Featured Guest: Kal Wahab

What he does: Kal is the Chief Administrative Officer at Oregon Health and Science University in Portland, OR and has over two decades of experience in health care, including 15 years in a combination of leadership roles on both the payer and provider side.  At OHSU he is responsible for serving Medicaid members in the Portland Metro region and as the administrative lead for the MSO in the Office of OHSU Payer Strategy, serves clinicians in a Clinically Integrated Network participating in an MSSP ACO and various Medicare Advantage and commercial value-based care arrangements.

On risk: "Risk is one of those things that, especially underwriting risk for a population, that somebody has to take the risk, right? It's either the payer or the provider, or maybe potentially even the member, unknowingly … Sometimes it can be like a hot potato. People want to pass it around to somebody else and let them manage it. But I think the reason it's important to prepare for managing risk as a healthcare provider is that the days of being able to get your fee for service increases and the payer just leaving you alone those days are behind us. As a provider, you're not able to afford to not pay attention to this anymore … Preparing for it is probably the best way to go, instead of hiding your head in the sand and delaying it and prolonging it, because I see the danger is that if you prolong your preparation for this, for managing risk as a provider, you'll get to a point where a more advanced model would be imposed on you, and you may not have a choice, and you would be ill-prepared for managing that risk at that point."

Transcript

Scott Nelson  0:01  
Welcome to The Risky Health Care Business Podcast, where we help you prepare for the future by sharing stories, insights, and skills from expert voices in and around the United States health care world with a mission to inform, educate, and help health care organizations and individuals, ranging from one doctor practices to large integrated systems and organizations throughout the dental, medical, and veterinary health care industry with risk, while hopefully having some fun along the way. I'm your host, Scott Nelson, a guy that grew up in Ohio and has been working all over the United States during my 20 plus year and counting career in the health care industry, with a commitment to accelerating health care performance through creativity, not just productivity. Let's dive in.

American health care is an ever-evolving landscape where managed care plans stand as a pivotal force and sculpt the way services are delivered and reimbursed. These plans are not just a component of the system—they are the backbone, intricately weaving together patient care, provider practices, and financial sustainability.
Managed care contracts dictate the terms and conditions under which healthcare providers deliver services. These agreements outline everything from the scope of services to the payment models, significantly impacting how care is accessed and administered. For providers, negotiating these contracts is crucial; they define reimbursement rates and influence operational decisions, directly affecting the financial health of practices and hospitals.
Reimbursement, the lifeblood of provider economics, hinges on these managed care contracts. Reimbursement models have evolved, shifting from fee-for-service to more innovative value-based care frameworks. This evolution aims to improve patient outcomes while controlling costs. Managed care organizations now emphasize performance metrics and patient satisfaction, aligning financial incentives with the quality of care provided.
The influence of managed care is vast and multifaceted.  And comes with risk.  Risk for the provider, risk for the patient, and risk for the payer. 
In this episode I'm speaking with Kal Wahab about managed care and payer contracting as a risk in health care.  Kal is the Chief Administrative Officer at Oregon Health and Science University in Portland, OR and has over two decades of experience in health care, including 15 years in a combination of leadership roles on both the payer and provider side.  At OHSU he is responsible for serving Medicaid members in the Portland Metro region and as the administrative lead for the MSO in the office of OHSU Payer Strategy, serves clinicians in a Clinically Integrated Network participating in an MSSP ACO and various Medicare Advantage and commercial value-based care arrangements.
Prior to OHSU, Kal's managed care organization experience included administrative roles at Aetna and Kaiser Permanente. 
His career has focused on delivering results on the promise of the Quadruple Aim, facilitate value-based care-enabled payer/provider collaboration, generate and harness value, align incentives, and create mutual accountability for the success of all lines of business. Let's talk with Kal about managed care and payer contracting risk in health care.
Kal, welcome to the show.

Kal Wahab  3:01  
Thank you, Scott. Nice to be here.

Scott Nelson  3:04  
Before we begin talking about risk in managed care and health care, let's go back to the beginning. How did you get into health care and where you are today?

Kal Wahab  3:11  
I don't think I ever imagined growing up not being in health care in one capacity or another. So, you know, I always thought I was going to be a dentist, and then that, you know, when I learned more about dentistry, I'm like, no, I want to go to medical school and then learned more about that and decided my area of interest was probably more around policy and population health, more so than being actually providing one-on-one health care. So that's kind of what shaped, really, my career. I, in that capacity of supporting clinicians, provide the best possible care for their patients, kind of became my goal. To that end, I've worked both on the delivery side for large systems like Kaiser Permanente, now at OHSU, Oregon Health Sciences University, and then also to understand the other side of the coin, as I would say, I'd prefer not to call it the dark side or the light side. I joined the health plan in the side of the business and worked for about 10 years in a couple of different health plans in the value-based care space to understand how to impact population health and provision of care to the patients and really supporting providers from a payer perspective. So yeah, spent the last 23 years almost half and half on both sides of the coin.

Scott Nelson  4:27  
I'd like to start our conversation with some terms that we'll probably use and discuss, and you actually already said one of them. So I'd like to get your thoughts around terminology like value-based, at-risk, downside risk. What are important terms that doctors, professionals, and health care organizations need to know and understand in the managed care and payer world?

Kal Wahab  4:48  
Good question. I feel like value-based care, to me, is an umbrella term that encompasses any sort of departure from fee for service medicine, where volume is king, and you get paid for just doing things. So under that umbrella there's different kinds of programs and incentives that you could put together that are often contracted outside of the fee for service contracts. And this includes quality metrics people may be familiar with, like HEDIS measures that measure population health screening rates and things like that, or how well populations of certain conditions or what disease conditions are managed by a provider system or a health plan. So aside from quality, may include utilization metrics. So your ER rates, your inpatient rates, your generic drug use rates could be part of the incentives that are in a value-based contract. It could also have the component of shared savings, where you set a financial target for the cost of the population, and as a system, you try to mitigate those costs, and if you come in below that target, then the health plan will share those savings with you. It also includes a version of that would then be the risk model, or the downside risk, which was one of your other terms. So risk comes into play in a couple of ways in value-based care contracts. You may be like in the early stages of your journey in the risk space, or a payer will put you the incentives that you could potentially earn for your quality work at risk. And so like, if you meet certain targets, like you get to keep your quality incentives for managing the population that you would have earned, but if you don't meet some financial target, for example, I may not pay out on the quality metrics. So that's really kind of looking at the total cost is the measure, but then paying you out or putting your quality payments at risk. And so that's kind of one way to do it. Another way to do it is really to put the total cost of that population's care in setting a target and putting you at risk for a portion of it. And so generally, in early stages of relationships or maturity, you know, the payer would put you at maybe 20% of the downside risk. So if you lose, if you're above your target by a million dollars, you're only liable for the first 20% of your share. So that's kind of one model. 50% is another model later on, and then in some advanced relationships, you know you could have full upside and full downside. So if you save $2 million you get to keep all of it. You don't have to share it. If you lose $2 million you have to pay up all of it. So it really depends on where you are on the spectrum, and the relationship that you have with a payer, and the market dynamics and kind of where you stand with that payer in relation to, like, the size of your organization, etc. So those are some key terms that I think it's good to understand the differences.

Scott Nelson  7:44  
Now with those models, specifically the at-risk, the downside risk, are those current day versions of previous models, such as capitation. For a while years ago, you didn't hear much about capitation. Now I am hearing more about it.

Kal Wahab  8:00  
I would say there are significant differences between the past models of capitation. I believe in those models, there was not a lot of nuance. It was really not a lot of focus on quality. It was just shifting the cost in the revenue to the provider, and really just staying out of it for most payers. And I think that's kind of one of the downfalls of that model. The current models really try to be more comprehensive. They include a quality component, and it's starting to include a patient experience component. So I think there are a lot gentler versions of that, and I think especially having that quality lens as part of the overall program it really lends itself well to differentiating this from the past models, and I think that's probably why I would say there's more acceptance of it, although over the years, I've noticed that we have not made as much progress, probably because of some of those lingering thoughts on the provider side about the relationship to capitation as I would have liked to see over the last 10, 12, years. But yeah, there are differences. I think it's not one size fit all, not really just putting everything on the provider and walking away. I think it's a very more, very much more of a collaborative model. And we'll get into some of that later on in the discussion hopefully as well on kind of what that collaboration looks like now.

Scott Nelson  9:27  
How do you view and think about risk in managed care and payer contracting, and why is it important to plan and prepare for it?

Kal Wahab  9:32  
The risk is one of those things that, especially underwriting risk for a population, that somebody has to take the risk, right? It's either the payer or the provider, or maybe potentially even the member, unknowingly. So I think it's one of those, sometimes it can be like a hot potato. People want to pass it around to somebody else and let them manage it. But I think the reason it's important to prepare for managing risk as a healthcare provider is that the days of being able to get your fee for service increases, and the payer just leaving you alone at that, those days are behind us. CMS is a leader in this space. It has been a leader in this space. And they've set a goal for 2030 that they want all of the Medicare lives and most of the Medicaid lives in some sort of a value-based care program. So as a provider, you're not able to afford to not pay attention to this anymore, and you would have most providers have already heard it from their payers, or they're in some sort of a value-based care contract. So it's not something that I think will go away. And so preparing for it is probably the best way to go, instead of hiding your head in the sand and delaying it and prolonging it, because I see the danger in that is that if you prolong your preparation for this, for managing risk as a provider, you'll get to a point where a more advanced model would be imposed on you, and you may not have a choice, and you would have you would be ill-prepared for managing that risk at that point. So it's better to get started, get your feet wet and start assessment and preparation.

Scott Nelson  11:06  
A lot of the conversations that I have with providers, whether or not they're doctors or hospitals, look at the hot potato and who's has the risk involved in it and it's not necessarily a shared risk model. So it's either going to be the payer, the patient or the provider. It's in every sector of health care. It's a physician in a medical group. It's a dentist in a dental group. We're in an inflationary situation right now, and their expenses are going up, and managed care and payer contracts have gone down, stayed the same, or possibly have increased 1 to 2 to 3% over somebody's last contract that they may have had. So where is the risk in managed care and payer contracting for doctors in health care? What are some of the areas that they should be concerned about? There are a lot of things that go into these contracts that the payers are looking at, and I'm sure that you look at within your work, things like actuarials, there's underwriting, there's a lot of different things that go into this.

Kal Wahab  11:59  
As a provider, as you seek higher and higher reimbursement from your payers, even if they accommodate those requests, which payers are seeing that and you're also, as a result, seeing a lot of payers and providers not coming to agreement in time, and lots of threats of termination are out there. You read about them all the time. When you get more reimbursement, it increases your total cost of care. So as a provider, you may be getting the fee for service increase, but if you're in any type of value-based program, and you're taking some sort of a risk, you know, like we talked about, about total cost of care potentially, well, if you're a high cost provider, you're not paying attention to utilization, you're actually setting yourself to fail on the value-based care front, as far as managing risk. So I really, I think it's a double edged sword for providers to increase and continue to, I understand where it comes from, I understand the cost of staffing going up. Technology has not been as much of a savior in health care in terms of reducing costs and taking work off of people's plates, so definitely familiar with that, but it's definitely some danger in becoming a high cost provider because of inadvertently charging more money for your services because you're trying to make ends meet on the fee for service space. So you really have to think about the whole picture and how you're setting yourself up for risk, managing risk down the road. That's the important part.

Scott Nelson  13:25  
Setting this up is the whole picture and taking that perspective. Let's talk a little bit about the process. So generally speaking, what does an overall process of this look like? Is the process starting off is the process different if I'm a doctor and a one to two doctor practice or versus an organization the size of yours that you work at? You hear a lot of times, economies of scale, strength in numbers. If I'm a one to two doctor practice, those doctors usually are telling me that they're not getting the rates, they're not getting the reimbursement, they're not getting the revenue that a larger type of medical group. What does that process look like from a starting point?

Kal Wahab  14:01  
If you're a relatively small clinic with just a handful of providers, you're not really going to be on a payer's radar for a value-based care or incentive program, because none of the metrics probably make sense at that sample attribution level you may have, and maybe that's one of the terms we didn't define earlier. So attribution is assignment methodology that payers use to assign members to a provider into a practice. So if you're a small practice, your attribution may be very small. Therefore any metric you want to have you know, whether it's rate of screening, whether it's looking at your diabetic population and how well they're managed, you're not going to have enough sample size, and so you're not going to be on the radar. So this really value-based care really starts making sense when you have 10, 20 providers in a practice. It also makes a lot more sense for primary care type practices because they don't own the additional assets where you know if they try to reduce cost for hospitalizations or inpatient procedures and things like that, or doing diagnostics in the inpatient setting or a higher level of setting, they're not losing that revenue by diverting that care. So they really set up better for value-based care, from my perspective. If they have a few specialists, then that are all philosophically aligned with that primary care providers in that practice, they also have a lot of leverage and inability to succeed in these types of programs. I feel like the larger systems where the hospitals and the diagnostic components of those hospitals and units rely on revenue to sustain themselves and their staffing levels, I think those are more at-risk or less well situated to do well in a value-based care setting, and that's a challenge I've heard from CFOs and others, including, you know, in our my own organization as well. How do you transition a system that depends on volume and fee for service to seamlessly to one that is getting compensated for value. So it's a very challenging place. As far as how the process works, there's payers that do it well, and then there's payers that don't do it well. I've had this learning by just talking to providers that I was trying to engage with to get them into value-based care arrangements. And so I'll tell you, kind of how my philosophy is, and then kind of what I might have heard from those providers others do. It's very, very important to, you know, reach out to the providers and not just be talking to the contracting team, but engage the clinical leaders in the practices, in the health systems you want to talk to. So from the get-go, engaging the clinical leaders, operational leaders, and the contracting folks in teams is the best practice, you know, to start and really be curious about their capabilities, about what they do well, what their challenges are, any programs they might have already participated in, what those experiences have been like, really just understanding and getting a better sense for how you could help them to be set up for success in any type of program you put in place. And so you have to have flexibility in your programs and have a little bit of plug-and-play capabilities so that you're not using the same boilerplate model across the board, across all your networks, across all your providers, because that's definitely a recipe for failure, and you will miss out on engagement from the practices. So you have to listen before you bring a model or idea of a model to them, because they have to be reasonably assured that they will be successful if they make an effort in a program. Nobody's asking for a guarantee, but they have to know that you're not rigging the game, because often, from a process perspective, to get into your question a little bit, these value-based contracts are brought in along with the fee for service discussions, and so a payer will tell you, I cannot give you a 5% increase. I can give you two and a half percent or 3%. You're gonna have to earn the rest of it through this value-based care program. So it's usually in conjunction with those fee for service negotiations. That's kind of been my experience. And so then you sign the contract, you start the performance year, say January 1, which is very typical. Some models have payments that come in monthly or quarterly for a piece of the work so that you can kind of clinics can operationalize some of the work efforts that they need to put in place to be successful. The big chunk of the money may come to you eight, nine months after the year's over, because they have to do all the claims run out and everything else to make sure that the performance periods claims are all accounted for in the total cost, for example. So if there's a shared savings component, you're not going to see that money. Some payers will advance after, like, say, six months of experience looking at your performance year, they may advance you a portion of your shared savings with the assumption that you're looking good so far. We think that this will stick towards the end of the year. So it's a long process. Sometimes these incentives are so paid so much later that in terms of like engagement in having people do the work now to potentially get paid way down the road, it's a very difficult proposition for clinics and clinic leaders to expend their valuable resources on programs, and so the pairs have to be aware of that, and have to make sure that you're at least providing some sort of remuneration for the work along the way, so that you're not asking the providers to wait forever to get anything that they might have earned. 

Scott Nelson  19:45  
What is that work using that January 1 if that's when the effective date for a lot of these contracts happen. So let's work backwards from there. So if I've got a contract that we've negotiated, we've agreed to it, when does that work start? If this is like a lease for your real estate, for the space that you're in, and you sometimes will start negotiating that a year before the lease comes up, for these contracts, when should you start looking at those and begin engaging with the contracts? And then what's the work? What do these groups need to be doing to be prepared for those negotiations and have that information to show?

Kal Wahab  20:21  
Excellent question. I don't think you can start early enough because holistic conversations where you're really trying to understand each other and what you can do for each other to be successful, they will take time, and they can take time, so I really feel you want to give yourself at least six months from the start of the conversation until the fourth quarter of the year, where you may be like working on executing the final red lines, in preparing for 1/1. In my one of the best practices that I learned over time in my value-based care implementation work was really having a kickoff meeting with the providers in December, November, December, really kind of helping them understand here's what I'm going to bring to the table, here's the kind of data I'm going to bring you, I'm going to orient you to some sample reports, and we're going to talk about how we're going to clinically support you. So a lot of that work can be started in the clinical and operation team. Operational team should definitely be engaged in the quarter before your effective date. And the health plans cannot share any data with you, specific to your membership or your attribution prior to the 1/1 effective date. But hitting the ground running on that 1/1 date is critical, especially for certain lines of business, for example, Medicare Advantage. Immediately once that 1/1 date comes in this hypothetical, you want to start reaching out to your members, because you'll have, at that point, you'll get a list, within the first month, reaching out to if you have risk stratification in your in the list that you get, you can start reaching to the higher risk members. If you have members that are new to you, to your practice, for instance, but they're now assigned to you through this payer, you can reach out to the new members right away, bring them in and start evaluating them, evaluating them, getting to know them. If they have any coding and documentation work, you can start doing that early in the year, not waiting until later, just being proactive in your outreach is a great way to start your contract. And then from there, you have ongoing reporting you're going to get from most payers, and some report packages are obviously better than others. And then you'll have, this is a pretty much an industry standard, for the most part you'll have what they call a joint operating committee meeting. You'll be a JOC. Sometimes you have joint executive committees that are more at higher level folks, but the operating committee generally clinical leaders, like medical director type folks, operational leaders that run clinics and clinical resources, care management folks, you'll be meeting throughout the year on a quarterly sometimes monthly basis to gauge your performance and to track it and to ensure that you're going to be successful. So there's a lot you can do before even your effective date. Give yourself six months, and then there's the work, then once it starts it really doesn't and shouldn't stop because population health management is ongoing and responsibility, in my mind.

Scott Nelson  23:22  
As you're sitting in these meetings, and where you're coming to the end of the process and you're going through red lines, you're negotiating some of these pieces, are there things that can be negotiated in addition to rates? So for example, can process be negotiated? Prior auths are a big thing these days. Can prior auths be negotiated so that certain things do not require a prior auth or that the timeline and the expectation of responsiveness for those things? Can those pieces be negotiated within these contracts?

Kal Wahab  23:50  
That's a very thoughtful question. Absolutely. I think, in my experience, anything can be negotiated, including like stars, and HEDIS targets, so depending on the sophistication of the provider and how far they may be from those safe clinical targets for HEDIS measures, they may negotiate, at least in their first year, a lower rate, because the rate that stars four or five star HEDIS rate might be unachievable for them. So absolutely, I've seen that. I've done it myself. You can accommodate the providers because your goal is to get them engaged in this work. Your goal is not to set them up to not succeed. The worst thing you want to do in these meetings is to come to them repeatedly showing non-performance or lack of performance or poor performance, and then the meeting is over, and then the provider just goes and does their own thing, and you do your own thing, and at that point you might as well not have value-based care. So definitely, you want to negotiate everything that would help you help the provider. The challenge here is that sometimes the payer doesn't really have the ability to stop a process that they use for every single encounter, or every single provider, every single patient in the market and so but even then, I think to your point, prior auths is one of those examples that you can ask for it in the beginning, but it would make more sense for a payer when you're taking 100% of the risk, like, say, for example, you're in a more advanced model, payers will be more open to bypassing that process, because you know, if you're authorizing care you're on the hook for it so they have less concern, and they want to enable you to do that, but if you're a smaller provider and not don't have enough volume, you're not taking risk, some of those processes are hard to get rid of and negotiate out. Now one can argue some of those processes that are put in place are just barriers. They're not really data driven. They're not as effective because most of the time they authorize most of the care anyway. So then, why are we doing that? I think that's a valid question. I think that's a question you can raise with your payer partners. But the challenge there, again, is that most providers will are not very choosy about who they partner with. They will take a lot more plans than they probably ought to take. And so I think one of the things that I've seen in the market, that I really appreciate is payers really being more selective about who they partner with for these kind of value-based care spaces, especially as you if you're interested in this journey towards taking more risk, all payers are not created equal. So I think there's definitely reasons to pick and choose and kind of have a select group of payers where most of your membership is going through those contracts. And so on the other side, like on the plus side, that also gives you an ability to earn more incentives and have more of your population be part of the incentive programs, and then having fewer payers and having fewer metrics as a result of those VBCs, it gives like it makes it more consistent for your delivery system to operationalize those contracts so you're not tending to 20, 40, 50 different metrics. You have your consistent set. You know that you negotiate with your key payers just to enable to do it more successful.

Scott Nelson  27:15  
There's a lot of groundwork here that's needed to get this working and throughout this entire process. You mentioned the term partners and both sides working as partners in this. Looking at potential obstacles, what are some potential obstacles even working as partners that may come up throughout this process, and what actions can doctors and organizations take to try to work through those and overcome those obstacles?

Kal Wahab  27:39  
I think one of the obstacles that I've seen is just like a natural resistance to more full transparency, even for things that you think would be okay to share, is just a little bit of resistance on possibly both sides, but maybe potentially a little bit more on the payer side to be more transparent, more open. And so like I see a lot of like things that could be hashed out if there was more transparency, more engagement could be garnered from the providers if there was more transparency. So I think that's one of the barriers. The other barriers is like things that require an investment, say, for the provider to pull put together an infrastructure for population health, right? So they may need to get an additional module for that electronic medical record, for example. So if you need that investment made, and you're not going to get paid for it right now, you may, you may earn some incentives down the road, over the course of multiple years, those the ROI for that like often doesn't pencil out, and that's one of the reasons a lot of CFO type folks, finance folks, are resistant to investing in these long term plays within the health system, provider systems to help them be successful. And so I think payers can do a lot in that space, as a partner and as a collaborator to help with some of those investments. They have mechanisms where they can front some funds to the providers to make those investments, and also for things like bi-directional data exchange, which is critical for both the payers and the providers to share information kind of behind the scenes without a human touch, those require an investment. And so I think that's where another place where you see a lot of things fall apart. And, you know, people don't achieve what they really could achieve as together, because neither side is really either able to or willing to make that investment to improve that collaboration. I think at the end of the day both sides have to be to realize, on the payer side and the provider side, that they're in it together, and they both say that they're doing this for their member or their patient, and they just need to keep that more in mind as they have these conversations, because I feel like sometimes they forget that part, that you're doing this for the patient and the member, although they their ads and their brochures will assure you that it's all they care about those things kind of fall to the ground sometimes in the middle of these negotiations on who's going to pay for what infrastructure potentially.

Scott Nelson  30:08  
When you talk about 10 to 20 providers, are you counting advanced practice providers as part of that 10 to 20 or are you just thinking doctors?

Kal Wahab  30:16  
I definitely don't think just in terms of doctors, because the reality is that advanced practitioners are key care delivery, and they can, especially in some states, they can do so much, almost the same level, and at times, maybe even better than some providers. So I counting all of those as well. I think the one distinguishing thing that I would like to state is that some payers attribution model may not attribute members to those like, if that's a like, if that advanced practitioner is not a paneling provider, for example, if they don't manage a panel of patients, then they don't kind of count, because you cannot assign members to them. So it just impacts that clinic's ability to have the volume that they need, because that practitioner is not seeing a panel so that they won't have the attribution. So that's the only distinction.

Scott Nelson  31:08  
When you mention investment I'm also thinking about groups and models, and not necessarily investing dollars into a practice, because a lot of dental practices are less than 10, there's a lot of medical practices consolidating, there're groups that are coming together, so they may have that 10 to 20 providers. But going in the direction of integrated provider associations, integrated physician associations, years ago groups would come together that may have one to two to four, whatever kind of physicians less than that 10 to 20. And going back to what I said earlier in the conversation about economies of scale, they would group together to have that strength in numbers, so if these groups these days fall under 10 what are their options that they can begin working on to try to improve their situation from a contracting perspective?

Kal Wahab  32:00  
That's a really good point. And I think one of the unfortunate things that I saw, at least early on, when I was in this space working with providers groups, is that sometimes the payers discourage providers coming together, because they really into IPA type organizations, because they think that, oh, they now have more clout and they're going to want more money. And so from a value-based care perspective, that's very disappointing, because to your point, that's exactly what these providers need to do. They need to come together and collaborate and share the investment in the resources needed build the infrastructures, gain benefits from the economies of scale that are resulted when they know that five or six providers, times 20 practices come together, and they hire centralized resources, care managers, nurses, MAs, and invest in population health platforms. And so I really feel like payers need to encourage more of that and not discourage but the problem is if you have the fee for service contracting folks in the midst of these conversations, they don't like to negotiate value-based care but I think it's important, it's definitely important.

Scott Nelson  33:07  
Thinking about a specific area or specific issue within contracting, coding and billing. We started getting into this more during Covid and that's virtual care visits. And payers, the government started introducing and opening codes where providers were able to bill for a virtual visit. In my experience providers used to not be that interested and that open to having virtual visits. Covid really changed that to where I think a lot of them, once they began to experience it, they noticed that the patients like it, and then they began to like it a little bit as well. Now there's a back and forth between the efficiency and the cost reductions and the expense associated with that, but over recent history now, as things that begin to change and go back to how they were pre-Covid, some of those codes have been pulled back, so physicians and medical groups have not been able to bill for those services. What are your thoughts and how do you see that going towards the future?

Kal Wahab  34:07  
Great question. Like everyone else working remotely, like patients, more patients experience working remotely, and their comfort with videos and online type platforms that allow those meetings, but also visits. I mean, I think that was a really good trend. I mean, I was really optimistic that it would lead to lower cost and better outcomes, potentially even more access, especially in rural areas, so I definitely think there's a lot of value in either the payer through a vendor solution or the provider systems themselves, having some sort of a capability in the telemedicine but a couple of challenges, one you already alluded to, it doesn't necessarily bring the cost down, so you may give a different type of experience to your patient. They may appreciate the ease and the convenience, not having to get childcare or commute in traffic. So all of that is great. I think where operationally some of the challenges are really around making sure the right patients, especially this happens a little bit more when you have, like, a payer that has a vendor for telemedicine right where you can just call in for urgent care type stuff. So making sure the right patient is the patient is the right patient for that type of an encounter. So that's key. I think getting the right person on the screen in front of the provider. Not every situation, not every patient is going to be comfortable with that. And especially when you think about it, if somebody needs interpretation services, things like that, it gets complicated. But the other part like where it doesn't automatically result in savings is that often they drive follow up care anyway. So you're then sent to some other setting, potentially, you know, an urgent care in person, an emergency room, etc. So it doesn't really kind of one and done the issues as like a potentially a hands on visit would. So the follow up care can drive in a lot of folks that do telemedicine, unless it's an established patient and it's with your own PCP, if I don't know you that, well, I'm gonna err more on the side of caution and recommend that you go get seen somewhere else more in person. So that part I've seen a lot and so it drives that but also for health systems to operationalize it within their already access-challenged clinics to have providers be up and running and kind of doing this, along with in-person visits, there's a lot of operational challenges with it as well, to make sure you give a consistent good experience. And so I think there's a lot of potential there. I really hope it stays as some sort of modality for us to deliver care to especially remote areas or occasions where a patient is not able to come in. So I'm delighted that there's more open minded providers about it, providers that are willing to participate in the program, but yeah, I mean, I don't know if it's a panacea for some of the challenges we're seeing in access and whether it's going to resolve that or not. 

Scott Nelson  37:09  
Looking back through recent history, what are some lessons learned in managed care and payer contracting and looking forward, what do you see as trends and potential issues that individuals and organizations should be anticipating and preparing for?

Kal Wahab  37:21  
As far as lessons learned, the biggest lesson is that if both payers and providers are not into this 100% that this is going to be a slow, slow journey. I've seen over the last, since 2013, so 11 years, it very kind of marginal improvement in where we are and where I thought we were we're going to be. So I thought we were going to be a lot farther along 11 years, 10 years down the road. But it's a lack of engagement on both sides. And you know, everybody's one side is waiting for the other and the other side is waiting for the other side. So I feel like from a lesson learned perspective, if we're going to go, if we're going to be serious about this journey, and moving along the spectrum from fee for service, volume based healthcare to a value-based care, we really need to work together. And I think the key is the more payer provider collaboration we have the faster this journey will be, the more we will be able to trust each other. I think one of the lessons that I still affecting, including some of my leadership, is people have been burned on one side or the other, often on the provider side, by these programs that were placed on them without that conversation without really understanding system capabilities, and that people didn't do well. And so we cannot do that. We have to make sure we have appropriate programs and we set people up for success in these programs, because that also held us off a lot, going backwards. Looking into the future, everybody obviously is talking about staffing and how difficult the cost of staffing is, or retention, morale, all of those are definitely key parts of the challenges we're going to be facing and addressing over the in the future. There's a lot of talk about AI coming in and solving all of those problems. I mean, if you if you listen to a vendor, if you go to one of the big national conferences, you're gonna have 200 vendors in the basement of the hotel telling you how they can solve all sorts of problems with AI and natural language processing and all of that. I think they can help but at the end of the day it's some of the more simple things that we're not addressing in providers in clinics, workflows that are barriers to the morale and to the fatigue and presenteeism, absenteeism, all of that we're not getting to the fundamentals. Like one of the joke I used to use is one of the use technology in health care is the telephone, like picking it up and calling a patient to talk to them, engage them, bringing bring them in for care and see what we can do for them. That doesn't happen very often, and you know, maybe potentially, AI could make the call for you, but, but again, it's really those simpler solutions that we need to address. And the other thing is, we really need to think about, what do we take off the providers in the clinic's plates? I think we have heard that we just keep dumping things on providers, especially primary care, and until we take things off of them at their plate, they're going to be in this chronic state of exhaustion, low morale, staffing challenges and people quitting that we've seen. So I really think that we need to become focused on the simple things that make their lives better and take things off their plates. That's kind of what I think will be the future. 

Scott Nelson  40:59  
That's a great point to conclude our conversation. Kal, thank you very much for your time and sharing your thoughts and experiences today. I really appreciate it.

Kal Wahab  41:06  
Appreciate the conversation, Scott. Thank you.

Scott Nelson  41:11  
Thank you for listening to The Risky Health Care Business Podcast. You can listen to all episodes from the resource center page of the SpringParker website, springparker.com, or click the Listen link in the show notes to listen and subscribe for free on your platform of choice. And remember, accelerating health care performance is achieved through creativity, not just productivity.