Redesigning Musculoskeletal Care: Insourcing, Data, and Outcomes in Health Systems and Health Plans

If we did kind of some creative math, it looks like we spend about $600 billion in MSK. When you go to a clinic, you have a resource list, right? And I still see that resource list being handed out. I believe that needs to change, right? If you can't come into my physical location at the hospital, these are all the different places you can go at. But did that really happen? Did the patient really get that service? I believe timing is everything. Is this the right time for preventing surgery? So if a patient really needed surgery, preventing or reducing that surgery is a failure of quality too. So it's more about how do we make sure if a patient needs surgery, they get surgery, but if they don't need surgery, they don't have a and welcome to Redesigning Healthcare Unfiltered.

This is episode eight, and we're going to be talking about MSK today. And really the point of talking about MSK today is because probably about three to five years ago that we saw a lot of health systems and health plans and providers make some of the decisions to hand off control around MSK. And right now, as my guest and I are walking through the industry again, we see that some people are trying to pull back that control, pull back that cost of care, pull back that care model, and really take control over it once again. So we're going to walk you through kind of some of the spend in this particular area, some of the whys in this particular area, and then we're also going to tell you how to do it if you're thinking about it, making sure that you have best practices. So again, welcome to uh redesigning healthcare unfiltered. I'm Rihanna. I'm the CEO of Healthworks and I'm your moderator today. Again, we want to walk you through kind of where the industry is. So we're going to use a patient example. I've got two. Um, one, I have an aunt who's 80 years old, and every time she goes to the doctor, she says, Oh, my hip hurts, or oh, my knee hurts. And probably 15 years ago, she had total hip replacement on one side, and she did really well and has been walking completely fine until about about a year ago. And then she had some pain and she couldn't determine herself whether it was coming from her knee or her hip. And so she went into the uh orthopedist and he said, Oh, no, we see that, you know, it's your knee. Why don't we get you some PT? And why don't you come back after about seven sessions and we'll see how it did? And we'll take some images now and take some images later. So she went and took images. She did her PT, which was actually a compliant patient. Yay, Charlotte. And then she went back to the doctor and she said, Oh, you know, so hers still doesn't feel good. And I really can't walk anymore. I'm really having difficulty getting up and walking around the neighborhood. And as an 80-year-old, that's something that we all want to be able to do. So we said, Oh, you know what, maybe you need total knee replacement. And that was a little bit daunting to her. So she said, Okay, maybe why don't we go back and do some more PT? And actually, with about 12 to 18 more visits, she felt really well. She got some of her strength and her mobility and her balance back. So she just kept on going through the motions and doing this. And then after about 13 months of being okay, she was like, Oh, this is really hurting me again. And she went back to the orthopedic surgeon, actually to a different one. And he's like, Oh, um, let's take some images, um, looked at the images together. And he said, you know what, you could just do a partial. And there's absolutely clinical reasons for doing a partial, and the recovery is pretty easy. And so why don't we consider this? And she said, Yeah, that sounds like a better idea. She's now a non-compliant patient because she didn't schedule the surgery, but it's something where it seems like, you know, this is a science and also an art in how do you make your body, you know, continue to age healthfully. And then what do you do? And what are the images showing you and what are your surgeons showing you? And it seems like patients are really in control, and sometimes that's great. Obviously, they they own the responsibility and the accountability. But with MSK, with pain and movement and mobility, we really want to make sure that we have an aligned care team and that we're all progressing in this journey together, and it's really outcome-centric. So we have a challenge in MSK. We've got solution finders, um, like, oh, let's go get surgery. Um, we've got people who are saying, hey, let's strengthen this particular area. Even if you have surgery, it's good for everything to, you know, be strong and mobile. And so there's a lot of different voices when you talk about MSK, and there's a lot of cost. So, right now, if we did kind of some creative math, it looks like we spend about $600 billion in MSK. And so, what I want to do with you now is actually pass it over to Pollock, my guest, to have her introduce herself, but also to help us define what MSK is. And then I'm going to ask her some questions on as you think about what the health plan should be doing around MSK and you think about what the health system should be doing around MSK, how do we really work together so that there's not just different elements of control and different applications of your benefit design, but actually something that drives better outcomes. So, Pollock's my pleasure to introduce you to this organization and this audience, and please introduce yourself.

Thank you so much for having me, Rayanne. It's always a fantastic opportunity when you get to discuss things on an open forum, right? So many folks have so many different ways of looking at things and being able to actually have contradicting ideas and have experiences that work in certain ways and that don't work in certain ways, I think is a really healthy place where we need to be in healthcare. And so, with that, I am Paulik Shah, I'm a physical therapist by training. I have gone through a fantastic journey and I'm really grateful for the opportunities along the way from being an expert clinician and teaching at the residency program at Stanford physical therapy. From there, I had the opportunity to co-found and be the chief clinical officer of an organization, Luna Physical Therapy, which was able to scale to 28 states, 49 metro markets. And the intention there was to really drive access to high-quality care. So what we brought along was outpatient physical therapy in the home and enabling care outside the traditional clinic settings. And I think that drove really, really extensive impact from an outcomes perspective, from collaboration with different partners and health systems perspective. And the idea is how do you look at care delivery in a scalable fashion that is quality driven. Now I am founder and principal at Nurtura Health Solutions. I always thought about how do you step in and out of different shoes as a clinician. And that made me think about the ways I could impact so many lives. And doing that in the same fashion and thinking about all the different healthcare challenges that we are having today and how there has to be a plug that helps significant impact. So when we think about, you know, where's the 20% that can really drive 80% of the outcomes? That's what I want to do with Nurture Health Solutions. I believe in teams that are already out there. And I do believe that the experience and the expertise, if that can provide the 20% plug coming from an advisory standpoint, that can really drive change at a larger scale. So that's what excites me about Nurtura Health Solutions. And doing that for health systems and health plans that are focused on AI care transformation and doing clinical workflow designs that can really scale and drive impact is absolutely the crux of where I would like to stay focused.

So thank you very much and appreciate your insight and appreciate you being here today. So I had the fortune of working with Pollack as she created this amazing, you know, care model and created these extraordinary care pathways. So again, we could actually showcase how the patient moved through the process, moved through their particular care journey and came out, not just lowering the cost of care, but also with better outcomes. And so, as we have been on this partner journey before, right now, as I walk into the offices of health systems and health plans, oftentimes I get the pleasure of talking with the CFO. And he or she right now is a little challenged. Obviously, there's a perfect storm with new regs and all sorts of things going on. Premiums from the government standpoint have changed considerably. Risk adjustment has changed, stars has changed. And so the funding sources for the health plans is very constrained. And also that means that the opportunity to reimburse the health systems is also tight. So as we were part of this journey to move some of the care efficiencies outside of the health system and outside of the health plan, right now we're being tasked. The CFO is saying there's no longer an ROI on this particular initiative, right? So we have to think of new initiatives so that the cost of care I can see from my seat is going down as much as possible. And therefore we can offer better benefits. And we just need to work together to align on this. So the challenge that Pollock and I will walk through with you all today is really so we we got really good at finding different clinicians and different vendors will call them to push MSK care outside of the typical health plan experience, handing it off to different entities to let them run their courses and ensure on our behalf that the member was being taken care of and had the optimal outcome. And same with the health systems, oftentimes they partnered with yet another entity to run some of their care pathways. So the patient population would come from the health system and maybe push through some of their PT and maybe use some of their surgeon, but the clinical design pathways were someone else's. And so now they too have to think about is this driving the right revenue and the right cost structure for us as a health system? So after we walk through what is MSK, we're gonna take kind of alternative sides. Pollock will think about how does a health system maybe look at pulling back some control and bringing this and building it in-house and then running it with their own staff and look at their own capacity and their own revenue opportunities. And then I'll walk you through as the health plan's partner, right? Um, Healthworks has sitting across the tables trying to help them find where you can reduce cost of care or improve member experience, because that's a very important thing right now, and also showcase better outcomes. So, Alec, do you want to give us a little overview and so we can have some parameters that walk us through what you think about is all included when you talk about MSK?

Yes, of course. Oh my gosh, when you think about all inclusive of MSK, it's so many different specialties, right? I'm not gonna actually talk about all the different clinical care providers, but more so when we think about patient-centered care. I believe MSK is a journey if you think about from an MSK patient and thinking about how we all can think about working at the top of our licenses and thinking about how we can incorporate an overarching approach to musculoskeletal care. So if you think about an orthopedic surgeon and if you're only looking at who needs surgery, that's not gonna do justice to the patient. If you're a physical therapist and you're only thinking about, hey, are you improving? Are you not? And then if you're not getting better or we've run out of insurance, let's have you go back to the surgeon, that's not doing justice to the patient either. So, what really is important is thinking about what is the patient's need from an MSK perspective, what kind of services can be beneficial, and how do we provide a comprehensive awareness to the patient so that they can drive that improvement for themselves, which will avoid getting them readmitted, because the only reason why they get readmitted or coming back to different specialties or going down the path of needing an X-ray imaging or surgery is because they didn't know what else I can do about my MSK condition. So figuring that piece out that all the outcomes of coming back to a hospital or readmissions is actually because the patient didn't know what to do. And how do we kind of fill that gap is how I think we can curate the right kind of service offering for our patients. So who has the capacity to do that? Right. And that's where I think that health systems, health plans, when you actually have the ability to look at the care journey from start to finish, you have the ability to paint that picture and make it cleaner, right? Um, so that's how I would look at it is how do you look at it from a patient experience journey of musculoskeletal care? And it's very evident where the gaps happened.

And because some of our viewers might not have always had MSK in their purview, and I think it's over like a hundred and fifty different conditions, walk us through some of the main or the bigger conditions that when you think of it from a clinician standpoint, what's the majority of the conditions that a patient might have that we need to put into this parameter so that we can think about it holistically? And we'll start talking about data in a minute, but just so that we have kind of a common definition of what kind of conditions would push a member into this kind of care pathway.

Of course. Andrea and you use Diane. So I'm going to use Diane's example who went through that knee joint replacement surgery. But Diane actually had once she had her first surgical visit in 11 days. If she was recommended to have surgery, that means she has only done two or three different physical therapy sessions or two or three sessions of PT, which isn't enough time to actually see the outcome. When she was actually pushed back to do more conservative care and she completed a significant course of care, she saw improvement in her function and then was recommended a partial knee replacement, right? So it's less about how quickly the patient needs to have surgery. It's more about asking the right question and embedding the right questions in the pathway before they get booked for surgery, right? So the question can be as simple as, hey Diane, how many physical therapy sessions have you done and have you engaged with it? And, you know, are you doing your exercises regularly? Because that really indicates ownership and accountability, even on the patient's side of things. So making these small changes in the pathway of the health system can really help in identifying and triaging patients in the right time. So if I think about the kind of common conditions, hip and knee joint replacements, of course, get a lot of attention because they are significantly large volumes. If you think about where orthopedics and musculoskeletal physical therapy also happens and conditions happen, spine pain, right? Like cervical pain, upper back pain, lower back pain, sciatica with ridiculopathy or without reticulopathy. And thinking about shoulder injuries. And like we were just discussing, you know, a pickleball wave comes in and then you have influx of pickleball, uh, shoulder pain patients. You have uh workers that have actually been spending a ton of time on the computer and end up having carpal tunnel syndrome. It's all about your musculoskeletal connective tissue, tendon injuries if you're a, you know, a weekend warrior versus somebody who is actually having an overuse condition, right? So something that you do every day or something that you actually decide to do, but your body's not prepared to do. Um, so everything under that roofing is included under MSK care. The reason why it is so, so important is because you can feel it and it impedes your day-to-day operations of your life. And that's the reason why it actually is a significant loss, maybe to an employer, or it's a significant loss in the working capacity of the individual, or the pain and the way it actually impacts the rest of your function, uh, maybe from a mental health perspective, or have you actually drive, you know, your future? So the impact of musculoskeletal care is significantly high on a person. And that's why it's such a big area of healthcare spending.

Appreciate that. And you and I work together very well. And it's important to start with okay, what are the parameters? What are we talking about? And so as we think about in-sourcing this, either from a health system perspective or from a health plan perspective, or maybe realigning how our relationship is with this external clinical entity, we have to start with, okay, this is we've defined what MSK is. And so whether it's, you know, knee pain or hip pain or lower back or arthritis or things like that, what's all inclusive? And then before we get into the fun stuff, the all the AI creation and the creative side of it, I think we really had to pull the data. And actually, you and I work together so we could do this with Wakely, right? So what's the current spend and what's the current prevalence? And what we're seeing is it's it's crazy the prevalence in the population today, right? At every different cohort, it's an issue. It's a significant issue. And I think, you know, sometimes it used to be kind of compounded because of obesity and things like that. So it's something that is very, again, to your point, something that's allows our function, our mobility, and our overall wellness is wrapped up in this particular condition. And so as you think about it from a step one of insourcing, walk us through kind of your thought process. I'll think about it from a health plan perspective. But if you think about it from a health system, if they wanted to really create this cohesive feeling for the patient and from a health system standpoint, keepage is everything, right? We will watch health systems bring things back in because then they can make sure that patient goes through their whole care ecosystem that they've designed on their campus, right? So it is well intended and also purposeful to make sure that their MSK protocols are aligned with their own service offering. So if you want to walk us through from your perspective, step one on insourcing, how do you think about it? How do you ready the team if you're sitting on a health system side?

Yeah. It's a really good way to think about what are our capacities, right? What's our starting point? Because there's so many wonderful initiatives. When you think about care management, it's happening at a very different scale at different organizations. So, an example I would like to give here is when you go to a clinic, you have a resource list, right? And I still see that resource list being handed out. I believe that needs to change, right? We have the right intention that we are going to make sure that you have access to care and that, you know, if you can't come into my physical location at the hospital, these are all the different places you can go at. But did that really happen? Did the patient really get that service? Did they actually improve? I believe that health systems can take on that accountability to actually see if that patient who came into your office, who saw the surgeon at the hospital, who came to your office to receive care, but you didn't have, say, you didn't have an opening, and they actually were handed out a resource list to think about where all you can get that service, not being able to track that patient through that service really doesn't help us drive the outcome of them getting better. So, in my opinion, the way that this can actually be navigated is that care management component should follow the patient as part of the health system's life that is being managed and identifying a collaborative integrated network of providers so that you can bring data back into the health system and actually see the outcome along the way really drives efficiency. If you think about what MSSP programs do and MIPS programs do, that is the intent is to actually have all external providers bring data back into the health system and report it. However, it takes a ton of effort to actually see if there was anything you could influence in that journey. So it's easier said than done. The idea here is the step number one is actually creating the centralized data layer because when you work with different vendors, the first and the most foremost step is to actually see how some of those outcomes can feed into your system. So if you're part of the MSSP program, accountable care organization kind of reporting, it really allows you to centralize that data. But what are we doing with that data and taking accountability and improving the clinical design or the workflow design is actually, I believe, the biggest opportunity to drive a reduced cost of care.

And so to complement that, I'll walk you through what I would have had to do when I was out sitting on the health plan side and the CFAO came to me and said, oh, you know what, this vendor isn't creating the ROI that we need now, go not only create a new kind of member experience care journey from a health plan perspective, but create it as a different cost. So from my perspective, I would have had to walk over to my network team, right, and say, okay, of all these conditions, right, how many PT visits do we need? OT speech or what have you? What do we need? And then who are our top surgeons that can do this with the best outcomes and really start to create, you call it kind of an interdisciplinary team and an integrated team, right? I'd have to do that from a health plan standpoint. And I probably have the right data, right? I could see the right costs, I could see the prevalence in the population, but I can't see, to your point, capacity, right? So then I'd have to start engaging my network and making sure, oh, you know, you can have those mock patient calls where you can see, okay, when are they scheduling you out? Can you get in a week? Can you get in 24 hours? Can you get in in seven weeks for different experiences? And so it's gonna be my step one, of course, is data, looking at cost data utilization and prevalence. But then also capacity data. As we have aging populations and the prevalence in these conditions will only get higher, can we actually handle this? Or do I, from a health plan perspective, need to build a better network to actually service what I'm trying to do? And then later we'll have to make sure that we have uh the components that you've built already is that clinical vision, right? So do we have the right type of imaging inserted at the right time? So there's not duplication of imaging, because that's what I think we saw at times too. We needed certain answers clinically that yes, the PCP said, oh, go get this, but really we needed something else. You know, you got an MRI, you needed a PT or a PET scanner, you got an X-ray and you needed something, you know, more thoughtful. So that's from my perspective. I'm gonna have to do a prevalence and capacity check and a network design kind of element. And then how do I look at this from a cost perspective? Looking at those unit costs, right? Is there an opportunity to kind of create more of a bundled approach or an episodic experience so that we know that the patient is getting everything in an aligned timeline with a particular capacity and access at that cost that the CFO is now telling me I need to be hitting? So it's a little bit different. And then also with like some of the new regs. Now, are we removing some of the authorization opportunities that we used to have two years ago or three years ago? So, do we actually have to teach the PTs how and when to send them to the surgeon a little bit more clearly and help them have a different maybe trigger system or PCPs and things like that? So there's also gonna be an element when the health plan takes control over this of making them a little smarter clinically. And so as we create this, and I'll let you walk it through from a health system perspective, but I'm gonna have to go once I've created this from a network perspective and a cost perspective and a utilization perspective, I need to overlay my clinicians and bring in my care management team, my utilization management team, and look at the rules and regs that have come out. And I'm supposed to be minimizing my prior off. So I actually have to influence care without all the hiccups and hurdles that we used to have. My job is gonna be a little bit difficult. And when you live in a health plan, you need about 18 people in your conference room at all times to make these decisions. So I know it's gonna be probably a three to six month experience just to create this insourcing opportunity that's thoughtful and can hold the capacity of the patients looking to use their benefit in this way. So now I'll pass it and we'll see if it's gonna be easier or harder on the health system side, or if you think we shouldn't even be thinking about this.

Yeah, I think it's a great question, Rayanne, because insourcing of the care delivery is a significant challenge. And being able to give and empower autonomous ability to care delivery and creative care models is where I believe we really, really need to allow that to happen. Especially with AI, you we are seeing a significant trend of solopreneurs. The market is actually encouraging solopreneurs to get their businesses started. So really having the ability to give the care delivery innovation an opportunity, whereas the ability to measure how that is working is where I see as the difference. So, you know, I think bringing revenue in-house is maybe an a motivation of doing the in-sourcing, but thinking about outcomes and thinking about the impact of the patient, the savings of the healthcare dollars is, I believe, a different way of looking at ROI and creating and innovating in the care model delivery side of things. So my thought here is it's a really hard thing to bring the entire network in-house with a health system perspective. But I would love to add a plug on the health plan side, Ray. And like you mentioned, bringing in that clinical angle, I think that would be phenomenal as a provider and a and overseeing a really large distributed care workforce. It was a challenge because when you think about how health plans are overseeing and making sure that overutilization fraud's not happening, I did see a gap of utilization management and outcomes being a completely disjointed process, right? It was really, really hard from a provider perspective to share that, hey, this patient needs X number of visits because they have made improvement. And if you stop at this time, they're going to go back to old ways. So not being able to see a particular service receiving higher utilization, but how it actually helped in the overall reduction in cost dollars was a big gap, in my opinion. And so thinking about clinical pathways, when you think about health plan, care transformation and bringing in a clinical workflow, I think speaks volumes to where innovation and care transformation can happen, because being able to not see of it as individual variables of cost drivers, but really being able to see as the cost reduction in the care of that entire patient would be really where the gaps are lying today.

Yeah, and that's the challenge from a lot of perspectives. One, I think from a regulation standpoint, race push health plans to actually kind of monitor and one, in a way, provide care, right? We have to provide affordable care, access to care, quality care. We're measured on those things, but we're not actually the deliverer of care, right? We're not the actually the clinician. So as people get cranky in the, you know, in the media, I have to sometimes share that health plans were constructed like car insurance, right? Like, oh, you know what? You don't want to have to pay for that accident, all the ramifications of that accident when it occurs. And you need a cost structure that I don't know how much my car engine should cost or the quarter panel. And so insurance was kind of constructed to make sure that we had parameters on here's what you know you should be doing from a care calendar in a way, and here's these are the physicians that could service you at a particular cost. And now, because of regs and because we have to showcase as a health plan quality of care and improvement, we do need to either bend these pieces out, but monitor and have oversight, or actually pull them in-house. And I think, again, the regulations are getting more and more demanding about access and delivery. And so we do need to have these really thoughtful partners such as yourself. And when we go in and sit with the medical directors or client services in a helpline, they do have to understand, I think, these very costly and high prevalence conditions in a way that they never had to before. So to me, we are gonna see, and I think you brought it before, like we're gonna have to have an orchestration layer over our network to make sure that we understand how the patients are moving through. And then we're gonna have to develop also a performance layer, right? So AI is gonna be amazing for all of this, but if we get it too far in clinical, it's gonna be licensed as a clinical device. I don't see health plans pushing all the way into that, like we watch the radiologists and things like that moving to that. We just need clinical kind of guidance and an orchestration layer. And then I think what you're saying is there should be kind of a trigger system or a check-in system to say, oh, what if they had their seven visits and they're still progressing, it might make sense to give them seven more rather than allowing that pain to come back and then they want to go to the specialist. So the health plan, because of the regs, has to get smarter and they have to start telling that story. It's not that they wanted to be smart, they don't want to be the clinician. The regulations are pushing them towards that. And then the health ones are being audited, right, for what are they doing with AI? And did they lessen the prior off situation? Are they paying claims faster? So all this does mean that I think we can, you and I together with others, be more proactive, be thoughtful, make sure that the design is really well thought out, understanding the network layer, the care pathway, right? And then the clinical resources that are aligned and the trigger systems of when each gate, so to speak, opens. And so I think it's an exciting time to have a better, more aligned incentive between the health plan and the health system, even though we're really buying for dollars, but also to make a cohesive experience for the patient because I think they're really getting lost right now. And that's I think what you and I have always tried to avoid is we really need to have the voice of the PT or the surgeon really help them navigate and make critical decisions, but own those decisions because they're going to be responsible for the outcome also. So I think we're in a really challenging time, but it's exciting. And so as we think about what the health system might be doing or what the health plan might be doing, if you were the master of this particular pilot, what would you measure or where would you kind of pull ups? Because you and I actually did this together. And I know that at different points you checked in with the PT, at different points you checked in with the patient, at different points you might have checked in with the surgeon. And so, not just the cadence of check-in of your resources in a way or your patients, but also at the end, what would you be looking for?

Yeah, uh loaded, loaded question. But the way I would look at it is what's the journey been, right? Like as you mentioned, we worked on certain things, and when we work on certain things, we have the ability to actually shape it, design it, to fill in the gaps we've seen in the past. So if I think about the direction of importance that I've seen at as we've implemented or created workflows, is one is excellence. You absolutely start with the right quality of care. Then you think about how do you actually do that great quality of care at scale. Once you've done the scale component, access has been happening. The next tier, which I believe is the time that we are in right now, is timing. I believe timing is everything. And most importantly, the reason being it actually is how a patient approaches care. A patient thinks about their care journey and a patient really engages with your care journey, right? So thinking about bringing excellence to scale. And then once you've had the scale, how do you think about timing? I believe is the place where we are. And the reason why timing is important is it's all about making sure that you have engaged the patient at the right time so that you're thinking about is this right for preventing medication? Is this the right time for preventing an X-ray and imaging? Is this the right time for preventing surgery? So if a patient really needed surgery, preventing or reducing that surgery is a failure of quality too. So it's more about how do we make sure if a patient needs surgery, they get surgery, but if they don't need surgery, they don't. It sounds simpler than you can imagine, especially because the way to execute on this is looking at that data layer. And when health plans and health systems have the ability to look at what has already been used utilized in a fiscal or a calendar year, what services have they received, and being able to layer the different siloed data sets, may it be a data set of utilization, maybe a data set of physical therapy providers, data set of surgery, data set of imaging. How do you actually bring those layers together and look at what a common and a baseline storyline looks like for that MSK population in your health system? And how do you help do that care navigation? I really liked and would like to pick on the word smarter. Like if we can get smarter, things can happen more real time. That would be a significantly less uh burdensome and significantly less frustrating experience for providers, in my opinion. Because what happens today, I'm okay with you mentioning, okay, let's do seven visits, then let's take a look at, you know, if the patient's progressing, let's do another seven visits. But what happens and how that process happens of applying for a prior odd, seven additional visits, the amount of documentations needed to get those seven additional visits approved really jeopardizes the patient's outcomes. And being able for health plans and health systems to get smarter and actually have that check-in layer in a way that it doesn't impede patient outcomes would significantly help clinicians in delivering the care that they are providing. So I agree. I mean, we got to get smarter and more faster. I do think health plans and health systems have the data. So, how does that get leveraged in the right way to improve timing? Uh maybe timing of how authorization works, timing of which care is delivered when to the patient is absolutely something that can really help in the AI world to make it a better experience and better care navigation.

So I think at times, and you sit down all different sides of the table. So I think if you saw this integration and if if health plans came together with their health systems, and it's gonna have to be local, right? Because care delivery is local, and they did share the data for some of the more common experiences, higher prevalence and the higher cost, there could be an elegance because right now, you know, the only thing that you've mentioned so far is some of the hiccups is prior auth. And what we're watching is do the regs, there's a swath of prior authentic swept away. So the prior auth timing is gonna have a mandate to it. So we can't sit on things. Um, and I just came from an OIG presentation on what they're watching and things like that. So they're not just telling you you have to do things faster or there's no more prior auth for these particular conditions. Um, they're actually auditing to it, and then they're gonna ask you questions as to why things took you, you know, seven days to get to or more. So I can appreciate that the government is stepping in and helping facilitate a cohesive care journey. And hopefully that's the output of what all these regs are embracing the industry to do. But I think as we think about it, because those prior authors are gonna go away in 2027, probably the conversations really do need to happen now is hey, we're not gonna hold you responsible for that prior auth. But now I think the health funds and the health systems are gonna share costs of care and savings of care and things like that. So um there's gonna be some quick discussions on some very interesting topics because I think a lot of health systems do already share in cost savings or um have an at-risk relationship. But I think they're gonna change even more and they're gonna be more specific. And that's just really hard from my perspective when I did sit on the provider side. Is the contracts are so specific, I can't actually do all the things that the contract said. So even if it's not prior off that I'm getting all the documentation to, it's the reporting, like, oh, I can't get all this data to you because your own system isn't tolerating it and we aren't truly integrated. And I think maybe that is actually step one of how we work together as a better industry and be more forced rights, is have all that interoperability. So we can say we can see the patient real time, so we can see some of the outcomes in a way in real time.

But Rihanna, I would like to add a quick plug here. I absolutely appreciate OIG and the federal plans having quality-focused, you know, reporting. Do you see enough happening on the commercial insurance side to actually embed outcome-focused programs and uh network performance measurement based on outcomes, similar to like MIPS? And while they keep like rotating and MIPS already sunseted for the moment, uh, the focus is on outcomes and outcomes collection. So would love to hear your perspective on is that the starting point? Because that's where, you know, merging cost and outcomes data is where I believe the layer needs to happen.

Yeah, I think that's the ultimate purpose of like this podcast, right? I think what we are all missing as we sit around the same table, whether you're a patient or a provider or the health system or the health plan, nobody honestly, from my perspective, is rated on outcome. And so what I see OIG and DOJ doing and CMS is they're touting what happens when you get audited. Oh, we found all this fraud. So it's still, I don't hear, right? Outcome, outcome, outcome. I think that's where we, you and I and the industry needs to move the discussion. The challenge that I've had before was because I, on the helpless side, I might only have them for a year, right? I only watch them through their calendar year. So at times, what's best in that calendar year isn't as from a cost structure. So I have competing priorities. And so we, I think as an industry, need to say, hey, we're gonna just start with certain outcomes of high prevalence conditions, and that's what we're all gonna align to, and we're all gonna share the dollars in this. And what I really see is the patient has to become more aware, educated, and accountable too. Because right now, it's is also the patient bouncing through the system, saying, Oh, these this drug, I have a prescription, I'm not gonna fill it. Sometimes that's very reasonable, sometimes it's not. Um, speaking for myself or my parents, I don't know that they all have the wherewithal to say, oh, I'm not gonna take this medicine because I don't want to feel nauseous. I don't want to feel dizzy and things like that. So I think we all have to become a little bit more health literate, and as you know, it's at like 7%. We also have to increase the quality of our care as we lower the cost of care. So we've got such a long journey from my perspective until we can actually focus on outcome. Because I think we might have had some of those outcome discussions when also it turned to the topic of rationing care. It was like, oh, we're looking for this outcome and we'll give you six of those to get to this outcome. And then we got in trouble in a whole different way. So right now, I think the value story has to be married with the outcome story. And I personally would love to flow up value-based care to make it outcome-centric, right? That's what we should be focusing on. And I don't know that value is actually focused on outcome. So I think the first step in that is let's stop talking about value because I don't know whose value we're driving, right? But we have to think about let's go to outcome-based care and then align the health plan with the provider, with the patient, and focus on that story. Because right now we have so many jumping jacks to do together in value-based care and so many regulations that actually hinder outcomes and costs, right? So we find pharma costs going crazy. Well, did everyone need to be on put on a GLP one? So we as an entity, as a population, also meet need to make our own thoughtful decisions of what do I consider well? And then maybe define it just like we started, you know, today with what's the definition of MSK. So what's well? What's an outcome that will get you to well? And then how do we align what our service offerings and what our benefit designs do to get to well? And that's gonna be a hard decision because it means some things we can't do. It doesn't get you better, it makes you feel better, you know, pain meds and things like that. So it's gonna be a tough decision. And I don't know that we're that sophisticated right now to get to outcomes or to get to well, because we'd have to align, and I don't think we're aligning very well right now.

Well, simplifying health care, only if it was easy.

That's why we're in healthcare, right? We're problem solvers and we just take on a couple at a time. So as we're wrapping up MSK, we weren't talking about replacing vendors or pulling vendors, it's really redesigning the model care, and I think that's where this last journey is that we really need a holistic redesign of care models together. But I know you're doing something super exciting on the cardiac rehab. Do you want to just paint a really quick story? So now we know that we can in-source MSK, both from a health system perspective and a health plan perspective, and hopefully drive better outcomes. But now I know your brain is never sitting still. You're thinking about cardiac rehab, and I'm watching that patient population really challenged right now. So, what are you digging into and what do you think you're gonna find?

Um, thanks for the teaser, Rayanne. I don't have a whole lot to share, but what I'm really gonna talk about is how this year the World Physical Therapy Day or Physiotherapy Day announced about wanting to drive awareness in cardiovascular condition and stroke rehab. And I was appalled and actually intrigued at the same time because could you believe that cardiac rehab are actually not physical therapy CPT codes or billable codes? Um, that was like the fundamental learning. So, physical therapists, when they are providing cardiovascular uh recovery, is not considered cardiac rehabilitation. Exercise physiologists are actually the ones that bill for cardiac rehab CPT codes. And so I will leave everybody with that. I would encourage everyone to look into cardiovascular conditions and how movement science and cardiovascular conditions tie together. And I believe that figuring out cardiac functional recovery is where I'm really, really starting to look into and um think there is absolutely an important area to be considered. The reason why that is so important is because even while cardiac rehab as a formal cardiac rehabilitation program exists, it is very associated with health systems. And only one in four eligible patients are actually adopting cardiac rehabilitation. Cardiovascular conditions, of course, as you know, is the number one cause of death in the country. So the fact that is such a huge area where function and mobility and returning back to life after a cardiac event is such an important aspect of it has really intrigued me in the last few months. And so I'm really, really excited to see where that path leads me.

Well, hopefully when you when you kind of have a sketch of that, you'll come back and you'll share it with us, and then we can teach our audience and those that are aligned here, right? The health system, the health plan, how to really embrace that because I think there is a challenge, right? I think people step away from their new cardiac condition and they don't really know what to expect next. Sometimes the meds are overwhelming. So they think, am I gonna stay in this state for the rest of my life? Or how do I actually get back to the old version of myself before that event? So I'm gonna look forward to that and I will pull this group along. And so with that, I want to thank you for your time. I want to thank you for your insight into how to really think about and consider can we actually pull MSK back into the health system ownership and accountability? Can we pull it back into the health plan, especially with all the new ranks going on? Can we create an easier clinical pathway and easier care journey for the patient? So thank you very much for your time and your expertise.

Thanks for having me.