Low-value care are medical services that provide little to no benefit to patients and continues to be a pressing issue in healthcare. These interventions, such as redundant lab tests or unnecessary imaging, not only strain health system resources but can also lead to financial harm and therapeutic cascades for patients. This episode explores how clinicians can identify and reduce low-value care through real-time cost transparency, contextual nudging, and evidence-based decision support, ultimately promoting more efficient and patient-centered care.
On today’s episode of In Network's Designing for Health podcast, Nordic Chief Medical Officer Craig Joseph, MD, talks with Mukul Mehra, MD, gastroenterologist and founder of IllumiCare. They discuss the intersection of clinical care and financial stewardship. Dr. Mehra shares his journey from practicing medicine to launching a company aimed at reducing low-value care through contextual nudging and clinical financial decision support. They also discuss perspectives on how cost transparency, provider incentives, and thoughtful design can improve patient outcomes and reduce unnecessary spending without compromising clinical autonomy.
Listen here:
In Network's Designing for Health podcast feature is available on all major podcasting platforms, including Apple Podcasts, Amazon Music, iHeart, Pandora, Spotify, and more. Search for 'In Network' and subscribe for updates on future episodes. Like what you hear? Leave a 5-star rating and write a review to help others find the podcast.
Want to learn more from Dr. Joseph? Order a copy of his book, Designing for Health.
Show Notes:
[00:00] Intros
[01:36] Choosing gastroenterology
[02:49] The start of IllumiCare
[04:29] Uncovering low-value care
[09:14] The therapeutic cascade
[11:13] Building cost awareness
[17:15] Clinical financial decision support
[29:27] Incentivizing low-value care reduction
[38:05] Mukul’s favorite well-designed thing
[40:15] Outros
Transcript:
Dr. Craig Joseph: Doctor Mehra, welcome to the podcast. How are you today, sir?
Dr. Mukul Mehra: I'm great. Thanks for having me.
Dr. Craig Joseph: And where do we find you today?
Dr. Mukul Mehra: Birmingham, Alabama. That of the IllumiCare office.
Dr. Craig Joseph: Awesome. I look forward to hearing more about IllumiCare and how you got there. But let's start at the beginning. You've always, since you were a small child, have always wanted to run a company. Is that true?
Dr. Mukul Mehra: Absolutely. After the Apgar score of nine, I declared that I'm going to have a company in health care one day, and they downgraded me from a nine to a seven on the Apgar.
Dr. Craig Joseph: So are we talking about the one-minute Apgar or the five-minute Apgar? It's very important. Our listeners want to know.
Dr. Mukul Mehra: You know too much. It was the five-minute Apgar.
Dr. Craig Joseph: It was a five-minute Apgar. You got a nine. Well that's good, that's good. That's how you get into some of the best schools. So let's assume that we're both being sarcastic. And that's not what you've always wanted to do. You wanted to go to medical school, I presume, and become a physician.
Dr. Mukul Mehra: I love math and physics. It still has always been my passion. And so it was really the electrical engineering route that I thought I was going to go to. I went to school at northwestern, but I found the human connective within the medical profession as the ultimate, you know, guide towards picking medical school.
Dr. Craig Joseph: And you became a gastroenterologist. How does one choose that specialty? I was just curious. Is it the procedures? Is it the disease processes that you deal with, or is it just you fell into it?
Dr. Mukul Mehra: My uncle is a gastroenterologist. The certainly I grew up with a background in gastroenterology, but you're right. I enjoy a profession where your diagnostic skills were valued and you had therapeutic interventions doing a procedure, and you were. The procedure was to our design often in gastroenterology cedars in the morning and in the afternoon in patient rounding in between. That was ideal to me. That or cardiology, I chose gastroenterology. Electrophysiology fascinated me the most. Okay. It is the ultimate compendium of an amalgamation of the physics electrical pathways and the heart stopping or going haywire.
Dr. Craig Joseph: So you were an, are a practicing gastroenterologist. How did you get into this idea of starting a company and you know, what was that? What was that process like? What problems were you seeing?
Dr. Mukul Mehra: The biggest problem I saw was a buzzword called value-based care. And it was fascinating to me that we were going into value-based care, and we thought we had a pretty good handle on at least what we consider high quality. We didn't have a grasp of cost, especially at the provider level. We were going to enter value-based care and not fundamentally expose us to the people who actually are ordering therapeutics. That was a problem, and the biggest inspiration for me came when a patient who was a patient of mine, she had colon gyrus, who had renal failure, she had pancreatitis and sepsis. So me and four other physicians ever it was about an 11-day admission. But what really happened at the end of this 11-day admission is we saved her life.
I did a New York epi with this paradigm. It was a very hard what is done? And when she came back to the office six weeks or so later, when she looked distraught, she showed me her bill. And that began the journey of deconstructing a patient bill from an inpatient stay into line item for non-charges. Even the charges appear on these bills. So what is the true cause? Or as close as we get to the true cost of the things that we did to this patient, medication ordering AB ordering in graphics study ordering. And it was fascinating to me because I, I convened this group of five physicians back and I said, look, it took me a while, but I want us to do a chart review in retrospect.
And 43% of the stuff that we did to that patient, we admitted, was probably not needed. This is the problem, because a portion of that bill now hits the patient's wallet, and we know that low value care is problematic to health systems, but it's a real problem to the patient. It was fascinating to me. I had this moment where I was like, we've always talked about iatrogenic risks. I mean, it's a Greek word. Dietro means healer. Genic means the producer. So the healer produces unintended consequences from their therapeutic decisions upon a patient. Like we know this happens. There's been a recent article on excess imaging being done, and it's radiating our patients when we do CTS or we draw a lot of blood from a patient, you know, we make them anemic. Those are after genic risks. But the real risk now in 2025 is the financial consequences of what we're doing to our patients when we're ordering meds as radiographic studies, whatever they are, and they're low value.
Dr. Craig Joseph: Let's talk about low value care. I think outside of the clinical world it's a little confusing. These are not things that have no value that you shouldn't do. Right. You hurt your foot. So I get an X-ray of your arm like, no, probably that's no value. But low value care. Some things that we do that in high, like, as you mentioned, kind of in hindsight, maybe we didn't need. Can you share what are some examples of low value care that you see in your world of things that you might have done or might still do sometimes?
Dr. Mukul Mehra: Well, like that patient who had pancreatitis and a stone in the bile duct if she had pancreatitis. So we feel that we're going to order a lipids in any amylase and come back high. We've established the diagnosis of pancreatitis. There is no forecasting of recovery based on the potential levels of amylase in lipids. So it's low value. Does it feel good when their amylase and lipids come down? Sure. That's human nature. Yet you know it doesn't in any way portend other patients. And I do, because the definition of severe pancreatitis is not based upon lipids or amylase elevation. So it's always for one, you're ordering them sequentially. Two, you're ordering both of them sequentially. Each of these lab tests have a cause, by the way. They are an extraction of blood. And it's not super comfortable getting blood drawn. That's low value care. But we don't do it with any sinister motives as physicians.
Dr. Craig Joseph: I love that example, one that I've heard is ordering EKGs routinely before non-cardiac procedures. So you're having a knee replacement and well, we'll check your EKG just to be sure. Again, for patients who have no heart disease that is known, it seems like that wouldn't do any harm. And except for the money, of course it costs money, but it does cause harm, right? Because it's not been shown in studies to be helpful. The benefit doesn't outweigh the disadvantages. The disadvantages besides cost are hey, it takes more time. Hey. Inevitable we find something, and the conversation almost always goes like, yeah, I ordered this EKG. It's slightly abnormal. I'm not sure it means anything, but now I need the cardiologist to take a look and then the cardiologist as well.
It's probably nothing, but if you're going to have surgery, we should probably make sure it's not. And then let's order some more tests which delay the knee procedure that you were trying to get in the first place. And some of those tests involve being poked with needles, and having dye injected, and people have allergic reactions and other kinds of problems sometimes. And so these things that seem like, again, we call them low value, but sometimes they're actually harmful besides the money and the time. So it getting rid of them or minimizing those low value tests. Again you perfect with well you don't need lipids and MLA should probably only need one and you certainly don't need to check them every day to see that they're going down when you can tell the patient's doing well. Otherwise we have science. This is not just our idea. Right. There are there are studies that show that whether it's going down quickly or going down slowly doesn't really matter once you've established that you have a diagnosis and you're dealing with it the right way.
Dr. Mukul Mehra: Yeah, absolutely. That's I said, in fact, you're describing a longer-term harm, which is the therapeutic cascade. Like if you take that same patient okay. So now they went to see the cardiologist. The cardiologist orders a lipid panel as part of their workup. Well, the LDL is a little bit high. But now the LDL is high. So they get put on a stat, maybe the data on using statins for primary prevention with that LDL is not that high. I'm a hepatologist too. So now three months later, that patient's Alt is 68. Now they're coming to see me for elevated liver enzyme. And so the consequences of low value care and the therapeutic cascade of future unnecessary tests, it's very hard to quantitate the financial value or, you know, loss in that case. But, nevertheless, it's not by the patient or health care system.
Dr. Craig Joseph: I have not heard that term therapeutic cascade, but I love it. It reminds me of one of the things I used to tell parents as a pediatrician. I would tell them that my job was to do as little as possible for as long as possible, and I would have used the term therapy to prevent therapeutic cascade. Right. Because, well, should we get a lap? Well, if I get a CBC, something's coming back abnormal on that CBC and guarantee it. Right. And it might be a series of letters that I'm not even sure exactly what the MCT does, but there's an MCQ, and it's off by 0.1, and now, do I need to send you to the hematologist to make sure that's not the end?
And yeah, clearly, you've established you've helped us clarify that low value care is something to be avoided. And again, there's always circumstances where you do want to get a live piece in an MLS. And you might want to repeat those because the diagnosis is not clear. And so that now no one's talking about that. But we are talking about routinely doing things that really don't have any, science to support them. And so you saw that problem. How did you go about trying to solve it.
Dr. Mukul Mehra: First of all, the first challenge was surely somebody exposing clots to providers in the acute care setting. We can talk later about why we chose the acute care setting as our area to focus on and IllumiCare, but they weren't the cost accounting system. Data does not talk to the clinical ordering system in the electronic medical record. So for example, magnesium, you're acquiring 50 bottles of 20% stock solution of magnesium. Each of the bottles is 50ml. Well that's not how we order magnesium. As a physician we order to grant Mag Run IV that translation doesn't exist because we want to get to the actual acquisition cost of the magnesium, not what shows up on this bill. Discharge, Minister Bill and that translation is very, very difficult to do for medications, especially intravenous medications and drips.
It's not as hard to do for tablets, but the cost chain and for laboratory and for radiographic studies, you know, there's some proxy measures of cost for those. So, we begin to expose flaws at the point of care. If you expose them retrospectively or in an aggregated fashion, it tends to have very little meaning to physicians. And so, we had this challenge of, well, how do we put the cost right where the physician is, the electronic medical record, they're reviewing issue. That was going to be a challenge.
Dr. Craig Joseph: So yeah, the translation between the bulk and how that actually gets delivered to the patient, that's a problem that CFOs and folks in inventory management have been having forever, right? How much does it cost to take care of this patient for heart attack? I don't know, right? How much does the room cost? How much does the nurse cost? How high? Every lab value. We seem to know, but often are paid nowadays through a DRG, through a standard number. A patient has a heart attack that's worth x thousands of dollars, and we don't really care how much it costs you, the insurer or the government doesn't really care. Obviously, the hospital, the doc from the chief financial officer on down in does care. And so what were some of the things that kind of the problems that you've had in making that come true and in terms of being able to say to docs, hey, this is actually going to cost this much money, like, how do you how do you actually do it?
Dr. Mukul Mehra: So, if you make a physician log in, put in their password, find a patient lookup something, it's not going to work. We all know that. I mean, there's enough clicking around in the electronic medical record that putting a link or a hyperlink to expose clause wasn't going to work. So, the first attempt we had at exposing was to create an EMR agnostic ribbon that would surface the insight at the point of care that, hey, you're ordering is pace. Did you know it's this much? Or here's a receipt view of the things that you've ordered and it was fascinating to see how enlightening it was to physician to clinician that they could now, for the first time, see the cost of a lab cost of the medication at the dose they were giving per day. The putative cost of the radiology study. And it was really, really cool for like two months.
Dr. Craig Joseph: One thing I just want to call out that design kind of principle, that that learning principle, the way adults like to learn versus the way kids are forced to learn is, yeah, I'm happy to learn something. As long as it's at the time that I need to learn it. Right. And that's what that was, at least for the first two months. That was key. Don't tell me how much it cost for this other patient or for this other dose. And don't tell me before or after I've already done it. I you're telling me, as I'm about to order this thing, this is going to cost the patient this much. All right, so two months, it worked great. And should we end our story there, or is there more? Sounds like there might be more.
Dr. Mukul Mehra: And so the feedback would be that it began to have very little influence in low value care ordering beyond perhaps the Hawthorne effect. So maybe the daily CBCs would go down or the BMP would go down, or the CMP would go down. But ordering a hepatitis panel or ordering lipids and amylase again and again, it was very hard to prove that we were having an effect. And honestly, the physician feedback was, well, it was neat to see cause for a month or two, I think I got it. And we don't really pay as much attention to the past. And somebody came to me and said, it's really hard to think through an algorithm of care without knowing when you may be doing something low value. And amalgamating that with the clinical literature that proves it's low value. So, what I understood was, look, we're showing you cause it's too much of a cognitive load exercise for you to think through where costs are valuable. Like it's really not valuable to see the cost of levothyroxine, but the patient has hypothyroidism, the tablets generic consent. What are you going to do with that? It's there. Tylenol acetaminophen. It's $0.02 for a 500-milligram tablet. And so we had to begin to reduce the noise and build a data set that we called clinical financial decisions for.
Dr. Craig Joseph: Before we go on, let me just call out the Hawthorne effect that you referenced that some of our listeners might not be aware of what is the Hawthorne effect and how do you think it came into play?
Dr. Mukul Mehra: I mean, the Hawthorne effect is like when my wife says she really appreciates me folding the laundry, which I hardly ever do. But then when she comes in the house, I find some laundry and just start folding. But when she's not really looking, do I go around and fold laundry? No, but I should.
Dr. Craig Joseph: I've never heard it explain that way, the way I've typically read about it. I think it was a cumbersome factory, and either it was called Hawthorne or was in a location called Hawthorne, but they started doing some experiments by changing the lighting in the factory. And they changed. They made a brighter. And they found that productivity went up like, amazing, amazing. We changed the brightness made it brighter, productivity went up. Everyone should clearly now make everything brighter in the factory. And then they lowered it, you know, they left it that way for a while, then they lowered it, the lighting. And you know what? Productivity went up and the idea was, hey, if I perceive that you're doing some research on me or my work, that's around me, I'm going to be more attentive to whatever it is I'm doing.
And so whatever it is you're checking for, you might actually find it. And so it makes complete sense to me that all of a sudden there's, hey, this is how much that costs. Well, clearly the lesson I should learn from that is that I should take this into account and be better steward of my patients’ finances and not order something. So how do you make things? How do you design to take away from the noise? And just to your point, hey, if I don't have enough thyroxine, if I don't have that hormone, I need Synthroid, like I just need it or I'm not going to survive. And so whether it cost $0.10 a pill or $10 a pill, it's really not relevant because it's an expense that has to have. But there aren't. There are things where it is relevant. And so how do you pick those out?
Dr. Mukul Mehra: That is the hardest bit. So we have close to 1100 rules around medication lab and radiology ordering that take into account the cost of the therapeutic, the cost of some alternative to that, the clinical context that makes those relevant, and then a thorough review of the clinical literature. The goal is can you choose an ergative path? There's another med, another route of that med administration, another lab not doing that lab, another radiographic study, not doing that study and quality the outcome but still be the same or improve. And if you can do that and lower the pause in that process, we call that rule set our clinical financial decision support. So clinical decision support just says well look you come in with fib, you should check for all right abnormality. That's clinical decision support. Clinical financial decision support is hey you came in here, you have a DBA.
If you don't have renal failure and the pH is at less than 7.2, you shouldn't be using I.V. sodium bicarbonate. It feels really good to get the PH. I mean, who wouldn't want somebody to put it in their blood? PH is low. Yet the outcomes if the pH is low and the kidney function is normal, is that you will raise the pH but impart no value in terms of morbidity or mortality, the patient's admission. And then there's a cost. So, in that case you don't need to use sodium bicarb. You can use a less expensive crystalloid or I.V. fluid or not use one, that's clinical financial decision support. And not every clinical value rule makes it through the final of clinical financial decision support. That then has to be imparted contextually to the right provider who's ordering it or somebody in their specialties ordering it because they've left the service.
And there's some clinical parameter inside of the patient's clinical window that says, look, this is trading on potential low value care. And we never say no value care because we're not at the bedside. And you and I have both been at the bedside. We don't like people not at the bedside or technology not at the bedside, but make absolute declaration.
Dr. Craig Joseph: So I think what you've called this and you've just kind of given us a clue is contextual nudging. So of course, most of us know what a nudge is. Just a little push in the right direction. Which to your point, sometimes it's wrong. Sometimes. Yeah. This is not a nine out of ten. This is the one out of ten. And I don't want to do that. But make it easier to do the right thing. You push me a little bit, but the key is the context. And so knowing what you know, sounds like you've written these rules to say, hey, based on the context of what's going on, this might not be the best way. I think it's fascinating that example that you gave of, well, you want to get the pH back to normal. Doing so doesn't seem to actually benefit the patient in the short term, doing that quickly. And so you're simply doing something to make you feel better, but you're not actually doing something to make your patient feel better.
And that kind of nudging is completely appropriate. And so that just works in the ear. I just get that nudge. How does that work? Because it does. Does it differ based on the kind of electronic health record I'm using or is it, does it look like it's coming from inside the EHR? Who do I feel is nudging me?
Dr. Mukul Mehra: Well, it's meant to feel like the institution is nudging you. IllumiCare uses really a black framework to nudge, because we think providers have been anchored into ignoring native EMR-looking nudges, and their ephemeral physician autonomy is super important. Clinician autonomy is super important when physicians are super highly educated, often, and been to school longer than anybody at the health system or anybody you know, on the payer world. And so we enjoy autonomy. And the nudge actually appears when you're in that patient's chart, you're the right provider to address that therapeutic because it's within your discipline. And then the nudge disappears. It fades away in seven seconds. That isn't really the mechanism that exists when you put insight into the native EMR alert window. But we know that what's important is to use all of those modality.
So with Epic and with clients, we push our clinical financial decision support insight into the Epic open architecture. We built it alongside of Epic and alongside of other clients. And when does that more heavy-handed approach occur? It occurs when the data analytics show that you succumb to low value care within that order more. You're an outlier. So we look at low value care variation. Look I think clinical variation is kind of important, but it's always going to be there. We're not all pieces of substrate for building a car, Toyota or a Honda. We just don't understand enough about different phenotypes of patients. So there's going to be clinical variation. But if you're an outlier in low value care, in ordering I.V. bicarb in patients that don't have a low pH and an elevated creatine, then you potentially will get that as a hard stop inside of the EMR architecture. Otherwise it'll just be a passive nudge.
Dr. Craig Joseph: I think most of us don't realize how complicated it is because it's not a simple rule. If you do this, then that happens. It's also looking at my past history and looking at what the patient is in front of me because, boy, your point, is well taken alert fatigue a real problem. And if I'm constantly getting pop ups and constantly getting told things, especially if I disagree with them, A, I take them wrong or, B, I agree with them. But like, I was just about to do it and you're badgering me. I'm just going to start making those things go away and they're going to be less important and not there. Explain to me about the seven seconds, I'm fascinated by this. How did you come up with that idea? I assume it just, hey, I see it on the screen. If I want to react to it, I will. Much of the time I don't want to react to it, but it's now planted in my head at seven seconds. The right amount of time is 10s better. Have you done that kind of side by side research or you just kind of picked a number and gone with it?
Dr. Mukul Mehra: We picked a number and I get to use usually make here to. So seven seconds seemed just enough time to digest the content and not feel that it's in any way intrusive, but it's configurable. We had a health system come to us and say, we think 10s allows people to not be annoyed, but they actually will read the abstract because we make a concise statement about whatever the PH. You know, sodium bicarb is only beneficial if you're acid and you have evidence of renal compromise. Otherwise it’ll potentially provide low value and can be harmful. Here's the cost per day of that. Here's a link to the abstract. And so we can track all of this. And we can track if somebody makes a change in the electronic medical record where they discontinue sodium bicarbonate, or they discontinue sodium bicarbonate but offer lactate and Ringer's, and then we look at these windows of time within the nudge for that, for that efficacy. Because that is how we measure efficacy is how do you, are you responding to them, and there's two kinds of responses. There's an immediate response. And a long-term response that our API is for learning here.
Dr. Craig Joseph: Let's talk about physician incentives. Every clinician wants to do right by the patient. It's difficult to sometimes, financially or otherwise, incentivize stocks to do less care, right? And I could totally make the argument going back to the EKG or anything else that we've talked about from a quality perspective or a low value perspective that, well, you know, once I had a patient that's a, you know, you're in trouble when I start that way. I had this patient one time, because you know, what's coming, which is they didn't fit. You know, this was one where I actually was going to harm the patient by doing knee surgery, because we didn't know that they had a heart problem. And even though, yes, you're right, only 1 in 10,000 times does that help?
But, boy, that was my patient. And so, there's the incentive for me to want to never miss anything. I'm not really seeing the forest for the trees because of that. So are there customers of yours who have figured out some way of incentivizing, either through money or other ways of, hey, you're doing the right thing? We want to call you out.
Dr. Mukul Mehra: Yeah, absolutely. And it's a poor strategy for IllumiCare when we engage a partner of system to begin to think through that. Why? Because thinking through cost as part of your clinical algorithm, that's not going to save you time. I mean, there is... IllumiCare is not a time saver. The stewardship module we're discussing and whether it's a little bit of time or more than just a little bit of time that a provider is having to think through low value care suggestion. There is some cognitive load to that. And physicians and providers should be rewarded for that. The health systems like MultiCare was really a pioneering health system for us. They recognized that one of the five quality metrics that they have wasn't being achieved by their hospitalist. And it was very frustrating. It's one that was honestly a metric that the providers didn't think they had complete control over.
The health system had a tough time tracking, so they scrapped it and they replaced it with low value care reduction. And we did data modeling on what is their low value care ordering before IllumiCare, you know, had gone live and what is the threshold that they would have to reach. And if you reach it allows the bonus. So, it is not just incentivizing reduction of care. It's really curbing low value care. And that is a real quality metric because of all of the reasons that we had discussed the consequences of low value care to the patient. And providers were like, well, I totally contract is. And by the way, in real time, I'm seeing these suggestions, and I'm not expected to follow all of them. You allow me a window of adjudication, understanding that not all of these are clinically relevant. And then there's techniques like there's a team effect. I'm a big fan of building incentives that are a team effect, because if one provider is like, whatever, I don't care. I don't care if it hurts the patient, don't care if it hurts the health system.
I'm tired and overworked. That's fine. I don't care about my bonus. Well, now you're having an effect on the whole team of hospitals. So, they're models that, look, you're part of a team. And really, honestly, the whole system in the patient or part of your team, but you're part of a more immediate team. All of your other hospital is. So if you want to take a reduction of low value care, you're actually hurting the rest of your team that is taking this scores on. And that is a fundamental model that we lead with in the engagement phase of IllumiCare. Discussing this with the health system. And they can't always pull it off right when IllumiCare goes live. But it's somewhere on the path, the happy path of fine in 6 to 9 months when it's up for negotiation. Let's do this though.
Dr. Craig Joseph: What about putting various physician ranking physicians I have found, and this might be a shocker to you. And I believe you're sitting. I found that physicians are very competitive. Is this a shocker to you? Are you still are you still with us or do you. Yeah. No, I think it's, it's a well-known fact, and I, I've, I have seen physicians who have that kind of attitude that you just described of. I don't think this is important. I don't think this is really valuable for my patient. And I'm not going to participate in this at all. And then they someone has the courage or stupidity to put up a list of, 100 doctors in the group, ranking them from most consistent with what we want them to do to least consistent with names and potentially numbers.
And, boy, I have seen physicians who are like, I still think this is dumb. I still don't see any purpose, but there's no way I'm going to let that guy outscore me on anything, because I don't think that guy's that smart. I'm going to beat him even though I don't. I don't care why. I just want to beat him. Have you used any of those perspectives?
Dr. Mukul Mehra: We do. We have an app. So after about 100 days of being live with the nudge technology, every provider can see their low value care spend for admission compared to their service. But we don't expose all the names for any one provider. But the leadership chief quality officer or chief medical officer do get a list of those providers. And like it was fascinating. There was one provider who would order magnesium the day after. One had been normal 1084 times in the last six months. He was a clear outlier, but other hospitals were doing the same thing too, just not that many times. Even when we ranked it by its mix index. We exclude patients in these detailed analysis like it couldn't have been on a magnesium drip.
They couldn't have been on, you know, an obstetrics service. So why is it still happening? And at that point, it's not IllumiCare who's going to be any more effective. It's really going to be somebody at the leadership level saying, did you know, like you are by far an outlier in repetitive magnesium load in patients, not on TPA and not on magnesium groups like, why do you do this?
Oh, and by the way, we have the stats that 97% of the time that they reordered it, it was still normal. So that's how you empower you. No change in no doubt. But I mean, one of the seminal experiments I did before IllumiCare is as an ERC physician, I knew we didn't have to. And these were outpatients. Use a stent pusher to push a stent up when you do a thing. I mean, you cut the sinker so that you can extract a stone. You just saved your sinker toe. Don't throw it away. And then when it's time to push a stent up, you just use the sphincter tone, but the stent on top of it and push the stand up.
Well, the stent pusher from the manufacturer. I looked up as I was curious, what is a stent pusher cost? It was $104. And so I began to create a list of $104. Who's using stent pushers? Who uses them the most? So I of course use none. And within six months we stopped ordering stent pushers in the GI line. None of this savings goes back to the physician. But people would come up to me and say, well, how do you, what is that? If you're not using a stent pusher? And I would show them, I'm doing any RCP, I'll show you, because nobody wanted to be the physician that was now responsible for ordering stent pushers. And when we go back to the GI lab, we reduced that pusher ordering and the expensive stent pushers so much that we felt comfortable asking the finance team for a collegiate scope. Oh, look, if we're saving $60,000 a year on stent pushers, we didn't need them. And the college's system is $40,000. You know, we felt empowered to asking for that. And these are the alignment and synergies that are needed in healthcare or propagating stewardship or low value care reduction so that all the entities involved, it's a win, the health system, the patient, and then the providers. So these are the ways that we model incentives even for subspecialists to like if you do these things, look, the next time you need something, the finance committee will say, well, look, you want this, you want another AP. We need to see some more efficiencies here. Perhaps we can get you an inpatient hospitalist AP down the road. And this is called alignment, which, you know, we've always been a misaligned health care system.
Dr. Craig Joseph: Alignment is essential to get everyone kind of rowing in the same direction. It sounds easy often, but boy, when you understand how the health care system works in the United States, when I say health care system with air quotes to get everyone kind of working as a team and making sure that people are paid and recognized for their good work and good deeds is complicated.
We could talk about this for another hour or two, but we have unfortunately run out of time. We like to always end with the same question, are there things that you deal with every day that are so well designed, it brings you joy when you deal with it?
Dr. Mukul Mehra: Something I use every day that is super well designed is honestly, it's the swimming pool.
Dr. Craig Joseph: The swimming pool.
Dr. Mukul Mehra: Yes. It is not technology. I don't know if the answer is supposed to be technology.
Dr. Craig Joseph: Oh no. But go on, I'm not stopping you. I want to hear.
Dr. Mukul Mehra: So this beautiful construct, which in America tends to be 25 yards long. And in some parts of America and in Europe, it's 25 to 50 m. If you're lucky, it has this black line and it is so consistent. It has four walls. And to me, I took up swimming as a way to break the cycle of overthinking when you just needed moments of mental relaxation. And it was very hard for me as a physician, you have your cell phone and IllumiCare book and get ahold of you all the time. And underwater nobody could get ahold of me. And during that hour I just find the ultimate therapeutic exercise to me is to go jump off the blocks, swim the 25 yards, do a flip turn which I didn't know how to do eight years ago. But I learned and it's a very consistent experience. The walls, the same, water buoyancy is the same and you can make it as challenging as you want. You can swim butterfly and you'll get short of breath pretty fast. Insulin breath stroke and breathe out of water all day long. But it's therapeutic. It's consistent. And it was a challenge I took up and I never grew up swimming.
Dr. Craig Joseph: But I love it. And what the black line you mentioned a black line that's at the bottom of the pool.
Dr. Mukul Mehra: It is. It's the center of the lane. Your goal is to swim center. You come off the wall and you're not center. So if you swim 25 yards and swim 25 back and you got off of that black line, you may swim 50.1 yard. If you're shooting for time and efficiency and consistency, the black line’s consistent. You weren't consistent because you didn't stay down the middle.
Dr. Craig Joseph: Yeah, obviously I'm not a swimmer because I'm asking what the black line is, but, no, that's great. I love that this has been great and what a great conversation. Thank you for teaching me and kind of explaining some things about how you've done your work, and I wish you only more success. And we'll have to check back in with you in a couple years to see what new things you've learned and how you've changed people to make it easy to do the right thing.
Dr. Mukul Mehra: But I learned from you, Craig, too. And thanks for having me on.
READ THE TRANSCRIPT
Show Notes:
[00:00] Intros
[00:46] What is TEAM
[06:06] The importance of consistent care pathways
[08:41] Data, surgeons, and the patient voice
[22:26] Pre-surgical prep
[23:25] Tech tools for follow-up and recovery
[26:36] Rethinking clinical decision support with AI
[29:25] Turning data into actionable insights
[32:32] Karen’s favorite well-designed thing
[33:52] Outros
Transcript:
Dr. Craig Joseph: Welcome to the podcast, Karen Joswick from Benevolence Health Advisors. How are you today?
Karen Joswick: I'm good, Craig, how are you doing?
Dr. Craig Joseph: I am, as always, excited to talk to people like you. Where do we find you today?
Karen Joswick: East coast, Delaware, the first state.
Dr. Craig Joseph: You and I met when we were, you were trying to educate me on the TEAM program, and I had said to you, I use Teams every day. I can even chat on it. And I told you I didn't need to know anything. And you were. You were like, no, no, no TEAM was with no s.
Karen Joswick: Yeah. We use the word TEAM in all senses of the word. I can't tell you how many times we've approached organizations and said, so how's your team doing? And people go; they're great. What are you talking about?
Dr. Craig Joseph: Why don't you tell us a little bit about yourself? How did you get to become the person that you are now?
Karen Joswick: Let's answer what TEAM is. TEAM is the new mandatory bundle payment program from CMS. It impacts about 25% of the hospitals across the United States, and the hospitals were selected based on their geography. Or CMS has a term called CBSA or core based statistical units. And so, it's kind of a big deal because it's a mandatory model. And there was a little bit of betting going on about what was going to happen in Washington. Was the administration going to keep it, you know, move forward with it. And there were a lot of naysayers that said it's going to get wiped like everybody else, or it's not going to be mandatory. And actually, that's not true.
The administration kept the TEAM model. They came out with some new proposed regulations in the last couple of weeks on it, and it's mandatory. So that means these hospitals have to comply. I went into healthcare wanting to make a difference and a change. Same reason why you probably went into medicine. You want to help people and make a change. And I started my career in it and then was asked because I understood all of this data and analytics and informatics work. Could I help the operational teams implement these programs? And kind of just grew from there. And I think part of it, I had a good amount of my career in the state of Maryland, and Maryland's known for innovative models. And so, I think it kind of was a natural growth in that way.
Dr. Craig Joseph: Fee for service versus value-based care. Fee for service, as I understand it is, hey, you do this thing, you get paid. Whether it turns out well, whether the patient really needed it, none of that really matters. You're going to get paid this amount of money with value-based care. It's more like the payer. In this case, the federal government is interested in results and paying for results.
And so, we've had value-based care for decades. That concept kind of started with the HMOs a gazillion years ago, I believe, and it's kind of been some fits and starts, and it's kind of going back and forth. So, this is, yet another, another attempt from the biggest payer in the United States for health care, the federal government, to make sure they're getting their money's worth. And as you mentioned, TEAM is not optional for the 25% of hospitals that were selected by the government. And they, I presume, know who they are at this point.
Karen Joswick: Gosh, I hope you do know who you are. I mean, there's a list out there. I will say, as of a couple of weeks ago, we've done some outreach, and I think most hospitals know. But early on, when the list was out there, there were some that were a little surprised, like, oh, we're on the list.
Dr. Craig Joseph: So hopefully people know, you know, if they're on the list and what do they need to do? So how is this different from other kinds of, value-based care who's being evaluated and what kind of information do they need to present and that kind of stuff.
Karen Joswick: Well, so first, if you don't know, check the list. So happy to send the list and where you find it. But one check the list, and two, if you're on the list, make sure you identify who your point of contact is going to be with CMS. They want to know who they should send emails and data files. There's going to be a whole bunch of information that's going to come straight from CMS to your organization. More importantly, it's going to be a reflection point for an organization to understand the volume of these surgical procedures and understand the key service lines.
So, in prior bundle payment programs, they were predominately in orthopedic space. This program's a game changer and includes cardiac surgery. Not a surprise, right? Think about what the federal government pays for a lot of open-heart surgeries. Right. So, they put CABG in. There is one example. They also included some spine in some bowel surgeries.
And so, I think this is indicative of where the government's trying to go is to lean into the high-cost procedures or also procedures where there's we know care continuum across whether it's in skilled nursing or home health. And, where we think there's opportunities to bend the cost curve and improve quality. And boy, when you think about seniors and the cost that Medicare is underwriting, cardiac surgery seems like a great place. So, the hips and knees and spines.
Dr. Craig Joseph: And I assume the idea from the government is that if this goes well, it won't be 25% of hospitals. It will be.
Karen Joswick: More. Yeah, yeah. All right. It's going to be more. And if it goes well, by the way, they save money. So, if it goes well, it doesn't mean the hospitals will make more money. There are some hospitals that are in a favorable position based on what we've kind of modeled and projected that some, some hospitals, because they're already a low-cost, high-quality provider, may be positioned well. There are most hospitals who are not, and so this is a haircut. Right. And for some of these health systems, it's not a trim. It's a pretty big haircut a couple million dollars a year. Craig, you know, in this day and age, that's huge. That's not just a rounding error for some of our health system partners. These are big cuts.
Dr. Craig Joseph: Maybe let's just dig in on one example. And so, you had mentioned CABG. You were talking about, bypass graft. So, a heart bypass, which is a major, it's a big operation. So maybe talk us through how it is today and then how will it be tomorrow or early of next year for those quarter of hospitals that are on the list?
Karen Joswick: Sure. Well, CABG is a is a good example to talk about. You know, there are patients who get, emergent CABG and there's not really much you can do about that, right. There are patients who are in the CATH lab. They get balloon pumped and they sent to the O.R. and kind of like, that's just going to run its course. Those are patients that you need a clinical pathway for. You need to be able to make sure you have data and insights, and you've got good partners to manage them across the continuum.
But then there's a cohort of patients which is most patients, right, where it is considered, a scheduled routine procedure. And so those are patients that are known to you as a provider ahead of time. And so there's an expectation that, how are you engaging those patients ahead of time? Have you been educating them on what their plan is after discharge? Right. We know for patients who have had this surgery that they need to be up and moving around, and they need to be exercising. And the patients who are up walking around the nursing unit in the hospital are going to be better walking around at home and going to cardiac rehab.
And so there's kind of these basic tenants that good science, right, good care we know about. But frankly, sometimes we're inconsistent and how we do it. And part of it's the patients not being educated, not being aware, not having the right support system at home. And some of it's that we are inconsistent in our clinical practice at some of our facilities, right, for lots of reasons.
And so the model really is kind of pressure testing and saying you need to be consistent, right. Reduce care variation, but also engage the patient ahead of the surgery and also figure out what your plan is going to be after surgery so that those patients who have a CABG, then maybe go home with home health or with cardiac rehab services and not get transferred to a skilled nursing facility for 20-30 days. Right? So really try and manage the cost of that episode and also improve the care. And we know patients who have a good destination right at home and good support system. They're going to be less likely to end up as a readmission. And I think we all know, like the challenges with readmission, not only around cost but quality. And it becomes a downward spiral.
Dr. Craig Joseph: Is the government looking, how are they going to be evaluating how consistent the care is? How are they going to be evaluating what kind of rehabilitation? That's one of my favorite terms as opposed to rehabilitation, you know, how do they evaluate that? Or is it just no, it's the outcomes. Like we don't really care what you did. If you have, majority of your patients don't bounce back and they're meeting certain criteria afterwards, it doesn't really matter what you did before. It sounds like it's somewhere between those two extremes.
Karen Joswick: Yeah. No, you're exactly right. So I think there is an expectation on your benchmark cost. That's just it, it's a cost program. There's a cost savings program. So are you less expensive than your competitors in your market? And also how do your outcomes fall? So, there's a variety of quality measures that are included in this program. Right. Some of it around patient experience. Some of it's just around like all cause readmissions and all cause morbidity mortality rates. So, there's measures in place to look at, like you said, outcomes. But then there's the biggest stick, or carrot, really is the cost.
Dr. Craig Joseph: You're being evaluated about your cost compared to your competitors compared to like kind of peer institutions in your area. It sounds like.
Karen Joswick: Yeah, your market. And the challenge with these, you know, sassy CMS is word CBSA. So, score based statistical areas I'll use in the word market. In some organizations, their market is small. In other words, it's like California, Oregon, and Washington, right. And so like, they're massive geographies being compared to Sacramento when you're in Oregon may or may not be right. Really fair assessments based on Metropolitan. And we see this in New York, on the East Coast. There's a lot in the New York New Jersey area, etc.
Dr. Craig Joseph: Is this significantly different than two years ago with a different program for a different surgery? Like you'd said earlier, orthopedic surgery tends to be the one that payers in general and the governments specifically look at. But is this much different? It sounds like one of the things that sounds different to me is the fact that I'm going to be judged based on how much I bill versus my other people, either in my region or my state. Is it more of the same or is this a particularly different kind of approach?
Karen Joswick: Yeah. So, yes. So, it's a little bit of the same. It's a bundled program. So we've had bundles for decades and decades in health care. So that part's not new in the fact that we're including orthopedic procedures. There's been a huge shift right over the last 15, 20 years to move routine hips and knees out of the hospital into ambulatory care. Right. Bundle those, that parts not new. What is new is that some of those other specialized procedures, like we talked about cardiac surgery, is a perfect example. And the fact that you're going to be graded, if you will, and compared against your market. So you're not beating against yourself, right.
Comparing against yourself, but you're trying to beat the market, not just improve your own cost. And that's important. For lots of reasons. One, you may not know where you sit compared to your market. Right? So, a lot of health systems don't have good benchmarking information and data about where they sit relative to the hospital down the street. The other thing that I think is a game changer on this one is the service line engagement typically and a fee for service world cardiac surgeries. The last area you touch for lots of obvious reasons. And so, this is one that's going to really challenge health systems to have their foot kind of in both canoes. Right. How do you balance fee for service and value-based care and hope that you don't hurt either side?
Dr. Craig Joseph: One of the things that was initially confusing me, and some listeners might be confused about with respect to needing to know how much I charge for this, my hospital charges for this procedure versus others in general.
I've always taken this simplistic view because I'm a simplistic person, that, hey, I could charge $100,000 or I could charge $1 million for this procedure, for this admission, this hospitalization, I'm going to get paid X number of dollars based on the DRG. And so that was always my kind of assumption. It doesn't really matter what I charge because I can send a bill for anything. I'm just going to get what I'm going to get. But now that's actually or maybe never, but certainly not now that that's not the case. The more I charge, even though I can charge $1 million and I'm going to get $50,000, it's going to not work great if I'm charging $1 million. And if my, others in my area are charging, for the same procedure, DRG half of that, it looks bad and it's going to be calculated as such.
Karen Joswick: Right. And I think the best way to really kind of needle down more on that is the total cost of care. So, for these patients, yes, you can charge for your surgery, but are your patients going to home health, which is, you know, maybe $1,000 of expense versus skilled nursing, which is maybe $25,000 for that post 30-day window? Are your patients having a bunch of extra scanning and imaging and so forth pre procedure that maybe they don't necessarily need is a is it a necessary variation in care based on the standards. So those are kind of the puts and the takes.
And then to your point, yes, there's a whole internal exercise that health systems should be doing around their fixed costs. So what are you charging versus what does it cost you to actually provide those services. And that's really where I think there's a sweet spot. Organizations that are looking at their internal cost structure, how well they're managing their internal costs to provide the care. And then also looking at the care continuum, what are those patients experiencing? Are they going to skilled nursing? Are they going to home health? Are they getting extra physical therapy appointments, imaging etc.?
Dr. Craig Joseph: So now that we all understand what this is, sounds like, step number one is to know if your hospital is in the group or not, which most people probably know by now. But sounds like there's a link that you can go to and see that list.
And then step two, once you know that you're in this list and probably it's not a bad idea for folks who aren't on the list now, given the fact that they might everyone might be on the list soon, is to start collecting some data and some of the data they surely have. Surely there are other programs or other quality metrics that hospitals have to be collecting. One of the new ones is, hey, how much am I charging for this on average? And again, not just for the procedure, but for all the care that's involved versus my competitors. So, they need to get that information. How you get that information, Karen, do you just call up? Hey.
Karen Joswick: It's a yes or no, right. So, if you're on the list and CMS has your contact information, you will eventually get claims data from CMS. But that's not going to be until later this year. So, you're going to need to look at your internal assets and tools. So, you know, depending on whether you're currently in MSSP. So a Medicare shared savings ACO, maybe you already have claims data, maybe you already have a pop health platform or a tool that you're using to do that, that some of the hospitals, for sure, there's many hospitals that frankly, they don't have those tools in play, and they're on the list and they don't have access to the data. And so, then there are certainly partners that have access to benchmarking, where they can give you the analytics to help at least start planning to do that work. And that's some of the work that we're doing to help organizations right now is forecast where they have opportunities to focus on care redesign.
Dr. Craig Joseph: Are there other data points that folks should be collecting that you're seeing that they don't have, that are unique for this program?
Karen Joswick: I'm a firm believer they really should know by those service lines which of those stocks are employed versus a community-based or a partner. I think that there is an opportunity around provider engagement to really be intentional. Certainly with your employee docs, but also with your community docs that you know right now, if you've got, you know, maybe a spine surgeon that's in the community, but they have privileges and they operate, but there's an opportunity to lean in around quality and engagement in this. There should definitely be conversations, right. And an evaluation of who's employed, who's in your community. The same thing is true with your post-acute partners. Who are you sending these patients to? Do you have their data? Do you have a partnership? Do you have a preferred partnership? So there's definitely some internal operational areas that the organizations should be evaluating as they prepare.
Dr. Craig Joseph: Is there anything that differs based on the specialty? So ortho versus cardiac versus GI is pretty much all the same. Or are there any numbers? Oh my. For gastroenterology really need to know X.
Karen Joswick: Cardiac surgery is usually the most expensive, and spine, kind of you know, follows some of the bowel surgeries are pretty expensive because they're usually very medically complex. You know, if I were sitting right there in the hospital today, I would want to look at my outliers. So, any patients in the last 12 to 24 months in your med teams, right? You're made exactly like they'll know that they'll know your outliers for your CABG. They'll be monitoring that, especially if they're involved in other registries like STDs, registries. Any of the quality improvement work that you're doing? I pull all of that and really dig deep, on where you are performing right now.
Dr. Craig Joseph: Okay. And you mentioned engaging with your clinical team, especially the surgeons and procedural, as.
Karen Joswick: I enjoy working with surgeons. And maybe it's because throughout my career I've had the ability to do that. So, you just kind of learn what motivates and engages them. Right? So, these are typically very passionate, quality focused. They truly are outcomes focused. They don't want a bad outcome. Nobody wants a bad outcome. And so I think if you position this program as an opportunity to really evaluate how their patients outcomes are doing and get them the support needed, whether it's special care protocols or figuring out how your care management team can help support them for discharge planning or realization like you talked about.
I see this as a great way to engage those surgeons, maybe in ways that you haven't since maybe the service line launched, or a program opened, or a new surgeon came on. Right? Typically, those movements are when organizations will have a, oh, we should. We just hired a new cardiac surgery specialist. Let's look at our clinical protocols.
Well, you should be doing that more routinely. So, I think this is a great opportunity to have those conversations. And then I'm a big proponent of sharing the data with them, helping them understand where they're sitting and help them be competitive, because by the very nature they're competitive. They want to know; they want to be better than others. And so, I think supporting them in that way is the best way to do it.
Dr. Craig Joseph: Yeah, I love that. From an intentionality perspective, physicians are 100% and surgeons 1,000% are competitive. And, sharing those data points with them, whether they agree that they're important or not, they want to do better than that next person, and especially if they have a negative opinion of that, of someone, they're like, oh, they're beating me at this thing. I don't really, even if I don't see the value, I will not allow them to beat me at this thing. So, yeah. And so, engaging with the surgeons and procedurals makes a ton of sense. We haven't talked about another, important person in this endeavor, which is the patient. Are there things that we should be doing to engage the patient directly, or is this something that now the clinical team and the operations folks are the ones who are the only important keys in this puzzle?
Karen Joswick: I think you know the answer to that one. Right? Patients are at the center of all that we do. It's amazing how many patients don't have a good understanding of what their recovery process could look like for these procedures. It's I mean, even for things that are, that are routine, like, like a knee, some people feel really, you know, you have different experiences. You'll ask a patient or a friend, hey. And they'll say, I had no idea it was going to be so hard to get up the stairs and shower. I had no idea what it was going to be like. So, there's I think there's an obligation, right, to make sure that we are really arming patients and families and their support systems better when they have these procedures.
And I think that's ultimately going to get us into a better place long term around outcomes. But if you haven't invested time and energy resources into educating patients ahead of the surgery, right? Not immersion. Right. But for the routine and scheduled, I just you're just not in a good place long term. And if people have time to focus and plan and worry about the steps to get someone into the house or make sure they have time off those first couple days, you know, as a supporter for their family or their loved one. It makes a big difference. And there's a lot of digital tools too, right, to be checking on your incision site and send us a picture of that. Right. There are so many tools that are out there now that it's kind of like we have to be doing this, in my opinion, for sure.
Dr. Craig Joseph: We need to involve the patients. And I love the idea of kind of doing, again, that pre check of trying to get you in the best shape you can be before the surgery, assuming that it's not urgent. Of course. You know, can it wait a few months for you to quit smoking or for you to start exercising a little bit? Yeah. If so, we know you're going to do better afterwards. And the concept of oh, no one asked you where your bathroom was located because it is upstairs. So that's where the showers are, we're going to have a problem if there's no one there to help you. And that's going to lead potentially to you, not to you kind of failing at home.
And then having to go to a post-acute facility. And then that's going to cost a lot more money. And it's also not as much fun to be in a facility like that as it is to be at home. It's certainly better to be at home. So sometimes these little pieces of work which don't cost a lot can really bring some value. Let's talk about how you kind of teased us a little bit with some digital tools that might be helpful. One of them is using the patient portal or an app that can take a picture that you can use. Take a picture with your phone and send it to your surgeon or your surgical team. And hey, there's really no reason for me to come in the main question that you're going to that you need to see me for is just to look at my wound. If the rest of it is just me talking to you on the phone, or over a video, then that's easy. And then that saves everyone time and money. Are there other things that you've seen kind of be successful in general for patient engagement for some of these, these procedures?
Karen Joswick: I think there's some really interesting ones specifically around I've seen for cardiac surgery and or those reminding the patient of just some of the exercises that they need to be doing. So, you know, like, did you do these exercises kind of post-surgery, you know, for cardiac surgery, it's, you know, making sure that they're doing there is, you know, incentive spirometry and they're coughing. Right. Just some of these basic things like, have you done this? And those are in the early days. We know that makes a big difference for folks that have had, you know, orthopedic procedures. It's obviously watching the, watching all of these surgical sites, but exercising and moving and, you know, did you get up and move around.
And so, I think that there are gentle reminders and app tools, right, that are ingrained into folks' phones that they can either go to the patient or to their supporter. You know, did mom get up today? And I think that we've certainly grown and evolved so much. I mean, we have reminders to my Amazon is going to run out of paper towels, and I get a reminder, hey, Karen, do you want to order more paper towels? Right? As opposed, why can't we do this with some of our surgical is, and I think we're seeing it, but it's not embedded in just this is good care. Then it goes back to that clinical pathway. This is just good care.
Dr. Craig Joseph: Yeah. I, you know, and that good care concept I think really resonates with clinicians especially. We don't really need to talk about TEAM versus another program. It's just oh it doesn't really matter what your insurance is. It doesn't matter how you're paying for this. These are things that we do for all of our patients who are undergoing these procedures.
Karen Joswick: And oh, by the way, come with some of the other commercial insurance companies who are having conversations if they haven't already. They're looking at this to say, well, why would it matter if it's Medicare or a commercial plan? Why wouldn't we want you to save money for our patients, too? So, I think I've heard from some health systems that we're doing work with that their commercial plan has said we'd like to talk about doing bundles and for these patients too. So, I don't think it's that far for health systems to see a knock on the door about this one.
Dr. Craig Joseph: It makes complete sense. And again, that I typically say that, my job when I, when I've been the CMO before with one foot in the I.T world and one foot in the clinical world, is to make it easy to do the right thing, that the hard part is figuring out what the right thing is in this case where we're being told, and I think there's some consensus about what the right thing is, and then we just need to enable it, pivoting off of that, enabling, making it easy to do the right thing. How do we do that? And the tool that most clinicians use all day is the electronic health record.
So, we're kind of like, I know I've just opened up a whole can of worms. Are there clinical decision support tools, or do we really need to rethink how we use clinical decision support for some of this? Have you seen any organizations successfully figure this out?
Karen Joswick: It's interesting. You said clinical decision support and I think probably everyone listening just like, got a chill, right? I mean, think about how we spent the last 20 years implementing these rule-based algorithms. If this then this, right. And these alerts that we have out to folks. And now we're moving towards more AI tools where we're trying to really learn from prior decisions to make more informed and more enabled, you know, decision support. And so, when I think about how clinical decision support can evolve with value-based care, we really need clinical decision support tools that help us manage some of the outliers and the ones that are, if you will, where we have blind spots. And that's not always been the case for CCDs or, you know, the decision support tools at the 80% that fits in the square peg.
Right? We'll tell you to do this. And so, you think about the patients who we'll pick on the cardiac surgery patients, since that's our theme today that we've been talking about. What about the patients who maybe don't have a good support system, or they don't have transportation, or they are not going to be able to get food at home. And we need to worry about meals on the wheel, meals on wheels, or we need to worry about follow up, transportation to home, whatever it may be. I think that's where there is power in some of the new models and some of the new testing that's happening in their EMR around AI, clinical decision support. And I think this is whereas informatics leaders, we've got to lean in and kind of harness that because it's the 20% that we keep missing. That can be a challenge.
Dr. Craig Joseph: Do we definitely focus on the easy part? Why? Because we're humans and that's easier to do that. And so, but your points well taken in that I found if I really, really want to irritate a physician, I should remind them to do something that they were just about to do. Yeah, they really dislike that. That's a big bummer. And so, kind of making sure that clinical decision support helps, whether it's a physician who's seeing the patient, pre-op or in a, in a follow up, appointment or it's more of a kind of a population health perspective.
Are there any tips or obvious things that we should be doing from a population health, from dealing with multiple patients for team or for other programs like it that we don't that you typically see folks aren't doing.
Karen Joswick: You know, I think that there is a tremendous opportunity to kind of keep your head down and lean in on some of the projects that a lot of health systems are already doing. And, right, those are data standardization. Right now, so many health care organizations are receiving claims data, maybe from a payer or from the federal government, and they just don't know what to do with it. You've got to be able to integrate claims and clinical data together. And if you don't have a roadmap and a plan for that, you're going to be behind. You're just going to be behind. It doesn't matter what model it is. So that's something that's really important. If you don't have a way to give performance dashboards right back to your providers, sometimes we would lovingly call them provider scorecards, right? So, if you don't have those things in play, and that they're actually being used. Right. So, it's not enough to have a dashboard, but are they actually being used in a collaborative sense and driving outcomes? You need to look at that because that kind of data is what's ultimately, we, we see the people who are top tier, top performers in these value-based care programs.
It's because they have the data right in front of them. And they are, you know, just moving right along and using those data insights. And then Craig, the last one I would say is it goes back to the claims a little bit. If you don't have a collaborative relationship with your payer, CMS or your commercial payers. And what I mean by that is there's some sort of data sharing. Right? So, think most health systems work with ten or 15 different insurance companies rate payers. And guess how many file formats are sent to them? Exactly. The number of payers is. Like nobody's using a consistent file format. Nobody's using consistent tools or definitions. And so, the onus, unfortunately, is sitting on the health system, and there are some tools that have starting to improve that. But if you don't have a strategy to take all of this external data in, normalize it and then share it with your clinicians and your operators, you're going to be very hard to blindly perform well without those insights.
Dr. Craig Joseph: Let me just jump up. And in that last word you said insights. That's so it's not the data that I'm interested in. It's what I am doing. What am I doing wrong or what am I not doing right that these insights can bring to me so that I can say, you're right. I never asked about stairs, or no one on my team asked about stairs, or they did, and the patient said, yeah, I have stairs. And then that was recorded dutifully in an electronic health record. And then no one did anything with that information, and we were setting ourselves up for failure. So, yeah, that, that that plan to actually take data and move it into insights and then make actions out of those, that's where a lot of people don't design their processes. Well, this was great, Karen. Thank you so much. We always end with the same question, which is that we're talking about design and intentionality. Is there something that you use that's so well designed that you feel joy whenever you interact with it? Anything like that in your life?
Karen Joswick: I've got kids, probably like most folks, and I have to track them all down and they are everywhere. So, I really appreciate some of the calendaring options to just share with them. But also, there's an app called Life 360 where you can track your kids. And so, like the teenage driver that's driving fast and so forth, so I think me, on a personal level, the ability to monitor and know what's going on with my kids in this tech-enabled world and still be close to them is a good place.
Dr. Craig Joseph: It was much more complicated than now to know people they needed to be. And so, I accept your calendar option, and I think there is some joy in that. It's a lack of stress. Right. Where's my kid? He was supposed to have called me. He didn't call me. Let me track his location. He's still on the baseball field or at the high school where I know that he's okay because he's obviously been paying some more attention to sports than to answering my texts.
Karen Joswick: For me, the calendar growing up was the calendar on the wall of the kitchen, and my signal to come home was the streetlights turning on when it was dark. So, it's, it's a very different world to imagine all of parenting and so forth. So, yeah, that's my season of life right now.
Dr. Craig Joseph: I love it; I love it. Well, thank you again. It's been a pleasure. And look forward to seeing how, team works out for the 25%, lucky participants starting next year.
Karen Joswick: Thanks, Craig. A pleasure. It's always great talking to you.