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Traditional Medicare vs Medicare Advantage vs Medicare Part D vs Medicare Supplement Explained
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jul 18, 2021
This video provides a high-level overview and comparison of the four main components of Medicare: Traditional Medicare (Parts A and B), Medicare Advantage (Part C), Medicare Part D, and Medicare Supplement (Medigap) plans. Dr. Eric Bricker, the presenter, aims to clarify the often-complicated distinctions between these options, responding to viewer requests for this topic. He uses a structured approach, breaking down each plan by its coverage, costs, and implications for both beneficiaries and healthcare providers, highlighting the significant differences in flexibility, benefits, and financial structures. The discussion begins with Traditional Medicare, explaining Part A for hospital coverage and Part B for physician and outpatient services. Dr. Bricker details the associated costs, such as the low or zero premium for Part A (for those who've worked enough), the proactive sign-up and premium for Part B, and the critical point of a 20% co-insurance for Part B services with no out-of-pocket maximum. He also notes that under Traditional Medicare, prices for providers are set by CMS (Centers for Medicare & Medicaid Services), it operates on a straight fee-for-service model with no prior authorizations or referrals, and offers broad access to doctors and hospitals. The video then shifts to Medicare Advantage, often called Part C, which bundles hospital, doctor, outpatient, and typically prescription drug coverage, along with additional benefits like dental, vision, and hearing. A key insight is that Medicare Advantage plans often have low or even zero premiums for beneficiaries, contributing to their rapid growth, now covering 40% of Medicare enrollees. Dr. Bricker explains the financial mechanics, where the government pays a fixed amount (around $1,000 per beneficiary per month) to commercial insurance companies (e.g., UnitedHealthcare, Humana), which then manage care. These plans achieve lower costs and offer extra benefits by implementing tighter care restrictions, such as HMO models with PCP gatekeepers, narrow provider networks, and extensive prior authorization requirements for tests, procedures, and surgeries. The video also touches on the rise of capitated and value-based payments to physician groups (like ChenMed, Oak Street) within the Medicare Advantage framework, where providers take on financial risk for keeping patients healthy. Finally, Dr. Bricker covers Medicare Part D, which provides prescription drug coverage for those on Traditional Medicare, noting its low or zero premium, tiered formularies, co-pays, co-insurance, and the concept of a "donut hole." He emphasizes that Part D plans, administered by private insurers, also involve prior authorizations and formulary controls for medications. The video concludes with Medicare Supplement (Medigap) plans, optional commercial insurance policies that beneficiaries can purchase to cover the out-of-pocket costs not covered by Traditional Medicare, particularly the 20% Part B co-insurance, without altering the provider's interaction with Medicare. Key Takeaways: * **Traditional Medicare Structure:** Consists of Part A (hospital coverage, often zero premium for eligible individuals) and Part B (physician and outpatient services, requires a premium). Part B has a 20% co-insurance with no out-of-pocket maximum, posing significant financial risk. * **Provider Reimbursement in Traditional Medicare:** Prices are set by CMS on a fee-for-service basis, with no prior authorizations or referrals required, offering beneficiaries broad access to providers. * **Medicare Advantage (Part C) as an All-in-One Solution:** These plans bundle hospital, physician, outpatient, and prescription drug coverage, often including additional benefits like dental, vision, and hearing, which are not covered by Traditional Medicare. * **Growth and Financial Incentives of Medicare Advantage:** Medicare Advantage is rapidly growing, now covering 40% of beneficiaries, partly due to low or zero premiums and added benefits. Insurance companies receive a fixed payment from the government per beneficiary (e.g., $1,000/month) and can achieve significant profit margins (e.g., $1,600/year per beneficiary). * **Care Restrictions in Medicare Advantage:** To manage costs and offer additional benefits, most Medicare Advantage plans utilize HMO models with primary care physician (PCP) gatekeepers, narrow provider networks, and frequent prior authorization requirements for tests, procedures, and specialist visits. * **Value-Based and Capitated Payments:** Medicare Advantage plans are a hotbed for innovation in payment models, frequently employing capitated and value-based payments to physician groups (e.g., ChenMed, Oak Street), where providers take on financial risk for patient health outcomes. * **Medicare Part D for Prescription Coverage:** This separate plan provides prescription drug coverage for those on Traditional Medicare. It features tiered formularies, co-pays, co-insurance, and a "donut hole" phase where beneficiaries pay a higher percentage of drug costs. * **Prior Authorizations for Medications:** Regardless of whether coverage is through Medicare Advantage or Part D, prescription drugs are subject to formularies and prior authorization controls by private health insurance companies. * **Medicare Supplement (Medigap) Plans:** These optional commercial insurance policies cover the out-of-pocket costs associated with Traditional Medicare, such as the 20% Part B co-insurance, providing financial protection without altering access to providers. * **Beneficiary Choice vs. Restriction:** Traditional Medicare offers broad choice and no referrals/prior authorizations but higher potential out-of-pocket costs. Medicare Advantage offers lower premiums and more benefits but comes with significant restrictions on provider choice and care access. * **Market Dynamics:** The shift from Traditional Medicare to Medicare Advantage is a significant trend, driven by both beneficiary demand for lower premiums and added benefits, and insurer profitability. * **Impact on Pharmaceutical and Medical Device Companies:** Understanding these different Medicare structures, especially the growth of Medicare Advantage, its prior authorization requirements, formularies, and value-based payment models, is crucial for market access, commercial strategy, and sales operations within the pharmaceutical and medical device sectors. **Key Concepts:** * **Traditional Medicare (Part A & B):** Government-run health insurance for people 65 or older, and some younger people with disabilities. Part A covers hospital stays, Part B covers doctor visits and outpatient care. * **Medicare Advantage (Part C):** Private insurance plans that contract with Medicare to provide all Part A and Part B benefits, often including Part D and additional benefits. * **Medicare Part D:** Prescription drug coverage, typically offered by private insurance companies. * **Medicare Supplement (Medigap):** Private insurance policies that cover costs not covered by Original Medicare, such as co-payments, co-insurance, and deductibles. * **Fee-for-Service:** A payment model where services are unbundled and paid for separately. * **HMO (Health Maintenance Organization):** A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. Often requires a PCP gatekeeper. * **PPO (Preferred Provider Organization):** A type of health insurance plan that has a network of providers but allows members to see out-of-network providers for a higher cost. * **Capitated Payments:** A payment arrangement where a fixed amount is paid per patient per unit of time, regardless of the services rendered. * **Value-Based Payments:** Payment models that incentivize healthcare providers to improve the quality and efficiency of care. * **Formulary:** A list of prescription drugs covered by a health insurance plan. * **Donut Hole (Coverage Gap):** A temporary limit on what the drug plan will cover for drugs. * **Prior Authorization:** A requirement that a healthcare provider obtain approval from a health plan before providing a service or prescribing a medication. * **Co-insurance:** The percentage of costs of a covered health care service you pay after you've paid your deductible. * **Deductible:** The amount you must pay out-of-pocket for covered healthcare services before your insurance plan starts to pay. * **Out-of-Pocket Maximum:** The most you have to pay for covered services in a plan year. **Examples/Case Studies:** * **Medicare Advantage Insurers:** UnitedHealthcare, Humana, Blue Cross plans (e.g., Anthem), Aetna, Cigna. * **Capitated Physician Groups:** ChenMed, Oak Street, Devoted. **Tools/Resources Mentioned:** * medicare.gov/your-medicare-costs/medicare-costs-at-a-glance * healthaffairs.org/doi/10.1377/hblog20210304.136304
IQVIA Technologies eTMF demo
IQVIA
/@IQVIA
Jul 14, 2021
This video provides an in-depth demonstration of the IQVIA Technologies eTMF (electronic Trial Master File) system, presented by Charles Patrell, a Solutions Engineer at IQVIA. The primary purpose of the demo is to showcase how the eTMF facilitates inspection readiness, drives quality and completeness, and ensures timeliness in managing Trial Master Files for clinical studies. The system is presented as a rule-based platform, granting specific rights and permissions to users, and its structure is based on the industry-standard TMF Reference Model, which is fully configurable to meet individual customer needs. The demonstration begins with an overview of the user's personalized homepage, which serves as a central hub for managing eTMF activities. This dashboard displays announcements, personal notes for follow-up, and an inbox for assigned tasks such as document rework or approval requests. A "work area" highlights documents in draft or unfinished states, emphasizing the system's "eTMF as a factory" concept, where continuous movement of documents is crucial to prevent backlogs. The homepage also features a study grid dashboard, allowing users to monitor the TMF health of their favorite studies and those recently accessed, with information integrated from CTMS (Clinical Trial Management System) and supported by study setup wizards. A significant portion of the demo focuses on the system's ability to track and analyze TMF health through key performance indicators (KPIs): completeness, quality, and timeliness. Completeness measures the percentage of finalized documents against those due by a specific date, quality assesses rework rates during the QC process, and timeliness tracks prompt document finalization. Users can drill down into a completeness dashboard for a specific study, comparing its performance against others in their portfolio and analyzing missing document statuses by country, site, organization, or risk level. The video also illustrates a streamlined document submission process, utilizing planned placeholders that automatically apply metadata, reducing manual data entry. Documents can be reviewed, assigned dates, and finalized, with the option for a risk-based specialist review before finalization. The system offers various views, including a folder tree structure for navigating by Zone, Section, and Artifact, alongside robust search and filtering capabilities, and the ability to export study items to Excel for authorized users. Finally, a study timeline feature allows users to visualize events and associated documents, enhancing oversight of trial progression. Key Takeaways: * **Centralized TMF Management for Inspection Readiness:** The IQVIA eTMF functions as a comprehensive system designed to maintain Trial Master Files in an "inspection ready" state at all times, ensuring compliance with regulatory authorities. * **Rule-Based System with Configurable Structure:** The eTMF employs a rule-based permission system and its structure is built upon the industry-standard TMF Reference Model, offering extensive configurability to adapt to specific customer requirements. * **User-Centric Homepage and Workflow Management:** The system provides a personalized user homepage displaying critical information such as announcements, personal notes, and an inbox for assigned tasks, streamlining individual workflow and task prioritization. * **"eTMF as a Factory" Concept:** The platform promotes a continuous workflow, conceptualizing the eTMF as a "factory" where documents must consistently move forward to prevent backlogs and ensure efficient trial conduct. * **KPI-Driven TMF Health Monitoring:** The eTMF utilizes a "Quality by Design" approach to define and track key performance indicators (KPIs) for TMF health, specifically completeness (finalized documents vs. due), quality (rework rates), and timeliness (prompt finalization). * **Granular Completeness Analysis:** Users can access detailed completeness dashboards to compare study performance, identify missing documents, and analyze status breakdowns by country, site, organization, or risk level, enabling targeted intervention. * **Streamlined Document Submission:** The system facilitates efficient document submission through pre-planned placeholders, which automatically apply relevant metadata (e.g., study, country, site, document type), significantly reducing manual data entry and potential errors. * **Risk-Based Document Review and Finalization:** The eTMF supports a structured document review and finalization process, including the option to implement a risk-based approach requiring specialist review for critical documents before finalization. * **Multiple Viewing and Navigation Options:** Users can view TMF items in various formats, including a detailed item list and a hierarchical folder tree structure (Zone, Section, Artifact), catering to different navigation preferences. * **Advanced Search and Filtering Capabilities:** The system offers robust search functionality, allowing users to search by keyword across metadata, content, or both, complemented by extensive filters (facets) to refine results, similar to e-commerce platforms. * **Study Timeline for Event Tracking:** A dedicated study timeline feature provides a chronological view of events that have occurred during a study, enabling users to quickly identify and review documents associated with specific milestones or changes. * **Integration with CTMS:** The eTMF integrates with Clinical Trial Management Systems (CTMS) to import study information and leverage industry-leading study setup wizards, simplifying the process of determining required documents for regulatory compliance. Tools/Resources Mentioned: * **IQVIA eTMF:** The core electronic Trial Master File system demonstrated. * **CTMS (Clinical Trial Management System):** Mentioned as a source for integrating study information into the eTMF. * **Excel:** Authorized users can export all study items to Excel for further analysis. Key Concepts: * **eTMF (electronic Trial Master File):** A digital system for managing all essential documents of a clinical trial, crucial for regulatory compliance and audit readiness. * **TMF Reference Model:** An industry standard for structuring the content of a Trial Master File, ensuring consistency and completeness. * **Inspection Readiness:** The state of having all necessary documentation organized, complete, and readily accessible to satisfy regulatory authority inspections. * **Quality by Design (QbD):** An approach to defining and monitoring KPIs within the eTMF, ensuring that the system is designed to achieve desired quality outcomes from the outset. * **KPIs (Key Performance Indicators):** Specific metrics used to evaluate the health and efficiency of the TMF, including Completeness, Quality (rework rates), and Timeliness. * **Placeholders:** Empty document slots created during the TMF planning process, which, when populated, automatically apply associated metadata, streamlining document submission.
Healthcare Customer Service is Terrible... Why?
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jul 11, 2021
This video provides a critical analysis of the consistently poor customer service within the healthcare sector, specifically focusing on health insurance companies and hospitals. Dr. Bricker begins by citing Forrester Research, which ranks health insurance customer service 15th out of 19 industries, highlighting major players like Blue Cross Blue Shield, Anthem, United Healthcare, Cigna, and Aetna for their particularly poor service. The problem extends to hospital billing, where the complexity is so severe that 40% of surveyed patients admit to skipping preventive care and screenings just to avoid the associated billing headaches, paradoxically leading to sicker patients and potentially more hospital services. Dr. Bricker argues that this pervasive poor customer service is not due to incompetence but rather a "calculated business decision." He posits that health insurance companies and hospitals lack the fundamental business incentive to improve customer service. For health insurers, their stock prices continue to soar despite poor service, indicating that the market does not penalize them. This is largely because health insurance is primarily a B2B service, where the true customer is the employer (HR, CFO), not the individual plan member. Similarly, hospitals, whose services are often episodic, do not rely on repeat patient business in the same way consumer-facing businesses do. Their primary "customer" is often the referring physician, and neglecting patient billing satisfaction does not significantly impact their revenue. The video contrasts this with industries known for excellent customer service, such as Zappos, Nordstrom, and Ritz Carlton. These companies thrive on direct consumer relationships and repeat business, making good customer service a core requirement for their success. Dr. Bricker emphasizes that these successful companies empower their employees to "own the problem" when a customer issue arises, a stark contrast to the common experience with healthcare providers who often deflect responsibility. He concludes that the structural dynamics of the healthcare industry, particularly the B2B nature of health insurance and the episodic nature of hospital care, are unlikely to change, making systemic improvement in customer service highly improbable. Finally, the discussion shifts to existing and emerging solutions that circumvent or directly address these systemic failures. Dr. Bricker mentions healthcare navigation and advocacy firms like Compass, which arose precisely because of the poor customer service from traditional players. He also highlights innovative models like Devoted Health (a Medicare Advantage plan) and Oscar (an Obamacare plan), which were founded on the principle of providing excellent customer service, often targeting direct-to-consumer markets. He expresses excitement for direct primary care, onsite/near-site clinics, and virtual care models, which allow individuals to receive care without having to navigate the complex and frustrating traditional health insurance and hospital systems, thereby completely avoiding the poor customer service dynamic. Key Takeaways: * **Pervasive Poor Customer Service in Healthcare:** Health insurance customer service is ranked 15th out of 19 industries by Forrester Research, with major carriers like Anthem, United Healthcare, Cigna, and Aetna specifically identified for poor service. Hospital billing customer service is equally problematic, leading to significant patient frustration. * **Patient Avoidance of Care Due to Billing Complexity:** A staggering 40% of surveyed patients skip preventive care and screenings to avoid the complexity and headache of hospital billing. This has severe implications for public health, potentially leading to sicker populations and increased need for more intensive, costly treatments later. * **Poor Customer Service as a "Calculated Business Decision":** The speaker argues that the lack of improvement in healthcare customer service is not due to incompetence but rather a strategic choice. Health insurance companies and hospitals do not face significant financial penalties (e.g., declining stock prices) for poor customer service, thus removing the incentive to invest in improvements. * **Structural Incentives Drive Behavior:** For health insurance, the primary customer is typically the employer (B2B model), not the individual plan member. This disconnect means that patient satisfaction is not a direct driver of business success for insurers. For hospitals, services are often episodic, reducing the need for repeat business driven by positive customer experiences. * **"Owning the Problem" is Key to Good Customer Service:** Exemplary customer service companies like Zappos, Nordstrom, and Ritz Carlton empower their employees to take ownership of customer problems and resolve them. This contrasts sharply with healthcare customer service, where responsibility is frequently averted or deflected. * **Lack of Return on Investment for Customer Service:** Healthcare organizations, particularly large insurers, have likely analyzed the ROI of investing in customer service improvements and concluded it's not financially beneficial, as their stock prices and revenues continue to grow regardless. * **Negative Impact of Neglected Billing on Patient Health:** While not necessarily a conscious decision, the neglect of billing customer service by hospitals can inadvertently generate more business. Patients skipping preventive care due to billing fears become sicker, eventually requiring more extensive and profitable hospital services. * **Existing Solutions Address the Gap:** The systemic failure of traditional healthcare customer service has led to the rise of healthcare navigation and advocacy firms (e.g., Compass) and innovative direct-to-consumer health plans (e.g., Devoted Health, Oscar) that prioritize customer experience. * **Emerging Models Bypass the Traditional System:** Dr. Bricker highlights the potential of direct primary care, onsite/near-site clinics, and virtual care as effective ways for patients to receive necessary care without having to engage with the notoriously poor customer service of traditional health insurance companies and hospitals. * **Unlikely Systemic Change:** The fundamental structural dynamics of the healthcare industry, particularly the B2B nature of health insurance and the episodic nature of hospital care, make it highly probable that traditional health insurance and hospital customer service will not significantly improve. Key Concepts: * **B2B vs. B2C Service Models:** This distinction is central to the video's argument, explaining why health insurance (B2B) has different customer service incentives than direct-to-consumer businesses (B2C). * **Episodic vs. Repeat Business:** Hospitals often provide episodic care, meaning patients may not return for extended periods, reducing the incentive for customer service driven by repeat business. * **Healthcare Navigation/Advocacy Firms:** Companies that help individuals navigate the complex healthcare system, often arising as a direct response to the poor customer service and complexity of traditional providers. * **Direct Primary Care (DPC):** A healthcare model where patients pay a monthly fee directly to their primary care provider, bypassing insurance for many services. * **Onsite/Near-site Clinics:** Employer-sponsored clinics that provide convenient healthcare services to employees, aiming to improve health outcomes and reduce costs. * **Virtual Care:** Healthcare services delivered remotely via telecommunications, offering convenience and potentially avoiding administrative complexities. Examples/Case Studies: * **Forrester Research:** Cited for its ranking of health insurance customer service and for identifying specific poor performers like Anthem, United Healthcare, Cigna, and Aetna. * **Zappos, Nordstrom, Ritz Carlton:** Used as examples of companies in consumer-facing industries that excel at customer service due to their business models. * **Compass:** Mentioned as a healthcare navigation/advocacy firm that exists because of the poor customer service from traditional providers. * **Devoted Health:** A Medicare Advantage plan founded on the principle of providing fantastic customer service. * **Oscar:** An Obamacare plan started by its CEO after a personal negative experience with UnitedHealthcare, specifically to offer superior customer service.
Mental Health Treatment Lowers Healthcare Costs
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jul 7, 2021
This video provides an in-depth exploration of the profound impact of mental health on overall physical health outcomes and healthcare costs, advocating for integrated mental health treatment within primary care. Dr. Eric Bricker begins by addressing the pervasive stigma surrounding mental health, particularly depression and anxiety, which he terms "the elephant in the room." He highlights the high prevalence of these conditions, noting that approximately 7% of the adult U.S. population experiences depression, with this figure rising to 11% among 18-25 year olds. Anxiety is even more common, affecting 19% of U.S. adults, with a significant 56% of those experiencing moderate to severe impairment in their personal and professional lives. The presentation then delves into how mental health conditions, beyond just mood disorders, can severely impair cognitive functions such as thinking, memory, and articulation. Dr. Bricker emphasizes that addressing these underlying mental health issues is crucial for improving a patient's ability to engage with and benefit from medical treatment. A compelling example is drawn from diabetes care, where 12% of individuals with diabetes also suffer from depression. Research indicates that depressed diabetic patients exhibit poorer adherence to appointments, dietary recommendations, and medication regimens (pills or insulin), leading to increased complications like worsening retinopathy, neuropathy, and nephropathy. This underscores the critical need to treat co-occurring mental health conditions to effectively manage chronic physical illnesses. To illustrate a successful intervention, the video highlights a decade-long study conducted by the Intermountain Health System in Utah, which involved over 100,000 participants and was published in the Journal of the American Medical Association. This innovative approach involved integrating mental health professionals (nurses, counselors, psychologists) directly into primary care clinics, fostering collaborative team-based care with primary care physicians. The results were overwhelmingly positive: improved compliance with best practices in diabetes care, a significant decrease in hospitalizations, and reduced emergency room utilization for patients receiving integrated care. Beyond clinical improvements, the initiative demonstrated substantial financial benefits, saving approximately $260 per member per year overall, with even greater savings for specific patient groups—$340 per year for those with diabetes and $285 per year for those with depression. Remarkably, the cost to Intermountain Healthcare for this mental health component was only $22 per member per year, yielding an impressive return on investment exceeding 10:1. This case study serves as a powerful testament to the clinical and economic advantages of prioritizing and integrating mental health services within the broader healthcare system. Key Takeaways: * **High Prevalence of Mental Health Issues:** Depression affects 7% of U.S. adults (11% in 18-25 year olds), and anxiety affects 19% of U.S. adults, with 56% of those experiencing significant impairment. Employers with younger workforces should anticipate higher rates of depression. * **Mental Health Impairs Cognitive Function:** Beyond emotional distress, conditions like depression and anxiety can significantly hinder a person's ability to think, remember, and articulate, impacting both personal and professional effectiveness. * **Strong Comorbidity with Chronic Diseases:** There is a significant link between mental health and chronic physical conditions, exemplified by 12% of diabetes patients also suffering from depression. * **Impact on Treatment Adherence and Outcomes:** Mental health issues directly impede adherence to medical appointments, dietary recommendations, and medication regimens, leading to worse physical health outcomes and increased complications for chronic conditions like diabetes. * **Integrated Care Model Success:** The Intermountain Health System demonstrated that embedding mental health professionals (nurses, counselors, psychologists) within primary care clinics leads to improved patient outcomes. * **Improved Clinical Metrics:** The integrated care model resulted in increased compliance with best practices in diabetes care, decreased hospitalizations, and reduced emergency room visits. * **Significant Healthcare Cost Savings:** Treating mental health proactively can substantially lower overall healthcare costs, with Intermountain Health saving $260 per member per year across their system. * **Targeted Savings for Specific Conditions:** The cost savings were even more pronounced for patients with specific comorbidities, saving $340 per member per year for those with diabetes and $285 per member per year for those with depression. * **Exceptional Return on Investment (ROI):** The Intermountain Health initiative demonstrated an ROI of over 10:1, with a cost of $22 per member per year for the mental health component yielding savings far exceeding the investment. * **Mental Health as a Business Imperative:** Addressing mental health is not just a clinical imperative but also a financial one, offering a tangible return on investment for healthcare systems and employers looking to reduce overall healthcare spend. * **Collaborative Care is Key:** Effective treatment of complex patient needs, especially those with co-occurring mental and physical health issues, requires a collaborative, team-based approach between primary care physicians and mental health professionals. * **Data-Driven Validation:** The Intermountain Health study, involving over 100,000 participants over 10 years and published in JAMA, provides robust evidence for the efficacy and cost-effectiveness of integrated mental health care. Tools/Resources Mentioned: * **Journal of the American Medical Association (JAMA):** The publication source for the Intermountain Health System study. * **National Institute of Mental Health (NIMH):** Cited as a source for statistics on depression and anxiety prevalence. * **National Center for Biotechnology Information (NCBI):** Cited as a source for research on diabetes and depression. * **Intermountain Health System:** A real-world healthcare system that implemented and studied the integrated mental health care model. Key Concepts: * **Integrated Care:** A healthcare approach that combines physical and mental health services to treat the whole person, often by embedding mental health professionals within primary care settings. * **Comorbidity:** The simultaneous presence of two or more diseases or medical conditions in a patient, such as diabetes and depression. * **Treatment Adherence:** The degree to which a patient follows medical advice, including taking medication, following dietary restrictions, and attending appointments. * **Return on Investment (ROI) in Healthcare:** A measure of the financial benefit gained in relation to the cost of a healthcare intervention or program. Examples/Case Studies: * **Intermountain Health System Study:** A 10-year study involving over 100,000 participants that demonstrated the clinical and financial benefits of integrating mental health professionals into primary care clinics, leading to improved diabetes care, reduced hospitalizations, and decreased ER utilization, with a 10:1 ROI.
MasterControl Whiteboard Quality Management System Overview
マスターコントロール株式会社
/@%E3%83%9E%E3%82%B9%E3%82%BF%E3%83%BC%E3%82%B3%E3%83%B3%E3%83%88%E3%83%AD%E3%83%BC%E3%83%AB%E6%A0%AA%E5%BC%8F%E4%BC%9A%E7%A4%BE
Jul 7, 2021
This video provides an in-depth exploration of MasterControl's Quality Management System (QMS), showcasing how it offers a closed-loop, connected platform to manage the entire product lifecycle in regulated industries. The presentation begins by highlighting the inefficiencies and errors inherent in traditional multi-system approaches to bringing a product to market. It then positions MasterControl as a unified solution that connects every phase, from initial project planning to regulatory approval, manufacturing, supplier management, and change control, thereby eliminating the need for disparate systems and paper-based processes. The demonstration walks through the core functionalities of the MasterControl QMS, starting with its project management capabilities. Users can set up projects with specific tasks, monitor progress, track dependencies, and view task durations and assignments. A key feature is the collaboration workspace, which enables team members to share, edit, and approve documents seamlessly, ensuring that the project plan is automatically updated upon document completion and submission. This integrated approach aims to foster better teamwork and maintain real-time visibility across all project activities. A significant portion of the video focuses on the system's robust regulatory management features, particularly for the pharmaceutical industry. It illustrates how MasterControl can structure and manage common technical documents (CTD), enabling easy monitoring of documentation approval and population into appropriate folders. When it's time for submission, the system can export all necessary documents in a format suitable for publishing tools, ready for submission to regulatory bodies like the FDA. Furthermore, the QMS facilitates comprehensive supplier documentation management, allowing internal managers to view all supplier-related information, corrective actions, and quality events, with the option to grant controlled access to suppliers themselves via a secure link. Beyond documentation, the video details MasterControl's capabilities in operational quality and compliance. It demonstrates how the system manages employee training and certification, showing how manufacturing operators can access pending training tasks, study necessary procedures and materials, complete exams (multiple choice, true/false, etc.), and provide electronic signatures to create a compliant training record. The QMS also handles quality events, such as non-conforming material reports (NCMRs), allowing users to document occurrences, route them for review, and initiate appropriate actions. An integrated analytics dashboard provides quality managers with at-a-glance insights into collected events, enabling tracking, trending, and drill-down analysis into specific failure codes. The demonstration concludes by showcasing supplier audit management and the critical process of change control, which can be initiated from a CAPA (Corrective and Preventive Action) to propose, assess, implement, and verify changes, thus rounding out the comprehensive quality story. Key Takeaways: * **Unified Quality Management System:** MasterControl offers a single, connected QMS that integrates all phases of the product lifecycle, from project planning to manufacturing and regulatory approval, eliminating the inefficiencies and errors associated with multiple disparate systems. * **Streamlined Project Management:** The system includes a projects module for setting up tasks, monitoring progress, tracking dependencies, and managing task durations and assignments, providing clear visibility into project status. * **Enhanced Collaboration:** A dedicated collaboration workspace allows team members to securely share, edit, and approve documents, ensuring that project plans are automatically updated upon document completion and approval. * **Robust Regulatory Document Management:** Specifically tailored for industries like pharmaceuticals, the QMS manages common technical documents (CTD) structures, facilitates monitoring of documentation approval, and prepares documents for submission to regulatory bodies like the FDA. * **Comprehensive Supplier Management:** The system centralizes supplier documentation, quality events, and corrective actions, allowing internal managers to oversee supplier performance and providing controlled access to suppliers for relevant information. * **Compliant Training Management:** MasterControl enables the management of employee training and certification, including access to procedures, study materials, exams, and the use of electronic signatures to create auditable training records for GxP compliance. * **Efficient Quality Event Handling:** The QMS provides tools for documenting and managing various quality events, such as non-conforming material reports (NCMRs), routing them for appropriate review and action, and ensuring a closed-loop process. * **Data-Driven Quality Analytics:** An integrated analytics dashboard offers quality managers real-time insights through charts and reports, allowing them to track and trend quality events, identify patterns, and drill down into specific failure codes for root cause analysis. * **Structured Supplier Audits:** The system supports the entire supplier audit process, from task assignment for auditors to documenting observations, collecting supporting information, and generating formatted audit reports. * **Controlled Change Management:** MasterControl facilitates a structured change control process, often initiated from a CAPA, allowing users to propose, assess, route for group review, implement, and verify changes, ensuring all modifications are documented and compliant. * **Accelerated Compliance and Time-to-Market:** By connecting all quality processes and ensuring electronic record-keeping and regulatory adherence, the QMS helps companies improve overall quality and accelerate the time it takes to bring products to market. * **Electronic Signatures for Compliance:** The system leverages electronic signatures for critical actions like training completion and document approvals, ensuring compliance with regulations like 21 CFR Part 11. Tools/Resources Mentioned: * **MasterControl:** The Quality Management System (QMS) itself, which is the subject of the overview. Key Concepts: * **Quality Management System (QMS):** A formalized system that documents processes, procedures, and responsibilities for achieving quality policies and objectives. * **Common Technical Document (CTD):** A set of specifications for a dossier for the registration of medicines, designed to be used across Europe, Japan, and the United States. * **Non-Conforming Material Report (NCMR):** A document used to record and track materials or products that do not meet specified quality standards. * **Corrective and Preventive Action (CAPA):** A system for investigating and correcting identified nonconformities (corrective action) and preventing potential nonconformities (preventive action). * **Supplier Corrective Action Report (SCAR):** A formal request to a supplier to investigate and correct a nonconformity related to their products or services. * **Change Control:** A formal process used to manage changes to a product, system, or process, ensuring they are documented, assessed, approved, and verified. * **Electronic Signature:** A method of signing a document or record electronically, often used in regulated industries to ensure authenticity and compliance with regulations like 21 CFR Part 11. * **FDA Submission:** The process of submitting documentation to the U.S. Food and Drug Administration for approval of new drugs, medical devices, or other regulated products.
What is TMF Reference model||DIA||Trial master file||Clinical Research
Vikas Singh
/@VikasSinghPharmalive
Jul 4, 2021
This video explores the Trial Master File (TMF) Reference Model, detailing its historical context, purpose, and structure. The speaker explains the evolution from paper-based clinical trial documentation, which was time-consuming for audits, to electronic Trial Master Files (eTMFs). The video highlights the challenge of inconsistencies arising from different companies and countries using varied eTMF systems, which the TMF Reference Model was created to address. As a supported initiative of the DIA, the model provides a unified interpretation of regulations and best practices for TMFs, serving as a reference tool for document location, keywords, and quality checks. It outlines the model's four main areas (Content, Location, Keywords, Quality Check) and various sections (e.g., Trial Management, Regulatory, Site Management), emphasizing its role in ensuring proper filing and management of essential clinical trial documents for regulatory compliance and operational efficiency. Key Takeaways: * **Standardization for Compliance:** The TMF Reference Model is crucial for standardizing clinical trial documentation, providing a unified interpretation of regulations and best practices to ensure consistency and facilitate regulatory audits, which is vital for FDA and EMA compliance. * **Evolution to eTMF:** The industry's transition from inefficient paper-based TMFs to electronic TMFs (eTMFs) was driven by the need for more efficient auditing, with the TMF Reference Model addressing initial inconsistencies in eTMF implementations. * **Structured Document Management:** The model defines specific sections and provides detailed information (e.g., Artifact ID, purpose, retention, language) for categorizing and managing essential documents, enabling precise location and quality control within clinical operations. * **Operational Efficiency:** By standardizing document filing and naming conventions, the TMF Reference Model significantly enhances the efficiency of clinical operations, data management, and compliance tracking
Compliant Social Media Publishing from Veeva PromoMats for US Pharma Companies
Pushpa Ithal
/@pushpaithal8264
Jul 1, 2021
This video provides an in-depth exploration of compliant social media publishing for US pharmaceutical and life sciences companies, specifically focusing on integration with Veeva Vault PromoMats. The speaker, Pushpa Ithal, CEO of MarketBeam, highlights the significant challenges faced by regulated industries in leveraging social media due to stringent compliance requirements and cumbersome Medical, Legal, and Regulatory (MLR) or Promotional Review Committee (PRC) approval processes. The presentation establishes that while social media's footprint is growing, the need for agility often clashes with the lengthy review cycles and the high risk associated with non-compliant content, making it difficult for companies to fully utilize these platforms. The core of the discussion revolves around three major challenges: compliance risks for both brands and employees, suboptimal and often manual review processes, and the resource-intensive nature of coordinating multiple teams (agencies, internal marketing, MLR/PRC). The speaker emphasizes that FDA guidelines, while existing, are broad, leaving companies to interpret and implement them in daily operations. This often leads to manual workflows, lack of traceability, and increased costs. A significant pain point identified is the difficulty in creating accurate mock-ups of social media posts for review, as platforms like Twitter, LinkedIn, and Instagram render content differently, making it hard for reviewers to approve content without a clear visual representation. MarketBeam presents its solution as a direct integration with Veeva Vault PromoMats, designed to automate and streamline the entire social media content lifecycle. The platform aims to eliminate human errors by ensuring that only approved content is published and by providing a complete audit trail. The demo illustrates how MarketBeam automatically generates platform-specific PDF previews of social media posts (including text, images, videos, hashtags, and URLs) and uploads them directly to Veeva Vault PromoMats, along with automatically attaching relevant claims and references. This automation significantly reduces the manual effort involved in content coordination, mock-up creation, and reference management, ultimately saving time and resources while enhancing compliance and traceability. Key Takeaways: * **Growing Social Media Footprint in Regulated Industries:** Social media's increasing adoption and influence present both opportunities and significant compliance challenges for pharmaceutical, biotech, and medical device companies. The expectation for agility on social media often conflicts with the need for rigorous regulatory review. * **Mandatory MLR/PRC Approval for All Content:** In regulated industries, all social media content, regardless of whether it's promotional, non-promotional, branded, or unbranded, must undergo a formal MLR/PRC review and approval process, which can significantly lengthen time-to-market. * **Three Major Challenges in Compliant Social Media:** Companies repeatedly face compliance risks (for both the brand and individual employees), suboptimal and often manual review processes, and high resource intensity due to multiple stakeholder involvement (agencies, marketing, MLR/PRC teams). * **Complexity of Social Media Content Review:** Unlike traditional content, social media posts comprise multiple elements (text, image, video, URL, tags, hashtags) that render differently across platforms, making it challenging for reviewers to visualize and approve the final published output without accurate mock-ups. * **MarketBeam's Veeva PromoMats Integration:** MarketBeam offers a direct, technical partnership integration with Veeva Vault PromoMats to streamline and automate the compliant social media publishing process, positioning itself as a unique solution in this space. * **Automated Mock-up and Reference Management:** The platform automatically generates platform-specific PDF previews of social media posts (e.g., Twitter, LinkedIn) with functional links and uploads them directly to Veeva Vault PromoMats. It also automatically attaches relevant claims and references from Veeva, reducing manual coordination effort. * **Elimination of Human Error in Publishing:** By ensuring that the content approved in Veeva is precisely what gets published through MarketBeam, the solution removes the risk of human error, such as posting outdated versions or making unapproved changes. * **Comprehensive Audit Trail and Traceability:** MarketBeam documents the entire content lifecycle, providing a complete trace of who created, approved, and published content, along with timestamps. This detailed record is crucial for FDA audit purposes, which often require extensive documentation of social media activities. * **Cost Savings Through Automation and Reuse:** Automating the review and publishing workflow, reducing manual tasks, and enabling the reuse of previously approved content (images, videos) significantly cuts down on operational costs and resource allocation. * **Compliant Employee Amplification:** For companies with employee advocacy programs, MarketBeam ensures that employees can only share pre-approved content without the ability to modify it, thereby reducing individual compliance risks. * **Importance of "Date of First Use":** The "Date of First Use" for a social media post is a critical piece of information that should be included and tracked during the approval process, as it is essential for regulatory records and audits. * **Future Platform Integrations:** MarketBeam plans to incorporate posting to YouTube and is considering integrations with messaging platforms popular in Asia, such as WhatsApp and WeChat, to expand its reach. * **Executive Thought Leader Content Review:** The platform also supports the review process for content posted by executive teams or thought leaders, ensuring even high-visibility posts undergo MLR/PRC approval before publication. Tools/Resources Mentioned: * MarketBeam (AI-driven social media publishing, amplifying, and monitoring platform) * Veeva Vault PromoMats (content management platform for regulated industries) * LinkedIn (social network) * Twitter (social network) * Facebook (social network) * YouTube (video sharing platform, future integration) * Vimeo (video sharing platform, recognized by MarketBeam) * WhatsApp (messaging app, future consideration) * WeChat (messaging app, future consideration) Key Concepts: * **MLR (Medical, Legal, Regulatory) Review:** The mandatory process in regulated industries for reviewing and approving all content to ensure compliance with relevant laws and guidelines. * **PRC (Promotional Review Committee) Approval:** A specific committee responsible for approving promotional materials, often used interchangeably with MLR review in the context of marketing content. * **FDA Compliance:** Adherence to regulations set forth by the U.S. Food and Drug Administration, particularly critical for pharmaceutical and medical device companies. * **Date of First Use:** The specific date a piece of content is first published or distributed, a crucial data point for regulatory tracking and audit trails. * **Corporate Publishing:** Managing and distributing content through official company social media channels. * **Employee Amplification:** Empowering employees to share company-approved content on their personal social media profiles to extend reach and engagement. Examples/Case Studies: * A medical device company experienced a "fire" (crisis) because an employee mistakenly posted an outdated, unapproved version of content, highlighting the risks of manual processes. * Large, multi-billion dollar companies are still using spreadsheets to manage social media content and its various components, indicating a widespread lack of integrated, automated solutions.
Marketing in Healthcare: How to Apply the 4 Ps of Marketing to Healthcare
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jul 1, 2021
This video provides an in-depth exploration of marketing within the healthcare sector, specifically focusing on the application of the traditional "4 Ps" of marketing – Product, Price, Placement, and Promotion – within a predominantly business-to-business (B2B) context. Dr. Eric Bricker emphasizes that understanding these Ps is crucial for success, particularly given the unique dynamics of the healthcare industry. He posits that the vast majority of successful marketing in healthcare is B2B, targeting entities like hospitals, pharmaceutical companies, employers, and insurance carriers, rather than individual consumers. The discussion begins with "Product," highlighting the critical need for any offering to possess a "10x better value proposition" than existing solutions. This means the product or service must be an order of magnitude superior, delivering significant improvements either to the "top line" (revenue generation) for providers or the "bottom line" (cost reduction, operational efficiency, increased speed, flexibility, or decreased risk) for payers. For instance, robotic surgery is cited as a top-line innovation for hospitals due to its higher billable rates, while Consumer Directed Health Plans (CDHPs) like Luminos and Definity are presented as bottom-line improvements for payers, offering actuarially superior plans compared to traditional PPOs. Following Product, Dr. Bricker delves into "Price" and "Placement." The key insight regarding price is that its primary function is to motivate the sales channel, whether an internal salesforce or external brokers and consultants. The market does not care about a company's expenses; rather, the price must incentivize those who sell the product. For "Placement," the video stresses the importance of selling where customers already go to buy. In the payer market, this means leveraging established channels like insurance brokers, benefit consultants, insurance carriers, or existing HRIS/Ben Admin platforms, rather than attempting to introduce a product through an entirely new or unrelated department, such as IT for a benefits solution. Finally, "Promotion" is discussed as the last of the four Ps, often mistakenly considered the entirety of marketing. Promotion encompasses both outbound efforts (e.g., emails, existing sales relationships) and inbound strategies (e.g., blogs, videos, content marketing). A key framework for promotion is "interrupt, engage, educate, and offer" (call to action). Dr. Bricker explicitly states that the Ps have a hierarchy, with Product being paramount. Without a 10x value proposition, even perfect execution of Price, Placement, and Promotion will fail. The video concludes by stressing the absolute necessity of market segmentation, arguing that the healthcare market is highly heterogeneous. Each segment requires a customized approach to all four Ps, as what works for national accounts may not work for the mid-market, particularly concerning placement and promotion strategies. Key Takeaways: * **Healthcare Marketing is Predominantly B2B:** The vast majority of successful marketing efforts in healthcare are directed towards businesses (e.g., hospitals, pharma companies, employers, insurers) rather than individual consumers. * **The "10x Value Proposition" for Product:** Any new product or service must offer an order of magnitude (10 times) better value than existing alternatives to successfully penetrate the market. This superiority must be clearly demonstrable. * **Dual Value Proposition Focus:** Products targeting healthcare providers (e.g., hospitals, pharmaceutical companies, medical device manufacturers) should emphasize "top-line" revenue generation, while those targeting payers (e.g., government, employers, insurance carriers) must focus on "bottom-line" improvements such such as decreased costs, increased operational efficiency, speed, flexibility, or reduced risk. * **Price Must Motivate the Channel:** The pricing strategy should not primarily be based on covering internal expenses, but rather on incentivizing the sales channel, whether it's an internal sales team or external brokers and consultants, to actively sell the product or service. * **Strategic Placement is Critical:** Products and services must be sold through established channels where customers already procure similar offerings. Attempting to introduce a product through an unfamiliar or unrelated department will likely lead to failure. * **Promotion is the Final P, Not the Only P:** While essential, promotional activities (outbound and inbound marketing) are secondary to having a superior product, appropriate pricing, and effective placement. A strong product is the foundation. * **Promotion Framework: Interrupt, Engage, Educate, Offer:** Effective promotional content should first interrupt the target audience, then engage them, educate them on the value proposition, and finally present a clear offer or call to action. * **Hierarchy of the 4 Ps:** The "Product" is the most crucial element; without a compelling, 10x better product, even perfectly executed pricing, placement, and promotion will not lead to market success. * **Market Segmentation is Non-Negotiable:** The healthcare market is highly diverse and heterogeneous. Marketers must identify specific market segments and tailor all four Ps—Product, Price, Placement, and Promotion—to the unique needs and buying behaviors of each segment. * **Placement Varies by Segment:** For example, national and jumbo employers might be amenable to direct sales, whereas the mid-market typically requires engagement through brokers, benefit consultants, or integration with insurance carriers/TPAs. * **Avoid Misaligned Placement:** Do not attempt to sell a product with a specific value proposition through a department that is not traditionally responsible for purchasing such solutions (e.g., selling a benefits solution through the IT department). * **Content Marketing for Inbound Leads:** Utilizing valuable content such as blogs and videos is an effective inbound promotional strategy to attract leads and educate potential clients. Key Concepts: * **4 Ps of Marketing:** Product, Price, Placement, Promotion – a foundational framework for marketing strategy. * **10x Value Proposition:** The idea that a new product or service must be an order of magnitude (ten times) better than existing solutions to gain significant market traction. * **Top-Line Value:** Benefits that increase revenue for the customer, typically relevant for providers (e.g., hospitals, pharma). * **Bottom-Line Value:** Benefits that decrease costs or improve efficiency for the customer, typically relevant for payers (e.g., employers, insurers). * **Channel Motivation:** The concept that pricing and other incentives must be structured to encourage the sales channel (internal or external) to actively sell the product. * **Market Segmentation:** Dividing a broad target market into subsets of consumers, businesses, or countries that have common needs and priorities, and then designing and implementing strategies to target them. * **Interrupt, Engage, Educate, Offer:** A framework for structuring promotional content to capture attention, foster interest, provide information, and prompt action. Examples/Case Studies: * **Robotic Surgery:** Presented as an example of a "top-line" product innovation for hospitals, allowing them to charge significantly more and boost revenue. * **Consumer Directed Health Plans (CDHPs):** Luminos and Definity are cited as early examples of CDHPs that offered a "10x better" actuarial proposition (bottom-line value) compared to traditional PPOs, leading to their acquisition by major insurance carriers. * **Selling Tomatoes Analogy:** Used to illustrate "Placement," emphasizing that while some niche sales might occur (e.g., roadside stand), the vast majority of purchases happen through established channels (e.g., grocery stores).
Selling in Healthcare: Prospecting, Pitching and Closing Strategies
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 29, 2021
This video provides an in-depth exploration of effective sales strategies specifically tailored for the complex business-to-business (B2B) environment within the healthcare industry. Dr. Eric Bricker, a physician and co-founder of Compass Professional Health Services, shares his personal journey and learned insights from thousands of sales meetings over a decade. He frames the sales process into three fundamental stages: prospecting, pitching, and closing, offering practical frameworks and methodologies for each. The discussion is grounded in real-world experience, highlighting the unique challenges and nuances of selling to diverse stakeholders within healthcare organizations. The first segment of the video delves into prospecting, or lead generation, utilizing Aaron Ross's "Nets, Seeds, and Spears" framework. Nets involve broad inbound marketing efforts like blog posts, videos, advertisements, and conferences, attracting a large volume of leads but typically yielding lower conversion rates. Seeds represent nurturing existing relationships and contacts, which, while taking a longer time to mature, tend to have higher conversion rates. Spears focus on highly targeted outbound efforts, directly hunting for specific individuals at identified companies. Dr. Bricker emphasizes the importance of using the telephone for spears, even if it primarily results in voicemails, as the act of calling and referencing an email makes a salesperson unique in today's digital landscape, despite the inherently low initial reply rates. Moving to the pitching stage, the video introduces the Miller-Heiman approach, which categorizes buyers into three distinct types crucial for complex B2B healthcare sales. The Economic Buyer, typically C-suite executives like the CEO or CFO, is concerned with the dollar value, return on investment, and budgetary alignment of the proposed solution. The User Buyer, often HR or benefits professionals, focuses on the tangible outcomes and benefits for their organization and employees, such as improved health metrics or reduced absenteeism. Lastly, the Technical Buyer, which could be a broker, benefits consultant, or a lower-level benefits manager, is interested in the practicalities of implementation, ease of use, and ongoing service details. Dr. Bricker stresses the difficulty of tailoring a pitch to all three buyer types simultaneously within a single meeting, a common scenario in healthcare sales. Finally, the video addresses the closing stage using the "Fit-Risk-Price" model, derived from the book "Hope is Not a Strategy." This model suggests that the buyer's priorities evolve over time. Initially, the primary concern is "Fit"—whether the service addresses their specific problem. Once fit is established, the focus shifts to "Risk," where buyers scrutinize potential issues, data security (e.g., AWS, disaster plans), and compliance. Only after these two stages are adequately addressed does the conversation naturally progress to "Price," considering the cost relative to competition and budgetary cycles. Dr. Bricker notes that questions about risk and price during earlier stages are positive buying signals, indicating progress along the sales timeline. He concludes by underscoring that selling is a vital skill for anyone looking to drive positive change or introduce new ideas and solutions within the healthcare ecosystem. Key Takeaways: * **Complex B2B Sales in Healthcare:** Selling in healthcare is inherently complex, often involving multiple stakeholders and requiring tailored strategies beyond generic sales approaches. * **Aaron Ross's Prospecting Framework:** Utilize the "Nets, Seeds, and Spears" model for effective lead generation. Nets (inbound marketing) offer broad reach, Seeds (relationship building) provide high conversion over time, and Spears (targeted outbound) require persistence but can yield specific, valuable leads. * **The Power of the Phone in Outbound:** Despite low answer rates, making phone calls and leaving voicemails, especially when combined with a same-day email reference, can differentiate a salesperson in a crowded market. * **Miller-Heiman Buyer Categorization:** Identify and understand the three distinct buyer types in healthcare B2B sales: Economic (focused on financial value), User (focused on outcomes and benefits), and Technical (focused on implementation and logistics). * **Tailoring Your Pitch:** Be prepared to dynamically adjust your pitch within a single meeting to address the specific concerns and priorities of each buyer type present, from C-suite executives to HR and technical managers. * **Economic Buyer Focus:** When engaging with economic buyers (e.g., CEO, CFO), emphasize the dollar value, return on investment, and how the solution aligns with their overall budget and strategic priorities. * **User Buyer Focus:** For user buyers (e.g., HR, benefits staff), highlight tangible outcomes and benefits such as improved employee health, reduced absenteeism, or better management of specific health conditions. * **Technical Buyer Focus:** Address the technical buyer (e.g., brokers, IT, benefits managers) by detailing the ease of implementation, ongoing support, data hosting, security protocols, and operational impact. * **"Fit-Risk-Price" Closing Model:** Guide the closing process by first establishing how your solution "fits" the client's problem, then thoroughly addressing all potential "risks" (e.g., data security, disaster recovery), and finally discussing "price" in the context of value and budget. * **Positive Buying Signals:** Recognize that questions about risk and price during the earlier "fit" stage are positive indicators that the buyer is progressing through their decision-making process. * **Persistence and Resilience:** Sales, particularly in complex B2B environments like healthcare, involves frequent rejections and requires significant persistence, resilience, and a willingness to learn from failures. * **Selling for Change:** Selling is not just about products or services; it's a fundamental skill for advocating good ideas, driving change, and implementing innovative solutions within any organization. Tools/Resources Mentioned: * "Predictable Revenue" by Aaron Ross (book) * "From Impossible to Inevitable" by Aaron Ross (book) * Miller-Heiman Group (sales approach/methodology) * "Hope is Not a Strategy" (book, referenced for the closing model) Key Concepts: * **Sales Funnel:** A conceptual framework illustrating the journey of a potential customer from initial awareness to purchase, typically divided into stages like prospecting, pitching, and closing. * **Nets, Seeds, Spears:** A prospecting methodology by Aaron Ross: * **Nets:** Broad, inbound lead generation (e.g., content marketing, ads). * **Seeds:** Nurturing existing relationships for long-term leads. * **Spears:** Targeted, outbound efforts to specific prospects. * **Economic Buyer:** The individual in an organization with ultimate financial authority to approve a purchase, typically focused on ROI and budget. * **User Buyer:** The individual or department that will directly use or benefit from the product/service, focused on outcomes and problem-solving. * **Technical Buyer:** The individual concerned with the practical implementation, integration, and operational aspects of a solution, focused on feasibility and ease of use. * **Fit-Risk-Price Model:** A closing strategy that prioritizes addressing the buyer's needs (Fit), mitigating potential concerns (Risk), and then discussing cost (Price) in that sequential order. Examples/Case Studies: * **Compass Professional Health Services:** Dr. Bricker's experience as CMO and co-founder, selling to over 2000 employer clients, including major national accounts like T-Mobile and Southwest Airlines, as well as mid-market employers (200-2000 employees). * **User Buyer Outcomes:** Examples of benefits discussed with user buyers include better health outcomes for employees, fewer days of absenteeism, decreased musculoskeletal claims, and improvement in hemoglobin A1C levels. * **Technical Buyer Risk Questions:** Examples of risk-related questions from technical buyers include inquiries about data hosting (e.g., Amazon Web Services), data center specifics, and disaster recovery plans.
Veeva Systems Interview Process | Tips on How to Be Successful
Generation Veeva
/@GenerationVeeva
Jun 28, 2021
This video provides an in-depth guide to the Veeva Systems Associate Consultant interview process, as experienced and presented by Tyler Binion, a current Associate Consultant in Veeva's Consultant Development Program (CDP). The primary purpose of the video is to equip prospective and current candidates with a clear understanding of what to expect during the five-step interview journey and to offer actionable tips for success. The speaker systematically breaks down each stage, sharing her personal preparation strategies, what she found effective, and common pitfalls to avoid, all aimed at helping candidates navigate the process confidently. The interview process is structured into five distinct phases, beginning with the University Recruiter step, followed by the Candidate Exercise, the Hiring Manager interview, a session for Role Specific Questions, and culminating in the Veeva Leadership interview. A recurring theme emphasized throughout the video is the critical importance of thorough research—not just into Veeva as a company and its clients, but also into the specific role, the interviewer, and, most importantly, understanding one's personal "why" for pursuing the position. This foundational understanding is presented as crucial for articulating genuine interest and aligning personal goals with Veeva's mission. A significant portion of the advice focuses on the Candidate Exercise, which is highlighted as potentially the most intimidating part due to its technical nature. This stage requires candidates to demonstrate problem-solving abilities and a rapid learning curve, often involving business cases where they must propose and configure a solution using specific software. The speaker details a structured approach to preparing for this exercise, including allotting dedicated time for studying the software, building the solution, and practicing the presentation, especially given the customer-facing nature of the consultant role. The video underscores that success hinges on strategic planning, diligent preparation, and effective communication of solutions. Key Takeaways: * **Understand Your "Why":** Before and throughout the interview process, candidates must clearly articulate their motivations for applying to Veeva and how the Associate Consultant role aligns with their personal and career goals. This "why" should be consistently communicated to recruiters, hiring managers, and leadership. * **Thorough Company and Client Research:** Dedicate significant time to researching Veeva Systems, its client base, and how the company delivers value. This knowledge is essential for demonstrating genuine interest and understanding the context of the role. * **Strategic Preparation for the Candidate Exercise:** This technical assessment requires candidates to solve a business problem and configure a solution using software. It's crucial to research business cases, understand problem-solving methodologies, and frame the task as providing a solution. * **Structured Planning for Technical Tasks:** For the Candidate Exercise, create a detailed plan that allocates specific time for learning the software, building/configuring the solution, and practicing the presentation. Avoid last-minute preparation. * **Develop Strong Presentation Skills:** Given that the Associate Consultant role is customer-facing, practicing the demonstration and presentation of solutions is vital. The goal is to explain complex technical solutions clearly to an audience that may lack technical understanding. * **Research Your Interviewers:** Before meeting with a hiring manager or other team members, research their background, team, and role. This helps in stimulating small talk, finding common ground, and asking more informed, relevant questions. * **Ask Role-Specific Questions:** In later stages, especially during the session for role-specific questions, inquire about work-life balance, typical challenges, and how successful consultants overcome obstacles. This demonstrates foresight and a desire to understand the day-to-day realities of the job. * **Engage with Leadership Thoughtfully:** During the Veeva Leadership interview, focus on asking questions that reveal more about Veeva's broader vision, company culture, and the qualities leadership values in successful employees. This shows a deeper interest beyond the immediate role. * **Demonstrate Learning Agility:** The Candidate Exercise specifically tests the ability to learn new software and apply it quickly to solve problems, highlighting the importance of a fast learning curve in a consulting role. * **Confidence Through Preparation:** The speaker repeatedly advises believing in oneself, which stems from thorough preparation. Confidence in one's efforts and abilities is a key factor in navigating the challenging interview stages successfully. **Key Concepts:** * **Consultant Development Program (CDP):** A new graduate development program at Veeva Systems designed to train Associate Consultants. * **Candidate Exercise:** A critical interview stage that assesses technical skills, problem-solving ability, and quick learning through a business case scenario involving software configuration and presentation. * **Business Cases:** Real-world scenarios presented to candidates to evaluate their analytical, problem-solving, and solution-designing capabilities. * **"Your Why":** The personal motivation and rationale behind pursuing a specific role or company, which candidates are encouraged to articulate clearly and consistently.
Robert Lustig's "Hacking of the American Mind" Summarized
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 27, 2021
This video provides an in-depth summary of Dr. Robert Lustig's book, "The Hacking of the American Mind," presented by Dr. Eric Bricker of AHealthcareZ. The core premise is that corporate entities strategically exploit human brain chemistry, specifically the reward pathways involving dopamine, to increase profits at the expense of public health. Dr. Lustig, a pediatric neuroendocrinologist, argues that this intentional manipulation contributes significantly to the burden of chronic diseases and the escalating costs within the U.S. healthcare system. The presentation delves into the fundamental differences between two key neurotransmitters: dopamine and serotonin. Dopamine is characterized as the "pleasure" or "euphoria" chemical, associated with rewards. Its release provides a brief mood elevation, but this is quickly followed by a drop to a mood level lower than the original baseline, leading to a craving for more dopamine and the development of tolerance. In contrast, serotonin is presented as the "contentment," "peace," or "calm" chemical, fostering a stable and steady mood. The video highlights that dopamine-stimulating substances and behaviors include sugar, caffeine, alcohol, nicotine, illicit drugs, prescription narcotics, social media usage, gambling, and sex, while serotonin is stimulated by tryptophan (an amino acid in protein), positive relationships, service to others, prayer, and meditation. A central theme is how various industries—including the food and beverage, alcohol, tobacco, illicit drug, pharmaceutical, social media, gambling, and sex industries—have engineered their products and services to trigger dopamine release, creating addictive feedback loops. Specific examples include the increased use of high fructose corn syrup in processed foods since the 1970s and Facebook's admitted design to stimulate dopamine through "likes" to encourage continued app usage. The video also introduces cortisol, the stress hormone, explaining how elevated stress levels lower baseline mood, intensifying the craving for dopamine and further inhibiting serotonin, thus creating a vicious cycle that undermines overall well-being. The profound consequences of this "hacking" are then detailed, linking constant dopamine stimulation to a rise in obesity, metabolic syndrome, cancer, cardiovascular disease, diabetes, decreased cognitive ability, memory impairment, addiction, and depression. Dr. Lustig estimates that a staggering 75% of the $4 trillion spent annually on the U.S. healthcare system is attributable to diseases stemming from these "hacked minds." The video concludes by positing that corporate practices, driven by profit motives, represent a significant and often unrecognized public health threat, urging a deeper understanding of these biological and commercial dynamics within the healthcare finance community. Key Takeaways: * **Dopamine vs. Serotonin:** Dopamine provides short-lived pleasure and euphoria, leading to cravings and tolerance, while serotonin fosters sustained contentment and peace. Understanding this biochemical distinction is crucial for comprehending human behavior and well-being. * **Corporate Exploitation of Brain Chemistry:** Various industries intentionally design products and services to stimulate dopamine pathways, creating addictive cycles that drive consumption and profit. This includes the food, beverage, pharmaceutical, social media, and gambling sectors. * **Pharmaceutical Industry's Role:** The video specifically identifies "big pharma prescription narcotics" as a category of substances that stimulate dopamine, highlighting the pharmaceutical industry's direct involvement in practices that can contribute to addictive behaviors. * **Examples of Dopamine Stimulation:** Specific examples include sugar and high fructose corn syrup in processed foods, and social media platforms like Facebook using "likes" to trigger dopamine release and encourage user engagement. * **Health Deterioration:** Chronic overstimulation of dopamine pathways is directly linked to a wide range of severe health issues, including obesity, metabolic syndrome, increased risk of cancer, cardiovascular disease, diabetes, and neurological impairments like decreased cognitive ability and memory loss. * **Mental Health Impact:** The "dopamine-seeking" cycle also significantly contributes to addiction and depression, as the pursuit of pleasure can biochemically inhibit the brain's capacity for peace and calm. * **Role of Cortisol:** Stress and sleep deprivation elevate cortisol levels, which lower overall mood, intensifying the craving for dopamine-stimulating activities and further exacerbating the negative cycle by inhibiting serotonin. * **Massive Healthcare Cost Burden:** Dr. Lustig estimates that 75% of the $4 trillion U.S. healthcare budget is spent on treating diseases that are direct consequences of this corporate "hacking" of the American mind, underscoring the immense economic impact. * **Public Health Threat:** The video frames profit-driven corporate practices as a major, yet often overlooked, public health enemy, suggesting a need for greater awareness and potentially systemic changes to address these issues. * **Serotonin-Boosting Activities:** To counteract dopamine overstimulation, the video briefly mentions activities that promote serotonin, such as consuming tryptophan-rich protein, fostering positive relationships, engaging in service to others, and practicing prayer or meditation. Tools/Resources Mentioned: * **Book:** "The Hacking of the American Mind" by Dr. Robert Lustig * **Article/Interview:** CNBC interview with Chamath Palihapitiya (early Facebook employee) where he admitted to Facebook's intentional design to stimulate dopamine. Key Concepts: * **Dopamine:** A neurotransmitter associated with pleasure, reward, and euphoria, but also leading to cravings and tolerance. * **Serotonin:** A neurotransmitter associated with contentment, peace, and calm, promoting stable mood. * **Cortisol:** The primary stress hormone, which can lower mood and exacerbate dopamine-seeking behaviors. * **Metabolic Syndrome:** A cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and type 2 diabetes. * **Dopaminergic Pathways:** Neural pathways in the brain that are activated by dopamine, often associated with reward and addiction.
The Dartmouth Atlas of Healthcare Shows Geographic Variation in the Frequency of Spine Surgery
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 23, 2021
This video provides an in-depth exploration of geographic variation in healthcare service utilization, specifically focusing on spine surgery rates across the United States, utilizing data from the Dartmouth Atlas of Healthcare. Dr. Eric Bricker begins by introducing the Dartmouth Atlas as a renowned resource that maps healthcare service utilization, emphasizing its value for understanding regional differences. The core purpose of the video is to apply this macro-level Medicare data to the context of employer-sponsored health plans, arguing that utilization patterns observed in Medicare beneficiaries are likely mirrored in commercially insured populations due to consistent surgeon practice patterns. The presentation systematically illustrates significant variations in spine surgery frequency by examining specific metropolitan areas. It highlights New York City and San Francisco as regions with relatively low and consistent rates, both averaging around 2.5 surgeries per 1,000 Medicare enrollees. In stark contrast, areas like Dallas-Fort Worth and Houston exhibit much higher rates, with considerable variability even within their own metro areas (e.g., Denton County in Dallas at 8.8 per 1,000 compared to Dallas city at 4.9). This pattern of high variability and elevated rates is further demonstrated in Chicago (Northwest Indiana at 6.8 vs. Chicago city at 2.7), Boston (Plymouth at 6.7 vs. Boston city at 3.4), and Los Angeles (Torrance at 6.5 vs. LA city at 4.0). Dr. Bricker posits that these dramatic differences are not attributable to greater underlying pathology in certain regions but rather to variations in the surgical practice patterns of orthopedic spine and neurosurgeons. He suggests that surgeons in high-utilization areas are simply more aggressive in recommending and performing surgery. An interesting additional factor discussed is the potential influence of tort reform, noting that states like Indiana and Texas, which have caps on punitive damages, tend to exhibit higher surgical rates, possibly due to a more favorable medical malpractice environment for surgeons. The video culminates by pointing out the highest rates of spine surgery are found in the rural Southeast, averaging around 8 per 1,000, which is a staggering 400% higher than in low-utilization areas like New York or San Francisco. The implications of these findings are particularly relevant for managing employer health plans. Spine surgery is highlighted as a critical area because it is often elective, highly controversial (with estimates suggesting up to 50% of procedures may be unnecessary), and falls under musculoskeletal conditions, which represent one of the top three cost drivers for employer health plans (alongside cancer and cardiovascular issues). Given these factors, Dr. Bricker advocates for the strategic implementation of second opinion programs. He advises that such programs would be most impactful and cost-effective if geographically targeted to areas with high surgical utilization, such as Dallas, Houston, Chicago, Boston, Los Angeles, and the rural South, rather than being uniformly applied across all employee populations, especially in already low-utilization regions like New York City. Key Takeaways: * **Significant Geographic Variation in Healthcare Utilization:** The Dartmouth Atlas of Healthcare reveals up to a 400% difference in spine surgery rates across various regions of the United States, with rural areas in the Southeast showing the highest utilization compared to metropolitan areas like New York and San Francisco. * **Surgeon Practice Patterns as a Primary Driver:** The observed variations in surgical frequency are more likely due to differing practice patterns among surgeons (e.g., some being more aggressive in recommending surgery) rather than a higher prevalence of underlying medical pathology in certain populations. * **Spine Surgery as a Key Cost Driver:** Spine surgery is identified as a major component of musculoskeletal costs, which collectively represent one of the top three diagnostic cost drivers for employer-sponsored health plans, making it a critical area for cost management. * **Elective and Controversial Nature of Spine Surgery:** A significant portion of spine surgeries are elective, not emergent, and are considered highly controversial, with some estimates suggesting that up to 50% may not be medically necessary, underscoring the importance of careful decision-making. * **Relevance of Medicare Data to Commercial Plans:** While the Dartmouth Atlas uses Medicare data, the speaker argues that the observed utilization rates and surgeon practice patterns are likely very similar for commercially insured individuals, making the insights applicable to employer health plans. * **Impact of Tort Reform:** States with tort reform (e.g., caps on punitive damages) may experience higher surgical rates due to a more favorable medical malpractice environment for surgeons, influencing practice patterns. * **Strategic Implementation of Second Opinion Programs:** To effectively manage costs and improve patient outcomes, employer health plans should consider implementing geographically targeted second opinion programs, focusing resources on high-utilization areas where such interventions are most likely to yield significant benefits. * **Data-Driven Decision Making for Benefits Design:** Leveraging healthcare utilization data, like that from the Dartmouth Atlas, allows for more informed and strategic design of employee benefits programs, ensuring interventions are placed where they can have the greatest impact. * **Musculoskeletal Health as a Focus Area:** Given its status as a top cost driver, musculoskeletal health, particularly conditions leading to spine surgery, should be a priority for employers seeking to optimize their healthcare spending and employee well-being. * **Understanding Regional Healthcare Dynamics:** Companies with employees distributed across different geographies can gain valuable insights into regional healthcare dynamics, which can inform not only benefits design but also broader strategies related to employee health and wellness. Tools/Resources Mentioned: * **Dartmouth Atlas of Healthcare:** An online resource that provides data on geographic variation in healthcare services using Medicare data. * **NCBI (National Center for Biotechnology Information):** Referenced as a source for supporting information (specifically, an article on PMC3841934). Key Concepts: * **Geographic Variation:** Significant differences in the frequency or patterns of healthcare services across different regions. * **Utilization Rates:** The frequency at which healthcare services (e.g., surgeries) are used by a population, typically expressed per thousand beneficiaries. * **Employer-Sponsored Health Plans:** Health insurance coverage provided by employers to their employees. * **Second Opinion Programs:** Programs designed to encourage patients to seek an additional medical opinion before undergoing certain procedures, often to ensure necessity and explore alternatives. * **Tort Reform:** Legislative changes aimed at limiting the ability of injured parties to file lawsuits or capping the amount of damages they can receive, often impacting medical malpractice environments. * **Musculoskeletal Costs:** Healthcare expenses related to conditions affecting muscles, bones, joints, ligaments, and tendons, identified as a major cost driver.
Mayo Clinic Documentary Summarized: The Future of Healthcare?
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 22, 2021
This video provides an in-depth exploration of the foundational principles that made the Mayo Clinic a world-renowned medical institution, and how these historical insights remain highly relevant for contemporary employee health plans. Dr. Eric Bricker, from AHealthcareZ, summarizes a PBS documentary on the Mayo Clinic, arguing that its unique operational model offers valuable lessons for improving healthcare quality and patient outcomes today. The central premise is that while direct access to the Mayo Clinic is not feasible for everyone, understanding its core tenets can guide individuals and employers toward selecting high-quality alternatives, particularly academic medical centers, for complex medical needs. The presentation delves into three distinct pillars upon which the Mayo Clinic was built. The first pillar highlights the revolutionary decision by its founder, Dr. W.W. Mayo, to place physicians and surgeons on salary in the late 1800s. This was a radical departure from the prevailing fee-for-service model, specifically designed to eliminate financial bias from medical judgment, ensuring that doctors' incentives were aligned purely with patient well-being rather than the volume of procedures performed. This model also fostered collaboration among physicians, removing competition for patients. The second foundational principle discussed is the Mayo Clinic's pioneering approach to coordinated care, where multiple medical specialties "revolve around the patient." This system was developed as medical specialization emerged, preventing patients from being "ping-ponged" between disconnected specialists. Dr. Bricker illustrates this with a compelling case study of a woman with lupus whose multi-organ involvement led to over a hundred hospital admissions elsewhere, but who received a rapid diagnosis at Mayo due to its integrated, patient-centric approach. The third pillar emphasizes the early and consistent adoption of scientifically proven processes. Historic examples include Mayo's swift implementation of aseptic surgical techniques (handwashing, sterile instruments), which drastically reduced operative infections and established its reputation. Other process innovations included the creation of a centralized medical records department for shared patient information and the strategic placement of the pathology department next to the operating room for immediate tissue analysis, significantly improving cancer surgery outcomes. Dr. Bricker extends this to a modern context with antibiotic stewardship programs, demonstrating how structured protocols continue to enhance patient safety and prevent severe infections like Clostridium difficile colitis. The practical application of these Mayo Clinic principles, according to Dr. Bricker, is particularly pertinent for employee health plans. He suggests that academic medical centers—hospitals affiliated with medical schools and residency programs—often embody these same characteristics: salaried physicians, coordinated multi-specialty care, and a commitment to adopting proven scientific processes. While these centers can sometimes be more expensive, they represent a superior option for specific, challenging medical situations. These include cases of questionable or undiagnosed conditions, complex diagnoses such as metastatic cancer, or complications arising from routine procedures, like bile duct damage during gallbladder surgery. The video concludes by encouraging patients to proactively seek care at such academic medical centers when faced with these demanding medical scenarios, highlighting the importance of informed decision-making in healthcare navigation. Key Takeaways: * **Salaried Physicians Promote Unbiased Care:** The Mayo Clinic's original model of placing physicians on salary, rather than fee-for-service, was designed to remove financial incentives that could bias medical judgment. This foundational principle ensures that treatment decisions are solely based on patient needs, not on maximizing billable procedures. * **Patient-Centered Coordinated Care is Crucial:** Mayo's innovation of having multiple specialists coordinate and "revolve around the patient" addresses the fragmentation common in modern healthcare. This integrated approach is vital for patients with complex, multi-systemic illnesses, preventing the inefficient and often ineffective "ping-ponging" between disconnected specialists. * **Early Adoption of Proven Scientific Processes Drives Outcomes:** The Mayo Clinic's historical success stemmed from its commitment to adopting scientifically validated techniques early, such as aseptic surgery. This proactive embrace of evidence-based innovation significantly improved patient safety and outcomes, setting new standards for medical practice. * **Centralized Medical Records Enhance Data Sharing:** Mayo was a pioneer in developing a centralized medical records department, ensuring all physicians had access to a single, comprehensive patient chart. This innovation in data sharing was critical for coordinated care and stands as a historical precursor to modern integrated electronic health records and data engineering needs. * **Intraoperative Pathology Improves Surgical Precision:** The practice of locating the pathology department next to the operating room for immediate tissue analysis during surgery allowed for real-time decision-making, such as determining tumor margins or malignancy. This process significantly enhanced the effectiveness of cancer surgeries and patient outcomes. * **Antibiotic Stewardship is a Modern Example of Process Innovation:** Dr. Bricker highlights antibiotic stewardship programs as a contemporary example of how structured protocols, managed by infectious disease specialists, can prevent bacterial resistance and severe complications like Clostridium difficile colitis, underscoring the ongoing importance of process optimization in healthcare. * **Academic Medical Centers as "Next Best Alternatives":** For employee health plans, academic medical centers (hospitals associated with medical schools and residency programs) often mirror Mayo's principles: salaried physicians, coordinated care, and early adoption of proven processes. These institutions can offer higher quality care than community hospitals for specific situations. * **Strategic Use of Academic Medical Centers:** It is advisable to seek care at academic medical centers for specific, challenging medical scenarios, including questionable or undiagnosed conditions, complex diagnoses (e.g., metastatic cancer), or complications arising from routine procedures (e.g., damaged bile ducts during gallbladder surgery). * **Cost-Effectiveness Varies for Academic Medical Centers:** While academic medical centers generally offer high quality, their unit costs can be significantly higher. However, some, like UT Southwestern in Dallas-Fort Worth, may offer a balance of quality and cost-effectiveness depending on regional market dynamics. * **Patient Advocacy in Healthcare Navigation:** Patients often need to proactively take charge of their healthcare journey, especially when facing complex or confusing diagnoses, by seeking referrals or directly pursuing care at academic medical centers, rather than solely relying on community physicians. * **The Body's Interconnectedness Demands Integrated Care:** The video reinforces the biological reality that the body's systems are interconnected, making a multi-specialty, coordinated approach essential for effectively treating illnesses that impact various organs simultaneously. Key Concepts: * **Fee-for-Service (FFS):** A payment model where healthcare providers are paid for each service they provide (e.g., office visit, procedure, test). The video contrasts this with salaried physicians. * **Aseptic Technique:** Medical practices and procedures performed to prevent contamination by microorganisms. Historically, Mayo Clinic's early adoption of handwashing and sterile instruments for surgery was a major innovation. * **Antibiotic Stewardship:** Programs designed to promote the appropriate use of antibiotics, improve patient outcomes, reduce microbial resistance, and decrease the spread of infections caused by multi-drug-resistant organisms. * **Clostridium difficile (C. diff) Colitis:** A severe infection of the colon caused by the bacterium Clostridium difficile, often occurring after antibiotic use, leading to severe diarrhea and potentially life-threatening complications. * **Academic Medical Center (AMC):** A hospital or health system that is affiliated with a medical school and often involved in medical education, research, and advanced patient care. Examples/Case Studies: * **Lupus Patient with Multi-Organ Involvement:** A woman with lupus experienced over 100 hospital admissions in 3-4 years due to the disease affecting her heart, lungs, kidneys, and brain. At Mayo, a rheumatologist diagnosed her within 20 minutes because all specialists revolved around her, demonstrating the power of coordinated care for complex, systemic diseases. * **Early Aseptic Surgery Success:** In the early 1800s, Mayo Clinic's adoption of aseptic technique (handwashing, sterile instruments) resulted in only 2 deaths out of 400 initial surgeries, an astonishingly low mortality rate for the time, which quickly established its reputation. * **Antibiotic Stewardship at Johns Hopkins vs. Community Hospital:** Dr. Bricker contrasts his residency experience at Johns Hopkins (with an antibiotic stewardship program, seeing 3 C. diff cases in 3 years) with working at a community hospital (without such a program, seeing 1 C. diff case almost weekly), illustrating the direct impact of process innovation on patient safety. * **Bile Duct Damage during Laparoscopic Cholecystectomy:** A common complication of gallbladder surgery (laparoscopic cholecystectomy) is damage to the bile ducts. This complex issue often requires referral to an academic medical center for specialized repair, highlighting when AMCs are critical for complications.
'America's Bitter Pill' by Steven Brill... Contemporary History of Healthcare in America
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 20, 2021
This video provides an in-depth exploration of the book "America's Bitter Pill" by Steven Brill, offering a contemporary history of healthcare in America with a specific focus on the creation and implications of the Affordable Care Act (ACA), or Obamacare. Dr. Eric Bricker, the speaker, positions the book as essential reading for anyone in healthcare finance, highlighting Brill's extensive access to key political figures, industry leaders, and administration officials during the ACA's development. The presentation delves into the complex political and economic forces that shaped the legislation, revealing insights that challenge common perceptions about healthcare reform and its outcomes. The core themes explored include the pervasive influence of corporate lobbyists on both Democratic and Republican politicians, the often-unseen power players behind major policy decisions, and the internal ideological schisms within the Obama administration regarding healthcare reform. Dr. Bricker emphasizes Brill's findings that the "coverage team" ultimately triumphed over the "cost reduction team," leading to an ACA designed more for expanding access to the existing high-cost system rather than fundamentally lowering costs. The video also highlights the surprising lack of cooperation and trust between the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS), despite CMS being a division of HHS, which has significant implications for future federal reform efforts. A central argument presented is that federal action to significantly lower healthcare costs is highly improbable because high healthcare costs directly translate into jobs, which politicians are unwilling to jeopardize. This perspective frames the American healthcare system as, in essence, a massive jobs program. Dr. Bricker concludes by discussing Brill's proposed solutions, which include hospitals selling their own insurance to eliminate the current health insurance industry middlemen, and implementing price controls for the pharmaceutical and medical device industries, drawing parallels to the "perverse incentives" of the fee-for-service model. Key Takeaways: * **Pervasive Corporate Lobbying:** Contrary to popular belief, corporate lobbyists exert significant influence over both Democratic and Republican politicians in Washington D.C., particularly evident during the crafting of Obamacare where medical device companies like Medtronic and Zimmer Biomet influenced policy decisions to avoid certain taxes. This underscores the deep entanglement of industry interests with legislative processes. * **Hidden Power Brokers in Policy:** The individuals publicly perceived as driving major healthcare reform (e.g., Kathleen Sebelius, head of HHS) were often not the true power players. Key decisions were frequently made by less-known figures within the administration and Senate, such as Nancy-Ann DeParle, Gene Lambrew, and Liz Fowler, indicating that public narratives may not reflect the actual dynamics of policymaking. * **Internal Administrative Divisions:** The Obama administration itself was deeply divided between a "cost team" (including Peter Orszag, Larry Summers, Ezekiel Emanuel, Bob Kocher) focused on reducing healthcare costs and a "coverage team" (Nancy-Ann DeParle, Gene Lambrew, Liz Fowler) prioritizing expanded access. The coverage team ultimately prevailed, leading to an ACA that expanded access without fundamentally addressing the underlying cost structure. * **ACA's Intentional Design for Coverage, Not Cost Control:** The legislation, according to Brill, was not a failure in controlling costs due to poor implementation, but rather was designed through a series of political deals with pharmaceutical, medical device, and health insurance industries that inherently prevented significant cost reduction. This suggests that the rising healthcare costs post-ACA were an anticipated outcome. * **Healthcare as a "Jobs Program":** A critical insight is that federal efforts to lower healthcare costs are highly unlikely because high costs equate to income for a substantial portion of the U.S. economy (20%), thereby creating jobs. Politicians are disincentivized to support measures that would reduce jobs and potentially lead to their removal from office, aligning political self-interest with maintaining high healthcare spending. * **Inter-Agency Distrust and Dysfunction:** There is significant distrust and lack of cooperation between the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS), even though CMS is a department within HHS. This internal friction, exemplified by CMS withholding information about the botched ACA website from HHS, poses a major impediment to any future federal healthcare reform efforts. * **Ineffectiveness of Certain Cost-Control Mechanisms:** Initiatives like Accountable Care Organizations (ACOs), often touted as cost-control measures, were never truly intended to lower costs within the ACA framework. They were designed to "sound good" and "look like" they were controlling costs, but were undermined by the political deals made to expand coverage. * **Brill's Proposed Solutions:** Steven Brill suggests two radical solutions: A) Hospitals should sell their own insurance, effectively eliminating the health insurance industry as a middleman, and B) Price controls should be imposed on the pharmaceutical and medical device industries, especially given the monopoly power granted by patent protections. * **Perverse Incentives of Fee-for-Service:** The video implicitly and explicitly critiques the fee-for-service model and the role of various "middlemen" (like the health insurance industry) for creating perverse incentives that drive up costs without necessarily improving care. * **High Recommendation for Industry Professionals:** Dr. Bricker strongly recommends "America's Bitter Pill" for anyone working in healthcare finance, emphasizing its ability to provide a foundational understanding of the complex forces at play in the American healthcare system. Tools/Resources Mentioned: * **Book:** "America's Bitter Pill" by Steven Brill * **Book:** "16 Lessons in the Business of Healing" by Dr. Eric Bricker * **Website:** AHealthcareZ.com Key Concepts: * **Obamacare (ACA):** The Affordable Care Act, a comprehensive healthcare reform law enacted in the United States in 2010. * **Fee-for-Service:** A payment model where services are unbundled and paid for separately. This gives providers an incentive to provide more treatments because payment is dependent on the quantity of care, not the quality. * **Lobbying:** The act of attempting to influence decisions made by officials in a government, most often legislators or members of regulatory agencies. * **Medical Device Tax:** A tax on the sale of medical devices, which was part of the ACA but faced significant industry opposition. * **Accountable Care Organizations (ACOs):** Groups of doctors, hospitals, and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. * **Price Controls:** Government-mandated maximum or minimum prices that can be charged for specific goods or services, discussed in the context of pharmaceutical and medical device industries. Examples/Case Studies: * **Corporate Influence:** Medtronic (Minnesota-based medical device company) and Zimmer Biomet (Indiana-based medical device company) were cited as examples of companies that successfully lobbied against the medical device tax through their respective Democratic senators and congressmen. * **Healthcare Institutions:** Cleveland Clinic, Columbia Presbyterian, New York Presbyterian Hospital, Geisinger, UPMC were mentioned as examples of hospitals whose presidents were interviewed by Steven Brill. * **Insurance Industry:** The CEO of United Healthcare was interviewed by Steven Brill, and the company was later cited as potentially executing Brill's strategy by acquiring doctors and facilities. * **Key Figures in Obama Administration/Senate:** * **Nancy-Ann DeParle, Gene Lambrew, Liz Fowler:** Identified as the true power players in crafting Obamacare. * **Peter Orszag, Larry Summers, Ezekiel Emanuel, Bob Kocher:** Members of the "cost team" within the Obama administration who ultimately lost the internal debate over cost control. * **Senator Max Baucus:** Spearheaded health reform in the Senate. * **Kathleen Sebelius:** Head of HHS, but had limited influence on Obamacare's creation.
Formulary for Prescription Medication Explained
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 16, 2021
This video provides an in-depth exploration of medication formularies, a fundamental concept in healthcare finance that dictates which prescription drugs are covered by health insurance plans. Dr. Eric Bricker, the speaker, aims to demystify this complex topic for healthcare professionals and consumers alike, highlighting its critical impact on patient access to medications and the financial aspects of healthcare. The discussion begins by defining a formulary as a list of covered medications and immediately emphasizes that not all medications are included, setting the stage for understanding the intricacies of drug coverage. The presentation then delves into the role of Pharmacy Benefits Managers (PBMs), explaining them as separate entities or departments within insurance companies responsible for determining pharmacy benefits and, consequently, the formulary. A crucial distinction is made regarding who possesses formulary information: doctors typically do not know individual patient formularies due to their vast patient base, while pharmacies have real-time access through their computer software. The video also identifies common categories of medications often excluded from formularies, such as over-the-counter (OTC) drugs (e.g., Tylenol, lower-dose ibuprofen), cosmetic treatments (e.g., wrinkle creams), and certain lifestyle medications (e.g., for erectile dysfunction), though coverage for the latter can vary. Further complexity is introduced through the concept of formulary tiers, particularly within a PPO plan structure, which is common in the U.S. Dr. Bricker outlines a typical four-tier system: Tier 1 for generics with the lowest copay (e.g., $5), Tier 2 for preferred brand-name medications with a medium copay (e.g., $25), Tier 3 for non-preferred brand medications with a higher copay (e.g., $50), and Tier 4 for specialty medications, which often involve coinsurance (e.g., 20% of the total cost) rather than a fixed copay, citing Humira for rheumatoid arthritis as an example. The video concludes by detailing specific rules associated with formularies, which vary by employer and PBM. These include Prior Authorization (requiring insurer approval for expensive medications), Step Therapy (mandating trials of less expensive generics before brand-name alternatives, like gabapentin before Lyrica), Mandatory Generics (only covering the generic version even if a brand is prescribed, such as atorvastatin over Lipitor), and Mandatory Mail Order (requiring chronic medications to be filled through the PBM's mail-order program for cost savings). Key Takeaways: * **Formulary Definition and Importance:** A medication formulary is the definitive list of drugs covered by a health insurance plan, and understanding it is crucial because not all prescribed medications are covered, directly impacting patient access and out-of-pocket costs. * **Role of Pharmacy Benefits Managers (PBMs):** PBMs are central to the pharmaceutical ecosystem, acting as the decision-makers for pharmacy benefits and formulary design, often as distinct entities from the health insurance carrier itself. * **Information Access Disparity:** While doctors typically lack specific knowledge of individual patient formularies, pharmacies possess real-time access to this information via their computer systems, making them the primary point of contact for formulary inquiries. * **Common Formulary Exclusions:** Formularies frequently exclude over-the-counter medications (e.g., Tylenol, 200mg ibuprofen), cosmetic treatments (e.g., wrinkle creams), and certain lifestyle drugs, though the latter can have variable coverage. * **Formulary Tiers and Cost Implications:** Many plans, particularly PPOs, utilize a tiered formulary structure (e.g., Tier 1 for generics, Tier 2 for preferred brands, Tier 3 for non-preferred brands, Tier 4 for specialty drugs), with each tier corresponding to different patient cost-sharing levels (copays or coinsurance). * **Prior Authorization (PA):** This rule requires healthcare providers to obtain explicit approval from the PBM or insurance company before certain medications, typically more expensive ones, will be covered, necessitating additional documentation and justification. * **Step Therapy:** Patients are often required to try and fail on a less expensive, often generic, medication first before the plan will cover a more expensive brand-name alternative, exemplified by trying gabapentin before Lyrica for neuropathic pain. * **Mandatory Generics:** If a brand-name medication has a direct generic equivalent, the formulary may only cover the generic version, even if the doctor prescribes the brand and indicates "do not substitute," as seen with atorvastatin for Lipitor. * **Mandatory Mail Order:** For chronic medications taken over extended periods, some PBMs mandate that prescriptions be filled through their mail-order program, which aims to reduce costs by cutting out the retail pharmacy middleman and often provides a cost break to the patient. * **Dynamic and Personalized Rules:** Formulary rules, including tiers and restrictions, are not universal; they are specific to each employer and PBM, requiring individuals to verify their particular plan details through HR or the PBM directly. * **Impact on Pharmaceutical Commercial Operations:** Understanding formularies and their associated rules is critical for pharmaceutical companies in developing market access strategies, patient support programs, and commercial operations, as these rules directly influence drug uptake and patient adherence. Key Concepts: * **Formulary:** A list of prescription drugs covered by a health insurance plan. * **Pharmacy Benefits Manager (PBM):** A third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. * **Prior Authorization (PA):** A process requiring a healthcare provider to obtain approval from a health insurance plan before a prescribed medication is covered. * **Step Therapy:** A type of prior authorization that requires a patient to try a less expensive medication first before progressing to a more costly alternative. * **Mandatory Generics:** A formulary rule stating that only the generic version of a drug will be covered, even if a brand-name equivalent is prescribed. * **Mandatory Mail Order:** A requirement by some PBMs for certain chronic medications to be filled and delivered through their mail-order pharmacy service. * **PPO Plan:** Preferred Provider Organization, a common type of health insurance plan. * **Formulary Tiers:** Categories of medications within a formulary, each associated with different cost-sharing levels (copays or coinsurance) for the patient. * **Copay:** A fixed amount a patient pays for a covered healthcare service or prescription drug. * **Coinsurance:** A percentage of the cost of a covered healthcare service or prescription drug that a patient pays after their deductible has been met. Examples/Case Studies: * **Over-the-Counter (OTC) Medications:** Tylenol, 200mg Ibuprofen (generic for Advil/Motrin) as examples of drugs typically not covered. * **Higher-Dose OTC Medications:** 600mg and 800mg Ibuprofen as examples of higher-dose versions that might be covered. * **Specialty Medications:** Humira for rheumatoid arthritis, often falling into Tier 4 with coinsurance. * **Step Therapy Example:** Requiring gabapentin (generic) to be tried before Lyrica (brand) for neuropathic pain. * **Mandatory Generic Example:** Atorvastatin (generic) being covered instead of Lipitor (brand) for high cholesterol.
Healthcare Software as Monday Morning Quarterback
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 15, 2021
This video provides an in-depth exploration of the role and misplacement of healthcare software within the prior authorization process, using AIM Specialty Health as a primary case study. Dr. Eric Bricker, the speaker, begins by introducing AIM Specialty Health as a major subsidiary of Anthem, responsible for a vast number of prior authorizations across the United States. While acknowledging the impressive technological infrastructure and operational scale of AIM, Bricker critically argues that the sophisticated software employed by such prior authorization entities is fundamentally "misplaced" and operates as a "Monday morning quarterback," questioning physician judgment after the fact rather than supporting decision-making at the point of care. The presentation details the extensive scope of AIM's operations, highlighting its involvement in prior authorizations for a wide array of medical services. These include advanced imaging (CT scans, MRIs), cardiology procedures (stress tests), sleep studies, radiation oncology (for various cancers like prostate, breast, lung, brain), medical oncology (chemotherapy for leukemia, lymphoma, solid tumors), specialty drugs (e.g., Remicade infusions), genetic testing, and orthopedic procedures (e.g., knee replacements). AIM conducts 10 million reviews annually and facilitates 1,500 doctor-to-doctor peer reviews daily, impacting 50 million lives and serving 40% of Fortune 50 companies. The sheer volume underscores the critical, albeit controversial, role these organizations play in healthcare access and cost control. Dr. Bricker references a conference video by Phil Merrell, the CIO of AIM Specialty Health, praising AIM's technological prowess. Merrell reportedly detailed AIM's advanced software integrations across various Blue Cross health plans, its utilization of both public and private cloud infrastructure, robust security measures for sensitive health data, and sophisticated application development capabilities. Bricker acknowledges Merrell's work as potentially "one of the best jobs in the entire industry" regarding healthcare technology implementation. However, this commendation serves as a setup for Bricker's central thesis: despite its technical excellence, the software's application is flawed because it's positioned externally to second-guess medical decisions. The core of Bricker's argument revolves around the concept of "Monday morning quarterbacking," where prior authorization software retroactively judges medical necessity. He points out that the 391,500 annual peer-to-peer conversations (representing 4% of all reviews) are not dialogues of agreement but rather contentious discussions where physicians must justify their treatment plans to an external entity. Bricker contends that all this technological effort and software development should instead be integrated directly into the electronic medical record (EMR) systems within hospitals and doctor's offices. Such an integration would transform the software into a real-time "decision-support tool," empowering physicians with immediate guidance and evidence-based recommendations, thereby optimizing care upfront rather than creating administrative hurdles and delays through post-hoc denials. He concludes by urging healthcare software developers to focus their skills on creating impactful, point-of-care solutions rather than "titanic deck chair straightening software" that addresses symptoms of systemic inefficiency. Key Takeaways: * **Massive Scale of Prior Authorization:** AIM Specialty Health, as a single entity, performs 10 million prior authorization reviews annually and handles 1,500 doctor-to-doctor peer reviews daily, affecting 50 million Americans and serving a significant portion of large corporations. This highlights the immense administrative burden and gatekeeping function of prior authorization in the U.S. healthcare system. * **Broad Scope of Services Covered:** Prior authorization extends across a wide range of high-cost and complex medical services, including advanced imaging, cardiology, radiation and medical oncology, specialty drugs, genetic testing, and orthopedics. This indicates that a substantial portion of critical medical care is subject to external review. * **Advanced Software Capabilities:** Prior authorization vendors like AIM utilize highly sophisticated software, featuring extensive integrations, public and private cloud infrastructure, robust security, and advanced application development. This demonstrates that significant technological investment is already present in these processes. * **Misplaced Technology and Incentives:** The speaker argues that despite its technical sophistication, this software is "misplaced" because it operates externally to "Monday morning quarterback" physician decisions. The current system creates misaligned incentives, focusing on denials and appeals rather than proactive, evidence-based decision support at the point of care. * **Inefficiency of Peer-to-Peer Reviews:** A substantial number of reviews (4% or nearly 400,000 annually for AIM) escalate to peer-to-peer conversations, which are inherently adversarial. This represents a significant drain on physician time and resources, indicating a breakdown in initial decision-making or communication. * **Vision for Integrated Decision Support:** The core recommendation is that prior authorization software should be integrated directly into hospital and doctor's office Electronic Medical Records (EMRs) as a real-time "decision-support tool." This would enable physicians to make informed decisions upfront, aligning technology with patient care rather than administrative oversight. * **Impact on Healthcare Professionals:** The video implies that the current system adds unnecessary stress and administrative burden on practicing physicians, who are forced to justify their clinical judgment to external entities. * **Call to Action for Software Developers:** Healthcare software developers are encouraged to redirect their talents towards creating solutions that genuinely improve patient care and optimize clinical workflows at the point of service, rather than building systems that perpetuate inefficiencies or act as external gatekeepers. * **Focus on Upstream Optimization:** The underlying message is that healthcare efficiency and quality would be significantly improved by shifting technological interventions upstream, providing tools that prevent inappropriate care or support optimal decisions from the outset, rather than reviewing them after the fact. Tools/Resources Mentioned: * AIM Specialty Health's proprietary software * Public cloud infrastructure * Private cloud infrastructure * Electronic Medical Records (EMRs) Key Concepts: * **Prior Authorization:** A process required by some health insurance companies for certain medical services, procedures, or medications to determine if they are medically necessary before they are performed or prescribed. * **Monday Morning Quarterback:** A metaphor used to describe someone who criticizes or second-guesses decisions after the event, when the outcome is already known, rather than offering support or guidance during the decision-making process. * **Decision-Support Tool:** Software or systems designed to assist healthcare professionals in making clinical decisions by providing relevant information, alerts, and recommendations based on patient data and medical knowledge. * **Peer-to-Peer Review:** A process within prior authorization where a physician from the insurance company or prior authorization vendor discusses a case with the treating physician to review the medical necessity of a requested service.
Population Health for High-Cost Claimants
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 14, 2021
This video provides an in-depth exploration of high-cost claimants within population health, challenging the common understanding of the "5/50 rule" in healthcare spending. Dr. Eric Bricker begins by establishing the familiar statistic that approximately 5% of individuals on a health plan account for 50% of the total healthcare expenditure, typically those with claims exceeding $100,000 annually. However, he immediately emphasizes that this 5% is a highly heterogeneous population, not a monolithic group, and understanding these differences is crucial for effective intervention. The presentation then delves into a critical distinction: roughly half of these high-cost claimants (2.5% of the total population) are "carryovers" from the previous year, meaning they had existing conditions or significant claims that continued into the new year. The other half (another 2.5% of the total population) are "brand spanking new," appearing as high-cost claimants "out of nowhere." This latter group alone accounts for 25% of the overall healthcare spend, a figure comparable to an organization's entire pharmacy spend, highlighting a significant, often overlooked, area for cost management. Dr. Bricker introduces a 2x2 matrix to further categorize these high-cost claimants based on two dimensions: whether their underlying disease was "known" or "unknown" prior to the high-cost event, and whether their high costs are "prolonged" (lasting more than a year) or "episodic" (lasting less than a year). He provides specific clinical examples for each of the four categories. For instance, "known prolonged" includes type 2 diabetics progressing to end-stage renal disease or individuals with metastatic cancer. "Unknown prolonged" might involve undiagnosed type 2 diabetics suffering a debilitating stroke or a healthy pregnant woman having a very premature delivery with lifelong consequences for the child. The core message revolves around identifying and strategically targeting the "unknown" categories, as these individuals lack established relationships with the healthcare system, presenting a unique opportunity for proactive intervention. Key Takeaways: * **The 5/50 Rule is Deceptive:** While 5% of claimants drive 50% of healthcare costs, this group is not homogenous. Effective population health strategies require a deeper understanding of the distinct subgroups within these high-cost claimants. * **Two-Halves of High-Cost Claimants:** Approximately half of high-cost claimants are "carryovers" from the previous year with ongoing conditions, while the other half are "new" claimants who develop high costs unexpectedly. * **Significant Opportunity in "New" Claimants:** The "new" high-cost claimants, representing 2.5% of the total population, account for 25% of overall healthcare spend. This financial impact is equivalent to an organization's entire pharmacy spend, suggesting it warrants comparable attention and resources. * **The Known/Unknown and Prolonged/Episodic Matrix:** High-cost claimants can be categorized into four types: Known & Prolonged, Known & Episodic, Unknown & Prolonged, and Unknown & Episodic. This framework helps in understanding the nature of their conditions and potential for intervention. * **Examples of Known & Prolonged Costs:** These include conditions like type 2 diabetes progressing to end-stage renal disease requiring dialysis, multiple sclerosis patients on high-cost medications, or individuals dealing with metastatic cancer. These are typically ongoing and predictable. * **Examples of Known & Episodic Costs:** This category includes individuals with pre-existing conditions who experience acute, short-term high-cost events, such as a type 2 diabetic having a small heart attack requiring a brief hospitalization and stents, or an MS patient experiencing a flare that doesn't necessitate long-term high-cost medication. * **Examples of Unknown & Prolonged Costs:** This group includes individuals whose first major health event reveals an underlying, previously undiagnosed condition leading to long-term high costs, such as an unknown type 2 diabetic suffering a stroke with prolonged rehabilitation, or a healthy individual experiencing severe trauma or a very premature birth with lifelong consequences. * **Examples of Unknown & Episodic Costs:** This category involves individuals with no prior known disease who experience an acute, high-cost event that resolves without prolonged sequelae, such as an undiagnosed type 2 diabetic having a small heart attack with a good outcome, a successful joint replacement surgery, or a sports injury. * **Intervention Challenges for "Known" Claimants:** Individuals in the "known" categories (both prolonged and episodic) typically have established relationships with healthcare providers and the system. This makes it difficult for external population health programs (e.g., nurse counselors, telephonic programs) to intervene effectively or unseat existing relationships. * **Prime Opportunity for "Unknown" Claimants:** The "unknown" categories (both prolonged and episodic), which collectively represent 50% of the high-cost 5% (or 25% of total spend), offer a significant opportunity for intervention. These individuals lack prior established relationships, making them more receptive to targeted programs and support. * **Strategic Resource Allocation:** Organizations should consider allocating as much time, attention, and resources to identifying and intervening with these "new" or "unknown" high-cost claimants as they do to managing their pharmacy spend, given the comparable financial impact. Key Concepts: * **5/50 Rule:** The observation that 5% of a population (e.g., health plan claimants) accounts for 50% of the total healthcare expenditure. * **High-Cost Claimants:** Individuals whose healthcare claims exceed a certain threshold (e.g., $100,000) within a specific period, significantly contributing to overall healthcare costs. * **Population Health:** An approach to health that aims to improve the health outcomes of a group of individuals, including the distribution of such outcomes within the group, often by addressing determinants of health and managing healthcare costs. * **Known vs. Unknown Disease:** Refers to whether a patient's underlying medical condition was previously diagnosed and managed by the healthcare system before they became a high-cost claimant. * **Prolonged vs. Episodic Costs:** Describes the duration of high healthcare expenditures, with "prolonged" indicating costs lasting for more than a year and "episodic" indicating costs lasting for less than a year.
Inspectable Mid-Term TMF Storage for Closed or Locked Studies - PhlexTMF for Viewing
Phlexglobal - a Cencora PharmaLex company
/@Phlexglobal
Jun 14, 2021
This video provides an in-depth exploration of the "TMF compliance gap," a critical challenge faced by pharmaceutical sponsors in managing their Trial Master Files (TMFs) after a clinical study has concluded. The presentation begins by establishing the context of TMF management during a live study, where the Electronic Trial Master File (eTMF) is typically secure and inspectable within the Contract Research Organization's (CRO) system. However, the core problem arises post-study closeout when the CRO returns the TMF to the sponsor for the reporting, assessment, and submission phase. This period, which can last several years until the TMF is ready for long-term archiving, carries a high likelihood of regulatory inspection, creating a significant compliance vulnerability. The video delves into the shortcomings of current practices that cause this compliance gap. It highlights that most eTMF systems are not designed or priced for the extended, inspectable storage required for closed studies, and CROs are generally unwilling to maintain these closed eTMFs themselves. Consequently, CROs often provide the eTMF in portable, non-secure electronic formats like DVDs or USB drives, cloud-based file folders, or even as printed paper documents. These formats are presented as inherently problematic because they are not easily inspectable or viewable, are prone to loss or misplacement, and lack the necessary security for sensitive clinical trial data. The speaker emphasizes the practical difficulties an inspector would face attempting to review such disorganized files, often leading to delays or requests for additional information, thereby increasing the risk of inspection findings and wasting invaluable time for the study team. To bridge this critical TMF compliance gap, the video introduces PhlexTMF for Viewing from Phlexglobal as an innovative and affordable solution. This system is designed to offer the intuitive navigation and easy access characteristic of an advanced eTMF, but within a secure and compliant framework specifically built for long-term storage and inspectability. The solution allows sponsors to seamlessly transition a final eTMF received from a CRO into a system that supports internal use and ongoing inspections. Furthermore, it facilitates the quick and easy addition of related clinical documents, a task often difficult or impossible with traditional methods. The overarching message is that PhlexTMF for Viewing ensures continuous inspection readiness and a simple transition to long-term archiving when the inspection risk eventually diminishes. Key Takeaways: * **The TMF Compliance Gap:** A significant challenge exists in managing Trial Master Files (TMFs) after a clinical study closes, particularly during the multi-year reporting, assessment, and submission phase when inspection risk remains high. * **CRO Handoff Issues:** Contract Research Organizations (CROs) frequently return eTMFs (electronic Trial Master Files) in non-compliant, unsecure, and difficult-to-inspect formats such as DVDs, USB drives, generic cloud folders, or even physical paper. * **Inadequate Long-Term Storage:** Most standard eTMF systems are not designed or priced to provide the long-term, inspectable storage necessary for closed studies, leading to a gap in compliance and data integrity. * **High Inspection Risk:** The period immediately following study closeout, prior to official archiving, is characterized by a high likelihood of regulatory inspections, making the TMF compliance gap a critical vulnerability for sponsors. * **Consequences of Non-Compliance:** Using non-inspectable or disorganized TMF formats can lead to significant delays during regulatory inspections, requests for additional information, and an increased risk of inspection findings, resulting in lost time and potential penalties. * **Need for Specialized Solutions:** There is a clear need for dedicated, secure, and compliant systems specifically designed for the long-term storage and inspectability of closed study TMFs. * **PhlexTMF for Viewing Solution:** PhlexTMF for Viewing is presented as an innovative and affordable solution that provides intuitive navigation and easy access to eTMFs in a secure and compliant system tailored for long-term use and inspection readiness. * **Seamless Transition and Archiving:** The solution enables a simple transition of the final eTMF from the CRO into a system that supports ongoing internal use and inspections, with a straightforward path to long-term archiving when appropriate. * **Enhanced Document Management:** PhlexTMF for Viewing allows for the quick and easy addition of related clinical documents, which is often a complex or impossible task with conventional post-closeout TMF management methods. * **Ensuring Ongoing Inspection Readiness:** The primary benefit of such a solution is to ensure that sponsors maintain continuous inspection readiness throughout the entire TMF lifecycle, even for closed studies, thereby mitigating regulatory risks. * **Regulatory Basis:** The problem and solution are framed within the context of regulatory requirements, with a specific mention of an MHRA presentation from 2018 by Andy Fisher, underscoring the regulatory imperative for robust TMF management. Tools/Resources Mentioned: * **PhlexTMF for Viewing:** The primary software solution discussed for bridging the TMF compliance gap. * **MHRA presentation (from 2018 by Andy Fisher):** Referenced as inspiration for the graphic depicting the compliance gap, highlighting the regulatory body's awareness of this issue. Key Concepts: * **TMF Compliance Gap:** The period after a clinical study closes where the Trial Master File (TMF) is no longer actively managed by the CRO in an inspectable eTMF system but is not yet ready for long-term archiving, leaving it vulnerable to inspection findings due to inadequate storage and accessibility. * **eTMF (Electronic Trial Master File):** A digital system used to manage and store essential documents and records for a clinical trial, ensuring compliance with regulatory requirements. * **Inspection Readiness:** The state of being prepared to present all required documentation and data to regulatory authorities (e.g., FDA, EMA, MHRA) during an audit or inspection without delays or deficiencies. * **Study Closeout:** The formal process of concluding a clinical trial, which includes final data collection, database lock, reporting, and the transfer of study documents, including the TMF. * **Long-Term Archiving:** The process of securely storing essential clinical trial documents and data for an extended period, often many years, as mandated by regulatory requirements, after a study has been fully completed and closed.
Income and Substitution Effects in Healthcare: If You Pay Doctors More, Will They Work More or Less?
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 13, 2021
This video provides an in-depth exploration of the economic concepts of the income and substitution effects, specifically as they apply to healthcare finance and the work-leisure decisions of medical professionals. Dr. Eric Bricker, the speaker, establishes the critical importance of these seemingly abstract economic principles for anyone working within the healthcare industry, particularly in finance. The core dilemma addressed is how changes in a person's pay influence the amount of time they dedicate to working for income versus engaging in leisure activities. The presentation meticulously breaks down the two opposing economic forces. The **Income Effect** suggests that if an individual's pay increases, they may choose to work fewer hours to maintain their desired income level, thereby increasing their leisure time. Conversely, if pay decreases, they might work more hours to compensate for the lost income and sustain their lifestyle. In contrast, the **Substitution Effect** posits that an increase in pay raises the opportunity cost of leisure (the income forgone by not working), making work relatively more attractive and leading individuals to work more. Conversely, a decrease in pay lowers the opportunity cost of leisure, potentially encouraging less work and more leisure. Dr. Bricker effectively illustrates these concepts with two compelling real-world examples from the healthcare sector. For the Income Effect, he recounts a situation where Medicare reduced its reimbursement for echocardiograms, directly impacting cardiologists' pay per service. In response, a cardiology group significantly increased their patient volume by 20% (from 20 to 24 patients per day) to maintain their overall income. This example powerfully demonstrates how intended cost savings through pay cuts can be nullified by providers increasing service volume. For the Substitution Effect, he describes a radiology group offering a substantially lower annual salary (e.g., $200,000 compared to a typical $600,000) but compensating with a highly attractive 16 weeks of vacation time. In this scenario, radiologists opted for the lower-paying job with more leisure, showcasing how a reduced opportunity cost of leisure (due to lower pay) can lead individuals to prioritize non-work time. The video concludes by emphasizing that the dominance of either the income or substitution effect is not universal but depends on individual preferences and specific market dynamics. Dr. Bricker underscores that decisions involving changes in pay or costs within healthcare are complex and do not always lead to predictable outcomes. Understanding these economic drivers is crucial for forecasting how healthcare providers will react to financial incentives or disincentives, which in turn profoundly impacts healthcare costs, the volume of services delivered, and overall system efficiency. The overarching message is that simplistic assumptions about cost reduction through provider pay cuts can be undermined by behavioral responses dictated by these fundamental economic principles. Key Takeaways: * **Dual Economic Forces in Healthcare:** Healthcare worker pay changes trigger both the Income Effect and the Substitution Effect, which influence the balance between work and leisure. Understanding which effect dominates is crucial for predicting provider behavior. * **Income Effect and Service Volume:** When pay per service decreases (e.g., Medicare reimbursement cuts), healthcare providers may increase their service volume to maintain their overall income, potentially nullifying intended cost savings. * **Substitution Effect and Leisure Prioritization:** When pay decreases, the opportunity cost of leisure also decreases, making leisure more attractive. This can lead providers to prioritize non-work time, even if it means accepting lower overall income, as seen with the radiology group offering extensive vacation. * **Real-World Impact on Cost Savings:** Decreasing doctor pay per service in a fee-for-service model does not guarantee cost savings. Providers may simply increase the number of services rendered to maintain their income, shifting the cost burden rather than reducing it. * **Unpredictable Outcomes of Payment Changes:** The response of healthcare providers to changes in pay is not uniform. It depends on whether the Income Effect (maintaining income by working more or less) or the Substitution Effect (trading work for leisure based on opportunity cost) dominates for a given individual or group. * **Importance of Opportunity Cost:** The concept of opportunity cost is central to the Substitution Effect. As pay increases, the cost of choosing leisure over work rises, incentivizing more work. Conversely, lower pay makes leisure less "expensive." * **Strategic Insights for Healthcare Stakeholders:** Professionals in healthcare finance, including those in pharmaceutical and medical device companies, must grasp these economic principles to accurately forecast the impact of payment adjustments on service delivery, market dynamics, and overall healthcare expenditures. * **Informing Commercial and Market Access Strategies:** For companies developing new drugs or medical devices, understanding how their products might influence reimbursement models and, consequently, provider behavior (via income/substitution effects) is vital for effective commercialization and market access strategies. * **Beyond Simplistic Policy Making:** Policy makers and industry leaders should avoid simplistic assumptions that reducing provider pay will automatically lead to cost reductions or decreased service utilization. Behavioral responses can lead to unintended and counterproductive outcomes. * **Individual Preferences Matter:** The dominance of either economic effect can vary based on individual preferences. Some providers may be more driven by income targets, while others prioritize leisure time, leading to diverse responses to similar financial incentives. Key Concepts: * **Income Effect:** The tendency for individuals to adjust their work hours to maintain a desired income level when their hourly or per-service pay changes. * **Substitution Effect:** The tendency for individuals to substitute work for leisure (or vice versa) based on the changing opportunity cost of leisure when pay rates fluctuate. * **Opportunity Cost:** The value of the next best alternative that must be forgone when making a choice. In this context, the income lost by choosing leisure over work. * **Fee-for-Service Reimbursement:** A payment model where healthcare providers are paid for each specific service they provide. Examples/Case Studies: * **Medicare Reimbursement for Echocardiograms:** Medicare's reduction in payment for echocardiograms led a cardiology group to increase their patient volume by 20% to maintain their income, demonstrating the Income Effect. * **Radiology Group with Vacation Incentive:** A radiology group offered significantly lower pay but included 16 weeks of vacation, attracting radiologists who prioritized leisure over maximum income, illustrating the Substitution Effect.
Implementing an eISF
MANA Risk Based Monitoring
/@Manarbm
Jun 10, 2021
This video explores the critical role and advantages of implementing an Electronic Investigator Site File (eISF) in modern clinical trials. Featuring Clinical Trials Expert Everett Lambeth, the discussion highlights how a cloud-based eISF system replaces cumbersome manual binders, offering a centralized electronic repository for all study documentation, including regulatory, subject source, and reference documents. The conversation emphasizes the eISF's utility in facilitating remote and decentralized trials, particularly in the context of increased flexibility necessitated by events like the COVID-19 pandemic. Key benefits such as significant time savings, enhanced remote real-time oversight for monitors, streamlined archiving, and improved inspection readiness are thoroughly discussed. The video also delves into essential eISF features, including integration with Learning Management Systems (LMS), customizable metadata for efficient document search and reporting, and robust mechanisms for protecting Protected Health Information (PHI) through role-based access and secure archiving. A significant portion is dedicated to the importance of 21 CFR Part 11 compliance, specifically regarding certified electronic copies and electronic signatures, which ensure document integrity and provide crucial audit trails. Ultimately, the eISF is presented as an indispensable tool for risk-based quality management, enabling proactive tracking of missing documents and real-time review of subject source data to enhance study quality and compliance. Key Takeaways: * **eISF as a Cornerstone for Modern Clinical Operations:** The eISF is presented as an essential, cloud-based solution that centralizes all clinical trial documentation, significantly improving efficiency and adaptability for traditional, virtual, and decentralized trials. * **Critical Regulatory Compliance (21 CFR Part 11):** Adherence to 21 CFR Part 11 is paramount, particularly through the implementation of certified electronic copies for paper-based documents and electronic signatures, which establish document authenticity and provide vital audit trails. * **Enhanced Operational Efficiency and Quality:** eISF systems drive operational improvements by saving time in document management, enabling remote real-time oversight, facilitating proactive identification of missing documents, and supporting continuous inspection readiness. * **Integrated Data and Document Management:** The value of eISF is maximized through integration with Learning Management Systems (LMS) and the effective use of customizable metadata, allowing for comprehensive tracking, reporting, and quick access to critical information. * **Robust PHI Protection:** Secure management of Protected Health Information (PHI) within the eISF is achieved through role-based access controls, dedicated secure folders, and optional de-identification/redaction processes, ensuring patient privacy and compliance. * **Facilitating Risk-Based Quality Management:** The eISF empowers risk-based quality management by providing real-time access to documents, enabling continuous monitoring, and allowing for immediate review of subject source documents, thereby enhancing overall study quality and data integrity.
The Technology Adoption Lifecycle Applied to Healthcare
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 9, 2021
This video provides an in-depth exploration of the Technology Adoption Lifecycle, a framework derived from Geoffrey Moore's seminal book "Crossing the Chasm," and specifically applies its principles to the healthcare industry. Dr. Eric Bricker introduces the concept, tracing its origins back to Everett Rogers' work on agricultural innovation, and establishes it as a critical framework for understanding how new technologies and trends are disseminated and adopted across a population. The core idea is that adoption does not occur uniformly but rather follows a predictable bell-shaped curve over time, segmenting the population into distinct groups with varying propensities for embracing new innovations. The framework identifies several key adopter segments. At the forefront are the Early Adopters, a small group driven by the novelty of technology, eager to be first, and generally not price-sensitive. Following them are the Pragmatists, comprising about 33% of the population, who seek new technologies to solve specific problems and are heavily influenced by the experiences and recommendations of their peers. They are somewhat price-sensitive. Next are the Conservatives, another 33%, who also have problems to solve but prioritize ease, low cost, and solutions that are "baked in" or require minimal effort; they are highly price-sensitive. Finally, the Skeptics, representing about 17% of the population (as exemplified by internet non-users), will never adopt the new innovation, often viewing it with suspicion or as a conspiracy. A central tenet of Moore's work, and the focus of the video, is the "chasm" – a significant gap that exists between the Early Adopters and the Pragmatists. Many promising technologies fail to cross this chasm, remaining niche products used only by enthusiasts. To successfully bridge this gap and achieve mainstream adoption, two critical strategies are highlighted. First, the technology must offer a "10x better" value proposition, meaning it must be remarkably superior to existing alternatives, so much so that people will naturally remark about its benefits to others. This word-of-mouth endorsement is crucial for influencing Pragmatists. Second, companies must employ a "niche strategy" initially, focusing on a specific, smaller market segment to become a "big fish in a small pond." This is followed by a "bowling pin strategy," where success in one niche allows for expansion into related verticals or market segments, systematically knocking down "pins" to broaden adoption. The video then illustrates these concepts with modern examples relevant to healthcare. Amazon Web Services (AWS) is presented as a prime example of a 10x value proposition in cloud computing, which rapidly grew into a multi-billion-dollar operation within 13 years, exceeding the typical 10-year adoption cycle. AWS started by targeting technology companies (its niche) and then expanded using a bowling pin strategy to include pharmaceutical clients like Allergan and Celgene, eventually even the FDA, demonstrating how a disruptive technology can move from early tech adopters to more conservative, regulated entities. Telemedicine is another healthcare-specific example, offering a 10x value proposition in convenience for certain conditions, initially adopted by early enthusiasts and then by pragmatists like law firms seeking to save their employees' valuable time, eventually becoming a widely offered benefit by employers and carriers. Key Takeaways: • The Technology Adoption Lifecycle, based on Geoffrey Moore's "Crossing the Chasm," provides a predictable framework for how new technologies are adopted across a population, crucial for innovators in any industry. • New technology adoption is not uniform; populations segment into distinct groups: Early Adopters, Pragmatists, Conservatives, and Skeptics, each with unique motivations and adoption patterns. • Early Adopters are driven by the desire for novelty and being first, often willing to experiment with new technologies regardless of price. • Pragmatists are problem-solvers who adopt new technologies when they see a clear solution to a specific need, and their decisions are heavily influenced by peer recommendations and proven success stories. • Conservatives are highly price-sensitive and prioritize ease of use and integration into existing systems, adopting new technologies only if they are simple, cheap, and require minimal effort. • Skeptics represent a segment of the population that will resist adopting new innovations, regardless of their perceived benefits or widespread acceptance. • The "chasm" is a critical hurdle between Early Adopters and Pragmatists; many technologies fail to transition from being niche products to achieving mainstream adoption. • To successfully cross the chasm, a new technology must offer a "10x better" value proposition, meaning it must be remarkably superior to existing alternatives to generate the necessary word-of-mouth momentum among Pragmatists. • An effective market entry strategy involves focusing on a specific "niche" initially, allowing the company to establish itself as a dominant player in a smaller market segment. • Expansion beyond the initial niche is achieved through a "bowling pin strategy," where success in one vertical or segment is leveraged to systematically penetrate related market segments. • The typical timeframe for a technology to move through the entire adoption lifecycle, from early adoption to widespread acceptance, is approximately 10 years. • Amazon Web Services (AWS) serves as a modern example of a 10x value proposition, demonstrating how cloud computing rapidly achieved widespread adoption across diverse sectors, including pharmaceutical companies (Allergan, Celgene) and government agencies (FDA). • Telemedicine illustrates the application of the adoption lifecycle in healthcare, offering a 10x convenience value for specific medical issues, moving from early adopters to widespread integration into employer benefits. • Understanding the characteristics and motivations of each adopter segment is vital for tailoring effective marketing, sales, and product development strategies for disruptive technologies, especially in complex industries like healthcare. • The power of word-of-mouth and tangible proof of value from peers is paramount for convincing the pragmatic majority to adopt new solutions. Key Concepts: * **Technology Adoption Lifecycle:** A framework describing how new technologies are adopted by different segments of a population over time. * **Crossing the Chasm:** The critical challenge of moving a new technology from early adopters to the mainstream market (Pragmatists). * **Early Adopters:** Individuals or organizations who adopt new technologies because they are new, cool, or they want to be first; not typically price-sensitive. * **Pragmatists:** The largest segment of adopters who seek new technology to solve specific problems and are influenced by peer adoption and proven results; somewhat price-sensitive. * **Conservatives:** Adopters who prefer existing solutions but will adopt new technology if it is easy, cheap, and integrated into what they already use; very price-sensitive. * **Skeptics:** Individuals or organizations who will not adopt new technologies, regardless of their benefits. * **10x Value Proposition:** The requirement that a new technology must be ten times better than existing solutions to compel mainstream adoption. * **Niche Strategy:** Focusing on a specific, smaller market segment to establish dominance before expanding. * **Bowling Pin Strategy:** A method of expanding market reach by leveraging success in one niche to penetrate related verticals or segments. Examples/Case Studies: * **Amazon Web Services (AWS):** Used as a prime example of a 10x value proposition in cloud computing, demonstrating rapid growth and adoption across various industries, including pharmaceutical companies (Allergan, Celgene) and government entities (FDA). * **Telemedicine:** Highlighted as a healthcare example, offering a 10x value proposition in convenience for specific conditions, with adoption moving from early enthusiasts to pragmatic organizations like law firms and eventually widespread employer offerings.
Health Insurance Case Management of NO USE in Acute Care Cardiovascular High Cost Claimant
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 8, 2021
This video, presented by Dr. Eric Bricker of AHealthcareZ, offers a critical perspective on the efficacy of health insurance case management and utilization management during acute care episodes, specifically for cardiovascular high-cost claimants. Dr. Bricker introduces the concept by categorizing high-cost claimants into three major diagnostic areas: orthopedic, cardiovascular, and cancer, then focuses on cardiovascular cases. He uses a compelling real-life patient story to illustrate his points, detailing the journey of a middle-aged woman born with a bicuspid aortic valve who, five years after a mechanical valve replacement, developed a severe peri-valvular abscess. The patient's case study unfolds from an initial fever and a visit to her primary care physician (PCP) to a subsequent hospital admission due to positive blood cultures indicating a serious bacterial infection. A CT scan revealed a peri-valvular abscess around her mechanical aortic valve, a condition untreatable by antibiotics alone and requiring immediate, complex cardiothoracic surgery. The surgery, lasting over six hours, involved replacing the infected valve and draining the abscess. Complicating matters, the patient developed a heart block during the procedure, necessitating the insertion of temporary electrical leads and later a permanent pacemaker. This extensive medical intervention led to an almost month-long hospitalization, including an ICU stay, and a six-figure medical bill. Dr. Bricker's central argument, derived from this case, is that during such acute, life-threatening medical crises, external utilization or case management from insurance carriers provides virtually no value. He asserts that once a patient is in the operating room or ICU with a critical condition, clinical decisions are solely based on immediate medical necessity and the expertise of the specialized medical team, rendering outside intervention irrelevant. Instead, he proposes a "bookends" framework for effective management of high-cost claimants, particularly for employers who often bear the financial risk through self-funded plans. He posits that the truly impactful intervention points are *before* the acute episode, through high-quality primary care and proactive identification of risks, and *after* the episode, by ensuring robust, high-skilled post-hospitalization follow-up care, ideally at a center of excellence. The speaker emphasizes that earlier, more astute PCP intervention (e.g., checking blood cultures for a patient with a mechanical valve and fever) could potentially mitigate the severity of such an event. He also highlights the critical role of specialized facilities and highly skilled surgeons in achieving positive outcomes for complex cases, noting that the patient was fortunate to be at a hospital associated with a dedicated cardiothoracic surgery center. The video concludes by advocating for a strategic shift in how healthcare costs for complex conditions are managed, moving away from reactive, in-episode interventions by carriers towards proactive, preventative, and post-acute care optimization, especially for conditions like heart attacks and atherosclerosis where prior events are strong indicators of future risk. **Detailed Key Takeaways:** * **Acute Care Case Management is Ineffective:** For cardiovascular high-cost claimants undergoing acute, critical care (e.g., major surgery, ICU stays), external utilization management and case management by insurance carriers offer minimal to no value. Clinical decisions are driven by immediate medical necessity and specialized medical expertise. * **"Bookends" Intervention Strategy:** The most effective approach for managing high-cost claimants involves interventions at the "bookends" of the care continuum: *before* the acute episode through high-quality primary care, and *after* the episode with robust, high-skilled post-hospitalization follow-up. * **Proactive Primary Care is Crucial:** High-quality primary care physician (PCP) engagement is vital for early detection and prevention. In the case study, a more vigilant PCP checking blood cultures for a patient with a mechanical heart valve and fever could have potentially prevented a severe, life-threatening infection. * **Importance of Post-Hospitalization Follow-up:** Ensuring patients receive the best possible follow-up care, ideally at a center of excellence, is critical for long-term outcomes, preventing recurrence, and managing chronic conditions after a major acute event. * **Major High-Cost Claimant Categories:** The three primary diagnostic categories contributing to high-cost claimants are orthopedic, cardiovascular, and cancer. This categorization helps in focusing targeted intervention strategies. * **Identifying High-Risk Individuals:** For conditions like heart attacks or atherosclerosis, leveraging claims data to identify individuals who have already experienced an event is key to proactive management and enrollment in high-quality preventative and follow-up care. * **Life-Threatening Nature of Cardiovascular Events:** The case study underscores how rapidly a seemingly simple symptom like a fever can escalate into a life-threatening cardiovascular crisis requiring extensive, highly specialized, and immediate intervention. * **Significant Financial Burden:** A single, complex cardiovascular hospitalization, especially with an ICU stay and major surgery, can easily result in a six-figure medical bill, highlighting the substantial financial impact on self-funded employers and the broader healthcare system. * **Value of Specialized Medical Facilities:** Access to specialized hospitals and highly skilled medical professionals (e.g., cardiothoracic surgeons, dedicated nursing units) is paramount for achieving positive outcomes in complex, high-risk cases. Lack of such resources can have dire consequences. * **Leveraging Data for Proactive Management:** Employers and healthcare stakeholders should utilize claims data and business intelligence to identify high-risk individuals and patterns related to high-cost claimants, enabling more targeted and effective pre- and post-episode interventions. * **Shift Towards Proactive Healthcare Management:** The overarching recommendation is a strategic shift from reactive, in-episode management by insurance carriers to a more proactive, value-based approach centered on preventative care and comprehensive post-acute support. **Examples/Case Studies:** * **Bicuspid Aortic Valve Patient:** The video features a detailed case study of a middle-aged woman born with a bicuspid aortic valve who previously had a mechanical valve replacement. She developed a high fever, which, after initial dismissal, led to the diagnosis of a peri-valvular abscess around her mechanical aortic valve. This required a six-hour cardiothoracic surgery for valve replacement and abscess drainage. During surgery, she developed a heart block, necessitating an external pacemaker and a subsequent procedure for a permanent pacemaker. Her hospitalization lasted nearly a month, including an ICU stay, and resulted in a six-figure medical bill. This case serves as a prime example of a cardiovascular high-cost claimant where acute care was critical, but external case management had no discernible impact.
Physician Culture Impact on Payment: Will Getting Rid of 'Bad Apple' Doctors Fix It?
AHealthcareZ - Healthcare Finance Explained
@ahealthcarez
Jun 7, 2021
This video provides an in-depth exploration of how physician culture significantly impacts healthcare payment and costs in the United States. Dr. Eric Bricker, the speaker, frames the discussion as a response to criticisms from prominent authors like Drs. Vivian Lee, Marty Makary, Atul Gawande, and Robert Pearl, who attribute rising healthcare costs partly to physician culture. While acknowledging the pushback from many physicians who believe they prioritize patient care, Dr. Bricker argues that both perspectives can be true due to the presence of "bad apples" within the profession. He posits that a minority of physicians, driven by motivations such as money, power, prestige, or promotions rather than patient well-being, disproportionately contribute to inflated healthcare expenditures. To clarify his argument, Dr. Bricker first defines organizational culture, drawing on a Harvard Business Review definition as "the consistent observable patterns of behavior within an organization." He then introduces a powerful analogy: a field of "wheat" (representing patient-first physicians) interspersed with "weeds" (representing those who prioritize self-interest). Just as a few weeds can spoil the appearance and health of an entire field, a minority of self-serving physicians can tarnish the reputation of the profession and drive up costs, even if the majority are dedicated to their patients. He further reinforces this concept with analogies like a bad apple spoiling the bunch or rabbit turds in a bowl of raisins, emphasizing that a small amount of negativity can compromise the whole. The core of Dr. Bricker's analysis centers on the fee-for-service payment model, which he describes as "fertilizer" that unfortunately nourishes both the "wheat" and the "weeds." While it supports patient-centric doctors, it also enables and rewards those who perform unnecessary or overly expensive procedures for personal gain. He contends that if the healthcare system insists on retaining the fee-for-service model, it must implement aggressive "weed control" measures. These measures include enhanced transparency to identify problematic practices, robust self-policing by medical boards and physician practices to remove "bad apples," and significantly expanded efforts in investigating fraud, waste, and abuse, potentially through a larger Office of the Inspector General (OIG) or private initiatives by employers. He cites examples of companies like Zappos and Southwest Airlines, known for their strong cultures, which prioritize hiring for attitude and cultural fit over mere skill to minimize "weeds" from the outset. Key Takeaways: * **Physician Culture's Dual Nature:** While the majority of physicians are dedicated to patient well-being ("wheat"), a minority prioritize personal gain (money, power, prestige, promotions) over patient care ("weeds"), significantly impacting healthcare costs. * **Definition of Culture:** Culture is defined as the consistent, observable patterns of behavior within an organization, highlighting that it's about what people repeatedly do, not just what they say. * **Fee-for-Service as a Double-Edged Sword:** The fee-for-service payment model acts as "fertilizer," rewarding both patient-centric practices and self-serving behaviors that can drive up unnecessary procedures and costs. * **The "Bad Apple" Effect:** A small percentage of physicians with self-serving motives can tarnish the entire profession and distort healthcare economics, akin to a few bad apples spoiling the bunch. * **Necessity of "Weed Control":** If the fee-for-service model is to be maintained, aggressive "weed control" is essential to mitigate the negative impact of self-serving physicians and practices. * **Transparency as a Primary Tool:** Increased transparency in physician practices and outcomes is crucial for patients and employers to identify and avoid "weeds" (problematic providers). * **Enhanced Self-Policing:** Medical boards and physician practices must take more proactive and stringent measures to identify, discipline, and remove "bad apple" doctors who engage in unethical or harmful practices. * **Aggressive Fraud, Waste, and Abuse Investigation:** There is a need for significantly expanded efforts by bodies like the Office of the Inspector General (OIG) or even private investigators hired by employers to actively seek out and eliminate fraudulent or abusive practices. * **Hiring for Culture:** Lessons from successful organizations like Zappos and Southwest Airlines demonstrate the importance of hiring for cultural fit and attitude over technical skills alone, as a "jerk" with skills can still ruin a positive culture. * **Underlying Issue of Selfishness:** The root cause of "bad apple" behavior and negative cultural patterns often boils down to selfishness, where individual gain is prioritized over collective good or patient welfare. * **Implications for Stakeholders:** The video implicitly suggests that employers, patients, and insurance carriers bear the financial brunt of these "weeds" and have a vested interest in promoting transparency and accountability within the healthcare system. Tools/Resources Mentioned: * **Harvard Business Review article:** Referenced for a definition of organizational culture. * **Dr. Bricker’s Book:** "16 Lessons in the Business of Healing." * **Netflix series "The Pharmacist":** Referenced for an example of egregious physician abuse (Dr. Claggett and an Oxycontin pill mill) and the failure of medical boards to act. Key Concepts: * **Physician Culture:** The consistent, observable patterns of behavior among medical professionals, influencing patient care and healthcare costs. * **Fee-for-Service:** A payment model where healthcare providers are paid for each service they perform, rather than a flat salary or capitated rate. * **Wheat vs. Weeds:** An analogy used to distinguish between patient-centric physicians ("wheat") and those driven by self-interest ("weeds"). * **Transparency:** The principle of making information about physician practices, costs, and outcomes openly accessible to patients and other stakeholders. * **Self-Policing:** The responsibility of professional bodies (e.g., medical boards) and organizations to regulate and discipline their members. * **Fraud, Waste, and Abuse:** Practices within healthcare that lead to unnecessary costs, often involving illegal or unethical billing and service provision. Examples/Case Studies: * **Zappos:** Highlighted for its strong corporate culture and unique hiring process, which included interviewing shuttle bus drivers to assess how prospective employees treated service staff, prioritizing attitude over skill. * **Southwest Airlines:** Cited for its HR philosophy of "hire for attitude, train for skill," emphasizing the importance of cultural fit among employees. * **Dr. Claggett (from "The Pharmacist"):** An example of a physician running an Oxycontin pill mill whose egregious abuses went unaddressed by the Louisiana medical board, illustrating a failure of self-policing.
Develop Your Career at Veeva
WayUp
/@WayUp
Jun 3, 2021
This video provides an in-depth exploration of early career opportunities and development programs at Veeva, a prominent technology company in the life sciences industry. The webinar, hosted by WayUp, features Sarah Young, Director of Generation Veeva, along with current program participants and alumni, who share insights into Veeva's culture, vision, and the day-to-day experiences within its various development programs. The primary purpose is to attract and inform recent graduates about how they can start and grow a successful career at Veeva, emphasizing the company's commitment to employee development, industry impact, and core values. The discussion begins with an overview of Veeva's vision: "to build the industry cloud for life sciences." This involves creating great software, leveraging data analytics and insights, and delivering solutions to pharma and biotech customers to enhance their operational efficiency. Founded in 2007 by Peter Gastner, an engineer with experience at IBM, PeopleSoft, and Salesforce, Veeva quickly grew to serve over 900 customers worldwide, including all of the top 20 pharma companies. A key highlight is Veeva's transition in 2021 to become the first public company to convert to a Public Benefit Corporation, legally obligating it to balance shareholder interests with those of its customers, employees, and communities, while striving to make the life sciences industry more productive and create high-quality employment. The video details Veeva's comprehensive support for the entire drug approval process, from clinical trials to commercialization. Examples include helping pharma companies streamline clinical trials, improve quality and regulatory standards, and enable healthcare providers to get the right drugs to the right patients through software and data analytics. The speakers illustrate this with real-world scenarios, such as pharma reps using Veeva software on iPads and the tracking of marketing analytics for drug advertisements. A significant innovation mentioned is the Veeva Clinical Network, a bold initiative aiming to deliver scalable, paperless, and patient-centric clinical trials by connecting sponsors (like Pfizer and Moderna), clinical research sites, and patients. The core of the webinar focuses on Veeva's "Generation Veeva" development programs, designed for new college graduates. Four distinct programs are highlighted: the Engineering Development Program (EDP) for associate software, DevOps, and performance engineers; the Consultant Development Program (CDP) for associate consultants who implement Veeva's software for customers; the Analytics Development Program (ADP) which offers technical back-end analytics and front-end customer-facing roles delivering business insights; and the Business Consultant Development Program (BCDP) for generalist consultants who focus on people, process, data, and technology to improve commercial pharma functions. These programs emphasize learning by doing, network building, mentorship, and personalized professional development, equipping participants with technical, analytical, problem-solving, consulting, soft skills, industry knowledge, and Veeva product expertise. Key Takeaways: * **Veeva's "Industry Cloud for Life Sciences" Vision:** Veeva's core mission is to build specialized software, data analytics, and insights solutions tailored for the complex pharmaceutical and biotech sectors, aiming to enhance operational efficiency across the industry. * **Comprehensive Support for Drug Approval Process:** Veeva's applications and services span all phases of drug approval, from optimizing clinical trials and ensuring regulatory standards to facilitating drug commercialization and enabling effective interactions between pharma reps and healthcare providers. * **Public Benefit Corporation Status:** Veeva's conversion to a Public Benefit Corporation signifies a legal commitment to balance the interests of shareholders with those of customers, employees, and communities, aiming to make the life sciences industry more productive. * **Veeva Clinical Network Innovation:** A key initiative is the Veeva Clinical Network, which seeks to revolutionize clinical trials by connecting sponsors, research sites, and patients to accelerate research and deliver scalable, paperless, and patient-centric trials. * **Generation Veeva Development Programs:** Veeva offers structured early career programs: EDP (software engineering), CDP (software implementation consulting), ADP (data analytics and insights), and BCDP (strategic business consulting for commercial pharma). * **Hands-on Learning and Responsibility:** All development programs emphasize "learning by doing," providing new grads with significant responsibility early on, such as configuring software for customers, interpreting data for clients, or contributing to core engineering projects. * **Mentorship and Network Building:** A strong focus is placed on mentorship from subject matter experts, "big buddy" support, and internal networking opportunities, fostering a supportive environment for professional and personal growth. * **Industry vs. Academia Coding:** For engineering roles, the transition from college coding (structured assignments) to industry coding (solving problems without clear solutions, navigating complex file systems, continuous learning, using diverse tools) is a significant growth area. * **Importance of Soft Skills:** Beyond technical expertise, the programs cultivate critical soft skills such as communication, problem-solving, critical thinking, business acumen, time management, and the ability to collaborate effectively in remote or hybrid environments. * **Tailored Professional Development:** Each program offers personalized professional development, allowing individuals to explore different opportunities within Veeva, potentially moving into roles like product management, sales, or solution engineering based on their interests and skills. * **Transparent Interview Process:** Veeva's interview process is designed to be transparent, often including hands-on case exercises (e.g., configuring a Veeva product, data analysis) and multiple conversations with team members to ensure a mutual fit between the candidate and the company culture. * **Advice for Job Seekers:** Candidates are advised to research company objectives, mission, vision, and values; practice technical fundamentals (e.g., LeetCode for coding); develop strong communication skills; and actively ask questions during interviews to assess if the company is the right fit for their career aspirations and work preferences. **Tools/Resources Mentioned:** * **Veeva Vault:** A major Veeva product for life science and biotech companies to track studies and progress. * **WayUp:** A platform for early career programs and job listings. * **Handshake:** A university job board platform. * **LeetCode/HackerRank:** Websites for practicing coding algorithms and problems. * **Google Chat/Video Conferencing:** Tools for daily collaboration in a remote work environment. **Key Concepts:** * **Industry Cloud for Life Sciences:** Veeva's strategic focus on building a specialized cloud platform tailored to the unique needs and complexities of the pharmaceutical and life sciences sectors. * **Public Benefit Corporation (PBC):** A legal designation for a for-profit corporation that is required to consider the impact of its decisions on society and the environment, in addition to its shareholders. * **Veeva Clinical Network:** An innovative initiative by Veeva to connect sponsors, clinical research sites, and patients to streamline and accelerate clinical trials, making them paperless and patient-centric. * **Commercial Operations (Pharma):** The business functions within pharmaceutical companies related to sales, marketing, and market access for drugs and medical products. * **Clinical Operations (Pharma):** The processes and activities involved in conducting clinical trials, including trial design, patient recruitment, data collection, and regulatory compliance. * **Media Measurement:** The process of tracking and analyzing the effectiveness of advertising campaigns, particularly in the context of reaching target audiences for pharmaceutical products. * **Health Data Linkage:** The process of connecting media consumption data with health data in a privacy-safe way to understand who advertisements are reaching and optimize marketing efforts for relevant patient populations. **Examples/Case Studies:** * **Pharma Reps with iPads:** Pharma representatives using Veeva software on iPads to interact with doctors and manage samples, demonstrating Veeva's role in commercial operations. * **COVID-19 Impact on Pharma Interactions:** Veeva provided solutions for pharma reps to continue interacting with healthcare providers remotely during the pandemic when hospital access was restricted. * **Drug Ad Marketing Analytics:** Veeva software tracks the marketing analytics behind drug advertisements seen on TV, helping companies understand their reach and effectiveness. * **Flu Drug Marketing:** An example of how Veeva's analytics helps pharmaceutical companies target advertisements for a flu drug to individuals likely to get the flu or who are health-active. * **Veeva Vault Surveys:** An example of an engineering project where customers using Veeva Vault can send surveys to non-users to gather information that aids their clinical operations, with the engineering team working on features like setting expiry dates for survey links. * **Candidate Exercise (CDP):** A seven-day interview exercise where candidates are given access to a Veeva product to complete a stripped-down configuration for an imaginary customer, providing a hands-on experience of the day-to-day work.