Provider Quality

Most people choose their providers based off a recommendation from friends or other providers. Every person wants to make sure they are utilizing a top provider, but the definition of quality varies by every oversite strategy. In this podcast we will explore the components to consider related to quality, and how access to that information should help support your health plan. We will debate different prospectives related to quality metrics, reporting structure and how employers can empower their covered lives.

This episode includes guest speakers:
Padmaja Patel, MD
President Elect, American College of Lifestyle Medicin

Nick Reber
Chief Executive Officer, Garner Health

John Ryan
Chief Executive Officer, OrthoIndy

Sandeep Wadhwa, MD, MBA
Global Chief Medical Officer, 3M

Transcript

Vital Incite’s The Pulse Transcript for 03/28/23

Speaker 1

Welcome to The Pulse, produced by Vital Insight, where we keep pace with what's trending and employee benefits. This series was developed to bring together nationally recognized subject matter experts from the health and pharmacy industry, as well as top academic and research institutions. Our goal is to provide unbiased information and offer scalable strategies that give you clarity amid the chaos and provide answers to your most burning questions.

I'm your host, Mary Delaney, managing partner at Vital Insight. In this episode, we'll discuss provider quality. Every person wants to make sure they are utilizing a top provider, but the definition of quality varies by oversight strategy. We'll explore the components to consider related to quality and how having access to that information should help support your health plan. We'll debate different perspectives related to quality metrics, reporting structure, and how employers can empower their covered lives.

Health care quality seems so important. But it is really true, though, that most people are going to decide where to seek care based off of where their doctor tells them to go, where their friends recommend, where they've had a good experience previously, or who is going to provide them. Perhaps the right answer. The reality is, is that quality metric movement has been around for a long time.

More than 20 years ago and has resulted in transparent quality information, accountability and improvements. But health care quality can be defined in many ways, and there are many organizations providing feedback on this topic. If you Google it, you will see how many organizations are involved. The problem is they all have their own measures and opinions. The lack of alignment and measures has contributed to the challenges for clinicians, facilities, insurers and when it comes to prioritizing outcomes that are meaningful for patients.

Unfortunately, also the admin costs related to quality has not been insignificant. Between 2008 and 2018, CMS invested more than $1.3 billion on quality measure development. These are some of the admin burden that we discuss in health care on an annual basis. Physicians in four common specialties general internists, family physicians, cardiologists and orthopedists spend more than $15.4 billion dealing with quality reporting.

It's such a hot topic that even CMS is reevaluating their approach, and the Universal Foundation approach is their new effort to try to implement a less burdensome strategy by aligning quality metrics, making sure their metrics are predominantly looking towards quality, safe and equitable care, reducing the provider burden as we discuss, and then making sure we're reducing unintended consequences, which I'm sure some of our panelists will be discussing.

So with that, I'd like to turn it over to our astute panelists and allow them to give you a few moments to introduce themselves. Dr. Patel, do you mind kicking us off?

Speaker 2

Hello, Mary. Good afternoon, everyone, and thank you for this invitation. I'm really excited to join this esteemed House speakers today signed with major Huddle, medical director of Lifestyle Medicine Center at Midland House in Midland, Texas. I serve as president for American College of Lifestyle Medicine. And this topic is very near and dear to my heart because I represent ACIM at National Quality Forums Leadership Consortium.

For last three years, Leadership Consortium, really whose goal is to define strategy and really define what are the priority areas where the nation should really focus on. So last year, in 2022, we defined social determinants of Health data collection and utilized nation as a top priority.

And as a UCLA member, we get to participate this year in an implementation collaborative. I also serve on security, which is called Quality Measure Collaborative, which is in private public partnership between America's Health Insurance Plan and CMS housed at U.S. And she Qureshi's role is really important because as we move towards value based care models, it's really trying to meet some of this.

I think goals that you just described, which is to find high quality evidence based measures, also aligning measures across payers, private and public and reduce provider burden, as well as reporting requirement burden. So I'm really excited to join this panel and have this discussion. Thank you. Thank you.

Speaker 1

You bring so much expertise to this topic, so we really appreciate it. And Nick Reber, do you mind introducing yourself?

Speaker 3

Yeah. Hey, Mary. Thank you for having me and really excited to be here. I'm Nick Reber. I'm the founder and CEO of Gardner Health. I'm a data and technology person originally, so I ran the research and new algorithmic trading development at Bridgewater, a large investment fund. And then after having some health issues, myself, actually helped get our health plan off the ground called Oscar Health and was on the leadership team there.

And so a lot of my perspective comes from data and technology and then using those tools to improve health outcomes and lower the total cost of care. And the company that I founded several years ago, Gardner, is really centered around the idea that from looking at the data, we can find that the number one clinical intervention that really seems to work to help patients have a better health outcome and lower total cost of care is getting them to high quality individual providers and individual doctors.

And so Gardner is really about that is how do you both measure the quality of individual physicians, but also then how do you make that actionable for for members? So that's really what we do. So I'm excited to be here today.

Speaker 1

Thank you. I know that you're going to give us a different perspective, so it's going to be wonderful to have this conversation. John Ryan, to my introducing yourself.

Speaker 4

Sure. Thanks, Mary. John Ryan. I'm the CEO of Ortho Inde, which is an ortho only health system based in Indianapolis, Indiana, founded 60 years ago as an orthopedic physician practice. We now stand about just shy of 100 physicians in our in our organization. One of the unique features of ortho inde is that we also have both inpatient and outpatient surgical facilities.

And in many ways, our programing spans what you would typically find in a hospital or a health system. We provide orthopedic, urgent care. We provide our own physical therapy and rehab services. We provide our own imaging services. And then, of course, orthopedic surgical intervention when it's when it's necessary. And finally, we staff all of the orthopedic trauma surgeon at one of the two level one trauma centers here in Indianapolis.

So quality is important to us. Like like you've already heard course from my vantage point, probably in three different verticals. One is, as a provider, we want to have high quality physicians. Secondly, as an employer, we employ a thousand people within our organization. And so we want we want quality health care for our employee population through our employee health plan, just like any other employer.

And then, of course, probably more personally as an individual, as a purchaser of health care, both for me and my my family. So quality is as important to me as anybody else. And speaking today. Thanks for having me today.

Speaker 1

Yeah. Thanks for joining us, John. I know how busy you are and we appreciate a perspective on this panel. And then last but certainly not least, Dr. Wadhwa, do you mind introducing yourself?

Speaker 5

My pleasure, Mary. Dr. Sandeep Wadhwa I'm the global chief medical officer for three health information systems. Three of them may surprise you, but we we're very deeply involved with health care payment systems. And so our group develops and maintains across the world different payment systems and quality measurement systems. So very delighted to be here. Formerly was the Medicaid director for the State of Colorado and have been involved with population health, serving self-insured employers for 20 years. And I've been a volunteer geriatrician for coming up at 25 years. Mary at University of Colorado.

Speaker 1

Wow. I didn't even realize all of that. So thank you so much. So with that, now we're going to kick off our panel discussion. And I really look forward to this. As you can tell, we really found experts with various backgrounds because we really wanted to challenge all of the theories out there and really try to come to some conclusion.

So with that, it was so funny as I was trying to prepare my questions because you guys gave me so much information to start with at our little intro calls, but it was probably the hardest thing I've ever had to do, is to figure out how do we fit enough information in this time? So I'm going to start off with a very simple question, and that is with so many different ways to start this conversation, maybe we should just think about in your own opinion, explain to us what the value is for quality metrics in the U.S. health care system and what outcome are we actually trying to achieve?

And Nick, do you mind, since this is what you do every day, do you mind sharing with us your thoughts?

Speaker 3

I think ultimately, if I'm putting myself in the lens of an employer, you know, ultimately we're caring about are we letting our employees lead healthy lives? We really measured the number of sick days and we try to optimize that and make sure people are healthy, living great lives with their families. And then also the total cost of care.

And we've seen that getting folks high quality health outcomes improve. Both of those simultaneous. So you can if you measure it right, you can have your cake and eat it to have the highest quality and that tends to keep folks healthier and lower the total cost of care.

Speaker 1

Next to Dr. Wadhwa, who do you also work in this field? All the time. So what would you what are your thoughts on this?

Speaker 5

Mary? Thank you. I really like next response and I'm very aligned with would I think and maybe amplify next point around one half of this equation to me is just as Nick was saying, really improving health outcomes. And there's many ways to measure that sick days, life adjusted expectancy. But but I think that that the top half of that equation really focusing on on measures of premature morbidity and mortality.

There's no reason why for here in the US our $4 trillion shouldn't be resulting in in the longest disability free life expectancy in the world. The other dimension, though, Mary, is safety. I think that that that what what for me when when when as a as a former purchaser patients employees and their your families go into health care not expecting to be harmed and I think there is more we can be doing on an really tackling and and bringing almost a six sigma approach to patient safety and reading that out in our system in in even a more overt winery.

Speaker 1

Dr. Patel, I saw your facial reaction a few times on that one. So why don't you go ahead and give us some feedback?

Speaker 2

No, I think I agree very much in what has been already said, but I think in addition to quality measures can also prevent misuse, overuse or underuse of health care services, and also help us identify any disparities in health care delivery, as well as health care outcomes. In all that, I think what's so important for quality measures are really for accountability, quality improvement in benchmarking, which the shift towards payment as it's happening in value based care.

You know, quality measures are more important now than ever before, But are most of the quality measures predominantly focus on process measures? And I think that doesn't necessarily move the needle in terms of improving health outcomes. So I think the recognition, I think nationally as well as within CMS, insurers and security everywhere, there's a general consensus around this and we need to know this needle more in terms of focusing on and developing more outcome measures. So I think that's really should be our focus. Thank you.

Speaker 4

All right. All all round it out. I think all the perspective that's been shared up to this point has been has has been very valuable. I was from a public policy perspective, I couldn't overstate the importance of quality in health care. Right. I mean, I think as a as a population, we want we want people to get care from the best and the brightest or the facilities that are that are the safest.

And so anything that we can do to shine a light on on those metrics is good, is good for for the citizens of the United States, the citizens of each of our states. And as I think about it from a from a business standpoint, it gets a little bit it gets a little bit more complicated because I think and this is a bit foreshadowing for where I think you're taking this conversation, Mary, but I, I from a business standpoint, we think of it more in terms of value.

Nick, Nick made this comment. It's it's it's high quality, but it's also matching high quality with low cost. And and when you think about quality through a consumerism of health care, you start to take into account not just the things that we made within our organization find important, like clinical outcomes, like safety metrics. But you also start to take into account patient satisfaction right there, their own individual perspective on whether that experience was a good one or not, which takes into account everything like how kindly were they treated when they walked in the door to the front desk?

And and that's where quality becomes a more complicated dynamic because it starts to interweave things into the conversation that that may have nothing to do with the care that was provided. But really more about the experience.

Speaker 1

When you say that comes to mind, when my mother had a total joint replacement, not in her and your her city, so don't worry about it. And she wanted to rank the facility really high quality because it gave her cake every day and she was pre-diabetic and I was beside myself. That that was what was going to happen in a quality metric.

Anyone else? I mean, I think there were already such great comments like Dr. Wadhwa.

Speaker 5

Reflecting on Dr. Patel and Mr. Ryan's comment that I am I it it so many of the measures we have for excellent disease control, I sometimes get nervous having an unintended consequence in that many of these diseases are preventable. And when we we focus particularly for chronic conditions on our kind of excellent chronic condition management, I applaud kind of the efforts for for almost all of the chronic conditions is on what are we doing in prevention.

But most of these chronic conditions are habits that are tough. I mean, that they don't get established in adolescence or earlier. And I am not going to say that those are are easy. But but when there's a part of me that cries every time I see a hemoglobin A1 metric, which is a metric of of diabetes control, and I think that I pick a number of 50% of type two diabetes is preventable.

And are we creating and holding our our system to to prevention goals, which I think I'm it I get it. There's individual goals, Mary of the people have these incentives but I think we can also look upstream for providers to to to be more accountable. And I just really love John's remarks about and looking at episodes or the the total cost of care, particularly, I think, John, you may have been getting within looking at things with an episode.

And I was just thinking that that risk adjustment or I've found that that conversation can go deeper if, if clinicians believe that their patients are the complexity and severity of their case or their situation is is captured. And I think we've got technologies now that are doing a better job of of of getting that the participation of providers to say, hey, I'll be held accountable for an episode, but, but make sure that you're capturing the complexity of of my my different patient population.

Speaker 1

He wants to attack that when I think you've all talked about how much effort is to click all the boxes so everything is considered. So who wants to go next?

Speaker 4

Well, one thing I don't and I totally agree with Dr. Wadhwa, what you're saying related to the importance of getting as upstream as you can, and particularly, you know, obviously diet and behavior and lifestyle things really important. A couple numbers that we thought were somewhat interesting on this is and so that is a huge part of the equation.

I also think there is and as we quantify real value, once people have a disease and treating it right. So I think those are both true. We see that just given the patient with the same disease going to the top, performing sort of 20% of the doctors in their area versus, you know, spend in the wheel on Google or asking your neighbor adds, you know, the difference there is about two days per year per patient.

So in other words, to sick days is what every patient in the US health care system can get back every time. If they actually if we get these quality metrics right and we treat their disease right. So I certainly agree it's even more than that. If you get upstream and you can totally change someone's life with diet and behavior and exercise and smoking cessation, but even if you just catch it at the point where you have the disease and now you have to find the right provider, it's about two days per year. Per patient is the difference in most of our local communities. So it's a it's a real stakes.

Speaker 2

Dr. Patel So I have to thank you. I need you to know this is a this is a perfect conversation going on, talking about upstream and addressing lifestyle behaviors or lifestyle interventions. So unfortunately and I think this will be very informative to my panel members here, because we all of us who practice lifestyle medicine make this as a as a first line of treatment.

This is what we do, a therapeutic dose of lifestyle medicine. And unfortunately, as you know, there's a huge gap of quality measures. There are no quality measures that allow lifestyle interventions as a first line of treatment. Now, all of you know that if you look at the clinical practice guidelines of all chronic diseases, you know, number one line of treatment is lifestyle intervention.

And unfortunately we completely skipped that and jumped to prescription as an intervention as a society. And even our current framework, whether it's managing diseases, whether it's quality measures, whether it's performance measures. How incentives are tied, this is all what we call as chronic Disease management, right, but not necessarily chronic disease remission. And Russell, which is what all of this clinicians who are trained in medicine are really doing on a regular basis. So there are real consequences of bringing this as a line of treatment. And often clinicians get penalized for not using, say, for example, a statin drug for hyperlipidemia. And it affects obviously their, you know, star rating.

And even though outcomes would be awesome right. So even though, you know, a patient's lipid trial isn't even in the normal range but the fact that they use lifestyle intervention instead of statin, it penalizes it. So the system has to really catch up to this idea that there are clinicians, there are, you know, who are using lifestyle interventions and doing the right thing. Yes, we haven't necessarily created the right incentives that would align with.

Speaker 1

That's those are the unintended incentives or outcomes that come from this. And I know we see in our data that certain PBMs really put, you know, restrictions on their pharmacies that they have to fill a drug. Well, the sad thing is those people may not need that drug anymore and they get dinged if they don't fill it. So, again, those unintended consequences.

So, John, you are managing a whole practice of people using these types of strategies. Is there anything, any flaws that you see in the approach that you can suggest?

Speaker 4

Well, maybe just a comment about kind of the lifestyle management before I, I kind of dive into the deeper aspects of of quality management. I, I, I can't speak a whole lot to lifestyle management. We're, we're in the business of fixing, fixing things. Right. We we our version of that is is probably tied to people that would come to us and in for instance have have our idea of chronic issues in orthopedics would be that they they're they've they've eventually gotten to bone on bone and they need they need some sort of surgical replacement Maybe it's a new shoulder, maybe it's a new hip, maybe it's a knee.

We know as an organization that clinical outcomes are far better in relationship to the lifestyle of that individual right. If that person presents to us as as obese, that that's going to mean a different outcome. And that surgical intervention that if someone comes to us who is not and that's just one example of of of a handful of of things that might influence outcome but it but as we start to dive into quality it it it it does it does sit with us that we we don't want to only fix the people that have the health that allows for for the higher chance of of a good clinical outcome for fear that if we we

don't do a surgical intervention on that someone who's unhealthy that that the quality outcome will be lower. Well of course the patient presented at a lower health before they arrive. So there is a kind of a natural tension that exists even in orthopedics. As it relates to that, I think more broadly in terms of flaws, it really starts to get into who the the inconsistency, Mary, that you spoke of at the outset around how we define and we measure a quality right there.

There is an inconsistency. We measure quality internally differently than CMS measures our quality as an organization, which is different than probably the way that NIC measures our quality as a as a provider or as as our physician, as our physicians perform, which is different than press Ganey which is which is measuring satisfaction, right. How how satisfied was the patient?

And it's the conformance of all of those that really creates a lot of confusion in and in dare I say, some danger in the market because you can end up going to a provider that has that that checked some box in terms of some quality metric. But it may be it may be that that quality metric is inconsistent with what you were really looking for in an organization to choose to go and get care from them.

And and so while I think there is this this this importance to to the need for us to be measuring quality, the inconsistency in how quality is defined and how it's measured presents real challenges to a provider like Ortho, indie or other providers like us. Even outside of orthopedics.

Speaker 1

Anyone else? Very good.

Speaker 2

If I can add just a couple of comments for positive notes in response to what John just said, and it's it's a reality. You know, we have way too many quality measures and there is no consistency across different stakeholders. And I think this is why the Universal Foundation, which is proposed by CMS leaders, which was published in New England Journal last month, I think it looks a good start.

I think it's a great beginning for us to create that a small group of measures which is consistent across all CMC programs and hopefully other commercial payers as well. So I think there is a recognition and hopefully we will get to that point where we'll have some sort of standard panel of measure say we will be measuring everything across. So thank you.

Speaker 1

And then that will give us give all providers the ability to improve to because they'll know what they're aspiring to improve with.

Speaker 5

I worry a little bit about about alignment. So so I and I think I think what Nick was getting at maybe maybe speaks to I think some aligned perspectives from from an employer and even from a patient sometimes on an alignment effort. You kind of get the parties to settle on kind of week to week like, like what everyone can agree upon and and what everyone agree upon, you know, may not may not be the tastiest of teas.

I get that. My nervousness, Larry, is is that that it it ends up being something that that providers and that that this is a negotiation between providers and payers and that the perspective that I think you know John and Nick and others were saying about what matters to patients around their values, whether it's safety or sick days and are we pushing ourselves to to expect more from this system.

So I think get that that there are some there are some questions that that I'm watching and looking at as we move towards financial alignment. You know, I want to see us really move up and feel good that we're moving up in in in disability for years and productivity and independence. And I'm not sure, Mary, that that I'm seeing that from this effort.

And and I also wanted a corollary to the next point, which is sometimes it's easier to measure the poor performers. And I think there's a corollary to next point about the high performers. I this is a mistake that the governor's office what what was our initiative going to be for next year? And I said I wanted to be the second healthiest state in the country.

I know, like that idea, it was a horribly rejected and I and I tried to argue with that, that too much pressure being number one. And that's the real difference between one and two here. But everyone hated it. But but there's something about it may be easier to find some of our outliers who are poor performers and give them the feedback or give me the insights on, wow, this complication rate is 40 50% higher, this readmission rate, this E.R. visit.

And so I that may be a way I just really like Nick's comment and thought there may be a mirror image of of trying to the light, but maybe also helping helping folks know and getting back or thinking about network design on on who are the folks that seem to be a standard deviation below performance.

Speaker 1

I love that comment because I think John Ryan, when we were speaking, you said you felt like every buddy, the normal consumer thinks that if your provider was put on your health plan, they must be high quality. So my question to you all, because we're starting to think about this from the employer perspective, is, is it more important to go to the very highest quality provider or stay away from the lowest quality provider?

Speaker 4

Yeah, I'll jump in. I mean, I mean, when I when I think about when I think about health care through the employers lens, cost is a is a pretty important component, right. I mean we're we're all battling with health care costs that are out of out of control. And so I as an employer I wait I wait cost but but at the same time, there is a there's a value proposition with cost, right?

If you if you have an employee that that ends up with a provider that is low quality, even if that call that provider is less expensive, it may actually be more expensive. Right. And so and so you're you're trying to find a good balance between measuring quality in terms of the care of the provider and also the cost associated with that with that care.

It it it won't do good for us to bring down health care costs if all that the you know, the best and the brightest at what they do get are charging two times the amount that that that you know the person that's in the 95th percentile tiles charging or from a quality perspective. So it is a conundrum now from a provider, just a real brief comment about it through the lens of a provider.

All this inconsistency in quality really causes us to to apply a bit of a shotgun approach right? We we aspire to have excellent patient satisfaction. We we aspire to have great clinical outcomes for worker's compensation. We aspire to get our get those patients back to work as quickly as possible. Right. So because everybody's looking at it a bit through a different lens, I mean, I think everybody's at in a 10,000 foot level's aligned.

We want top quality care for a lower for a lower cost. But when you start to get into the weeds of of the perspectives through these different lenses, it just everybody may balance that proposition a little bit differently. And as a lifestyle.

Speaker 2

Medicine clinician, I would say my fellow clinicians who are really delivering, you know, lifestyle medicine is an inherently high value care. It costs very little. You are empowering patients to make lifestyle changes. You're putting chronic diseases in remission. But does doesn't mean you have a higher five star rating. Not necessarily. So the way we are being measured, it sometimes backfires.

Actually, I know we have a doctor around us. I have to say this when it comes to risk score, that is an additional challenge, said lifestyle medicine. Clinicians are facing in value based care models right now. When you put your accounting to system mission. So for example, diabetes into remission, it lowers your risk score, it lowers your incentives, right?

So it lowers your even the MSP calculation. So the question is should saving goes down. So the current framework that we have creates, again, comes down to managing disease and not necessarily reversing or putting into remission. So I would say we just don't we have a very flawed system right now and we really cannot fully rely on that typical clinician.

Speaker 1

Unfortunately, it's the definition of quality, which I know we didn't solve for that here. But you know, that is what we're people are trying to get to. So any one final couple seconds here, anything else we need to share before we close?

Speaker 4

Mary, If we solve for qual the definition of quality, this would be a very valuable podcast. We may all be in Ireland together. I agree with Dr. Wadhwa.

Speaker 1

I have a quote from you that I still remember when I first met you, and that was that pharmacology is the art of selective poisoning. I think you said that all care has risks. Can you just kind of explain that a little bit more?

Speaker 5

Oh, sure. Mary, thank you for bringing that up. Yes, that was the first line of the first day in our second year pharmacology class in medical school, the professor had our full attention and opened up with pharmacology is the art of selective poisoning. And and Mary, obviously it stuck with me 30 years later and it, it it it was such a powerful statement and it really, really imparted this sense to me about the thoughtfulness that goes into prescribing medicines that that we we there's side effects and adverse events and as I went through medical school, you begin to appreciate that all therapies and even many diagnoses come with risks and and that that so much

of of the art and science of medicine is is being aware and cognizant of those risks and and needing to make a decision and and so I think that that that lesson for me was was powerfully conveyed and and and internalized. And as I think about that, Mary, I, I think about that. It's oftentimes hard to see risks and harms a at just the patient doctor level or in that that these patterns may be very hard to discern one on one.

And so I think I've kind of further extrapolated that point too, to really be part of of efforts to look at risks and harms at a population level. And and it just it's always struck me that that those are areas where we can learn that some of these risks are just back to the statement they are intrinsic to that that the test the diagnosis or the treatment that if they're happening higher than expected, then then let's learn and see how we can improve. Mary So I thank you. It's nice that that quote made an impact.

Speaker 1

It certainly did. You have made an impact in my life, so I have really enjoyed even preparing for this. I hope we can work together more in the future. There are so many things I have heard throughout this and I try to take notes to see if I can help wrap it up. So what I've heard is that since we hope to move from a pay for procedure to a paper for performance approach, the topic of evaluating outcomes is imperative.

But what I've also heard from our panelists are a few different things, and there's quite a bit here, so I appreciate everything that you all have shared with us today. The correct measure for quality are critical, but these are still being revised because we are likely missing the mark. Everyone is agreed that improving health care quality will be will reduce the incidents that create more costs and risks, like Dr. Wadhwa just suggested.

And Nick has suggested that we need to figure out how to get people back to work and function sooner. Then I also have noted here that the current approach provides significant administrative burden to our providers, which then of course adds to the cost of health care, which we know is a big issue in the United States without adding value.

That's what we call medical spend, waste and our vital insight world. So we're always looking for where the medical spend waste is. So we need to reduce the number of measures that are used and then well-defined, those that are most imperative and then provide those to the providers so they have a clear understanding of how they can move forward.

Because if they all get better, the whole system gets better, then we need to watch for unintended consequences. I think John pointed out that surgeons maybe select who they're going to do surgery on based off of trying to grab the healthiest patients because, of course, then they're going to look better, get better bonuses, etc.. But is that really going to serve our society?

Or Dr. Patel pointed out that as providers are being penalized or that providers are being penalized for helping people control their risk or their disease without medications, because some of our measures are everybody should be on a drug if they have diagnosis, which of course we've just heard drugs can cause also other side effects. And aren't we all going to be better off if we can get people off of drugs and helping them control their disease?

And then we also heard that there's an issue raised for our providers that if they're improving the risk of people, they're not going to get paid as much. And isn't that the ultimate goal is to improve the risk of the people that we're working on? But when we do a pay for performance, those performance dollars are based off of the risk of the population.

Instead of looking historically, what was the risk and did you actually prevent them from getting riskier, improve their risk, which is really the ultimate outcome? And then John talked about an experience of care being critical to get people engaged in the right services at the right time that really focus on the triple aim approach. And then certainly everyone is agree that it's imperative to provide good quality at a price it provides value.

The low hanging fruit for employers is to move people away from the poor providers where we see secondary costs related to sepsis readmissions, revisions of surgeries, etc.. So I think Dr. Juarez suggested, and I think I'm going to steal this line from you also is is our goal is to have the longest disability free life expectancy at the lowest cost.

And wouldn't that be great if we could get there? So in summary, I think employers should address provider quality cautiously. The assessment of quality has to evolve to get us all in a better place. And then thank you, though I do want to thank all of you Nick, John, Doctor, Doctors Patel and Wadhwa for what you've added to this conversation.

It's been fascinating. There's been an invigorating discussion that I'm confident will help everyone gain better understanding of the complexity related to this issue. So thank you all. And then lastly, I want to share with you that our next episode is managing specialty medications. And the question is, do we move these specialty meds between PBMs? Do we keep them under the medical plan or are we looking at place of service?

And I think there's a lot of things we're finding and strategies that have proven to be incredibly impactful. So I hope you'll join us in May for our next podcast. Thank you very much for joining us today. Have great day.