats along the way in early-stage companies.

Jason Crosby

Yeah, sounds like a natural evolution from the early 2000s. You know, you got see telehealth early on and home health. And now that’s kind of all you’re hearing about, right? So kind of makes sense now that you as you mentioned with Corstrata. So tell us, let’s dive into that. You you’ve touched on it; tell us a little bit more about the operations of Corstrata and the problems you’re trying to solve, who and who you’re trying to solve them for, right. Which who’s your typical client? What type of provider setting? Dive into that a little bit for us.

Joe Ebberwein

Sure. Yeah. You know, wounds are an interesting problem because no one really owns wound outcomes. You know, you’ve got cardiologists that are dealing with cardiovascular issues or endocrinologists dealing with kidney and diabetes function and that kind of thing. But nobody really owns wounds because they cross multiple comorbidities. You might have wounds related to vascular issues, lower extremity wounds.

Huge prevalence of diabetic foot ulcers in the diabetes population. One in four diabetics will get a diabetic foot ulcer in their lifetime and one in four of those will have an amputation. And then the five-year mortality rates are off the chart. Crazy for people that are that recover from an amputation. So those are the kind of wounds. Additionally, you have a multitude of other words related to different conditions.

Whether it be pressure injuries from immobility, or you know a lot of times you hear them referred to as bed sores and unfortunately that’s highly prevalent in skilled nursing facilities and a lot of them can be prevented with the right with the right education, with the right techniques, the right surfaces, et cetera. So it’s a $96 billion problem, 15% of all Medicare patients members have a wound and the real problem that we’re trying to solve.

And chipping away at it is that there are only 15,000 board certified when nurses in the country and that equates to about one nurse for every 600 patients. It’s not sustainable. The number of diabetics obviously we know that that’s growing. We’ve got about 37 million diabetics and another 96 million pre diabetics.

So it’s a really, you know it’s like a freight train going down the track and it’s it doesn’t have a good ending. There’s a big wall at the end of it and it’s all-around access to these specialists. So as I said, no one knows wounds across multiple specialties, multiple provider settings, whether it’s home health, skilled nursing facilities, we’re about 1/3 of the patients have a wound, L tags.

Rural hospitals, all of these different care settings have patients that present with wounds and yet we don’t have the expertise to really manage them and get evidence-based care.

One out of 10 nurses that are certified in wound and ostomy care practice in the post-acute space, so in that includes home health Hospice sniffs rural hospitals.

90% are practicing in the hospital settings and outpatient wound centers. So I mean you, you can see there’s such a disparity with where the experts are. We’re solving that problem with technology in a number of different ways. And I can go into that if you want or…yeah.

Jason Crosby

So with that the key obviously being technology adoption.

Joe Ebberwein

Right.

Jason Crosby

I on the on the provider side and some are a little bit more accustomed to that adoption. Some aren’t with that and with the gap in in qualify nurse on the, on the outpatient side as you just mentioned.

What are you seeing those as your key barriers or what other barriers are you seeing? To that to entry into those spaces.

Joe Ebberwein

There are a number of barriers, one of them that’s really interesting is some providers don’t want to take wound images of their patients wounds and you can kind of see that right because of litigation discoverable in the chart, et cetera. But what’s interesting is most of those patients say with a pressure injury or pressure ulcer, if it gets bad enough somebody is probably photographing that wound and what we tried to get across our client says do you want, you know, a qualified professional taking photographs of the wind over time to show the progression and have the medical records support that decline or hopefully improvement or do you want you know, the patient’s nephew to have the photograph in a in a court of law. So a lot of times we can get over that barrier pretty quickly the other.

The other barrier is we’re really a value add to our customers, so whether it’s home health or Hospice or skilled nursing facilities because we are nursing model, we’re not billing any Part B, we’re not billing any commercial Medicaid. We bill our clients and our clients to get a return on investment from having access to experts. So we can reduce nursing time, home health visits, we can reduce. So we can reduce their spend on advanced wound dressings and also really to be honest help them with coding and reimbursement as well because a lot of times they’re misidentifying wounds and they’re leaving dollars precious dollars on the table from a reimbursement standpoint.

Jason Crosby

Sure, that sounds like if if 15% of the Medicare population have wounds and there’s obviously a growing number there. I would just imagine there’s greater demand for that type of service. Where are you starting to see some of those trends knowing that you’ve got the aging population, you’ve got hospital closures, not only rural hospitals, but you’ve got WellStar for goodness sake?

Joe Ebberwein

In Atlanta, yeah.

At the hospital, large hospital in Ohio. And that’s only gonna continue, right? So, go down that path a little bit. Are you are you gonna, do you envision continued demand for such a service or is that just going to become a barrier for you as well?

Joe Ebberwein

Umm, I think it’s gonna become quite an opportunity for further penetration in multiple markets. And I’ll tell you just a couple of examples. We are we’re working with some large hospital systems and on the West Coast and these are these are big hospital systems in urban settings and because of lack of staffing, they’re closing their ostomy clinics so.

Literally, we’re getting that business to our virtual consultations. We are able to do a 30 minute live video with the patient in their home, troubleshoot the appliance, save a ER visit and assist these hospital systems that are desperate for staffing of these nurses on indeed.com. I went on there today, there are 4001 Open wound nurse positions across the US.

Well, if they’re only 15,000 certified period, you can see there’s such a disparity with COVID kind of the great resignation of a large number of nurses who are considering leaving the profession. It’s a big and growing problem. So hospital systems, as you mentioned in rural facilities. Really just about anybody that in the post-acute space. Also that is dealing with the wound, a wound patient.

Jason Crosby

So what? What do you what do you say to those? Then there’s obviously the appetite that the man for the service that you guys are providing.

But many reasons, as we you just laid out there still slow adoption to that whether you’re still nursing facility, rural hospital provided a large health system. You know practice setting across the board, there’s not provider that can’t utilize the service. What do you tell those that are just hesitant to look in that direction and starting investigating you know a service like yours, what do you say to them to get them across the line?

Joe Ebberwein

Great question. And I do think that COVID and the adoption of telehealth broke down a lot of those barriers for us because a lot of facilities had to move to virtual care, they had to, you know, put the systems in place, not only from a technology standpoint, but also all the infrastructure. And so that has actually helped us in that in telling that story, but.

You know, for instance, when we talked to, say, rural hospitals that now are either not able to admit a wound patient or they’re having to transport them to a higher acuity system because of lack of expertise, it becomes really an amazing impetus to start considering using virtual care.

Jason Crosby

So, in the markets, almost telling them itself, “hey, this is why you need to look into it.” They don’t necessarily need the sales pitch. I mean, just listen to the market.

Joe Ebberwein

Right.

Jason Crosby

And let the market tell you need to look into. No, that that makes sense. What? Continue going down that path. Let’s pivot somewhat into that, you know, to me that virtual health, Telehealth is kind of the A disruptor that we need. So continue looking at that and let’s also look into your crystal ball, right. What are some innovations that you’re seeing in these service areas that you’re you know, what are you seeing coming down the horizon there?

Joe Ebberwein

Yes. So interestingly, we have and this is one example, but we have a diabetic foot ulcer prevention program. So obviously diabetic foot ulcers don’t just occur in the Medicare population. These are people that are working, they’re 40s, fifties, some even younger that have severe diabetes, they develop neuropathy and they end up with a diabetic foot ulcer and it’s just an incredible kind of cycle. It can spiral down well.

We have working with companies that have electronic sensors for measuring temperature and pressure in the soles of shoes. A lot of technology is moving toward prevention, and most diabetic foot ulcers are preventable. If you have the right early detection. So that’s one example. There are sensors built into orthotics for measuring compliance; and you know what ends up happening is that data, that sensor data that tells that someone’s getting into trouble, that comes to an entity like Corstrata, and then we’re able to intervene. We had a really interesting this is just an anecdotal story, but we had an interesting encounter with a gentleman who was using one of these monitoring systems.

And every weekend he would alert. And so we knew something was going on the weekend where he was getting elevated temperatures, which is a precursor to ulceration. And so, one of our nurses said, OK, let’s dig into this, let’s do a video call. I want you to show me every shoe you have. I want you to tell me what you’re doing on the weekend. We’ll turns out he had a part time job and a Funeral Home, and he had to wear a certain kind of black shoe. And it was not the proper shoe to relieve that pressure. So, we got him in the right shoe. The alert stopped coming in. But that’s the that’s the illustration of you got all this great sensor data, but what do you do with it? And then that human intervention, that biofeedback and coming up with a plan to to really prevent that ulceration.

Jason Crosby

Wow, that’s a great, applicable story that anybody listening can certainly resonate with right? I mean that’s great. Appreciate you saying that. So what’s now in the strategic road map for Corstrata? What are you guys working on today and over these next couple of years?

Joe Ebberwein

Yeah. So it’s been interesting over this last year where we had predominantly really been working mostly in the post-acute space like Home health, Hospice, skilled nursing facilities. What we’re starting to see are some of the emerging models for really acute care services in the home hospital at home, if you will.

And we’re working with a number of those who organizations that really help facilitate a hospital building a hospital at home program.

What where that becomes really interesting is, and this was really accentuated during the pandemic, you’ve got these acute patients; Who really, when there weren’t enough beds in the hospital, could be managed in the home with the right equipment. And when I say hospital at home, I’m talking there is hospital grade equipment, hospital bed, vital signs monitoring, all going back to kind of a Star Trek central station constantly monitored, daily nursing visits, nurse practitioner visits, etcetera. So you know, imagine that they’re really setting up a command center in the home that is, you know, transmitting data so hospital at home is an emerging market and a lot of those patients have wounds and ostomies. And so they’re engaging with us to do virtual consults for the people that maybe do not have experience with wounds, other innovative type things that we’re seeing are mobile physician groups that are doing primary care. Obviously the proliferation of ACOs and the whole value-based care bundles. You know we are in discussions with some payers that also have mobile clinical teams. So yeah, it’s really kind of been an interesting year and it’s a shift in who’s approaching us for those kinds of consults. Ostomy is a big deal as well, even though it’s not a big number like the wound population, it’s a really high 30-day readmission rate into the hospital. And so ostomies kind of go hand in hand with wounds because of the certification of their nurses.

Jason Crosby

Interesting that you know here you just talked about what, 20 years ago the focus was all in the skilled nursing facility if that and now you can span across any provider setting a CEO’s practice setting, it doesn’t matter come a long ways and there’s just the last 20 years. So another exciting few years ahead, I’m sure.

Joe Ebberwein

We’re seeing such incredible stories, both with individuals living with ostomies that literally were driving to an ostomy clinic 4 hours away. That can now do this in the privacy of their home to people with long term chronic wounds that just never had the right evidence based treatment plan. And we’re getting those wounds closed, obviously saving a lot of money for the providers. But the human impact Is amazing as well.

Jason Crosby

Well finally, Joe if our audience supposed to learn more, how do they go about doing so?

Joe Ebberwein

Sure. So lots of ways to contact us. Obviously our our website Corstrata.com, we’re on LinkedIn and Twitter and Facebook and just about any social media. So very easy to get us.

Jason Crosby

With some great information and even better conversation there lots of lots of data to support. You know what you guys are doing is a great thing. It’s a service that’s needed out there in the marketplace. So really appreciate that. And I’m sure the listeners will, will find it. This is useful as I did. You definitely opened my eyes to a lot of things there. I appreciate that and the we really appreciate your time and joining us today.

And I wanna thank our listeners for your time. We look forward to our next podcast and until then everybody have a great rest of your day.

Joe Ebberwein

Thanks for having me.

Jason Crosby

Welcome to Beyond the Stethoscope Vital Conversations with SHP. I’m Jason Crosby. If Strategic HealthCare Partners alongside our principles. Mike Scribner and John crew your hosts for today’s episode today. Our guest is Sean Cavanaugh, chief policy officer and chief commercial officer for Aledade. For last several years have provided the technology and services to independent physicians as part of their successful ACO ventures. Previously he served as the deputy administrator and director of the Center for Medicare at CMS. Sean thanks for joining us today and welcome to the podcast.

Sean Cavanaugh

Thanks for having me, guys.

Jason Crosby
So, with that will jump right on the conversation. We’ll start off with John first.

John Crew

Thanks, this is John, Sean, we do appreciate you being with us today. I do the question. I have first is and I think as Georgia experience as well as nationally. We’re seeing primary care diminished independent primary care physicians diminish. We’re seeing more and more of the young residents coming out or preferring the employment model when you look long term and value-based care models do you see a Direct Line where you would be working eventually with employed physicians in these models?

Sean Cavanaugh

Yeah, I think anybody who’s committed to improving healthcare, which means doing what’s right for the patient’s working within a business model where you get rewarded for?
Preventing hospitalization rather than doing a hospitalization.

I think we’d be willing to work with them and I think anybody should be willing to work with them as you correctly point out you know in my current position, with Aledade. We’ve very much focused on the independent primary care. Doc and that’s because of alignment. We think they’re already there and their mindset.They’re fully aligned with value-based care and doing the right thing by the patient. I think and you’ve probably experienced this for hospitals. I have a lot of sympathy for hospitals. They’re in a difficult position as the world transitions to value-based care if we’re really gonna reduce hospitalizations. How do they change their business model. It’s not as simple as it is for independent physicians. But in the long run? I think they’re going to get there, and I think we’ll be happy to work with them and not just us we’re not the only value-based company out there.

Some already work with hospitals with some success. So, you know if this movement to value-based care is going to work. It’s gonna have to include everybody validates starting with the independent primary care physician because we think there’s where you get the best alignment initially.

Mike Scribner

So, when you think about the independent primary care that most interest Aledade? What are the characteristics of them that kind of lead you to believe that they’re gonna be most successful with BBC in the first place.

Sean Cavanaugh

Mike thanks for that question, we get that question often from insurers as well. Like Are you guys pull you know going in and finding the elite high performing primary care practices and forming like a specialized high value network and we’re no.

You know, we’re not taking just the high performers what we’re looking for is well first of all one thing we look for is some basics people need to be on an electronic health record, which most people are but not everybody. They need to have a pretty good track record as far as program integrity, not prescribing tons of opioids. But those are fairly low bars. Hopefully beyond that, what we’re looking for is practices that are tied to their community that know their patients.

That are looking for a better way to deliver care and are willing to consider the use you know our tools. You know as you know, we provide some data and Analytics. And some workflow tools to the practices what we find is if they give the tools a chance. They love them and then it doesn’t take any coaching to get them to use them. But that’s what we’re looking for someone who’s willing to try something a little bit different and do the right work for their patients and what we find is typically with independent practices, they feel like they’re doing that already.
And so, we’re enhancing their ability to do it.

Mike Scribner
Can you talk a little bit more about the kind of tools that you’ll do provide and the things that enhance the practice’s ability to be successful.

Sean Cavanaugh

Sure, what I usually say is it boils down to two buckets, one is. Who’s not in your practice that should be in your practice today?
Right rather than sitting and waiting for someone to come in. We’re going to give you data that your whole population, but not just dump a bunch of data on you. We’re gonna show you very specifically who just got discharged from the hospital. Yesterday that you should be reaching out to today. There’s all sorts of evidence that patients that could discharge from the hospital if they see their primary care physician within a couple of days much lower readmission rates better for the patient better for Medicare better for the practice.
In fact, I’ll tell you Mike a little story, a true story from you heard at the outset that I used to work at CMS.

When I was at CMS, there were studies coming out showing just that transitional care works patient gets discharged from hospital. Some see their PCP. They do better than those who don’t. We created a new billing code in Medicare called transitional care management. That’s specifically pays for practices to see those patients and pays pretty well. I think compared to some other visits. Then we waited two years and we looked at the data. And no one was using the code. So, you know the greatest plans coming to failure so I went around to the physician groups and I asked them. Why isn’t anybody using the code the first thing I heard from you know the family physicians. The Internist was we don’t know when our patients been discharged from the hospital? How are we supposed to do that?

So sometimes it’s as simple as that tapping into the local HIE tapping into directly to the hospitals and not just you know, creating a very simple way for the practice come in turn on their computer in the morning get a list of patients who left the hospital yesterday their phone numbers and it worked. List called these people bring them in.
So, like I said the first thing is giving you an understanding what’s happening in the patients who aren’t in the practice. A lot of data analytics to show you which ones really could use some help if you reached out to them.

The second bucket is: Who is we know who’s coming in your practice today and who’s in a value-based contract? What’s the most important thing for you to know about these patients? What are the quality gaps they haven’t had fill? What hospitalizations have they had recently? What specialists are they seeing? How many times have PCP knew you were seeing 3 cardiologists he or she couldn’t do something about that.

So, we get we give this 360 degree view to PCP’s and then we let them do what they do best which is provide great primary care, we don’t interfere with how they practice medicine. They know what’s best but we’re making sure they’re seeing the right patients at the right time.

John Crew

Sean to that effect, data to be actionable data needs to be as current as it can you share a little bit about how you received data and then how you disseminate that back to practices as real time as possible.

Sean Cavanaugh

Yeah, John, you’re exactly right you know the ability to take timely action is only as good as the data you’ve got. First of all, the tool. We give practices and we literally give it to them called the validate a it. Ingests data from numerous sources, so first of all we get claims data from the payers. We have partnerships with and sometimes that’s Medicare or sometimes it’s a commercial insurer. We get notifications as I said of admissions and discharges and transfers from the local hi. You’re directly from hospitals. We get lab results from the major lab companies.
Just massive and you know script Part D results on drug utilization. Massive amounts of data but as you said. We’re constantly fighting is the battle to get it faster and more accurate because finding something out claims data can be two months lagged.

Ironically, one of the things we found in a little bit proud of this having come out of CMS is the data. We get the fastest from a payer on a claims data tends to come from Medicare itself and we’ve been talking to the big insurers united.

Aetna and those guys and saying come on, guys you gotta be able to beat the government right? The thing is, they have these huge legacy systems that they’re all working to upgrade. But what we try to convince them is it’s in your interest too. The sooner these doctors know what’s going on with the patients, the better the care your members will get but we do have at times. We can only be as fast as the payer partners, but we try to get as timely data as possible.

John Crew

Thank you.

Mike Scribner

Sean as the ACO’s have matured that you guys operate. Has it been more difficult to when you get past the low hanging fruit? Is it a little bit tougher to plow the ground to continue to have success or does it catch a flow that just continues to improve?

Sean Cavanaugh

Yeah, that’s a very fair question. If we’re only getting low hanging fruit. There’s more low hanging fruit than I thought because we’re still improving even our earliest ACOs, which started in 2015. They’re still getting incremental improvements, they’re getting I think part of what you see is it takes time, like anybody who’s thinking that this will turn around in a dime is wrong.
When we look, we did a study and we’ve updated it several times. We looked at 5 different ACO. We started in five very different states across the country back in 2016 and we followed them every year. Since then, and what we’ve this is a study. This is not using CMS data. This Is Us doing all Medicare claims data matching those people against similar beneficiaries in their community and we see consistently every year, the same result and continuing to grow which is.

People in an Aledade ACO get more primary care so I think we’re up to in the 5th year, 4th year. It’s 35 more than similar beneficiaries in the community. 35% more primary care and what that leads to is about 14% fewer Ed visits about 15% fewer inpatient visits. Umm I forget the exact number around SNF visits. We haven’t plateaued yet it is plausible. But that’s why one of the things we’re thinking about is like? What’s the second engine like? How do we expand the ability of these practices to do more physicians and their staff only have so much time in the day are there services we could augment to help them so.

Until today, Aledade has always focused our services on the practice. What can we do for the practice. We’ve now created a subsidiary called Aledade Care Solutions, which will be patient focused? What can we do directly for the patient. But this is where there’s an important distinction between US and Optum and some others.

We’re going to do it in partnership with the practice. The practice will get to decide when the Aledade services are used who they’re used for and any data. We collect about patients by servicing them directly. We’ll go directly back to the PCP because we think that’s key keep the PCP in the driver’s seat.

So back to your question Mike. Yeah, there’s probably low hanging fruit out there, but there’s a lot of it. We’re still working on that and as we do like the problem with the phrase low hanging fruit. You forget these are patients. They’re getting better. Care like they’re going to the hospital last so that’s important, but we think with some adding some services and helping the practices directly with patients. We’ll be able to move beyond that, too.

John Crew

Sean when you have markets that aren’t as sophisticated as other in terms of the growth of value-based care, and you come into it. There’s this perception right wrong or indifferent by providers that this is gonna change my workflows within my within my practice. It’s going to be more time consuming. I’m gonna have to hire more people and so I may or may not see a return. I’m sure you’ve been exposed to that? How do you deal with that as you first come in and working with providers to introduce them to the value-based model.

Sean Cavanaugh
First of all, we tell them we, we do have no interest in blowing up your practice and changing making your life, miserable. We’re going to take you stepwise through this. We’re going to take you through different steps. You can do incrementally. We’re not going to throw the whole playbook at you. On Day One so things will change cuz. Let’s be honest, rather than churning patients through the practice like when you need to make more money right now, you’re incentive is to see more patients for shorter period of time.

To see the less difficult patients overtime, not on day one your business model is going to change where you’re going to want to focus on the harder patients. You’re going to want to refer out less when you’re capable of treating them. But that’ll happen gradually over time. The other thing we tell them is there’s some things that help you along the way our practices. When we have them doing more transitional care visits more annual Wellness visits. They see their Medicare fee for service revenue going up day one.

So what we call good fever service like if you’re doing these good preventive seat. Fever service services. You can see practice revenue going up 1015 before you get a set of shared savings check so there is a transition here that we can work with practices. I know you guys have done the same.

It’s not turning things on a dime and it’s not like seeing a drop in revenue, while you wait for a shared savings check there’s a pretty good pathway here.

Mike Scribner

So Sean what do you what do you all typically see as the role of the specialist in that I get that it’s very primary care based and very cornerstone in that world but. What is an effective relationship with various specialists look like?

Sean Cavanaugh

Yeah, that’s a great question one of the things I want to say is. I think the whole country is grappling with that question I know CNS is CMS has been struggling to come up with a specialist strategy and they’re continuing to talk to people what we’ve found that works best is especially in smaller communities where there’s not just a professional but often a personal relationship between the PCP and a specialist is to sit down and have communication about expectations. You know in some of our communities that literally we invite the specialists in and we explain.

We’re doing an ACO here’s why we’re doing it. Here’s what our goals are and the goals of the ACO are really good for the patient and so when the specialist see that they understand like they want what’s good for the patients too. But what we find is PCP’s often go into this conversation, thinking they’re going to lecture specialists. But when if you’re a neutral party in these conversations, you hear the specialists having very good.

Demands of the PCP’s too when you send me a patient be very specific about what you want you know how many specialists get a patient walking in, who said doctor so and so sent me why I don’t know. He just told me to come. See you so improving the communications and understanding what the expectations are I’m sending you to the specialist for this very specific purpose. I wanna hear back what the results are I want an understanding of who’s gonna manage that patient if this is.

If you’re referring to a cardiologist is my turning over management of this problem to the cardiologist or do I just need a second opinion on something? When we’ve seen these two-week communication. We’ve seen some bonds formed that are really fantastic where the specialists now becomes a preferred specialist because they’re seen as a partner and they’ve their business does better. But I’m gonna be frank with you. This is not true everywhere. I think sometimes there’s. A distrust is too strong a word but misunderstanding what the purpose of the ACO is.
The other thing is, and this is where we’re all trying to get better is. It’s really hard to know who’s a true high value specialist. So, the other thing is being transparent about the data. Here’s what you know Aledade. We provide our doctors data on specialists you know outcomes cost.

But we encourage them to have a discussion with the specialist about it and the typical. PCP doesn’t want to change their specialists like meaning switch, they want their specialists to be the most efficient and the highest quality. So, I guess if I had used one word instead of rambling on, I would have said communication like the communication between the specialists and the PC is so critical and it’s hard because everybody’s so busy taking a step back and talking about? What are we trying to accomplish here together it’s hard?

Mike Scribner

Where do you see the specialist being involved like where do two-part question? Where do you see CMS going in terms of coming up with value-based incentives for them and then what it? Where is Aledade place and is there any sort of financial model around that within the all’s ACO?

Sean Cavanaugh

Yeah, so I’ll answer Aledade first and CMS at Aledade. We’re experimenting we have such a broad network now you know in in 40, some states. Before we roll anything out to all of our practices. We test it in some markets. So, we’re testing a couple of different specialists approaches.

One is you know, there are some companies that have started up that will give you real time consults by phone or technology. That’s one pathway. Another pathway is literally trying to create profile specialists in your community and create. You know a preferred list of those who are signing compacts to work with the ACO who are shown as high value.

But it’s hard work and so we don’t have one single product. We’re rolling out across the country. We’re collaborating with doctors locally trying to see what works. And I think we’re a small part of what CMS is going through now. I’ll tell you when I was at CMS. We got requests from all different specialty societies, who all wanted to a value-based model for themselves, so the Orthopedists had some ideas and the cardiologists and the. And nephrologists and I think what? With CMS quickly learned is it doesn’t have the capacity to create new models for every specialty. It has had its bundled payment for care improvement, which are you know.

Certain hospitalization and post-acute care bundles that are typically special that’s oriented, but that’s been a mixed bag. I have seen them out in the community. This is CMS folks talking to the specialist talking to the ACOs trying to find a path forward. I do think they’re looking for some model where you could embed a bundled specialist model within an ACO.
What gets really hard there is pricing it accurately a number of specialist models that CMS is tried have had either overly generous prices or the rice has been too low and so you’ve seen results all over the map. I think that’s what you’re going to see is them trying to embed some sort of specialist bundles as an option. Or maybe mandatory within ACO. I don’t know, but that seems to be where they’re headed.

John Crew

Showing our in your in your response I caught something that I wanna ask you about in your pilot programs. You mentioned or at least. I thought that you mentioned a model that maybe you’re looking at telemedicine and as part of that downstream in terms of Specialist consults things of that nature did it did, I understand that correctly or is that something that do you see telemedicine playing a role in your models?

Sean Cavanaugh

Yes, I think certainly telemedicine has a role whether it’s extending primary care or improving communications between primary and specialty care.

The specific test that I was referring to is this group that is willing to so if you’re a PCP and you have a question about a patient’s cardiac condition. You can get a specialist console like within 10 minutes and what the results. We’ve seen from that are 2/3 of the time what the specialist is telling the PCP is what you were planning to do makes sense so it’s just.
Reaffirming the instincts of the PCP but giving them some comfort and then there’s just subset where they steer them a different way like. Either you know, escalating the care or saying this person does not have you know you don’t need to refer them to a specialist but it’s giving obviously that’s one level of support. You can give to PCP’s. It’s not a solution to? How do we integrate specialty care primary care better, but it could be an interesting piece of it and what we found in this test just because you asked is there are multiple versions of this. The one our PCP is like the most was the one where they got immediate feedback. Meaning, they didn’t send the patient home and wait 36 hours to get some feedback from a specialist and that’s hard to do, but that’s what they it seems to be essential like to get that feedback while the patient. Still, there, and they can change what they’re gonna do while the patient still in the office. But we have a lot more to learn here. I don’t want to suggest we solve this puzzle.

Mike Scribner

Sean, as y’all have you know sets the breath that that you do? Obviously, we deal with practices that are both urban and rural based? What differences have y’all seen in the operations of your ACO rule versus urban and what allowances have you had to make for that.

Sean Cavanaugh

Yeah, well as I said, so one of the differences is the options for specialists’ options for facility partners. You know in a rural community, you know the options can be less the upside is there may be a personal relationship. There so you might be easier to communicate with the specialist and have that sit down in the talk. We love the rural communities, and we tend to operate more in rural communities than a lot of ACOs and that’s because we work with imprint and practices and when you get into the major metropolitan areas? What you see is heavy consolidation or the practices have been bought up by the Big Health Systems, so that’s one of the differences. We see for us in the near term the opportunity to work in some of the major metro areas is limited.
Going back to your first question, though I don’t think that’s a permanent condition. I think everybody’s gonna be pivoting to value. At some point and we will be working with people employed physicians’ health systems in the larger urban areas. I hope that answers your question, Mike.

Mike Scribner

It does kind of bring me full circle back to question John asked way back at the beginning do you see value-based care and the financial incentives of that being so great as to shift that move toward employment in the 1st place toward independence is. So much more financially attractive in the future that it just shifts that tide in general.

Sean Cavanaugh

Yes, I do see that we’ve seen small aspects of it, so think of the world three ways. You’ve got truly independent. PCP’s you’ve got independent PCPS who’ve joined a hospital CIN and you’ve got people who sold their practice to the hospital. Those people are at phase three different landscapes. We work with the first two quite a few of the physicians. We’ve recruited in the last two recruiting cycles are physicians, who were in that Middle Group. They’ve been independent, but they’ve been working through the hospital CIN.

So certainly, we’re seeing that shift where the hospital hospitals are losing some of their CIN physicians because and again. I hope this is temporary. They don’t feel they had the clinical independence or the voice in that CIN that they would have working with Aledade or other independent groups that are truly physician led.

I think you’ve seen a smaller to a much smaller degree. The more extreme which is the in the third group, the hot employed physicians. The ones who went and either sold or practices or went straight out of training into the hospital citizens and I’m sorry into hospital employment.

But I don’t think that means they’re happy you know; we’ve talked to enough of them and we think there’s an opportunity and we’re exploring this of creating if those physicians saw like a turn key solution where they could come out of hospital employment. What they don’t want to do is look for real estate have to buy an EHR they wanna practice medicine right. Imagine a world where they could walk into an office tomorrow.

They could have in place an EHR staffing and more important value-based contracts for their patients and they could build up a practice from a value orientation from the beginning and they could pay for all that stuff that they were given through future shared savings. I think if someone and you know be frank. There’s something alludes kicked around. If someone developed a model like that. I do think you’d see that third group of employed physicians start to move out cuz. I think they went into employment for legitimate reasons. But I think they missed their clinical autonomy and the ability to do the right thing.

John Crew

Sean, I have a question, in relationships specifically to the MSP MSSP and the successor models. We are seeing at least with our client base. We’re seeing us significant shift of the traditional red, white and blue moving to MMA so we’re seeing a decline in the in the in the traditional model and a significant increase in the ma long term do you see there being continued long term success for models that are associated with strictly with the red, white, and blue.

Sean Cavanaugh

No, I think if you wanna be successful in value-based care if you want to be successful in senior care specifically you’re gonna have to be able to do both, you’re gonna have to be good at. MSP, which is the ACO program but you’re going to have to learn how to work in ma as well. And I think not a lot some practices don’t want to hear that, and I don’t blame them M. The Medicare fee for service patient is their last patient where the insurers not requiring prior auth and all that, but the world is just changing as you said Medicare itself is still growing dramatically with the aging of the baby boomers, so senior care as a field is growing, but as you said the part that’s growing is the MA enrollment.

Those seniors choosing to remain in tradition what I call traditional Medicare or some people call fee for service. They’re actually declining somewhat in an absolute sense, so even as the program as a whole grows.

An absolute number of people in traditional Medicare is going down. So, we’ve encouraged our we’ve been talking to our practice quite a bit at this, if you’re going to be really good at seeing your care. You’re going to have to learn how to do ma and at a clinical level. It’s very similar right. This is the same patients. It’s more, the stars measures getting good at that and getting good at complete and accurate. Diagnosis which is the risk adjustment part of MA.

And as you know that’s where a lot of people trip up there’s some who get tempted and to fraudulent things. We’re very careful to tell our doctors, we’re going to do this, the right way.
You know, and we’re coaching them on how to do that today.