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On today's episode of “Achieving Health,”
we'll be joined by special guest Andy
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Wegman, Senior Director of Reimbursement
Services at Banner Health.
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He'll share his perspective on the latest
CMS rulemaking and how his organization
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is preparing for upcoming
payment and policy changes.
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Stay tuned.
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This is “Achieving Health,”
a podcast from Forvis Mazars,
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where we delve into the topics
that matter most to healthcare
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organizations
across the continuum of care.
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Our goal is to help you
navigate the dynamic healthcare landscape
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and achieve health at your organization.
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Welcome to Achieving Health.
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I'm Chad Mulvany. And I'm Shawn Stack.
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Thank you for joining us.
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I'd like to welcome our guest
for today's episode, Andy Wegman.
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Andy is senior director
of reimbursement services at Banner
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Health, one of the nation's largest
nonprofit health systems.
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Andy, there's been a lot of movement
on the regulatory
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front over the last couple of months
between CMS normal
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sort of rulemaking cycle for facility
and outpatient
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rules,
and adding to that, the rules implementing
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the One Big Beautiful Bill act,
the work requirements, the Medicaid cuts.
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And we're very excited to hear how you and
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Banner are approaching
strategic reimbursement in this landscape.
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Thank you so much for being here.
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Well thanks, Shawn, thanks, Chad.
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Happy with the opportunity
to speak on these.
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Yes, there's a lot of different changes
taking place right now as we speak.
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And trying to navigate
these can definitely
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be overwhelming at times.
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Andy, maybe before we get into the meat,
would you please share a little bit
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about your career path, how you came
to the industry in your current role,
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so our audience can have some perspective
on your background?
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Definitely, yeah.
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So, in 2007, I actually began working
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as an auditor one at Noridian
Healthcare Solutions.
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So, fun fact;
I actually had to apply twice.
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The first time
my application was actually rejected
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because the hiring supervisor was looking
for someone with an accounting degree.
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So, I have a business management degree,
I do now
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have a graduate accounting certificate,
but not an accounting degree.
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So, second time
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I applied for the position,
it was with a different hiring manager
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and she was willing
to take a chance on me.
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So, I guess I'll just say, Pam Marie,
if you're listening,
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thank you for taking that chance on me
19 years ago.
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While working at Noridian, I worked my way
up; auditor two, senior auditor.
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In 2016, I was promoted to the provider
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audit and reimbursement Manager
over jurisdiction E.
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I was in that role for four years
until I came over to Banner Health in 2020
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as a reimbursement consultant.
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In 2022, I was promoted
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to my current role of Senior
Director of Reimbursement Services.
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Andy, sounds like a great background,
particularly that early career,
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having to apply two times,
because I would imagine that
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when you interviewed
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with banner, it basically demonstrated
that you could negotiate with a MAC.
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Yes. For
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those of our listeners who don't know,
do you want to say
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a little bit about Banner
and talk about the system?
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Yeah, I'd love to.
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So, Banner Health is one of the nation's
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largest fully integrated
nonprofit health systems.
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We pioneer a sustainable care model
that prioritizes
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prevention, manages chronic disease,
and reduces health spending.
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We operate 33 hospitals
in more than 400 sites across six states,
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delivering seamless care from primary
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to quaternary medicine,
including health insurance,
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physician networks, world-renowned
specialty services, and behavioral health.
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We are accountable to the communities
we serve.
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We reinvest every dollar back
into advancing care research
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in our facilities, providing more than $1
billion each year in community benefit.
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Through our partnership
with the University of Arizona,
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we drive clinical discoveries
across more than 800 trials
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and train more than 1300 residents
and fellows annually.
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We are headquartered in Phoenix, Arizona,
and we serve Arizona, California,
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Colorado, Nebraska, Nevada, and Wyoming.
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Yeah, that's a huge footprint
and certainly
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a very complex organization.
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So, with that background in mind,
when you think about this
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rulemaking cycle,
what are the two or three
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most interesting either proposed—so,
thinking like physician fee
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schedule, OPPS—or finalized—so,
the facility rules—from
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this round of Medicare rulemaking?
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So, I think I'll probably mainly focus
on really OPPS,
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you know, as we know, just the other day
CMS released the IPPS final rule.
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So, still diving into that one.
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Happy to see some things got passed on
and unhappy to see some things didn't.
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But when we look at OPPS,
I think for every 340B
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hospital, number one is going to be that
the payments for separately payable drugs
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being reduced from average sale price plus
6% to average sale price minus 3-3.4%.
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Even though this is a quote unquote
“budget
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neutral” issue, this is still going
to have a significant impact.
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Yeah, I fully agree with you.
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And I think when you sort of look
at the separately payable Part B drug cut,
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the policy rationale for it
to me is somewhat questionable
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because as you mentioned, you know, CMS
tries to say that they're lowering
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drug prices for recipients of those drugs,
but at the same time, they're raising
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cost sharing for everybody else
by making it budget neutral.
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And I think the other thing that to me
is just sort of interesting is,
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you know, when you look,
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and we were talking about this
before we started recording,
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when you look at the survey sample
that CMS is basing this on, right?
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The first time around, the Supreme Court
knocked down this policy
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because they didn't
actually use hospital data.
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They fielded the survey earlier
this spring.
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But yet, you know,
approximately 40% of hospitals responded.
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Half of the non-340B,
less than 30% of the 340B.
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And when you look underneath that,
it looks like it's, you know,
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you don't see, they noted that
there weren't major teaching hospitals,
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that most of the 340B respondents
tend to be lower revenue and rural.
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So, I do think that there may be some
questions about the validity of that cut.
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I agree.
Was the sample statistically valid?
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And as well as, you know, the concerns
regarding the uniformity
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of the data collected? Absolutely.
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Yeah.
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So, Andy, are there any changes
coming out of these rules, either
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proposed or inpatient,
that you've been shocked
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that your colleagues,
not necessarily at Banner,
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I know you network a ton and talk to folks
outside of Banner in your profession,
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that folks might be missing
or underappreciating
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and things that are keeping you up
at night that you think
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people might not be realizing
the full impact?
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Lately, there's been a lot
that's been keeping me up all night,
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I will just say that.
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You know, I'll say one thing
and I won't necessarily say,
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I don't know if the field
is underappreciating it or not, but
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I'll say one thing that
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gave me some, I'll say breathing room,
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is related to the Medicaid managed care
state-directed payments,
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with CMS proposing to allow the state
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to delay the prohibition
of separate payment terms for these
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state-directed payments
until the new payment limit is met.
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We are a heavily governmental provider,
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so the majority of our patients
are Medicare and Medicaid patients.
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And with the abundance of Medicaid
patients,
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we utilize these state-directed
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payments to help bridge
that gap between how much it costs
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to provide care and what we receive back.
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So, just as an example,
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you know, the national average
is that Medicaid payments cover
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57 to 59% of the costs
to take care of a patient.
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So, for every dollar that we spend,
we receive less than $0.60 back.
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The state-directed payments
are to help bridge that gap.
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So, in Arizona, Banner serves 39%
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of all Medicaid inpatients in the state.
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If we focus on two specific
main counties, Maricopa and Pima,
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we serve 40 to 43% of those
Medicaid inpatients in those counties.
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So, to be able to postpone
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the separate payment terms
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helps us to be able to track this better,
to make sure that our payments
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that we are receiving are truly based
on our Medicaid utilization.
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It's not based on how fast
you're billing to the Medicaid payer,
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what issues you're having with claims,
denials, things like that.
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Now, Andy,
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I know that you have at least two, right,
critical access hospitals in Arizona.
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I know you have Payson
Medical Center and Page Hospital.
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And then I think you have
when I was looking, I think
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2 or 3 in in Colorado
that are also rural hospitals, right?
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You have East Morgan County, Sterling
Regional Medical Center and McKee,
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I think Medical Center.
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I know those are, typically,
those are Medicare/Medicaid payer mix.
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But I've been concerned
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and I wondered if you think the same,
that your academic medical centers
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as well, you're seeing a lot of transfers
of Medicaid patients, right?
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So, that payer mix, too, is really hard
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to navigate
with these types of cuts, right?
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Even at your, what most people would call
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or consider, your urban hospitals
that should be okay.
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But you're seeing a lot of those Medicaid
patients?
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Correct.
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Yes, I mean, it's all of our facilities,
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you know, and I will say this to,
you know, as we discuss and we go into,
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let's just say,
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like the work requirements and things
like that, that's where we start,
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you know, getting into the part
where our Medicaid
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eligibility for our patients
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is going to start to decrease.
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Right.
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And so, what this is going to do
is just put pressure
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on self-pay
and put more pressure on the hospitals.
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Yeah.
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So, what are you doing?
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What strategically
are you pulling into alignment here
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to maybe help address
and fill in some of these gaps?
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I mean, outreach?
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Payer?
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Is there any payer/provider
collaboration?
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Because let's face it, these Medicaid
managed care plans are also going
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to be losing these members,
eligible members,
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if they don't comply with either,
you know, the work requirements
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or revalidations, right,
every six months?
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I mean, are you doing anything here
strategically to prepare for this?
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Yeah.
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So, I mean,
I will say our patient access teams
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have continually done an amazing job
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just navigating these things
when they're in our buildings.
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And we can try to help them
if they don't have coverage
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so they know what's necessary
for applying.
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But,
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you know,
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as I mentioned too, you know, Banner’s
not only a healthcare provider,
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we also have the insurance side of things,
right?
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So, you know, Banner’s
taking an active role
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in patient and our member engagement
and outreach, you know?
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We're tasked with educating members
about the new requirements,
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identifying those at risk of noncompliance
and conducting
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outreach prior
to even potential disenrollment.
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So, our responsibilities have now expanded
to making sure
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that we're supporting our members’
navigation and compliance,
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making sure,
you know, we're connecting with
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the requirements of the employment
support services.
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You know, do we need to connect members
with job training programs, workforce
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agencies,
educational opportunities, all of this?
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It's really a whole team approach
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of what's needed
to navigate this moving forward.
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And you bring up a really important
point here, Andy,
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because you wear, Banner wears
two very separate hats, right?
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Because let's face it, I've talked
to many organizations who own payers.
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It is a very separate entity
and it's kept very separate.
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But you see the struggle on both sides.
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So, don't you agree
that partnerships in this space
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with the payers on the Medicaid
managed care side are just so important
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for payers and providers
to collaborate in that effort?
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100%, yes.
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I mean, you know,
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even when we're looking at,
you know, when we see
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patients that, you know, individuals
that lose healthcare coverage, right?
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So, if they do fall through the cracks,
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these individuals are less likely
to seek preventative care.
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So, we need to try to make sure
that we can
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keep them on their coverage
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instead of, you know,
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them seeking
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the emergency department
when something gets even more serious.
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We need to make sure that we keep
that preventative care going forward.
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It just helps everybody to be more healthy
237
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throughout the whole process as opposed
238
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to, you know, getting up to a diagnosis
239
00:14:08,147 --> 00:14:11,584
just with little time
to really address the issue.
240
00:14:12,117 --> 00:14:13,185
Yeah, couldn’t agree more.
241
00:14:13,185 --> 00:14:16,822
I mean,
continuity of care is truly a big risk.
242
00:14:16,822 --> 00:14:20,626
And I just got off the stage
talking at a symposium and I said,
243
00:14:20,659 --> 00:14:24,430
you know, this is one of the things
that quote unquote “legacy providers”
244
00:14:25,030 --> 00:14:30,436
really have done a phenomenal job
over the last decade in perfecting
245
00:14:30,436 --> 00:14:35,774
and honing is continuum of care
and cuts like this and,
246
00:14:36,108 --> 00:14:40,579
you know, disruption
have really challenged us over the last
247
00:14:40,579 --> 00:14:45,818
five years in continuing that continuum
of care for our members and our patients.
248
00:14:46,452 --> 00:14:49,755
Andy, you mentioned earlier the importance
249
00:14:49,755 --> 00:14:52,758
of state-directed payments to Banner.
250
00:14:52,958 --> 00:14:55,427
How is Banner preparing for those cuts?
251
00:14:55,427 --> 00:14:55,661
I mean,
252
00:14:55,661 --> 00:14:58,864
you know what the runway looks like,
so what is the organization doing
253
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to make sure
that when they start to kick in
254
00:15:00,733 --> 00:15:04,470
and given how important they are,
you're going to be able to navigate them?
255
00:15:05,237 --> 00:15:05,471
Yeah.
256
00:15:05,471 --> 00:15:09,074
So, that's a good
and a very difficult question, right?
257
00:15:09,074 --> 00:15:14,980
You know, we have to look at this,
you know, not only in the short term
258
00:15:14,980 --> 00:15:17,983
but long term as we're doing our
long-range
259
00:15:17,983 --> 00:15:23,355
forecasting and seeing
what will it be looking like,
260
00:15:23,355 --> 00:15:26,592
you know, five years,
10 years down the road
261
00:15:27,226 --> 00:15:29,628
when these reductions
262
00:15:29,628 --> 00:15:32,631
are fully implemented.
263
00:15:32,698 --> 00:15:35,634
I mean,
not really giving any specifics, but,
264
00:15:35,634 --> 00:15:38,904
you know, Banner,
as well as any other healthcare provider,
265
00:15:38,904 --> 00:15:40,873
we're going to have to evaluate, you know,
266
00:15:40,873 --> 00:15:45,177
are there certain programs
that are no longer sustainable?
267
00:15:45,477 --> 00:15:49,248
Are there service line reductions
that are needed
268
00:15:49,682 --> 00:15:54,186
to be able to keep things moving, right?
269
00:15:54,219 --> 00:15:57,723
You know,
hospitals operate on a razor-thin margin.
270
00:15:57,756 --> 00:16:02,594
You know, I think that's something that
a lot of people may forget.
271
00:16:02,695 --> 00:16:06,432
You know, they see the bill that they get,
but especially, you know,
272
00:16:06,498 --> 00:16:09,868
talking with Banner Health
nonprofit, everything is,
273
00:16:10,402 --> 00:16:14,273
you know, anything that we get
is invested back into our communities.
274
00:16:14,273 --> 00:16:19,345
And with the reduction
of these state-directed payments,
275
00:16:19,345 --> 00:16:22,881
it just makes it
that much more difficult to
276
00:16:23,782 --> 00:16:27,019
invest in the items
that we need to invest in.
277
00:16:27,353 --> 00:16:30,723
Yeah, to make sure that they have access
to the services they needed.
278
00:16:30,723 --> 00:16:31,590
And I think, you know,
279
00:16:32,591 --> 00:16:35,627
without naming specific services,
what's unfortunate about
280
00:16:35,627 --> 00:16:39,198
this is the services that I worry about
are the ones that are already,
281
00:16:39,198 --> 00:16:42,634
that we struggle with to access
in many areas of the country, particularly
282
00:16:42,634 --> 00:16:45,738
those that are either rural
or socioeconomically disadvantaged.
283
00:16:45,738 --> 00:16:49,141
And there's a reason why those services
aren't more readily available
284
00:16:49,174 --> 00:16:51,377
because of the payer mix
and the underpayment.
285
00:16:51,377 --> 00:16:54,380
And then when you start to layer on
everything else, you know,
286
00:16:54,413 --> 00:16:58,350
we were talking about 340B earlier,
you know, when you think about what
287
00:16:58,350 --> 00:17:01,387
the intent of 340B was from Congress.
288
00:17:01,387 --> 00:17:04,623
And now CMS is basically implementing
289
00:17:04,623 --> 00:17:08,260
a budget-neutral shift
in where those funds flow.
290
00:17:08,293 --> 00:17:12,331
They're also doing the 3% recoupment
from the prior settlement.
291
00:17:12,331 --> 00:17:16,402
It really does start to put a tremendous
amount of pressure on the organization.
292
00:17:16,402 --> 00:17:18,303
And then you layer in the work
requirements
293
00:17:18,303 --> 00:17:20,372
and the loss of coverage,
both from the exchange
294
00:17:20,372 --> 00:17:24,376
and through the Medicaid work
requirements for your expansion states
295
00:17:24,376 --> 00:17:25,577
in One Big Beautiful Bill.
296
00:17:25,577 --> 00:17:27,980
So, yeah, it's a lot to navigate.
297
00:17:27,980 --> 00:17:28,180
Yeah.
298
00:17:28,180 --> 00:17:31,183
It's a difficult cycle
to think about, right?
299
00:17:31,183 --> 00:17:34,186
So, we think, our 340B
300
00:17:34,219 --> 00:17:37,222
hospitals are hospitals
301
00:17:37,256 --> 00:17:40,259
that have a disproportionate share
302
00:17:40,426 --> 00:17:43,162
of low-income patients.
303
00:17:43,162 --> 00:17:45,531
And so, that's how they're qualifying.
304
00:17:45,531 --> 00:17:49,001
And so,
now we're going to be paying them less.
305
00:17:49,101 --> 00:17:52,504
And we're shifting, CMS is shifting
306
00:17:52,504 --> 00:17:56,308
those funds to other service lines
307
00:17:56,308 --> 00:18:00,979
that are not necessarily
going to benefit the hospitals
308
00:18:00,979 --> 00:18:05,818
that have a disproportionate
share of low-income patients.
309
00:18:06,218 --> 00:18:10,956
Now, keeping in mind, Andy,
I know that you're
310
00:18:11,824 --> 00:18:14,259
modeling these,
you're modeling the reimbursement changes
311
00:18:14,259 --> 00:18:18,497
that you think are going to be impacting,
you know, as we as we come up
312
00:18:18,497 --> 00:18:23,435
on all these state-directed
payment issues and cuts.
313
00:18:23,435 --> 00:18:26,972
But keeping in mind
that this is not just state-directed
314
00:18:26,972 --> 00:18:31,343
payment cuts for hospitals,
it's also for Medicaid programs.
315
00:18:31,343 --> 00:18:35,948
So, I assume as you model
these reimbursement shifts and cuts,
316
00:18:36,515 --> 00:18:40,385
I assume your government relations
folks are also talking
317
00:18:40,419 --> 00:18:43,856
to state Medicaid agencies saying,
do you realize what is going to happen,
318
00:18:43,922 --> 00:18:45,224
what type of impact
319
00:18:45,224 --> 00:18:48,360
this is going to have on these communities
that we service, right?
320
00:18:48,393 --> 00:18:53,465
I mean, this is kind of dire across
the board as far as coverage, right?
321
00:18:53,465 --> 00:18:56,068
Because they're going to have to cut
as they
322
00:18:56,068 --> 00:18:58,470
run out of money
for some of these additional programs.
323
00:18:58,470 --> 00:19:03,542
But it could, like you
said, it could really impact these
324
00:19:04,543 --> 00:19:07,112
challenged areas even more.
325
00:19:07,112 --> 00:19:07,746
Correct.
326
00:19:07,746 --> 00:19:11,617
And, I mean, a lot of times
I always reference things
327
00:19:11,617 --> 00:19:15,354
back to Arizona, since that's
where we have our biggest presence.
328
00:19:15,354 --> 00:19:18,624
And, you know it's,
you know, it's an expansion state.
329
00:19:18,624 --> 00:19:21,627
The
330
00:19:22,261 --> 00:19:27,199
expansion
population is funded by the hospitals.
331
00:19:27,332 --> 00:19:30,335
And so,
332
00:19:31,436 --> 00:19:35,107
we put up that local share to draw down
333
00:19:35,107 --> 00:19:38,977
federal dollars to ensure
that these patients have coverage.
334
00:19:39,278 --> 00:19:43,482
And so, when things
335
00:19:43,482 --> 00:19:49,021
like hold harmless limits get reduced,
for state-directed payments
336
00:19:49,021 --> 00:19:52,024
the methodology
337
00:19:52,024 --> 00:19:55,694
going from average
commercial rate to Medicare rates.
338
00:19:55,694 --> 00:20:01,033
I mean, these things all play a very
important role in trying to determine,
339
00:20:01,066 --> 00:20:04,536
you know, what kind of coverage
is going to be out there
340
00:20:05,270 --> 00:20:08,440
five years down the road for the
341
00:20:09,474 --> 00:20:12,344
patients that need that coverage.
342
00:20:12,344 --> 00:20:15,214
You know, you make a great point
about the provider taxes
343
00:20:15,214 --> 00:20:17,616
and the phasedown of the hold
harmless limit.
344
00:20:17,616 --> 00:20:19,418
Obviously, the state knows this is coming.
345
00:20:19,418 --> 00:20:22,387
So, what conversations
have they been having so far,
346
00:20:22,387 --> 00:20:26,558
if any, about trying to sort of sustain
that expansion
347
00:20:26,558 --> 00:20:30,429
population, given that it was more
or less self-funded by the hospitals?
348
00:20:30,796 --> 00:20:31,096
Yeah.
349
00:20:31,096 --> 00:20:36,034
So, we do work
really closely with AHCCCS,
350
00:20:36,034 --> 00:20:39,504
or the State of Arizona, as their program.
351
00:20:39,504 --> 00:20:45,143
You know, as we have new models
come out each year,
352
00:20:45,143 --> 00:20:49,781
you know, initial proposals
and looking at estimates on
353
00:20:49,982 --> 00:20:54,219
how much is needed for coverage
and making sure that the funding
354
00:20:54,219 --> 00:20:57,923
is appropriate,
making sure that we're updating
355
00:20:57,923 --> 00:21:02,861
any of our calculations
to just ensure that we're
356
00:21:03,629 --> 00:21:06,999
keeping
that funding as stable as possible,
357
00:21:07,466 --> 00:21:11,670
but trying to, on the other hand
as well, ensure
358
00:21:11,670 --> 00:21:15,540
that we are able to provide funding
359
00:21:15,540 --> 00:21:19,778
for other programs to
360
00:21:20,979 --> 00:21:24,483
work on
that gap that I was kind of talking
361
00:21:24,483 --> 00:21:28,754
about earlier from the shortfall
of seeing Medicaid patients.
362
00:21:28,754 --> 00:21:32,291
And so, it's just, it's a balancing act.
363
00:21:32,457 --> 00:21:33,191
It really is.
364
00:21:33,191 --> 00:21:35,460
And we work closely with the state.
365
00:21:35,460 --> 00:21:40,065
We have some other consultants
that we work with as well, the hospitals,
366
00:21:40,065 --> 00:21:46,138
we all work together to try to navigate
these waters as they're coming at us.
367
00:21:46,438 --> 00:21:47,706
Yeah, Andy, you bring up a good point.
368
00:21:47,706 --> 00:21:50,709
I mean, there's
just so many vulnerable services
369
00:21:51,043 --> 00:21:54,212
that are going to become more vulnerable
through these cuts.
370
00:21:54,279 --> 00:21:58,250
I mean, things like, for listeners, things
like inpatient
371
00:21:58,784 --> 00:22:01,453
psychiatry, crisis stabilization
372
00:22:01,453 --> 00:22:05,857
units, substance use disorder treatment
programs, things like rural maternity
373
00:22:05,891 --> 00:22:09,828
units,
neonatal support services, swing beds,
374
00:22:09,828 --> 00:22:13,532
rural outpatient clinics, community
health programs.
375
00:22:13,532 --> 00:22:15,500
These are really important services
376
00:22:15,500 --> 00:22:19,271
that these just, you know,
these disproportionate communities
377
00:22:19,571 --> 00:22:23,909
now, through Medicaid expansion
and through the programs that Medicaid
378
00:22:23,942 --> 00:22:27,579
offers, these great programs,
these are at risk, right, Andy?
379
00:22:27,579 --> 00:22:32,951
And I'm assuming that your communities
that Banner serves are big recipients
380
00:22:32,984 --> 00:22:37,122
now of these services, and
those might be challenged in the future.
381
00:22:37,522 --> 00:22:41,493
They are, you know,
and I will say that, you know, Banner,
382
00:22:42,461 --> 00:22:43,995
we just, we have a history.
383
00:22:43,995 --> 00:22:46,198
We are going to do
what's best for our communities.
384
00:22:46,198 --> 00:22:48,700
And we're, you know, we buckle down.
385
00:22:48,700 --> 00:22:52,571
We make sure that we're going through
everything and making sure that we're
386
00:22:52,571 --> 00:22:56,308
providing just the best
387
00:22:56,675 --> 00:23:00,679
care to our patients,
the best community stewards.
388
00:23:00,679 --> 00:23:04,583
And yeah, it'll definitely,
it gets difficult
389
00:23:04,583 --> 00:23:07,619
with these reductions.
390
00:23:07,753 --> 00:23:11,456
It's just going to be
some difficult waters to manage through.
391
00:23:11,456 --> 00:23:15,560
And almost paralyzing
for a rural hospital
392
00:23:15,560 --> 00:23:18,864
that is not part of a larger system,
right, Andy?
393
00:23:18,864 --> 00:23:22,000
I mean, they don't have the resources
necessarily.
394
00:23:22,234 --> 00:23:22,534
Yeah.
395
00:23:22,534 --> 00:23:24,703
I mean, it definitely helps with,
396
00:23:24,703 --> 00:23:28,473
you know, with our critical access
hospitals, you know,
397
00:23:28,507 --> 00:23:35,013
having certain functions centralized
so they're not bearing all these costs.
398
00:23:35,080 --> 00:23:38,083
You know,
I think what's interesting is too,
399
00:23:38,116 --> 00:23:41,653
a lot of times
people think, well, Medicare pays 101%.
400
00:23:41,720 --> 00:23:42,053
Well,
401
00:23:43,054 --> 00:23:45,190
you're
not getting more than what you pay in.
402
00:23:45,190 --> 00:23:46,858
I will say that.
403
00:23:46,858 --> 00:23:53,732
So, there's definitely
the need for efficiency and making sure,
404
00:23:54,132 --> 00:23:57,602
you know,
if your rural facilities are struggling,
405
00:23:57,636 --> 00:24:01,873
you know,
do we have our university or community
406
00:24:01,907 --> 00:24:05,410
hospitals that can, you know, just assist
407
00:24:05,544 --> 00:24:08,547
as a, just as a whole health system?
408
00:24:08,947 --> 00:24:12,350
You know, Andy, the other thing,
when you say, you know, critical access
409
00:24:12,350 --> 00:24:18,023
hospitals get paid by Medicare at 101%,
I mean that that presumes
410
00:24:18,023 --> 00:24:21,593
that there hasn't been a significant shift
to MA, which in a lot of cases,
411
00:24:21,593 --> 00:24:24,062
that's not how those contracts
are structured.
412
00:24:24,062 --> 00:24:27,132
So, you kind of layer
on that piece of pressure as well.
413
00:24:27,199 --> 00:24:29,734
I think, you know,
414
00:24:29,734 --> 00:24:35,474
one of the interesting things that I'll be
watching over the next couple of years
415
00:24:35,674 --> 00:24:40,612
is kind of the tension
between the policy community, both in D.C.
416
00:24:40,612 --> 00:24:44,883
and state capitals,
who have, for whatever reason, decided
417
00:24:44,883 --> 00:24:48,854
that consolidation
integration is driving cost.
418
00:24:48,854 --> 00:24:51,857
But then at the same time,
all the services that we've been talking
419
00:24:51,857 --> 00:24:55,694
about that Shawn specifically called out
that are important for communities
420
00:24:55,694 --> 00:24:59,798
to have access to,
all communities to have access to, like,
421
00:24:59,931 --> 00:25:03,001
what's the tension
between allowing integration to occur
422
00:25:03,001 --> 00:25:05,070
in order to support access
to those services
423
00:25:05,070 --> 00:25:09,040
or having a regulator block
it just sort of blindly?
424
00:25:09,040 --> 00:25:12,177
Because now evidently consolidation is,
425
00:25:13,078 --> 00:25:13,311
you know,
426
00:25:13,311 --> 00:25:17,549
they're looking at the cost side of it,
but they're also not looking fully at,
427
00:25:17,582 --> 00:25:21,419
you know, the avoided cost of providing
that care in the community
428
00:25:21,453 --> 00:25:22,521
versus having someone either
429
00:25:22,521 --> 00:25:24,623
a) not get the care or b)
have to go someplace else
430
00:25:24,623 --> 00:25:26,658
where it's going to be more expensive,
likely.
431
00:25:26,658 --> 00:25:30,362
Or delay it until they're so sick that
their care is going to be so expensive.
432
00:25:30,395 --> 00:25:32,197
right? Correct. Exactly.
433
00:25:32,197 --> 00:25:35,934
And then they end up
in the emergency department and well,
434
00:25:35,934 --> 00:25:39,538
now the cost of providing that care
just quadrupled.
435
00:25:39,704 --> 00:25:40,372
Yeah.
436
00:25:40,372 --> 00:25:43,375
As opposed to just being able
to take the preventative
437
00:25:43,375 --> 00:25:46,511
measures,
having that coverage on the front end.
438
00:25:47,913 --> 00:25:50,949
Andy, what else is, not that we haven't
already talked about enough,
439
00:25:50,949 --> 00:25:53,952
but what else is keeping you up at night
on the regulatory front?
440
00:25:53,985 --> 00:25:57,389
On top of all these items
that we've already been discussing, right?
441
00:25:57,822 --> 00:26:02,294
You know, I think—and personally,
one of the things that,
442
00:26:02,394 --> 00:26:07,399
you know, as I'm reading all the various
proposed rules and things like that is—all
443
00:26:07,399 --> 00:26:11,736
of CMS’ proposals to, and I'll just say it
in air quotes, “codify
444
00:26:11,736 --> 00:26:15,740
their long-standing policy”
for this, that and the other thing, right?
445
00:26:15,874 --> 00:26:16,841
You know,
446
00:26:16,841 --> 00:26:20,111
a little bit about, you know, the IPPS
proposed rule that came out, right?
447
00:26:20,111 --> 00:26:25,984
So, initially discussing
the need to fragment all of your overhead
448
00:26:26,017 --> 00:26:30,021
for every department
utilization of those services.
449
00:26:30,055 --> 00:26:32,624
And, you know, CMS was obviously focusing
on nursing
450
00:26:32,624 --> 00:26:34,693
allied health
since it's paid as a passthrough cost.
451
00:26:34,693 --> 00:26:39,264
But I mean, is that appropriate
just to pick that one
452
00:26:39,364 --> 00:26:42,400
and not the other ones, right?
453
00:26:42,434 --> 00:26:45,203
And, you know,
luckily with the final rule,
454
00:26:45,203 --> 00:26:48,940
they did not make any changes to that,
you know?
455
00:26:48,974 --> 00:26:54,546
So, they're—sorry, they didn't make
any changes to the current rule.
456
00:26:54,579 --> 00:26:58,583
So, it's not to the point
where you need to fragment everything out.
457
00:26:58,583 --> 00:27:01,786
But something that did get finalized
458
00:27:01,786 --> 00:27:06,458
in the final rule is regarding removing
certain costs
459
00:27:06,458 --> 00:27:11,796
from the accumulated cost stat
for allocating A&G costs.
460
00:27:12,197 --> 00:27:16,301
You know, right now, you know,
the focus of this was really CMS
461
00:27:16,301 --> 00:27:21,106
focusing on transplant
costs—we do operate two transplant
462
00:27:21,139 --> 00:27:25,610
hospitals—and with the ruling,
their big focus was on
463
00:27:25,610 --> 00:27:29,948
purchased services and really looking
at like the purchased organs.
464
00:27:30,348 --> 00:27:35,153
But we have purchased services all
throughout other departments as well. So,
465
00:27:36,254 --> 00:27:39,190
it just leads us down a rabbit
hole of saying, okay,
466
00:27:39,190 --> 00:27:43,194
well then we should probably be looking
at these purchased services
467
00:27:43,194 --> 00:27:48,266
because they may not be receiving
any benefit from A&G.
468
00:27:48,433 --> 00:27:51,302
And so, they shouldn't be receiving
that allocation either.
469
00:27:51,302 --> 00:27:57,075
And then, when all this picking
and choosing and I'll just say fragmenting
470
00:27:57,075 --> 00:28:00,979
and everything, it just really opens up
the hospitals for more audit risk.
471
00:28:00,979 --> 00:28:04,883
And then it just gets to be based
on each auditor's
472
00:28:04,883 --> 00:28:06,851
interpretation of the regulations.
473
00:28:06,851 --> 00:28:12,691
And so that's really my concern,
you know, as this shift
474
00:28:12,991 --> 00:28:16,194
really starts to move things
475
00:28:16,194 --> 00:28:19,998
from how things have been operating
476
00:28:20,031 --> 00:28:25,003
to more of a well, now each auditor
is going to be taking a look at something.
477
00:28:25,003 --> 00:28:28,973
They may come up with a different response
than the next auditor,
478
00:28:29,040 --> 00:28:33,611
and it's just going to make it
a little bit more difficult to ensure
479
00:28:34,045 --> 00:28:37,482
you're handling these things
consistently.
480
00:28:37,782 --> 00:28:42,320
So, switching gears,
what's one piece of advice
481
00:28:42,320 --> 00:28:45,990
you give, Andy,
to someone who recently moved into a
482
00:28:46,291 --> 00:28:50,195
formal leadership role in reimbursement,
healthcare,
483
00:28:50,562 --> 00:28:54,499
anything that you'd want to share there
for someone new coming in?
484
00:28:55,033 --> 00:28:55,433
Yeah.
485
00:28:55,433 --> 00:28:58,937
So, I mean, actually there's a
there's a couple of them.
486
00:28:59,237 --> 00:29:02,574
I mean, first and foremost, I would say
487
00:29:02,574 --> 00:29:07,178
just make sure your values align
with the company that you're working for.
488
00:29:07,512 --> 00:29:11,015
Just on the, right on the front end,
you know?
489
00:29:11,015 --> 00:29:13,618
When you work for a company
that shares your same values
490
00:29:13,618 --> 00:29:15,987
and they're a part of a team
that cares about you
491
00:29:15,987 --> 00:29:17,622
both personally and professionally,
492
00:29:17,622 --> 00:29:20,291
there's nothing you won't do
to ensure everyone’s successful.
493
00:29:20,291 --> 00:29:23,094
So, that's definitely number one.
494
00:29:23,094 --> 00:29:27,132
I've been very, very happy
working with Banner.
495
00:29:27,132 --> 00:29:30,135
It's been a great company.
496
00:29:30,201 --> 00:29:34,038
The second one, it's
497
00:29:35,340 --> 00:29:37,709
kind of funny, but just, I
498
00:29:37,709 --> 00:29:41,813
realized early on in my career
that I don't know
499
00:29:41,813 --> 00:29:44,816
everything. So,
500
00:29:45,717 --> 00:29:48,720
you know, that is brought to my attention
every single day.
501
00:29:48,753 --> 00:29:51,422
You know, there's always the new,
new thing popping up.
502
00:29:51,422 --> 00:29:54,559
And I will say, be honest,
503
00:29:54,559 --> 00:29:57,562
admit that you may not know
the answer to a question.
504
00:29:57,662 --> 00:30:00,899
I feel like sometimes
people are so afraid,
505
00:30:00,899 --> 00:30:04,335
and so they do the whole let's fake
it ‘til you make it, right?
506
00:30:04,402 --> 00:30:07,071
No, just ask the question, you know?
507
00:30:07,071 --> 00:30:10,675
If you don't know,
say that you don't know, you know?
508
00:30:10,742 --> 00:30:14,746
Not knowing something is the catalyst
to researching a topic,
509
00:30:14,779 --> 00:30:18,082
discussing it with your peers,
and just eventually learning
510
00:30:18,082 --> 00:30:21,352
something new
that can help you throughout your career.
511
00:30:21,452 --> 00:30:25,690
When leading a team,
you need to listen to them and build
512
00:30:25,690 --> 00:30:28,860
both personal
and professional relationships with them.
513
00:30:28,993 --> 00:30:33,665
Trust your team members as they look to
you to grow and take on more challenges.
514
00:30:34,465 --> 00:30:39,270
A lot of it too, is knowing and building
relationships with your colleagues,
515
00:30:39,270 --> 00:30:42,674
not only just at your organization,
but outside of your organization,
516
00:30:42,674 --> 00:30:47,212
that you can lean on in those—maybe
it's a PAMA question,
517
00:30:47,278 --> 00:30:51,316
you know, a lab question
or something—building that network of
518
00:30:51,316 --> 00:30:56,354
trusted advisors that you know know more
than you do in that one specific area.
519
00:30:56,387 --> 00:30:58,389
Don't
you think that's important too, Andy?
520
00:30:59,424 --> 00:31:00,358
100%.
521
00:31:00,358 --> 00:31:03,561
And even with the things that you do know.
522
00:31:03,561 --> 00:31:06,631
So, another fun fact, right? So,
523
00:31:07,732 --> 00:31:10,001
when starting off as an auditor one,
524
00:31:10,001 --> 00:31:13,037
I'll say the first real
525
00:31:14,072 --> 00:31:18,243
auditable issue that you learn is Medicare
bad debts.
526
00:31:18,276 --> 00:31:21,579
And so, I've known about Medicare
527
00:31:21,579 --> 00:31:25,149
bad debts and the reimbursement of them
for over 19 years.
528
00:31:25,149 --> 00:31:28,720
But there's still always different nuances
529
00:31:28,820 --> 00:31:31,723
that come up regarding Medicare bad debts.
530
00:31:31,723 --> 00:31:35,760
So, it's
just not only the stuff that you may not
531
00:31:35,760 --> 00:31:39,197
have the best grasp of,
but just even things that you do.
532
00:31:39,197 --> 00:31:42,667
And things change, it's important
to be able
533
00:31:42,667 --> 00:31:45,670
to have
534
00:31:46,137 --> 00:31:50,675
peers—again, inside,
outside of your organization—that
535
00:31:50,675 --> 00:31:54,479
you can discuss situations with.
536
00:31:54,479 --> 00:31:58,082
And you know, what-if scenarios
and things like that.
537
00:31:58,082 --> 00:32:03,521
And as we've seen now, especially over
the past couple of years here, I mean,
538
00:32:03,521 --> 00:32:09,060
just all the different regulatory changes
coming down,
539
00:32:09,527 --> 00:32:13,197
it's a lot to try to take on.
540
00:32:13,197 --> 00:32:16,200
And you can't just take it on
as one person.
541
00:32:16,234 --> 00:32:20,872
You definitely need to utilize your team,
your peers
542
00:32:21,139 --> 00:32:25,043
to navigate these to make sure
you're handling things accurately.
543
00:32:25,143 --> 00:32:26,811
Yeah, couldn’t agree more.
544
00:32:26,811 --> 00:32:30,281
What's something you and your colleagues
recently accomplished that you're proud
545
00:32:30,281 --> 00:32:33,651
of, Andy, or challenges
546
00:32:33,851 --> 00:32:37,355
did you have that you overcame
and how did you do it?
547
00:32:37,789 --> 00:32:38,189
Yeah.
548
00:32:38,189 --> 00:32:42,193
So, I think, you know, one thing
that I've been really proud
549
00:32:42,694 --> 00:32:45,463
of my team is just we've been
550
00:32:45,463 --> 00:32:50,268
successful obtaining additional
IME and DGME FTE cap space
551
00:32:50,268 --> 00:32:55,373
for every round of section 126,
as well as section 4122.
552
00:32:55,373 --> 00:32:59,277
And when you kind of talk about
challenges, I guess I wouldn't necessarily
553
00:32:59,277 --> 00:33:02,613
say it’s a challenge, but just,
I think knowing where
554
00:33:02,613 --> 00:33:05,817
your health system’s
short-term and long-term
555
00:33:05,817 --> 00:33:09,954
risks are for physician
staffing in your markets is key.
556
00:33:10,154 --> 00:33:14,025
You know, working with senior leadership
and your GME office
557
00:33:14,025 --> 00:33:16,394
to map out a plan to address those risks.
558
00:33:16,394 --> 00:33:20,064
You know, Banner’s
been expanding their GME footprint
559
00:33:20,098 --> 00:33:24,435
substantially over the past few years,
and we continue to do so
560
00:33:24,469 --> 00:33:26,838
to meet the needs of our community.
561
00:33:26,838 --> 00:33:27,505
At Banner here
562
00:33:27,505 --> 00:33:31,542
we have something, we call it “One Team,”
you know, we're all one team.
563
00:33:31,542 --> 00:33:34,779
We all work together for a common purpose.
564
00:33:34,779 --> 00:33:38,182
And, you know, obviously at the
end of the day, that is for our patients.
565
00:33:38,182 --> 00:33:42,186
And looking at things
from different perspectives,
566
00:33:42,186 --> 00:33:46,791
whether it's reimbursement services
or if it's,
567
00:33:46,824 --> 00:33:50,661
you know, the GME office,
568
00:33:50,828 --> 00:33:56,701
you know, the intricacies of training
residents, right, or senior leadership
569
00:33:56,701 --> 00:34:01,539
and what they're seeing in the markets
and what we
570
00:34:01,539 --> 00:34:05,076
might be facing here
in the next few years.
571
00:34:05,109 --> 00:34:08,713
It's just really important
for us to all work together to make sure
572
00:34:08,813 --> 00:34:14,619
that as one team, we are moving
in the direction that we want to
573
00:34:14,652 --> 00:34:16,621
for our patients.
574
00:34:16,621 --> 00:34:18,790
Well, Andy, this was fantastic.
575
00:34:18,790 --> 00:34:20,258
I want to thank you again for joining
576
00:34:20,258 --> 00:34:23,194
today's episode
and and sharing your insights.
577
00:34:23,194 --> 00:34:25,730
You're a wealth of knowledge.
I always enjoy talking to you.
578
00:34:25,730 --> 00:34:29,000
And we'd also like to thank our listeners
for tuning in.
579
00:34:29,033 --> 00:34:31,135
You can follow “Achieving Health” on Apple
580
00:34:31,135 --> 00:34:35,306
Podcasts, Spotify, Amazon Music,
or wherever you listen to podcasts.
581
00:34:35,306 --> 00:34:39,744
You can also now find us in the Health
Podcast Library.
582
00:34:39,744 --> 00:34:42,747
If you want to learn more about the topics
we discussed
583
00:34:42,747 --> 00:34:46,184
here, be sure to check out the show notes
for related content.
584
00:34:46,184 --> 00:34:49,520
You can also subscribe to our Healthcare
FORsights
585
00:34:49,520 --> 00:34:53,191
and follow us on LinkedIn
to get regular insights and updates.
586
00:34:53,191 --> 00:34:58,496
And we welcome you to reach out to me,
Chad and the team here at Forvis Mazars
587
00:34:58,629 --> 00:35:03,468
if you have any questions about how
these topics may affect your organization.
588
00:35:03,701 --> 00:35:07,338
Chad and I will be back
next week on Wednesday, August
589
00:35:07,338 --> 00:35:10,541
19, for the next round of “Washington
Watch” updates.
590
00:35:10,541 --> 00:35:15,379
Until then, here's wishing good health
for you and the communities you serve.
591
00:35:16,180 --> 00:35:20,218
You can follow “Achieving Health”
on your favorite podcast platform or visit
592
00:35:20,218 --> 00:35:24,589
forvismazars.us/AchievingHealthPodcast
to learn more.
593
00:35:24,956 --> 00:35:29,660
“Achieving Health” is produced by Forvis
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594
00:35:29,660 --> 00:35:34,031
of Forvis Mazars Global, a leading global
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595
00:35:34,031 --> 00:35:37,702
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596
00:35:37,802 --> 00:35:43,040
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00:35:43,040 --> 00:35:47,011
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599
00:35:50,548 --> 00:35:54,986
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600
00:35:54,986 --> 00:35:58,523
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601
00:35:58,523 --> 00:36:01,893
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602
00:36:01,893 --> 00:36:05,363
Such analysis and conclusions
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603
00:36:05,363 --> 00:36:08,599
or conclusions by Forvis Mazars
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604
00:36:08,599 --> 00:36:12,770
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605
00:36:12,837 --> 00:36:15,173
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606
00:36:15,173 --> 00:36:19,143
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607
00:36:19,177 --> 00:36:23,114
Further, the panelists’ conclusions
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608
00:36:23,114 --> 00:36:27,351
with or without changes in industry
information and legal authorities.
00:00:00,500 --> 00:00:04,471
On today's episode of “Achieving Health,”
we'll be joined by special guest Andy
2
00:00:04,471 --> 00:00:07,874
Wegman, Senior Director of Reimbursement
Services at Banner Health.
3
00:00:07,907 --> 00:00:12,112
He'll share his perspective on the latest
CMS rulemaking and how his organization
4
00:00:12,112 --> 00:00:15,515
is preparing for upcoming
payment and policy changes.
5
00:00:15,548 --> 00:00:17,217
Stay tuned.
6
00:00:17,217 --> 00:00:21,187
This is “Achieving Health,”
a podcast from Forvis Mazars,
7
00:00:21,187 --> 00:00:24,424
where we delve into the topics
that matter most to healthcare
8
00:00:24,424 --> 00:00:27,227
organizations
across the continuum of care.
9
00:00:27,227 --> 00:00:30,864
Our goal is to help you
navigate the dynamic healthcare landscape
10
00:00:30,864 --> 00:00:33,867
and achieve health at your organization.
11
00:00:35,035 --> 00:00:36,636
Welcome to Achieving Health.
12
00:00:36,636 --> 00:00:38,772
I'm Chad Mulvany. And I'm Shawn Stack.
13
00:00:38,772 --> 00:00:39,973
Thank you for joining us.
14
00:00:39,973 --> 00:00:43,276
I'd like to welcome our guest
for today's episode, Andy Wegman.
15
00:00:43,309 --> 00:00:46,346
Andy is senior director
of reimbursement services at Banner
16
00:00:46,346 --> 00:00:50,216
Health, one of the nation's largest
nonprofit health systems.
17
00:00:50,283 --> 00:00:53,987
Andy, there's been a lot of movement
on the regulatory
18
00:00:53,987 --> 00:00:57,657
front over the last couple of months
between CMS normal
19
00:00:57,690 --> 00:01:00,693
sort of rulemaking cycle for facility
and outpatient
20
00:01:00,693 --> 00:01:03,930
rules,
and adding to that, the rules implementing
21
00:01:03,930 --> 00:01:07,934
the One Big Beautiful Bill act,
the work requirements, the Medicaid cuts.
22
00:01:07,934 --> 00:01:11,671
And we're very excited to hear how you and
23
00:01:11,671 --> 00:01:14,874
Banner are approaching
strategic reimbursement in this landscape.
24
00:01:14,908 --> 00:01:16,509
Thank you so much for being here.
25
00:01:16,509 --> 00:01:17,811
Well thanks, Shawn, thanks, Chad.
26
00:01:17,811 --> 00:01:20,413
Happy with the opportunity
to speak on these.
27
00:01:20,413 --> 00:01:26,386
Yes, there's a lot of different changes
taking place right now as we speak.
28
00:01:26,386 --> 00:01:30,557
And trying to navigate
these can definitely
29
00:01:30,590 --> 00:01:33,593
be overwhelming at times.
30
00:01:33,593 --> 00:01:37,897
Andy, maybe before we get into the meat,
would you please share a little bit
31
00:01:37,897 --> 00:01:41,134
about your career path, how you came
to the industry in your current role,
32
00:01:41,134 --> 00:01:44,571
so our audience can have some perspective
on your background?
33
00:01:44,637 --> 00:01:45,438
Definitely, yeah.
34
00:01:45,438 --> 00:01:48,641
So, in 2007, I actually began working
35
00:01:48,641 --> 00:01:52,178
as an auditor one at Noridian
Healthcare Solutions.
36
00:01:52,178 --> 00:01:56,282
So, fun fact;
I actually had to apply twice.
37
00:01:56,282 --> 00:01:59,786
The first time
my application was actually rejected
38
00:01:59,786 --> 00:02:03,556
because the hiring supervisor was looking
for someone with an accounting degree.
39
00:02:03,556 --> 00:02:07,160
So, I have a business management degree,
I do now
40
00:02:07,160 --> 00:02:10,697
have a graduate accounting certificate,
but not an accounting degree.
41
00:02:10,697 --> 00:02:12,398
So, second time
42
00:02:12,398 --> 00:02:17,036
I applied for the position,
it was with a different hiring manager
43
00:02:17,036 --> 00:02:18,838
and she was willing
to take a chance on me.
44
00:02:18,838 --> 00:02:21,508
So, I guess I'll just say, Pam Marie,
if you're listening,
45
00:02:21,508 --> 00:02:24,878
thank you for taking that chance on me
19 years ago.
46
00:02:24,878 --> 00:02:29,115
While working at Noridian, I worked my way
up; auditor two, senior auditor.
47
00:02:29,249 --> 00:02:32,719
In 2016, I was promoted to the provider
48
00:02:32,719 --> 00:02:35,722
audit and reimbursement Manager
over jurisdiction E.
49
00:02:35,855 --> 00:02:39,592
I was in that role for four years
until I came over to Banner Health in 2020
50
00:02:39,626 --> 00:02:41,461
as a reimbursement consultant.
51
00:02:41,461 --> 00:02:44,497
In 2022, I was promoted
52
00:02:44,497 --> 00:02:47,934
to my current role of Senior
Director of Reimbursement Services.
53
00:02:48,034 --> 00:02:51,371
Andy, sounds like a great background,
particularly that early career,
54
00:02:51,437 --> 00:02:53,873
having to apply two times,
because I would imagine that
55
00:02:53,873 --> 00:02:54,440
when you interviewed
56
00:02:54,440 --> 00:02:57,777
with banner, it basically demonstrated
that you could negotiate with a MAC.
57
00:02:59,112 --> 00:03:00,013
Yes. For
58
00:03:00,013 --> 00:03:03,950
those of our listeners who don't know,
do you want to say
59
00:03:03,950 --> 00:03:07,353
a little bit about Banner
and talk about the system?
60
00:03:07,787 --> 00:03:08,521
Yeah, I'd love to.
61
00:03:08,521 --> 00:03:11,991
So, Banner Health is one of the nation's
62
00:03:11,991 --> 00:03:15,762
largest fully integrated
nonprofit health systems.
63
00:03:15,795 --> 00:03:19,866
We pioneer a sustainable care model
that prioritizes
64
00:03:19,866 --> 00:03:24,637
prevention, manages chronic disease,
and reduces health spending.
65
00:03:24,671 --> 00:03:29,709
We operate 33 hospitals
in more than 400 sites across six states,
66
00:03:29,842 --> 00:03:31,911
delivering seamless care from primary
67
00:03:31,911 --> 00:03:35,715
to quaternary medicine,
including health insurance,
68
00:03:35,782 --> 00:03:40,019
physician networks, world-renowned
specialty services, and behavioral health.
69
00:03:40,353 --> 00:03:43,389
We are accountable to the communities
we serve.
70
00:03:43,423 --> 00:03:48,428
We reinvest every dollar back
into advancing care research
71
00:03:48,428 --> 00:03:53,800
in our facilities, providing more than $1
billion each year in community benefit.
72
00:03:54,033 --> 00:03:56,803
Through our partnership
with the University of Arizona,
73
00:03:56,803 --> 00:04:00,506
we drive clinical discoveries
across more than 800 trials
74
00:04:00,506 --> 00:04:04,310
and train more than 1300 residents
and fellows annually.
75
00:04:04,410 --> 00:04:10,283
We are headquartered in Phoenix, Arizona,
and we serve Arizona, California,
76
00:04:10,316 --> 00:04:14,387
Colorado, Nebraska, Nevada, and Wyoming.
77
00:04:15,221 --> 00:04:17,824
Yeah, that's a huge footprint
and certainly
78
00:04:17,824 --> 00:04:20,827
a very complex organization.
79
00:04:21,394 --> 00:04:24,397
So, with that background in mind,
when you think about this
80
00:04:24,397 --> 00:04:27,934
rulemaking cycle,
what are the two or three
81
00:04:29,002 --> 00:04:32,338
most interesting either proposed—so,
thinking like physician fee
82
00:04:32,372 --> 00:04:36,743
schedule, OPPS—or finalized—so,
the facility rules—from
83
00:04:36,976 --> 00:04:39,779
this round of Medicare rulemaking?
84
00:04:39,779 --> 00:04:43,916
So, I think I'll probably mainly focus
on really OPPS,
85
00:04:43,950 --> 00:04:49,856
you know, as we know, just the other day
CMS released the IPPS final rule.
86
00:04:49,856 --> 00:04:52,458
So, still diving into that one.
87
00:04:52,458 --> 00:04:59,799
Happy to see some things got passed on
and unhappy to see some things didn't.
88
00:04:59,799 --> 00:05:04,137
But when we look at OPPS,
I think for every 340B
89
00:05:04,137 --> 00:05:09,509
hospital, number one is going to be that
the payments for separately payable drugs
90
00:05:09,509 --> 00:05:15,181
being reduced from average sale price plus
6% to average sale price minus 3-3.4%.
91
00:05:15,348 --> 00:05:19,752
Even though this is a quote unquote
“budget
92
00:05:19,786 --> 00:05:25,024
neutral” issue, this is still going
to have a significant impact.
93
00:05:25,792 --> 00:05:28,027
Yeah, I fully agree with you.
94
00:05:28,027 --> 00:05:33,466
And I think when you sort of look
at the separately payable Part B drug cut,
95
00:05:33,866 --> 00:05:38,738
the policy rationale for it
to me is somewhat questionable
96
00:05:38,771 --> 00:05:41,974
because as you mentioned, you know, CMS
tries to say that they're lowering
97
00:05:41,974 --> 00:05:46,779
drug prices for recipients of those drugs,
but at the same time, they're raising
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00:05:47,113 --> 00:05:50,383
cost sharing for everybody else
by making it budget neutral.
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00:05:50,583 --> 00:05:54,320
And I think the other thing that to me
is just sort of interesting is,
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00:05:54,987 --> 00:05:56,022
you know, when you look,
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00:05:56,022 --> 00:05:58,691
and we were talking about this
before we started recording,
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when you look at the survey sample
that CMS is basing this on, right?
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00:06:02,962 --> 00:06:05,298
The first time around, the Supreme Court
knocked down this policy
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because they didn't
actually use hospital data.
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00:06:07,734 --> 00:06:10,002
They fielded the survey earlier
this spring.
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00:06:10,002 --> 00:06:13,973
But yet, you know,
approximately 40% of hospitals responded.
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00:06:14,640 --> 00:06:19,345
Half of the non-340B,
less than 30% of the 340B.
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00:06:19,345 --> 00:06:23,116
And when you look underneath that,
it looks like it's, you know,
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you don't see, they noted that
there weren't major teaching hospitals,
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that most of the 340B respondents
tend to be lower revenue and rural.
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00:06:30,056 --> 00:06:35,628
So, I do think that there may be some
questions about the validity of that cut.
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00:06:35,828 --> 00:06:38,865
I agree.
Was the sample statistically valid?
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00:06:38,865 --> 00:06:42,702
And as well as, you know, the concerns
regarding the uniformity
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of the data collected? Absolutely.
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00:06:45,471 --> 00:06:45,738
Yeah.
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00:06:45,738 --> 00:06:49,675
So, Andy, are there any changes
coming out of these rules, either
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proposed or inpatient,
that you've been shocked
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that your colleagues,
not necessarily at Banner,
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00:06:58,351 --> 00:07:04,023
I know you network a ton and talk to folks
outside of Banner in your profession,
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that folks might be missing
or underappreciating
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00:07:08,561 --> 00:07:12,632
and things that are keeping you up
at night that you think
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00:07:12,999 --> 00:07:16,936
people might not be realizing
the full impact?
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00:07:17,437 --> 00:07:20,239
Lately, there's been a lot
that's been keeping me up all night,
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00:07:20,239 --> 00:07:21,441
I will just say that.
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You know, I'll say one thing
and I won't necessarily say,
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00:07:25,211 --> 00:07:28,948
I don't know if the field
is underappreciating it or not, but
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I'll say one thing that
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gave me some, I'll say breathing room,
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00:07:34,120 --> 00:07:38,991
is related to the Medicaid managed care
state-directed payments,
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00:07:39,292 --> 00:07:42,662
with CMS proposing to allow the state
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00:07:42,662 --> 00:07:47,333
to delay the prohibition
of separate payment terms for these
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state-directed payments
until the new payment limit is met.
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We are a heavily governmental provider,
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so the majority of our patients
are Medicare and Medicaid patients.
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00:08:01,347 --> 00:08:06,853
And with the abundance of Medicaid
patients,
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we utilize these state-directed
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00:08:10,256 --> 00:08:14,560
payments to help bridge
that gap between how much it costs
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00:08:14,560 --> 00:08:18,898
to provide care and what we receive back.
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00:08:18,898 --> 00:08:21,901
So, just as an example,
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00:08:22,201 --> 00:08:25,872
you know, the national average
is that Medicaid payments cover
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00:08:25,938 --> 00:08:29,976
57 to 59% of the costs
to take care of a patient.
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00:08:29,976 --> 00:08:34,881
So, for every dollar that we spend,
we receive less than $0.60 back.
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00:08:35,381 --> 00:08:37,917
The state-directed payments
are to help bridge that gap.
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00:08:37,917 --> 00:08:41,554
So, in Arizona, Banner serves 39%
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00:08:41,554 --> 00:08:44,657
of all Medicaid inpatients in the state.
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00:08:44,757 --> 00:08:49,629
If we focus on two specific
main counties, Maricopa and Pima,
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00:08:49,662 --> 00:08:54,200
we serve 40 to 43% of those
Medicaid inpatients in those counties.
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00:08:54,200 --> 00:08:58,070
So, to be able to postpone
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00:08:58,104 --> 00:09:01,107
the separate payment terms
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00:09:01,641 --> 00:09:06,412
helps us to be able to track this better,
to make sure that our payments
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00:09:06,412 --> 00:09:10,850
that we are receiving are truly based
on our Medicaid utilization.
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00:09:10,850 --> 00:09:14,854
It's not based on how fast
you're billing to the Medicaid payer,
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00:09:14,854 --> 00:09:19,191
what issues you're having with claims,
denials, things like that.
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00:09:19,392 --> 00:09:19,959
Now, Andy,
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00:09:19,959 --> 00:09:24,864
I know that you have at least two, right,
critical access hospitals in Arizona.
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00:09:24,864 --> 00:09:29,135
I know you have Payson
Medical Center and Page Hospital.
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00:09:29,135 --> 00:09:33,072
And then I think you have
when I was looking, I think
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00:09:33,105 --> 00:09:38,110
2 or 3 in in Colorado
that are also rural hospitals, right?
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00:09:38,110 --> 00:09:42,181
You have East Morgan County, Sterling
Regional Medical Center and McKee,
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00:09:42,214 --> 00:09:43,683
I think Medical Center.
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00:09:43,683 --> 00:09:49,555
I know those are, typically,
those are Medicare/Medicaid payer mix.
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00:09:49,555 --> 00:09:53,826
But I've been concerned
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00:09:53,859 --> 00:09:57,830
and I wondered if you think the same,
that your academic medical centers
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00:09:57,830 --> 00:10:01,667
as well, you're seeing a lot of transfers
of Medicaid patients, right?
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00:10:01,667 --> 00:10:05,671
So, that payer mix, too, is really hard
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00:10:05,671 --> 00:10:07,740
to navigate
with these types of cuts, right?
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00:10:07,740 --> 00:10:10,876
Even at your, what most people would call
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00:10:10,910 --> 00:10:14,413
or consider, your urban hospitals
that should be okay.
169
00:10:14,413 --> 00:10:16,816
But you're seeing a lot of those Medicaid
patients?
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00:10:16,816 --> 00:10:17,850
Correct.
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00:10:17,850 --> 00:10:22,388
Yes, I mean, it's all of our facilities,
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you know, and I will say this to,
you know, as we discuss and we go into,
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let's just say,
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00:10:27,860 --> 00:10:31,530
like the work requirements and things
like that, that's where we start,
175
00:10:31,597 --> 00:10:36,202
you know, getting into the part
where our Medicaid
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00:10:36,202 --> 00:10:39,305
eligibility for our patients
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is going to start to decrease.
178
00:10:42,375 --> 00:10:43,242
Right.
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00:10:43,242 --> 00:10:46,412
And so, what this is going to do
is just put pressure
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00:10:46,412 --> 00:10:49,582
on self-pay
and put more pressure on the hospitals.
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00:10:50,016 --> 00:10:50,483
Yeah.
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00:10:50,483 --> 00:10:53,586
So, what are you doing?
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00:10:53,619 --> 00:10:56,856
What strategically
are you pulling into alignment here
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00:10:56,856 --> 00:11:00,793
to maybe help address
and fill in some of these gaps?
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00:11:00,826 --> 00:11:02,228
I mean, outreach?
186
00:11:02,228 --> 00:11:02,895
Payer?
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00:11:02,895 --> 00:11:05,598
Is there any payer/provider
collaboration?
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00:11:05,598 --> 00:11:09,301
Because let's face it, these Medicaid
managed care plans are also going
189
00:11:09,301 --> 00:11:12,371
to be losing these members,
eligible members,
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00:11:12,371 --> 00:11:17,109
if they don't comply with either,
you know, the work requirements
191
00:11:17,109 --> 00:11:20,913
or revalidations, right,
every six months?
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00:11:20,946 --> 00:11:25,317
I mean, are you doing anything here
strategically to prepare for this?
193
00:11:25,751 --> 00:11:26,052
Yeah.
194
00:11:26,052 --> 00:11:30,356
So, I mean,
I will say our patient access teams
195
00:11:30,356 --> 00:11:33,359
have continually done an amazing job
196
00:11:33,392 --> 00:11:36,796
just navigating these things
when they're in our buildings.
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00:11:36,796 --> 00:11:40,833
And we can try to help them
if they don't have coverage
198
00:11:40,833 --> 00:11:45,471
so they know what's necessary
for applying.
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00:11:45,604 --> 00:11:46,138
But,
200
00:11:46,138 --> 00:11:46,372
you know,
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00:11:46,372 --> 00:11:48,841
as I mentioned too, you know, Banner’s
not only a healthcare provider,
202
00:11:48,841 --> 00:11:50,976
we also have the insurance side of things,
right?
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00:11:50,976 --> 00:11:55,514
So, you know, Banner’s
taking an active role
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00:11:55,514 --> 00:11:58,851
in patient and our member engagement
and outreach, you know?
205
00:11:58,918 --> 00:12:03,622
We're tasked with educating members
about the new requirements,
206
00:12:03,756 --> 00:12:07,393
identifying those at risk of noncompliance
and conducting
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00:12:07,393 --> 00:12:10,396
outreach prior
to even potential disenrollment.
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00:12:10,396 --> 00:12:15,267
So, our responsibilities have now expanded
to making sure
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00:12:15,267 --> 00:12:18,871
that we're supporting our members’
navigation and compliance,
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00:12:18,871 --> 00:12:22,675
making sure,
you know, we're connecting with
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00:12:22,675 --> 00:12:26,612
the requirements of the employment
support services.
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00:12:26,879 --> 00:12:30,816
You know, do we need to connect members
with job training programs, workforce
213
00:12:30,816 --> 00:12:34,353
agencies,
educational opportunities, all of this?
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00:12:35,521 --> 00:12:38,591
It's really a whole team approach
215
00:12:38,591 --> 00:12:42,795
of what's needed
to navigate this moving forward.
216
00:12:42,962 --> 00:12:46,265
And you bring up a really important
point here, Andy,
217
00:12:46,398 --> 00:12:52,071
because you wear, Banner wears
two very separate hats, right?
218
00:12:52,071 --> 00:12:56,976
Because let's face it, I've talked
to many organizations who own payers.
219
00:12:57,309 --> 00:13:00,546
It is a very separate entity
and it's kept very separate.
220
00:13:00,546 --> 00:13:03,716
But you see the struggle on both sides.
221
00:13:03,716 --> 00:13:07,653
So, don't you agree
that partnerships in this space
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00:13:08,220 --> 00:13:12,458
with the payers on the Medicaid
managed care side are just so important
223
00:13:12,458 --> 00:13:15,594
for payers and providers
to collaborate in that effort?
224
00:13:16,095 --> 00:13:17,463
100%, yes.
225
00:13:17,463 --> 00:13:20,466
I mean, you know,
226
00:13:21,133 --> 00:13:24,770
even when we're looking at,
you know, when we see
227
00:13:26,038 --> 00:13:30,309
patients that, you know, individuals
that lose healthcare coverage, right?
228
00:13:30,342 --> 00:13:33,279
So, if they do fall through the cracks,
229
00:13:33,279 --> 00:13:37,583
these individuals are less likely
to seek preventative care.
230
00:13:37,583 --> 00:13:41,387
So, we need to try to make sure
that we can
231
00:13:41,754 --> 00:13:44,456
keep them on their coverage
232
00:13:44,456 --> 00:13:47,626
instead of, you know,
233
00:13:48,594 --> 00:13:49,728
them seeking
234
00:13:49,728 --> 00:13:54,500
the emergency department
when something gets even more serious.
235
00:13:54,533 --> 00:13:58,637
We need to make sure that we keep
that preventative care going forward.
236
00:13:58,671 --> 00:14:01,874
It just helps everybody to be more healthy
237
00:14:01,907 --> 00:14:04,910
throughout the whole process as opposed
238
00:14:04,910 --> 00:14:08,147
to, you know, getting up to a diagnosis
239
00:14:08,147 --> 00:14:11,584
just with little time
to really address the issue.
240
00:14:12,117 --> 00:14:13,185
Yeah, couldn’t agree more.
241
00:14:13,185 --> 00:14:16,822
I mean,
continuity of care is truly a big risk.
242
00:14:16,822 --> 00:14:20,626
And I just got off the stage
talking at a symposium and I said,
243
00:14:20,659 --> 00:14:24,430
you know, this is one of the things
that quote unquote “legacy providers”
244
00:14:25,030 --> 00:14:30,436
really have done a phenomenal job
over the last decade in perfecting
245
00:14:30,436 --> 00:14:35,774
and honing is continuum of care
and cuts like this and,
246
00:14:36,108 --> 00:14:40,579
you know, disruption
have really challenged us over the last
247
00:14:40,579 --> 00:14:45,818
five years in continuing that continuum
of care for our members and our patients.
248
00:14:46,452 --> 00:14:49,755
Andy, you mentioned earlier the importance
249
00:14:49,755 --> 00:14:52,758
of state-directed payments to Banner.
250
00:14:52,958 --> 00:14:55,427
How is Banner preparing for those cuts?
251
00:14:55,427 --> 00:14:55,661
I mean,
252
00:14:55,661 --> 00:14:58,864
you know what the runway looks like,
so what is the organization doing
253
00:14:58,898 --> 00:15:00,733
to make sure
that when they start to kick in
254
00:15:00,733 --> 00:15:04,470
and given how important they are,
you're going to be able to navigate them?
255
00:15:05,237 --> 00:15:05,471
Yeah.
256
00:15:05,471 --> 00:15:09,074
So, that's a good
and a very difficult question, right?
257
00:15:09,074 --> 00:15:14,980
You know, we have to look at this,
you know, not only in the short term
258
00:15:14,980 --> 00:15:17,983
but long term as we're doing our
long-range
259
00:15:17,983 --> 00:15:23,355
forecasting and seeing
what will it be looking like,
260
00:15:23,355 --> 00:15:26,592
you know, five years,
10 years down the road
261
00:15:27,226 --> 00:15:29,628
when these reductions
262
00:15:29,628 --> 00:15:32,631
are fully implemented.
263
00:15:32,698 --> 00:15:35,634
I mean,
not really giving any specifics, but,
264
00:15:35,634 --> 00:15:38,904
you know, Banner,
as well as any other healthcare provider,
265
00:15:38,904 --> 00:15:40,873
we're going to have to evaluate, you know,
266
00:15:40,873 --> 00:15:45,177
are there certain programs
that are no longer sustainable?
267
00:15:45,477 --> 00:15:49,248
Are there service line reductions
that are needed
268
00:15:49,682 --> 00:15:54,186
to be able to keep things moving, right?
269
00:15:54,219 --> 00:15:57,723
You know,
hospitals operate on a razor-thin margin.
270
00:15:57,756 --> 00:16:02,594
You know, I think that's something that
a lot of people may forget.
271
00:16:02,695 --> 00:16:06,432
You know, they see the bill that they get,
but especially, you know,
272
00:16:06,498 --> 00:16:09,868
talking with Banner Health
nonprofit, everything is,
273
00:16:10,402 --> 00:16:14,273
you know, anything that we get
is invested back into our communities.
274
00:16:14,273 --> 00:16:19,345
And with the reduction
of these state-directed payments,
275
00:16:19,345 --> 00:16:22,881
it just makes it
that much more difficult to
276
00:16:23,782 --> 00:16:27,019
invest in the items
that we need to invest in.
277
00:16:27,353 --> 00:16:30,723
Yeah, to make sure that they have access
to the services they needed.
278
00:16:30,723 --> 00:16:31,590
And I think, you know,
279
00:16:32,591 --> 00:16:35,627
without naming specific services,
what's unfortunate about
280
00:16:35,627 --> 00:16:39,198
this is the services that I worry about
are the ones that are already,
281
00:16:39,198 --> 00:16:42,634
that we struggle with to access
in many areas of the country, particularly
282
00:16:42,634 --> 00:16:45,738
those that are either rural
or socioeconomically disadvantaged.
283
00:16:45,738 --> 00:16:49,141
And there's a reason why those services
aren't more readily available
284
00:16:49,174 --> 00:16:51,377
because of the payer mix
and the underpayment.
285
00:16:51,377 --> 00:16:54,380
And then when you start to layer on
everything else, you know,
286
00:16:54,413 --> 00:16:58,350
we were talking about 340B earlier,
you know, when you think about what
287
00:16:58,350 --> 00:17:01,387
the intent of 340B was from Congress.
288
00:17:01,387 --> 00:17:04,623
And now CMS is basically implementing
289
00:17:04,623 --> 00:17:08,260
a budget-neutral shift
in where those funds flow.
290
00:17:08,293 --> 00:17:12,331
They're also doing the 3% recoupment
from the prior settlement.
291
00:17:12,331 --> 00:17:16,402
It really does start to put a tremendous
amount of pressure on the organization.
292
00:17:16,402 --> 00:17:18,303
And then you layer in the work
requirements
293
00:17:18,303 --> 00:17:20,372
and the loss of coverage,
both from the exchange
294
00:17:20,372 --> 00:17:24,376
and through the Medicaid work
requirements for your expansion states
295
00:17:24,376 --> 00:17:25,577
in One Big Beautiful Bill.
296
00:17:25,577 --> 00:17:27,980
So, yeah, it's a lot to navigate.
297
00:17:27,980 --> 00:17:28,180
Yeah.
298
00:17:28,180 --> 00:17:31,183
It's a difficult cycle
to think about, right?
299
00:17:31,183 --> 00:17:34,186
So, we think, our 340B
300
00:17:34,219 --> 00:17:37,222
hospitals are hospitals
301
00:17:37,256 --> 00:17:40,259
that have a disproportionate share
302
00:17:40,426 --> 00:17:43,162
of low-income patients.
303
00:17:43,162 --> 00:17:45,531
And so, that's how they're qualifying.
304
00:17:45,531 --> 00:17:49,001
And so,
now we're going to be paying them less.
305
00:17:49,101 --> 00:17:52,504
And we're shifting, CMS is shifting
306
00:17:52,504 --> 00:17:56,308
those funds to other service lines
307
00:17:56,308 --> 00:18:00,979
that are not necessarily
going to benefit the hospitals
308
00:18:00,979 --> 00:18:05,818
that have a disproportionate
share of low-income patients.
309
00:18:06,218 --> 00:18:10,956
Now, keeping in mind, Andy,
I know that you're
310
00:18:11,824 --> 00:18:14,259
modeling these,
you're modeling the reimbursement changes
311
00:18:14,259 --> 00:18:18,497
that you think are going to be impacting,
you know, as we as we come up
312
00:18:18,497 --> 00:18:23,435
on all these state-directed
payment issues and cuts.
313
00:18:23,435 --> 00:18:26,972
But keeping in mind
that this is not just state-directed
314
00:18:26,972 --> 00:18:31,343
payment cuts for hospitals,
it's also for Medicaid programs.
315
00:18:31,343 --> 00:18:35,948
So, I assume as you model
these reimbursement shifts and cuts,
316
00:18:36,515 --> 00:18:40,385
I assume your government relations
folks are also talking
317
00:18:40,419 --> 00:18:43,856
to state Medicaid agencies saying,
do you realize what is going to happen,
318
00:18:43,922 --> 00:18:45,224
what type of impact
319
00:18:45,224 --> 00:18:48,360
this is going to have on these communities
that we service, right?
320
00:18:48,393 --> 00:18:53,465
I mean, this is kind of dire across
the board as far as coverage, right?
321
00:18:53,465 --> 00:18:56,068
Because they're going to have to cut
as they
322
00:18:56,068 --> 00:18:58,470
run out of money
for some of these additional programs.
323
00:18:58,470 --> 00:19:03,542
But it could, like you
said, it could really impact these
324
00:19:04,543 --> 00:19:07,112
challenged areas even more.
325
00:19:07,112 --> 00:19:07,746
Correct.
326
00:19:07,746 --> 00:19:11,617
And, I mean, a lot of times
I always reference things
327
00:19:11,617 --> 00:19:15,354
back to Arizona, since that's
where we have our biggest presence.
328
00:19:15,354 --> 00:19:18,624
And, you know it's,
you know, it's an expansion state.
329
00:19:18,624 --> 00:19:21,627
The
330
00:19:22,261 --> 00:19:27,199
expansion
population is funded by the hospitals.
331
00:19:27,332 --> 00:19:30,335
And so,
332
00:19:31,436 --> 00:19:35,107
we put up that local share to draw down
333
00:19:35,107 --> 00:19:38,977
federal dollars to ensure
that these patients have coverage.
334
00:19:39,278 --> 00:19:43,482
And so, when things
335
00:19:43,482 --> 00:19:49,021
like hold harmless limits get reduced,
for state-directed payments
336
00:19:49,021 --> 00:19:52,024
the methodology
337
00:19:52,024 --> 00:19:55,694
going from average
commercial rate to Medicare rates.
338
00:19:55,694 --> 00:20:01,033
I mean, these things all play a very
important role in trying to determine,
339
00:20:01,066 --> 00:20:04,536
you know, what kind of coverage
is going to be out there
340
00:20:05,270 --> 00:20:08,440
five years down the road for the
341
00:20:09,474 --> 00:20:12,344
patients that need that coverage.
342
00:20:12,344 --> 00:20:15,214
You know, you make a great point
about the provider taxes
343
00:20:15,214 --> 00:20:17,616
and the phasedown of the hold
harmless limit.
344
00:20:17,616 --> 00:20:19,418
Obviously, the state knows this is coming.
345
00:20:19,418 --> 00:20:22,387
So, what conversations
have they been having so far,
346
00:20:22,387 --> 00:20:26,558
if any, about trying to sort of sustain
that expansion
347
00:20:26,558 --> 00:20:30,429
population, given that it was more
or less self-funded by the hospitals?
348
00:20:30,796 --> 00:20:31,096
Yeah.
349
00:20:31,096 --> 00:20:36,034
So, we do work
really closely with AHCCCS,
350
00:20:36,034 --> 00:20:39,504
or the State of Arizona, as their program.
351
00:20:39,504 --> 00:20:45,143
You know, as we have new models
come out each year,
352
00:20:45,143 --> 00:20:49,781
you know, initial proposals
and looking at estimates on
353
00:20:49,982 --> 00:20:54,219
how much is needed for coverage
and making sure that the funding
354
00:20:54,219 --> 00:20:57,923
is appropriate,
making sure that we're updating
355
00:20:57,923 --> 00:21:02,861
any of our calculations
to just ensure that we're
356
00:21:03,629 --> 00:21:06,999
keeping
that funding as stable as possible,
357
00:21:07,466 --> 00:21:11,670
but trying to, on the other hand
as well, ensure
358
00:21:11,670 --> 00:21:15,540
that we are able to provide funding
359
00:21:15,540 --> 00:21:19,778
for other programs to
360
00:21:20,979 --> 00:21:24,483
work on
that gap that I was kind of talking
361
00:21:24,483 --> 00:21:28,754
about earlier from the shortfall
of seeing Medicaid patients.
362
00:21:28,754 --> 00:21:32,291
And so, it's just, it's a balancing act.
363
00:21:32,457 --> 00:21:33,191
It really is.
364
00:21:33,191 --> 00:21:35,460
And we work closely with the state.
365
00:21:35,460 --> 00:21:40,065
We have some other consultants
that we work with as well, the hospitals,
366
00:21:40,065 --> 00:21:46,138
we all work together to try to navigate
these waters as they're coming at us.
367
00:21:46,438 --> 00:21:47,706
Yeah, Andy, you bring up a good point.
368
00:21:47,706 --> 00:21:50,709
I mean, there's
just so many vulnerable services
369
00:21:51,043 --> 00:21:54,212
that are going to become more vulnerable
through these cuts.
370
00:21:54,279 --> 00:21:58,250
I mean, things like, for listeners, things
like inpatient
371
00:21:58,784 --> 00:22:01,453
psychiatry, crisis stabilization
372
00:22:01,453 --> 00:22:05,857
units, substance use disorder treatment
programs, things like rural maternity
373
00:22:05,891 --> 00:22:09,828
units,
neonatal support services, swing beds,
374
00:22:09,828 --> 00:22:13,532
rural outpatient clinics, community
health programs.
375
00:22:13,532 --> 00:22:15,500
These are really important services
376
00:22:15,500 --> 00:22:19,271
that these just, you know,
these disproportionate communities
377
00:22:19,571 --> 00:22:23,909
now, through Medicaid expansion
and through the programs that Medicaid
378
00:22:23,942 --> 00:22:27,579
offers, these great programs,
these are at risk, right, Andy?
379
00:22:27,579 --> 00:22:32,951
And I'm assuming that your communities
that Banner serves are big recipients
380
00:22:32,984 --> 00:22:37,122
now of these services, and
those might be challenged in the future.
381
00:22:37,522 --> 00:22:41,493
They are, you know,
and I will say that, you know, Banner,
382
00:22:42,461 --> 00:22:43,995
we just, we have a history.
383
00:22:43,995 --> 00:22:46,198
We are going to do
what's best for our communities.
384
00:22:46,198 --> 00:22:48,700
And we're, you know, we buckle down.
385
00:22:48,700 --> 00:22:52,571
We make sure that we're going through
everything and making sure that we're
386
00:22:52,571 --> 00:22:56,308
providing just the best
387
00:22:56,675 --> 00:23:00,679
care to our patients,
the best community stewards.
388
00:23:00,679 --> 00:23:04,583
And yeah, it'll definitely,
it gets difficult
389
00:23:04,583 --> 00:23:07,619
with these reductions.
390
00:23:07,753 --> 00:23:11,456
It's just going to be
some difficult waters to manage through.
391
00:23:11,456 --> 00:23:15,560
And almost paralyzing
for a rural hospital
392
00:23:15,560 --> 00:23:18,864
that is not part of a larger system,
right, Andy?
393
00:23:18,864 --> 00:23:22,000
I mean, they don't have the resources
necessarily.
394
00:23:22,234 --> 00:23:22,534
Yeah.
395
00:23:22,534 --> 00:23:24,703
I mean, it definitely helps with,
396
00:23:24,703 --> 00:23:28,473
you know, with our critical access
hospitals, you know,
397
00:23:28,507 --> 00:23:35,013
having certain functions centralized
so they're not bearing all these costs.
398
00:23:35,080 --> 00:23:38,083
You know,
I think what's interesting is too,
399
00:23:38,116 --> 00:23:41,653
a lot of times
people think, well, Medicare pays 101%.
400
00:23:41,720 --> 00:23:42,053
Well,
401
00:23:43,054 --> 00:23:45,190
you're
not getting more than what you pay in.
402
00:23:45,190 --> 00:23:46,858
I will say that.
403
00:23:46,858 --> 00:23:53,732
So, there's definitely
the need for efficiency and making sure,
404
00:23:54,132 --> 00:23:57,602
you know,
if your rural facilities are struggling,
405
00:23:57,636 --> 00:24:01,873
you know,
do we have our university or community
406
00:24:01,907 --> 00:24:05,410
hospitals that can, you know, just assist
407
00:24:05,544 --> 00:24:08,547
as a, just as a whole health system?
408
00:24:08,947 --> 00:24:12,350
You know, Andy, the other thing,
when you say, you know, critical access
409
00:24:12,350 --> 00:24:18,023
hospitals get paid by Medicare at 101%,
I mean that that presumes
410
00:24:18,023 --> 00:24:21,593
that there hasn't been a significant shift
to MA, which in a lot of cases,
411
00:24:21,593 --> 00:24:24,062
that's not how those contracts
are structured.
412
00:24:24,062 --> 00:24:27,132
So, you kind of layer
on that piece of pressure as well.
413
00:24:27,199 --> 00:24:29,734
I think, you know,
414
00:24:29,734 --> 00:24:35,474
one of the interesting things that I'll be
watching over the next couple of years
415
00:24:35,674 --> 00:24:40,612
is kind of the tension
between the policy community, both in D.C.
416
00:24:40,612 --> 00:24:44,883
and state capitals,
who have, for whatever reason, decided
417
00:24:44,883 --> 00:24:48,854
that consolidation
integration is driving cost.
418
00:24:48,854 --> 00:24:51,857
But then at the same time,
all the services that we've been talking
419
00:24:51,857 --> 00:24:55,694
about that Shawn specifically called out
that are important for communities
420
00:24:55,694 --> 00:24:59,798
to have access to,
all communities to have access to, like,
421
00:24:59,931 --> 00:25:03,001
what's the tension
between allowing integration to occur
422
00:25:03,001 --> 00:25:05,070
in order to support access
to those services
423
00:25:05,070 --> 00:25:09,040
or having a regulator block
it just sort of blindly?
424
00:25:09,040 --> 00:25:12,177
Because now evidently consolidation is,
425
00:25:13,078 --> 00:25:13,311
you know,
426
00:25:13,311 --> 00:25:17,549
they're looking at the cost side of it,
but they're also not looking fully at,
427
00:25:17,582 --> 00:25:21,419
you know, the avoided cost of providing
that care in the community
428
00:25:21,453 --> 00:25:22,521
versus having someone either
429
00:25:22,521 --> 00:25:24,623
a) not get the care or b)
have to go someplace else
430
00:25:24,623 --> 00:25:26,658
where it's going to be more expensive,
likely.
431
00:25:26,658 --> 00:25:30,362
Or delay it until they're so sick that
their care is going to be so expensive.
432
00:25:30,395 --> 00:25:32,197
right? Correct. Exactly.
433
00:25:32,197 --> 00:25:35,934
And then they end up
in the emergency department and well,
434
00:25:35,934 --> 00:25:39,538
now the cost of providing that care
just quadrupled.
435
00:25:39,704 --> 00:25:40,372
Yeah.
436
00:25:40,372 --> 00:25:43,375
As opposed to just being able
to take the preventative
437
00:25:43,375 --> 00:25:46,511
measures,
having that coverage on the front end.
438
00:25:47,913 --> 00:25:50,949
Andy, what else is, not that we haven't
already talked about enough,
439
00:25:50,949 --> 00:25:53,952
but what else is keeping you up at night
on the regulatory front?
440
00:25:53,985 --> 00:25:57,389
On top of all these items
that we've already been discussing, right?
441
00:25:57,822 --> 00:26:02,294
You know, I think—and personally,
one of the things that,
442
00:26:02,394 --> 00:26:07,399
you know, as I'm reading all the various
proposed rules and things like that is—all
443
00:26:07,399 --> 00:26:11,736
of CMS’ proposals to, and I'll just say it
in air quotes, “codify
444
00:26:11,736 --> 00:26:15,740
their long-standing policy”
for this, that and the other thing, right?
445
00:26:15,874 --> 00:26:16,841
You know,
446
00:26:16,841 --> 00:26:20,111
a little bit about, you know, the IPPS
proposed rule that came out, right?
447
00:26:20,111 --> 00:26:25,984
So, initially discussing
the need to fragment all of your overhead
448
00:26:26,017 --> 00:26:30,021
for every department
utilization of those services.
449
00:26:30,055 --> 00:26:32,624
And, you know, CMS was obviously focusing
on nursing
450
00:26:32,624 --> 00:26:34,693
allied health
since it's paid as a passthrough cost.
451
00:26:34,693 --> 00:26:39,264
But I mean, is that appropriate
just to pick that one
452
00:26:39,364 --> 00:26:42,400
and not the other ones, right?
453
00:26:42,434 --> 00:26:45,203
And, you know,
luckily with the final rule,
454
00:26:45,203 --> 00:26:48,940
they did not make any changes to that,
you know?
455
00:26:48,974 --> 00:26:54,546
So, they're—sorry, they didn't make
any changes to the current rule.
456
00:26:54,579 --> 00:26:58,583
So, it's not to the point
where you need to fragment everything out.
457
00:26:58,583 --> 00:27:01,786
But something that did get finalized
458
00:27:01,786 --> 00:27:06,458
in the final rule is regarding removing
certain costs
459
00:27:06,458 --> 00:27:11,796
from the accumulated cost stat
for allocating A&G costs.
460
00:27:12,197 --> 00:27:16,301
You know, right now, you know,
the focus of this was really CMS
461
00:27:16,301 --> 00:27:21,106
focusing on transplant
costs—we do operate two transplant
462
00:27:21,139 --> 00:27:25,610
hospitals—and with the ruling,
their big focus was on
463
00:27:25,610 --> 00:27:29,948
purchased services and really looking
at like the purchased organs.
464
00:27:30,348 --> 00:27:35,153
But we have purchased services all
throughout other departments as well. So,
465
00:27:36,254 --> 00:27:39,190
it just leads us down a rabbit
hole of saying, okay,
466
00:27:39,190 --> 00:27:43,194
well then we should probably be looking
at these purchased services
467
00:27:43,194 --> 00:27:48,266
because they may not be receiving
any benefit from A&G.
468
00:27:48,433 --> 00:27:51,302
And so, they shouldn't be receiving
that allocation either.
469
00:27:51,302 --> 00:27:57,075
And then, when all this picking
and choosing and I'll just say fragmenting
470
00:27:57,075 --> 00:28:00,979
and everything, it just really opens up
the hospitals for more audit risk.
471
00:28:00,979 --> 00:28:04,883
And then it just gets to be based
on each auditor's
472
00:28:04,883 --> 00:28:06,851
interpretation of the regulations.
473
00:28:06,851 --> 00:28:12,691
And so that's really my concern,
you know, as this shift
474
00:28:12,991 --> 00:28:16,194
really starts to move things
475
00:28:16,194 --> 00:28:19,998
from how things have been operating
476
00:28:20,031 --> 00:28:25,003
to more of a well, now each auditor
is going to be taking a look at something.
477
00:28:25,003 --> 00:28:28,973
They may come up with a different response
than the next auditor,
478
00:28:29,040 --> 00:28:33,611
and it's just going to make it
a little bit more difficult to ensure
479
00:28:34,045 --> 00:28:37,482
you're handling these things
consistently.
480
00:28:37,782 --> 00:28:42,320
So, switching gears,
what's one piece of advice
481
00:28:42,320 --> 00:28:45,990
you give, Andy,
to someone who recently moved into a
482
00:28:46,291 --> 00:28:50,195
formal leadership role in reimbursement,
healthcare,
483
00:28:50,562 --> 00:28:54,499
anything that you'd want to share there
for someone new coming in?
484
00:28:55,033 --> 00:28:55,433
Yeah.
485
00:28:55,433 --> 00:28:58,937
So, I mean, actually there's a
there's a couple of them.
486
00:28:59,237 --> 00:29:02,574
I mean, first and foremost, I would say
487
00:29:02,574 --> 00:29:07,178
just make sure your values align
with the company that you're working for.
488
00:29:07,512 --> 00:29:11,015
Just on the, right on the front end,
you know?
489
00:29:11,015 --> 00:29:13,618
When you work for a company
that shares your same values
490
00:29:13,618 --> 00:29:15,987
and they're a part of a team
that cares about you
491
00:29:15,987 --> 00:29:17,622
both personally and professionally,
492
00:29:17,622 --> 00:29:20,291
there's nothing you won't do
to ensure everyone’s successful.
493
00:29:20,291 --> 00:29:23,094
So, that's definitely number one.
494
00:29:23,094 --> 00:29:27,132
I've been very, very happy
working with Banner.
495
00:29:27,132 --> 00:29:30,135
It's been a great company.
496
00:29:30,201 --> 00:29:34,038
The second one, it's
497
00:29:35,340 --> 00:29:37,709
kind of funny, but just, I
498
00:29:37,709 --> 00:29:41,813
realized early on in my career
that I don't know
499
00:29:41,813 --> 00:29:44,816
everything. So,
500
00:29:45,717 --> 00:29:48,720
you know, that is brought to my attention
every single day.
501
00:29:48,753 --> 00:29:51,422
You know, there's always the new,
new thing popping up.
502
00:29:51,422 --> 00:29:54,559
And I will say, be honest,
503
00:29:54,559 --> 00:29:57,562
admit that you may not know
the answer to a question.
504
00:29:57,662 --> 00:30:00,899
I feel like sometimes
people are so afraid,
505
00:30:00,899 --> 00:30:04,335
and so they do the whole let's fake
it ‘til you make it, right?
506
00:30:04,402 --> 00:30:07,071
No, just ask the question, you know?
507
00:30:07,071 --> 00:30:10,675
If you don't know,
say that you don't know, you know?
508
00:30:10,742 --> 00:30:14,746
Not knowing something is the catalyst
to researching a topic,
509
00:30:14,779 --> 00:30:18,082
discussing it with your peers,
and just eventually learning
510
00:30:18,082 --> 00:30:21,352
something new
that can help you throughout your career.
511
00:30:21,452 --> 00:30:25,690
When leading a team,
you need to listen to them and build
512
00:30:25,690 --> 00:30:28,860
both personal
and professional relationships with them.
513
00:30:28,993 --> 00:30:33,665
Trust your team members as they look to
you to grow and take on more challenges.
514
00:30:34,465 --> 00:30:39,270
A lot of it too, is knowing and building
relationships with your colleagues,
515
00:30:39,270 --> 00:30:42,674
not only just at your organization,
but outside of your organization,
516
00:30:42,674 --> 00:30:47,212
that you can lean on in those—maybe
it's a PAMA question,
517
00:30:47,278 --> 00:30:51,316
you know, a lab question
or something—building that network of
518
00:30:51,316 --> 00:30:56,354
trusted advisors that you know know more
than you do in that one specific area.
519
00:30:56,387 --> 00:30:58,389
Don't
you think that's important too, Andy?
520
00:30:59,424 --> 00:31:00,358
100%.
521
00:31:00,358 --> 00:31:03,561
And even with the things that you do know.
522
00:31:03,561 --> 00:31:06,631
So, another fun fact, right? So,
523
00:31:07,732 --> 00:31:10,001
when starting off as an auditor one,
524
00:31:10,001 --> 00:31:13,037
I'll say the first real
525
00:31:14,072 --> 00:31:18,243
auditable issue that you learn is Medicare
bad debts.
526
00:31:18,276 --> 00:31:21,579
And so, I've known about Medicare
527
00:31:21,579 --> 00:31:25,149
bad debts and the reimbursement of them
for over 19 years.
528
00:31:25,149 --> 00:31:28,720
But there's still always different nuances
529
00:31:28,820 --> 00:31:31,723
that come up regarding Medicare bad debts.
530
00:31:31,723 --> 00:31:35,760
So, it's
just not only the stuff that you may not
531
00:31:35,760 --> 00:31:39,197
have the best grasp of,
but just even things that you do.
532
00:31:39,197 --> 00:31:42,667
And things change, it's important
to be able
533
00:31:42,667 --> 00:31:45,670
to have
534
00:31:46,137 --> 00:31:50,675
peers—again, inside,
outside of your organization—that
535
00:31:50,675 --> 00:31:54,479
you can discuss situations with.
536
00:31:54,479 --> 00:31:58,082
And you know, what-if scenarios
and things like that.
537
00:31:58,082 --> 00:32:03,521
And as we've seen now, especially over
the past couple of years here, I mean,
538
00:32:03,521 --> 00:32:09,060
just all the different regulatory changes
coming down,
539
00:32:09,527 --> 00:32:13,197
it's a lot to try to take on.
540
00:32:13,197 --> 00:32:16,200
And you can't just take it on
as one person.
541
00:32:16,234 --> 00:32:20,872
You definitely need to utilize your team,
your peers
542
00:32:21,139 --> 00:32:25,043
to navigate these to make sure
you're handling things accurately.
543
00:32:25,143 --> 00:32:26,811
Yeah, couldn’t agree more.
544
00:32:26,811 --> 00:32:30,281
What's something you and your colleagues
recently accomplished that you're proud
545
00:32:30,281 --> 00:32:33,651
of, Andy, or challenges
546
00:32:33,851 --> 00:32:37,355
did you have that you overcame
and how did you do it?
547
00:32:37,789 --> 00:32:38,189
Yeah.
548
00:32:38,189 --> 00:32:42,193
So, I think, you know, one thing
that I've been really proud
549
00:32:42,694 --> 00:32:45,463
of my team is just we've been
550
00:32:45,463 --> 00:32:50,268
successful obtaining additional
IME and DGME FTE cap space
551
00:32:50,268 --> 00:32:55,373
for every round of section 126,
as well as section 4122.
552
00:32:55,373 --> 00:32:59,277
And when you kind of talk about
challenges, I guess I wouldn't necessarily
553
00:32:59,277 --> 00:33:02,613
say it’s a challenge, but just,
I think knowing where
554
00:33:02,613 --> 00:33:05,817
your health system’s
short-term and long-term
555
00:33:05,817 --> 00:33:09,954
risks are for physician
staffing in your markets is key.
556
00:33:10,154 --> 00:33:14,025
You know, working with senior leadership
and your GME office
557
00:33:14,025 --> 00:33:16,394
to map out a plan to address those risks.
558
00:33:16,394 --> 00:33:20,064
You know, Banner’s
been expanding their GME footprint
559
00:33:20,098 --> 00:33:24,435
substantially over the past few years,
and we continue to do so
560
00:33:24,469 --> 00:33:26,838
to meet the needs of our community.
561
00:33:26,838 --> 00:33:27,505
At Banner here
562
00:33:27,505 --> 00:33:31,542
we have something, we call it “One Team,”
you know, we're all one team.
563
00:33:31,542 --> 00:33:34,779
We all work together for a common purpose.
564
00:33:34,779 --> 00:33:38,182
And, you know, obviously at the
end of the day, that is for our patients.
565
00:33:38,182 --> 00:33:42,186
And looking at things
from different perspectives,
566
00:33:42,186 --> 00:33:46,791
whether it's reimbursement services
or if it's,
567
00:33:46,824 --> 00:33:50,661
you know, the GME office,
568
00:33:50,828 --> 00:33:56,701
you know, the intricacies of training
residents, right, or senior leadership
569
00:33:56,701 --> 00:34:01,539
and what they're seeing in the markets
and what we
570
00:34:01,539 --> 00:34:05,076
might be facing here
in the next few years.
571
00:34:05,109 --> 00:34:08,713
It's just really important
for us to all work together to make sure
572
00:34:08,813 --> 00:34:14,619
that as one team, we are moving
in the direction that we want to
573
00:34:14,652 --> 00:34:16,621
for our patients.
574
00:34:16,621 --> 00:34:18,790
Well, Andy, this was fantastic.
575
00:34:18,790 --> 00:34:20,258
I want to thank you again for joining
576
00:34:20,258 --> 00:34:23,194
today's episode
and and sharing your insights.
577
00:34:23,194 --> 00:34:25,730
You're a wealth of knowledge.
I always enjoy talking to you.
578
00:34:25,730 --> 00:34:29,000
And we'd also like to thank our listeners
for tuning in.
579
00:34:29,033 --> 00:34:31,135
You can follow “Achieving Health” on Apple
580
00:34:31,135 --> 00:34:35,306
Podcasts, Spotify, Amazon Music,
or wherever you listen to podcasts.
581
00:34:35,306 --> 00:34:39,744
You can also now find us in the Health
Podcast Library.
582
00:34:39,744 --> 00:34:42,747
If you want to learn more about the topics
we discussed
583
00:34:42,747 --> 00:34:46,184
here, be sure to check out the show notes
for related content.
584
00:34:46,184 --> 00:34:49,520
You can also subscribe to our Healthcare
FORsights
585
00:34:49,520 --> 00:34:53,191
and follow us on LinkedIn
to get regular insights and updates.
586
00:34:53,191 --> 00:34:58,496
And we welcome you to reach out to me,
Chad and the team here at Forvis Mazars
587
00:34:58,629 --> 00:35:03,468
if you have any questions about how
these topics may affect your organization.
588
00:35:03,701 --> 00:35:07,338
Chad and I will be back
next week on Wednesday, August
589
00:35:07,338 --> 00:35:10,541
19, for the next round of “Washington
Watch” updates.
590
00:35:10,541 --> 00:35:15,379
Until then, here's wishing good health
for you and the communities you serve.
591
00:35:16,180 --> 00:35:20,218
You can follow “Achieving Health”
on your favorite podcast platform or visit
592
00:35:20,218 --> 00:35:24,589
forvismazars.us/AchievingHealthPodcast
to learn more.
593
00:35:24,956 --> 00:35:29,660
“Achieving Health” is produced by Forvis
Mazars LLP, an independent member
594
00:35:29,660 --> 00:35:34,031
of Forvis Mazars Global, a leading global
professional services network.
595
00:35:34,031 --> 00:35:37,702
Ranked among the largest public
accounting firms in the United States,
596
00:35:37,802 --> 00:35:43,040
the firm's 7,000 dedicated team members
provide an Unmatched Client Experience
597
00:35:43,040 --> 00:35:47,011
through the delivery of assurance, tax
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598
00:35:47,011 --> 00:35:50,515
in all 50 states and internationally
through the global network.
599
00:35:50,548 --> 00:35:54,986
The information set forth in this podcast
contains the analysis and conclusions
600
00:35:54,986 --> 00:35:58,523
of the panelists based upon his, her,
or their research
601
00:35:58,523 --> 00:36:01,893
and analysis of industry
information and legal authorities.
602
00:36:01,893 --> 00:36:05,363
Such analysis and conclusions
should not be deemed opinions
603
00:36:05,363 --> 00:36:08,599
or conclusions by Forvis Mazars
or the panelists
604
00:36:08,599 --> 00:36:12,770
as to any individual situation
as situations are fact specific.
605
00:36:12,837 --> 00:36:15,173
The listener should perform
their own analysis
606
00:36:15,173 --> 00:36:19,143
and form their own conclusions
regarding any specific situation.
607
00:36:19,177 --> 00:36:23,114
Further, the panelists’ conclusions
may be revised without notice,
608
00:36:23,114 --> 00:36:27,351
with or without changes in industry
information and legal authorities.
