Value-Based Care Explained | The Future of ACOs, Medicare & Healthcare Policy

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Hi, I'm Gary Jacobs and this is Policy Prescriptions. Today
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we're discussing how value based care moves from an idea
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to reality. Policy Prescriptions is powered by Health Speirian, a
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health policy consulting firm that helps organizations navigate Washington with
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data driven insight and strategic guidance. In my book The
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Zen Lobbyists, I offer a mindful approach to transforming healthcare
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in this country. On this show, we cut through the
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noise to examine what truly drives health policy, focusing on
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the underlying forces and strategies. My guests today are Aisha Pittman,
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the Senior vice president of Government Affairs at the National
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Association of Accountable Care Organizations, where she leads the organization's
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advocacy and thought leadership efforts, Rayke, and Taro a managing
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partner at Hellespirian, where he leads a team of policy
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professionals in the development of comprehensive policy analysis, advocacy strategies,
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and legislative solutions. Aisha, Welcome to the show.
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Thanks Garry, thanks for having me. So I've great to
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be here.
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I'm so glad you're here. And Ray, what a pleasure
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to have you and give color comicary to the real
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world of value based care and where we're going from here.
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Thank you for joining.
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Thank you, I'm thrilled to be here.
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So why don't we begin the conversation by trying to
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explain to those listening what we mean when we refer
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to the notion of value based care and a practical
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approach to how you implement value based care in the
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country today through accountable care organizations. Aisha, in your role
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as head of federal policy at the National Association of
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Accountable Care Organizations, who I've worked with you for years
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at what a pleasure to have you. Can you kind
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of give context to the beginning of the conversation where
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we go from here?
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Yeah, I think you know, when people hear value based
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care and they think, what is exactly that does that mean?
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I always say, it's really about strengthening the patient and
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provider relationship to achieve better health outcomes and avoid negative outcomes.
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And so while that also sounds very laudable, what does
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that mean in practice? It's really about rethinking how we
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pay for care and shifting resources on where we spend
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dollars so when providers are held accountable for the costs.
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They think about ensuring that patients are getting the right
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care at the right time, in the right setting, and
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that shifts where we pay for costs. So if we
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think about sort of the alternative of fee for service,
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that is where providers are, you know, it's patients come
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in for a visit and they feel like they might
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not always have the tools and the time to help
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patients navigate across the whole broader healthcare continuum. What value
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based care or accountable care does is really shift time
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and resources so that those providers can really be the
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quarterback for the patient, have full data on the patient,
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help them navigate, help them achieve the best outcomes, and
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ultimately lower costs. And when they're able to successfully do that,
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they share in those savings of lower costs, and then
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that allows them to reinvest in how they design care
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for patients.
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So, in the context of your work and the contents
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and the context of what you just described, you have
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members and you your employees give a trade association. Correct.
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I think a lot of people really don't understand how
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the relationship of trades work in Washington at times. So
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knowing that, in our first podcast, we talked about the
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democratization of lobbying, and we're lobbying can go to a
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broader population out there by providing real time data and
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information to people doing the hard work. Can you give
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a little perspective on your members and what they're trying
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to do to change the system. And then Ray as
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having clients that are members of Ayisha's trade association, how
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that fits together?
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So, Nathos, we say we represent providers of value based care.
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That's a broad set of folks. So it is health systems,
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it is individual, small practices, is large multi specialty practices,
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but it's all of the providers who are really thinking
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about how do we shift costs and better care for patients.
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And so I just always say I represent the folks
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who are all across the country doing the hard work
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of implementing this, and my job is to think about
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how we can make their lives easier.
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That's great, thanks and Ray from a client perspective, you
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have many clients that are members and nicos and other organizations.
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The hard work is getting their applications done, helping them
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operate these very challenging systems. Can give a little view
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on that.
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Sure, So I would take a step back and say,
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even before the applications, it's helping them understand what the
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options are, so helping them understand what the new models
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are and how that may work for their practice. And
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it's going back to what Aisha said, it's thinking about
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who their patient population is and thinking about who they're
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trying to serve, who they're working to serve, who they're
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already caring for every day. And then when you put
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that into context for them, then they already understand that
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they're providing value to their patients, but making the connection
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of how these particular models are actually going to pay
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them differently, have different incentives for them, and then have
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help their ability to really provide care for their patients
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and to provide them the data that they need and
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to support them in the care that they're providing every day.
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So it's getting them to a point where they're making
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the connection of how this model can be helpful to
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them to their patients, getting them to the application, and
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then through the implementation phase, also listening to them of
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what their experience is because we all know that these
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models when they're first rolled out, they have some stumbling blocks.
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Oftentimes they need some course correction along the way. And
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so from hearing from our clients better understand and then
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can help inform CMS and CMMI of what changes may
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need to be made, what improvements can be made over
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the years, so that we can ultimately get these models
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improved and then ideally scaled over time so that then
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they can be made available to a wider population not
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only of our clients, but of others that can potentially
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participate in future years.
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That's great, Thank you, Ray, It's a good summary you
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just came off of. And I attended your national meeting
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in Baltimore, your spring meeting. It's always a delight to
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be there. You had a session with CMS representatives like
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the alphabet soup of the new models and the organizational
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components of how AHHS and CMS are collaborating to create
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these models. Can you kind of give a sense to
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the direction that you see us moving now and was
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it different from the last administration or do you see
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this moving quicker? Where do you see is going from here?
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Yeah, I think we're at a really pivotal point with
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the overall shift from fafer service to value based scare.
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One of the things that we highlighted at our conference
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in traditional Medicare is more than fifty percent of beneficiaries
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or an accountable care relationship. And then when you look
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across MA commercial Medicaid, we see over thirty percent adoption.
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So the movement is here. It's no longer something that
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is so forward looking. It's here, it's now. I think
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from our conference, what I really took away with a
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lot of our CMS partners is that it's not just
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the ACO program that we're focused on now, it's really
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thinking about how you put an insert value into all
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of the things that our CMS is doing. So always
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have really great, amazing relationships with our CMS partners that
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are designing the specific ACO models and other value based
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care models. But this time we also had representation from
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the Center for Program Integrity. There's a recognition that acos
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are really really help them with identifying fraud, waste and abuse,
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and the data that in on the ground knowledge that
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they have the providers and acos have can really help
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support those efforts with CMS. We also had this CMS
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Chief Health Technology Officer. They're talking about the health tech
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ecosystem and a lot of those aspects of the health
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tech ecosystem is how do you get better data to
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patients and to providers for the overall goal of improving
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outcomes and lowering costs, which is what value based care is.
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So I think what I really took away from the
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energy of our conference last week is we're at this
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point where it's not just ACOS is this program that
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everyone likes kind of good, but it's value based care
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across all aspects of healthcare.
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You know. The other thing that I noticed, he shows
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that even in the sessions and the breakout sessions, there
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were CMS people, some of them had worked for me
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in the past, of them have worked for you in
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the past, and they're leading a lot of this transition now.
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So one of the most wonderful things that I love
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about the work we all do is we get to
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mentor people and watch them evolve and grow. And now
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some of those people are leading these various program initiatives
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at CMMI and CMS, and it's just so wonderful and
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heartfelt to see that happening. And right, I know, you
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see that a lot. You've employed a lot of people
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that have gone back and forth to CMS and CMMI.
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We absolutely we often joke that we're a feeding ground
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to CMS and CMMI. Which is a good thing. We
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like to be able to say that, but yeah, I
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mean it actually is. It's great because you know, we
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get the opportunity not only to have them, well they're
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here with us, work with them, and they get to
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know our clients, the issues that we're focused on, the
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populations that we particularly care about here at the firm,
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but also then when they're over at CMS and CMMI,
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I mean we see them, you know, working through these
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models and building these new innovative approaches to care that
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really reflect a lot of what they were doing here,
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but it's taken them and sometimes a little bit of
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a different direction, adding different spins on them, and it's
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just it's fun to watch. I totally agree.
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Yeah. The other thing I wanted to just kind of
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get into a little bit on the model's side is
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that many of us, you know, embraced the ACO movement
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early on and have been leaders in its growth and evolution,
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and it's been such a joy to be part of that.
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Now we're to transition through the models at CMMI, where
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a lot of us were in what was called a
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CEO reach and now we're in we're moving to ACO lead.
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Can you kind of give a perspective from an industry
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standpoint of what that looks like from Reach the LEAD
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and how are your members reacting to the new model
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and what are the good and the bad and the
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ugly of it.
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Yeah, I would say overall, there's so much excitement about LEAD,
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and I think it addresses long term challenges that we've
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seen with ACO. So just the biggest piece around sustainability
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for folks who don't know. When you're successful at an
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ACO and then you read you your contract, you are
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penalized for that success and your overall budget to manage
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patients is reduced because of your prior success, and LEAD
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is tackling that head on in a number of ways.
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It's also thinking about the fact that acos have not
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always historically brought in more of a complex medicare beneficiaries
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and Reach tested an approach for bringing in high needs,
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complex patients, and now it's done in a much more
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expansive and integrative way in LEAD. And then the innovation
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center models have always just been a little bit more
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innovative than MSSP, the permanent ACO program, So tools that
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let you really redesign care and fully move away from
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fee for service so we're excited about a number of
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varying capitation options. That's important because it's an issue of
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cash flow, and capitation has been proven to be a
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really successful approach to get away from managing to the
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CPT codebook but allowing providers to just care for their
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panel of patients the way they see fit. Then on
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top of that, they're really thinking about how do we
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bring specialists into the model. Acos are a primary care
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driven model and that is important and never going to
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change about it. It's primary cares are quarterbacks for patients,
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but how do you integrate and bring other providers along
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the continue into the ACO and LEAD is really thoughtfully
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thinking about that with the KARA CMS administered risk arrangements
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that will allow acos to think of ways to incent
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specialists for participation in accountable care. So we're excited about
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all of these aspects of LEAD, which really signal a
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sort of next iteration, next generation of accounta care.
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What I loved at your conference again was the integration
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of the CMMI people that are making the decisions on
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what the model looks like and the people in the
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field who are, you know, debating should we do it,
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should we not do it, which the risk and then
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they go to a group like Healthspirian and say, okay,
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help me navigate through this. So Ray give a perspective
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on what that means. And I think one that comes
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to mind that you and I worked on together was
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like the American Academy of Home Care and Medicine, and
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they were advocating to be involved so much as taking
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care of the most the sickness of the sick of
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the most chronic people that stay at home, and doctors
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come and do house calls and nurse practitioners come and
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provide care. You were central to the advocacy of getting
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them a better place in the lexicon of ACO options.
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Maybe you can give a little story on that.
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So a lot of these models, I mean they reflect
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an evolution of other models as well. So the point
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you're mentioning, Gary, I mean independence at Home was one
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of the first models that was tested, and it was
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it went on for many years. It kept getting extended
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and saw some great successes, but that was focused on
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those providers that were able to go into the home
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and what we see in ACO reach, but especially now lead.
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It took a lot of the lessons from Independence at home,
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but also it took some time to be able to
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figure out how this model could work for providers that
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are going into the home because there are some restrictions
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to what providers are able to do in the home.
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So working with cms to better understand what needs to
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be adjusted to be able to reflect those providers that
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are providing care in the home that looks a little
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bit different than office based practices and making sure that
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the model takes those into account is it takes a
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lot of work and a lot of conversations that are
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happening because even if you're looking at the same population
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of patients, the way in which the rules are written,
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the way in which the requirements, all of that needs
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to be worked through. And one of the great values
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of the LEAD model now that we didn't mention, is
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the fact that it's a ten year model. Because of
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the fact that it's a tenyure model, which is also
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one of the great attributes to it, is that will
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also allow greater time to be able to make these
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types of adjustments so that over that ten year period
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we can see those improvements that need to be made
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because we're not going to be looking at a really
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narrow window for us to prove success before the model
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either goes away or has to be up for determination
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as to whether or not it can be reevaluated to
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be able to continue because as we know, especially as
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we're thinking of a high needs population, in order to
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be able to see any sort of improvement in their care,
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in order to be able to save costs, it's going
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to take time for all of that to be measured,
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and having a narrow window like two years or five years,
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you really can't get there. But having a ten year
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period will actually allow us to be able to do that.
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So that's kind of the excitement of being able to
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work with groups like the Academy of Home Care Medicine
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or many other groups that really want to be.
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A part of models.
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It takes time to be able to figure out how
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to kind of make these adjust these models so that
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they work a little bit better for different provider types,
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so that they can also be a part of them,
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because again, they're caring for the same types of patients,
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they just maybe caring for them in a different setting.
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And it seems to me that there's been a interesting
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evolution of people from the industry going to CMMI and
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CMMI people going back to the industry, and it seems
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to give more of a robust appreciation for the challenges
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and difficulty of making models work and that the people
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that are actually executing on the models that are being
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created at the Innovation Center are true to form, to
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really have It's not just the business, it's the passion
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behind it to transform healthcare in this country. And that's
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what's so exciting to me that you you know this,
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it's like a warrior mentality in a good sense of
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getting up every day, advocating for what you believe in
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and having a place to go to say, is this
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embodies so much of what I believe. Let's make it
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happen and then you actually can do it. An old
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boss of mind used to tell me Gary's strategy is great,
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but vision with that execution is hallucin and stop hallucinating
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it get to the real work. And so I get it.
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At it's nice to strategize, but it's really difficult to
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do the work. And everybody that's doing the work, hats
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off to them because you're moving the needle forward and
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transforming healthcare in the country, and that's really a beautiful
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thing to watch let me go to a little bit
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of a shift here and Aisha, we don't rehearse this
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in advance to everybody listening. So I just want you
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to know that Aisha and I do share a passion
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for yoga and meditation and some of the things that
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I've talked about on our podcast. In fact, I did
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not know this, and I was at Aisha's nake COO's
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meeting in the fall in Washington last fall, I believe
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it was, and I was talking to people about my
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book and selling my book, and one of the people
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that worked for Ayisha came up to me and said, Gary,
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make sure you're in the session at nine o'clock. So
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I go into the session at nine o'clock and lo
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and behold, an award is giving out given out for
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advocacy on behalf of ACOS and I was the recipient,
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which was totally a shock and I had no idea.
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And the context of the award was the Cliff Galas
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Award for Advocacy. And Cliff is a buddy of mine
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that I remember being in rooms twenty years ago talking
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about how providers taking risk is where we need to
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go and what an ACO could look like and we
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created the whole idea and model behind it. So it
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was such a wonderful moment. But what was after that
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presentation was done? Aisha then led the group and must
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have been almost a thousand people in the room in
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a subtle little yoga practice with a little meditation at
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the end, and I was so I just wanted to
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jump into your heart and tell you how much I
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appreciated and love that you were ready to come out
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with that, because I know that I've done that a
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lot in my career and people really don't remember the
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details of what you ever talked about. They remember something
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like that, and when it comes from your heart, it's
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so real and people feel it and touch it. And
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I wanted to thank you for doing that.
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Thanks Gary. It was It's funny because it was a
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moment where something changed in our agenda and we were like,
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we're gonna have a little bit of time. What can
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we do? And I was like, oh, maybe we could
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have a mindful moment. I was like, well, I'm trained
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in yoga, I can do this. And so it was
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funny because I think no one on staff had realized that,
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and they are like, what is this? And it just
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ended up being magical. Is there is something about a
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room full of people who work together. I think to
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your point about seeing folks come in and out of
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the administration, going from industry and into the administration, there's
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such relationships built there, both professional and personal. And having
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all of those folks in one room together and then
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breathing together. It's so hard to put words into just
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how it feels. Where you know, we're all connected in
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so many ways, just as humans, but people were really
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really passionate about changing our healthcare system.
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Your influence of spreading, Gary, I just came from an
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event in Chicago, as you know, and they had Sunrise
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yoga one morning, so I think it's definitely happening. This
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was at the National Partnership for Healthcare and Hospice Innovations
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National Summit, and I can't say I participated. My flexibility
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is a little questionable, but I will next time.
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But it's amazing that MAHA as an agenda and the
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strategies that used to be a little out there on
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the California coast and then moving eastward are now becoming
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more mainstream. And honestly, the key in writing this book
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was that I knew my approach to lobbying was different
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than most of my peers, but as effective, and it
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really came down to human to human collaboration. And you know,
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at the end of the day, we're all. Are we
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human beings having occasional spiritual experiences or are we spiritual
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beings having occasional human experiences. At the end of the day,
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we are people that care about each other. You don't
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go to Washington and do this work unless you really
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believe that you can make a difference. And I always
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believe that members of Congress are trying to the right thing.
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They get a little misled and they need guidance, and
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people like us are there to help them understand the
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ramifications of certain decisions that they're making. And it, you know,
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it makes the role of the advocate that much more important.
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And as we've said in a previous podcast, citizens have
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a right to lobby their governor petition their government. And
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there's never been a time when voices need to be
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expressed so that the movement forward for this country continues
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as it is, and we're part of that. From a
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healthcare perspective, you know, making sure that it's affordable, available,
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and accessible is critical to what we do. So as
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we kind of wrap up a little bit here, what
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is the future state you look towards to see in
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the next couple of years. Where do you think this
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all will lead us?
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I mean, I think the future state is again it
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goes back to what I used to say. I mean,
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it's already here in the sense that these models exist.
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I think where we're going to see more and more
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of is the holistic approach to care. And it takes
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me back to what I work with an Osteopathic Association
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for so many years. That's their approach to care, but
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not only looking at medical but also looking at the
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non medical care. So as we think about incorporating more
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of nutrition, physical activity, all of those components. But you know,
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the other piece is that we'll have a little bit
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more of a balancing of you know, where the incentives are,
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how providers are getting paid, the entry points, kind of
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the runways that providers have, so that it's not as
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daunting for providers to enter value based care, and that
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it feels more normalized and that it's not a consistent. Oh,
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here's a new model I have to evaluate. Here's another
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model which is better for me that it seems much
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more calm, and it's not a consistent change, and we're
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starting to see that, especially as we talked about with LEAD,
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and that's going to be a ten year model. So
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having more predictability, more sustainability for providers, I mean that's
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very important as well, because that allows them to be
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able to then focus on the care that they're providing
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to their patients. So ideally that's the that's the approach,
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and that's where we're gonna land.
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Gray. Do you see a world where FIFA service goes
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the way of the dinosaur? Or do you see it
436
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always there?
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Fee for service will always be here in some way.
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I don't. I don't think it goes away in full,
439
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but I do think that we will see a very
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large shift to where most patients will be in some
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sort of an accountable care relationship, but there will still
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be some fee for service.
443
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Yeah.
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I don't reluctantly I agree with that, but I I've
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been watching it as a consumer of healthcare of late
446
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and doing you know, just going through a lot of
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preventive work. I know that I've taken it upon myself
448
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to call my PCP and say we need to have
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a conversation because I visited this doctor, that doctor, and
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this doctor, and I don't know if you're in the loop,
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but I need some guidance from you in that loop.
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So I've become a pre proactive patient. And I have
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a concier primary care doctor because in Northern Virginia it's
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impossible to find a good primary care doctor without it
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being a concier practice. And we collaborate more than ever before,
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and it just become a beautiful relationship. But I've had
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to work it as much as she's had to work
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it to make it work.
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For us right well. And that's the thing that we
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didn't touch on is that from the patient's perspective, I mean,
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even being so dicated on healthcare, being engaged in healthcare,
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having done it for so many years, it's still difficult
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to navigate for a patient like yourself, like myself. And
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so when we think about patients that may not have
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the time or may not have as much information, it
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should be easy for them as well. So having their
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providers in an aco or have them be more coordinated,
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that makes it easier for them also because they the
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patient shouldn't be having to do the hard work. It
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should be made easier for them as well as for
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the provider. So getting to that state, that's actually where
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we want to end up as well.
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So, Yisha, what do you think about future state going forward?
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What does this look like five years, ten years from
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now in a perfect world for you.
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In a perfect world, we would have far more patients
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in accountable care relationships. So one of the things that
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we always look at from NACAS we look at the adoption.
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I already say it's more fifty three percent of traditional
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medicare beneficiaries are in it. I think if we're really
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successful in five years, we're at like eighty percent or higher.
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So really closing that gap of the remaining traditional medicare beneficiaries.
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And to get there, it's sort of putting more effort
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into these programs and making sure the incentives are right,
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supporting practices and providers with the ones that have been
486
00:30:24.720 --> 00:30:27.799
on the sidelines the whole time, getting in and being
487
00:30:27.839 --> 00:30:31.039
able to do these types of arrangements.
488
00:30:31.880 --> 00:30:35.160
So one of the questions, since you raised that, Aisha,
489
00:30:35.319 --> 00:30:41.079
there is a difference between the role of CMMI and
490
00:30:41.200 --> 00:30:46.200
CMS in putting out models and then providers responding, and
491
00:30:46.240 --> 00:30:50.759
then there's legislation, right, So can you give the audience
492
00:30:50.799 --> 00:30:55.359
a little perspective of here's the model world and then
493
00:30:55.640 --> 00:31:00.559
sometimes we want to move a model away from amid
494
00:31:00.720 --> 00:31:05.039
into legislation and what does that look like? How do
495
00:31:05.400 --> 00:31:06.279
how does that get done?
496
00:31:07.480 --> 00:31:11.400
Yeah, So when I talk about MSSP being the only
497
00:31:11.480 --> 00:31:15.440
permanent programs, the only one in statue, and so from
498
00:31:15.480 --> 00:31:20.880
the Innovation Center, we've tested several different iterations of ACOS
499
00:31:20.920 --> 00:31:23.240
and none of them have quite met the criteria to
500
00:31:23.240 --> 00:31:26.039
be able to be expanded. I'm hopeful that Lee gets
501
00:31:26.119 --> 00:31:28.839
us there, but also we don't always have to wait
502
00:31:28.920 --> 00:31:33.279
for it to meet CMMI's charge of being able to
503
00:31:33.279 --> 00:31:38.200
be expanded. We also have an opportunity to work with
504
00:31:38.240 --> 00:31:41.920
our congressional champions to just put more permanent models in place.
505
00:31:42.160 --> 00:31:44.720
So one of the things NACOS has worked on the
506
00:31:44.720 --> 00:31:48.079
past several years is a piece of legislation, the Value
507
00:31:48.079 --> 00:31:50.640
and Healthcare Act, and one of those provisions in there
508
00:31:50.839 --> 00:31:56.960
is establishing a permanent higher risk ACO program that's higher
509
00:31:57.039 --> 00:31:59.920
risk than what's available in MSSP. So that's kind of
510
00:32:00.079 --> 00:32:04.160
of this concept of taking reach and lead aspects and
511
00:32:04.200 --> 00:32:08.720
making that permanent. And so I still think there's some
512
00:32:08.839 --> 00:32:13.039
willingness from Congress to get that done at some point.
513
00:32:13.559 --> 00:32:16.200
I think the other thing that Congress really has supported
514
00:32:16.240 --> 00:32:19.880
with is the incentives for providers to join. So the
515
00:32:20.799 --> 00:32:26.920
MACRA back in twenty fifteen created a APM Advanced APM
516
00:32:27.000 --> 00:32:31.519
bonus or incentive for providers who were in them that
517
00:32:31.599 --> 00:32:34.680
went directly to the practice, not even through the ACO
518
00:32:34.880 --> 00:32:38.480
for participation in these models. We're in the last year
519
00:32:38.519 --> 00:32:40.599
of it. But then the other piece of MACRA is
520
00:32:40.640 --> 00:32:46.000
for clinicians that are in risk bearing APMs, they receive
521
00:32:46.200 --> 00:32:49.200
higher payment. And so this is that first year where
522
00:32:49.240 --> 00:32:52.920
clinicians have a differential payment of being in value or not.
523
00:32:53.599 --> 00:32:57.960
And these incentives have worked, there's some challenges with them,
524
00:32:58.000 --> 00:33:02.519
and so Congress, the the Committees of Oversight, and the
525
00:33:02.960 --> 00:33:07.599
House Stock and Republican caucuses have been thinking about how
526
00:33:07.640 --> 00:33:11.720
do we fix and improve these incentives for the long term.
527
00:33:11.759 --> 00:33:14.160
And so I think that's another piece that's going to
528
00:33:14.160 --> 00:33:17.039
be really critical to closing those gaps.
529
00:33:18.200 --> 00:33:22.799
Do you think that this Congress makes any progress in
530
00:33:22.839 --> 00:33:27.680
that direction or it's just so overwhelmed with the drama
531
00:33:27.759 --> 00:33:28.799
of the day, if you will.
532
00:33:29.759 --> 00:33:33.160
I like to celebrate small wins, So I think we'll
533
00:33:33.200 --> 00:33:39.440
get progress in that there have been numerous hearings on affordability.
534
00:33:40.400 --> 00:33:44.240
They have been thinking about how you insert value based
535
00:33:44.279 --> 00:33:48.720
care across all aspects of healthcare. So even if we
536
00:33:48.759 --> 00:33:52.960
don't get legislation passed or even introduced, I think we're
537
00:33:53.000 --> 00:33:58.279
having the right conversations and the building blocks are in place.
538
00:33:58.319 --> 00:34:02.000
So if we think about MACRA, took many years for
539
00:34:02.079 --> 00:34:05.519
that to get past. Part of the impetus behind it
540
00:34:05.640 --> 00:34:09.039
was getting out of this cycle of the every year
541
00:34:09.159 --> 00:34:12.679
dealing with the SGR. It's a you know, probably a
542
00:34:12.719 --> 00:34:15.119
full decade to get that done. So we're I'm not
543
00:34:16.719 --> 00:34:20.519
I'm not overly optimistic in that it can happen so quickly,
544
00:34:20.639 --> 00:34:25.880
but I am optimistic in that the right discussions, conversations, hearings,
545
00:34:26.360 --> 00:34:31.320
and committed congressional champions and their staffers are in place
546
00:34:31.480 --> 00:34:35.039
to continue the good work and really think about what's
547
00:34:35.079 --> 00:34:36.960
the most thoughtful policy.
548
00:34:38.920 --> 00:34:41.280
I agree with you. I think we're We've done a
549
00:34:41.320 --> 00:34:47.440
really good job of educating and communicating with them and
550
00:34:47.519 --> 00:34:52.440
now it's the hard work of taking the building blocks
551
00:34:52.480 --> 00:34:56.760
and putting it into statute. And I don't even think
552
00:34:56.800 --> 00:35:01.239
it's so bipartisan, it's it's non partisan. It's very bipartisan
553
00:35:01.320 --> 00:35:05.000
because we know we have champions on both Democratic site
554
00:35:05.000 --> 00:35:09.360
and the Republican side, just creating an environment to finally
555
00:35:09.360 --> 00:35:12.079
get it done right. I mean that's where I see us.
556
00:35:13.079 --> 00:35:15.599
Well, my PTSD was kicking in when I used to
557
00:35:15.599 --> 00:35:20.480
said the word SGR, so that happened. But my perspective
558
00:35:20.519 --> 00:35:22.719
is I agree, I think the building blocks are in place,
559
00:35:22.760 --> 00:35:27.559
and I love Congress focusing on the incentives. I know
560
00:35:27.679 --> 00:35:30.280
also from the experience with Independence at Home, which was
561
00:35:30.320 --> 00:35:34.320
also in statute by Congress, is that there are some
562
00:35:34.480 --> 00:35:38.679
potential challenges when Congress puts a model in statute because
563
00:35:38.719 --> 00:35:41.360
many of the changes then have to go through Congress
564
00:35:41.360 --> 00:35:44.519
in order to change the model depending on how it's written.
565
00:35:44.760 --> 00:35:47.639
So we have to be very careful with that, and
566
00:35:47.719 --> 00:35:51.360
so sometimes having the flexibilities of having the model fully
567
00:35:51.719 --> 00:35:56.039
sit at CMMI, from our experience, has been a little
568
00:35:56.079 --> 00:35:59.679
bit more valuable. But they are definite ways that we
569
00:35:59.719 --> 00:36:01.360
can we can approach it.
570
00:36:01.360 --> 00:36:05.599
It's a constant sort of tug and pull of maximum flexibility,
571
00:36:05.639 --> 00:36:10.719
which is what CMMI has versus something that is permanent
572
00:36:10.800 --> 00:36:13.199
and sable. Sometimes there is a benefit that it takes
573
00:36:13.239 --> 00:36:16.199
a little bit more effort to go through rulemaking to
574
00:36:16.320 --> 00:36:20.239
change something, because then it means that there's there's more
575
00:36:20.360 --> 00:36:22.800
if you don't like the changes, there's more opportunity to
576
00:36:22.840 --> 00:36:26.360
slow them down. So I think that's the the uh
577
00:36:26.679 --> 00:36:27.719
that that tullet pole.
578
00:36:30.639 --> 00:36:36.480
Last question I want to raise is money in the
579
00:36:36.559 --> 00:36:42.199
legislative process. You in Washington, we're hearing more money has
580
00:36:42.280 --> 00:36:47.719
been spent in the last two quarters on lobbying efforts,
581
00:36:47.920 --> 00:36:50.880
and healthcare has been the dominant place where the money's
582
00:36:50.880 --> 00:36:55.840
been spent. I ran a pack for several years, and
583
00:36:55.880 --> 00:37:01.599
I know our dust process to be compled and managing
584
00:37:02.320 --> 00:37:05.960
the dollars and going to your employees and seeking funds
585
00:37:06.239 --> 00:37:12.000
to get that done. Where do you see money in
586
00:37:12.039 --> 00:37:17.960
the decision making process for good old you know, walking
587
00:37:18.000 --> 00:37:21.480
around the hill and doing the right doing good by
588
00:37:21.920 --> 00:37:25.320
doing the right thing with the right people and bringing
589
00:37:25.360 --> 00:37:29.599
them to Capitol Hill to educate. Is it all about
590
00:37:29.679 --> 00:37:32.320
money still or do you think just a bit of
591
00:37:32.360 --> 00:37:37.880
a transition there, Because my premise again compassion being influenced,
592
00:37:38.440 --> 00:37:42.800
meaning that when I talk to a congress person, they're
593
00:37:42.960 --> 00:37:45.039
just as human as I am. They have the same
594
00:37:45.719 --> 00:37:50.440
issues with their parents that I have. They have kids
595
00:37:50.480 --> 00:37:54.159
or grandkids like I do, and we all share in
596
00:37:54.239 --> 00:38:00.599
the same conundrums of life right and learning that like
597
00:38:00.960 --> 00:38:04.840
I need to put my mom or dad in hospice.
598
00:38:05.719 --> 00:38:09.599
That's universal. It doesn't matter if you're we disagree on
599
00:38:09.679 --> 00:38:12.480
everything else, but we do care about the end of
600
00:38:12.519 --> 00:38:17.360
life for our family member. So there are commonalities that
601
00:38:17.440 --> 00:38:21.800
I don't think it's just about money buying influence. I
602
00:38:21.840 --> 00:38:28.000
think compassion as a way of influence is a path forward.
603
00:38:28.880 --> 00:38:32.679
And for trade associations who don't have large packs historically,
604
00:38:34.280 --> 00:38:36.159
how do you do that? How do you get through that?
605
00:38:36.960 --> 00:38:44.039
Yeah, I will say from a Nathos perspective, until this year,
606
00:38:44.079 --> 00:38:47.760
we have never done any We have struggled to have
607
00:38:47.800 --> 00:38:51.599
a pack and didn't have funds to actually do any
608
00:38:51.679 --> 00:38:55.119
political donation. So we are just now stepping into that.
609
00:38:55.440 --> 00:38:57.480
And so I think to your point, it is leading
610
00:38:57.639 --> 00:39:02.039
with the best policy, the thing that works most, what
611
00:39:02.239 --> 00:39:08.599
is going to benefit medicare, beneficiaries, patients, the system writ large.
612
00:39:08.920 --> 00:39:13.360
So it is bringing that compassion, real stories and being
613
00:39:13.440 --> 00:39:19.000
really honest about what the intentions are for why you
614
00:39:19.039 --> 00:39:22.800
think something is the best policy. On the flip side,
615
00:39:22.880 --> 00:39:27.199
I will say I don't necessarily think putting money towards
616
00:39:27.800 --> 00:39:32.239
things related to healthcare is always bad. I know some
617
00:39:32.280 --> 00:39:35.639
of those things tracking with lobbying dollars are not just donations.
618
00:39:35.679 --> 00:39:40.559
It also tracks association staff time dedicated to going onto
619
00:39:40.599 --> 00:39:44.840
the hill and educating folks. And these are really complex policies,
620
00:39:45.320 --> 00:39:49.440
so it takes many, many conversations. I have now been
621
00:39:49.480 --> 00:39:52.440
with Nako's for four years, and I did work in
622
00:39:52.480 --> 00:39:56.039
the Accountplicare space Before that. We used to be on
623
00:39:56.280 --> 00:39:58.840
going into an office and just say have you ever
624
00:39:58.920 --> 00:40:01.800
heard of an AC? And so we've done a lot
625
00:40:01.840 --> 00:40:04.119
of the work now where we don't have to answer
626
00:40:04.159 --> 00:40:07.480
that question, but now our questions are, well, let me
627
00:40:07.559 --> 00:40:11.320
talk to you and explain benchmarking, which is really complex,
628
00:40:11.719 --> 00:40:15.320
and why we're asking for this particular change. So some
629
00:40:15.519 --> 00:40:19.119
of that piece about increase in spending is because healthcare
630
00:40:19.199 --> 00:40:22.639
is complex, and so you need an army to be
631
00:40:22.719 --> 00:40:26.159
able to go out there and talk about the really
632
00:40:26.239 --> 00:40:29.880
complex policies and what are practical solutions.
633
00:40:31.159 --> 00:40:35.760
And what I find is that they look to somebody
634
00:40:35.840 --> 00:40:40.039
they can trust, who is authentic and who is genuine,
635
00:40:40.320 --> 00:40:42.880
and you can just pick up the phone and go
636
00:40:42.960 --> 00:40:46.360
hey Gary, hey, Ray, hey, hoy, you shut what do
637
00:40:46.400 --> 00:40:52.079
you think about this benchmark provision in this proposed bill
638
00:40:52.239 --> 00:40:58.000
that Johnny is offering. They don't really know because it's
639
00:40:58.039 --> 00:41:01.199
a lot to put on them, right. I mean, if
640
00:41:01.239 --> 00:41:03.800
you're a Chairman of Energy and Commerce in the House
641
00:41:03.840 --> 00:41:09.199
of Representatives, like Breg Guthrie, a great human being. I
642
00:41:09.239 --> 00:41:11.920
really have enjoyed getting to know him over the years.
643
00:41:12.360 --> 00:41:17.440
West point Graduate somebody that I don't have in my
644
00:41:17.519 --> 00:41:20.559
circle of friends. People like that so often, so it's
645
00:41:20.599 --> 00:41:24.159
always so refreshing and rewarding for me to get to
646
00:41:24.480 --> 00:41:29.199
know guys like that. But him actually saying at one
647
00:41:29.199 --> 00:41:33.079
point to me, Gary, these are such complex issues. Can
648
00:41:33.119 --> 00:41:37.440
you kind of put away your advocacy had for the
649
00:41:37.480 --> 00:41:40.400
particular issue and just talk to me about how this
650
00:41:40.440 --> 00:41:42.559
would work in the real world. I mean, that's what
651
00:41:42.679 --> 00:41:46.880
people really need to know, regardless of party, regardless of
652
00:41:46.920 --> 00:41:48.800
anything else. You know, That's what I think.
653
00:41:49.360 --> 00:41:51.440
Yeah, I mean, so there's no doubt that, I mean,
654
00:41:51.480 --> 00:41:53.960
money can help open doors, but if you don't have
655
00:41:54.280 --> 00:41:57.440
the policy backing, if you don't have a story to tell,
656
00:41:57.599 --> 00:42:00.679
if you don't have data. But also it's about that connection.
657
00:42:00.840 --> 00:42:04.920
I mean, finding that connection and making that relationship or
658
00:42:04.920 --> 00:42:07.840
building that relationship. That's what allows you to come back in.
659
00:42:08.039 --> 00:42:09.840
That's what allows you to do exactly what you just
660
00:42:09.880 --> 00:42:12.440
described Gary, to be able to you know, then be
661
00:42:12.519 --> 00:42:15.519
a trusted source. And that's what really matters. If you
662
00:42:15.559 --> 00:42:17.119
have to write a check every time to get in
663
00:42:17.159 --> 00:42:19.280
the door, I mean, that's that's not what's going to
664
00:42:19.320 --> 00:42:22.440
be helpful. And it's really about having that long term
665
00:42:22.480 --> 00:42:25.119
relationship to where you're a trusted partner and that's what
666
00:42:25.239 --> 00:42:27.960
needs to be built and that's that's where you're successful.
667
00:42:28.039 --> 00:42:30.239
So you don't need a big pack in order to
668
00:42:30.280 --> 00:42:33.000
be able to do that, you.
669
00:42:32.960 --> 00:42:35.440
Know, I really do believe that now. It used to not,
670
00:42:36.280 --> 00:42:39.840
but now that I've gotten to know people at the
671
00:42:39.960 --> 00:42:42.960
levels that I've gotten to know, I mean deeper relationships.
672
00:42:44.360 --> 00:42:47.320
We're all the you know, oneness is the common fray
673
00:42:47.400 --> 00:42:51.519
that links us all together. And then we joke about
674
00:42:51.519 --> 00:42:53.960
that for hours. But in any event, I want to
675
00:42:53.960 --> 00:42:57.639
thank you both so much for participating in our podcast today.
676
00:42:58.079 --> 00:43:01.079
I think it was a great conversation. So much more
677
00:43:01.119 --> 00:43:04.360
to go in the work we're doing, but thank you
678
00:43:04.480 --> 00:43:09.800
for being part of our work today and I appreciate
679
00:43:09.880 --> 00:43:14.559
it so much. Thank you. Thanks, And that's it for
680
00:43:14.639 --> 00:43:18.599
this episode of Policy prescriptions. Join us next time as
681
00:43:18.639 --> 00:43:22.079
we explore practical ways to make the shift toward open,
682
00:43:22.119 --> 00:43:25.599
effective policy engagement. If you want to connect with me,
683
00:43:26.199 --> 00:43:30.320
go to Garymjacobs dot com. To learn more about Ray,
684
00:43:30.800 --> 00:43:34.599
go to Hellespirian dot com. And to learn more about
685
00:43:34.599 --> 00:43:39.199
Aisha Nakos, go to nacos dot com. Thank you all,
686
00:43:39.440 --> 00:43:40.960
and now Mistay, my friends,