The Big Picture On CMS, Checks & Balances, Future of Interoperability w/ Marc Ryan

Erik Sunset: [00:00:00] All right. Hello and welcome back. I’m Erik sunset, your host of the doc, buddy journal here at DocBuddy. We deliver healthcare solutions that take the pain and costs out of broken workflows, like with op notes, which gives ASCs and their affiliated clinics, the power of instantly generated operative reports.

Erik Sunset: You can learn more about that and all of our solutions at doc, buddy. com. And today we’re joined by Marc Ryan. Marc is the Chief Solutions Officer with Lilac Software. Marc’s got extensive leadership experience across health plans and healthcare technology. Most recently, Marc was the founding executive and president of MedHoc, excuse me, which was recently acquired by Hearst Health.

Erik Sunset: He has launched and operated multiple health plans and served in senior government positions. Marc is also the author of the Healthcare Labyrinth. Marc, thanks so much for joining us today.

Marc Ryan: Hey, Erik. Thanks so much. It’s a pleasure to be with you and I look forward to the next, uh, you know, 30 or so minutes talking about health care from a provider [00:01:00] perspective.

Erik Sunset: That sounds great. And thanks for carving a little time out of your schedule for, uh, for the DocBuddy journal. Um, if I didn’t give you a fair shake in the read in, now’s your chance. What else should listeners know about you? What should they know about Lilac software? And then we can kind of get into our discussion.

Marc Ryan: Yeah, just real quick. I’m, uh, I’m a sort of policy wonk on health care. I have a health care site called healthcare labyrinth dot com where I do news feeds, blogs and podcasts as well. And I know there’ll be in the show notes and lilac software is a new venture. I’ve moved on from. MHK or MedHawk and Lilac Software.

Marc Ryan: I’ve co founded it with two other folks, and it’s really, we’re hoping changing the paradigm of how health plans operate. It’s really very focused on data analytics with data aggregation and solutions there. And our goal really is to bring providers and health plans together, overcome some of [00:02:00] this prior authorization controversy, which probably saves.

Marc Ryan: pennies on the dollars and let’s go and save a lot more money by focusing on care management, um, working with providers and working with members to really better care. And so you can learn more about that at lilacsoftware. com.

Erik Sunset: Love it. Love it when we have guests on the show that are taking the long view of healthcare, big picture macro items. Uh, that’s similar to what we DocBuddy as well. And then diving into, uh, to the meat and potatoes of our show today, Marc, you know, we have solutions across all care settings, really, and our providers that are serving seniors and those with disabilities.

Erik Sunset: Um, are seeing their number of Medicare advantage enrollees increase, uh, rather dramatically year over year. Uh, can you tell us a little bit more about why that may be?

Marc Ryan: Sure. Well, there’s a big, huge trend out there, Erik, on Medicare Advantage. And as people know, there’s the traditional [00:03:00] Medicare Fee for Service program, as well as the Medicare Advantage program. These are the private plans that serve. And recently, for the first time in the last year or so, we’ve gone over 50 percent penetration in the private Medicare Advantage.

Marc Ryan: versus traditional fee for service. And that really happened, I think, for a couple of reasons. Number one, aging is occurring. And so the more people coming in, it just tend, they tend to go to managed care. And I would also note that I’m a late baby boomer, I’m a little bit older than you. And I’ve always been associated with managed care.

Marc Ryan: So those late baby boomers, as opposed to say, our parents who are more indemnity policy people. They’re more used to managed care, so they’re looking more at Medicare Advantage for the pros there, and obviously there are cons, but they’re used to those cons because they’ve always been in managed care. So the combination of aging and that is really having Medicare [00:04:00] Advantage grow considerably.

Marc Ryan: I would also tell you some people would argue Medicare Advantage is over reimbursed and they have an advantage. So to speak over fee for service, others will tell you that that that generally will be there because they’re regardless of overpayments, for example, and that’s the controversial issue, they tend to be able to provide more benefits.

Marc Ryan: And so people are also attracted because there are vision and hearing and lower premiums and things like that compared to fee for service. And as we also know, Medicare supplement is very expensive. You don’t need Medicare supplement with a Medicare Advantage plan. If you don’t get Medicare supplement or you can’t afford it, uh, the fee for service benefit is really more like an 80 20 and you’re on the hook for, you know, maybe about 20 percent of your costs.

Marc Ryan: So those are some of the reasons providers are seeing, you know, these MA lives increased dramatically compared to [00:05:00] the traditional program.

Erik Sunset: Yeah. And I know you touched on it sort of on the intro there on prior authorization, you know, penny wise and perhaps pound foolish, they’re, they’re controversial. They can be a time suck for providers, for patients, for really all stakeholders. Um, and it seems like there is a better way to do that. I know you’ve got some thoughts there.

Marc Ryan: Yeah, absolutely. So I will be honest with your listeners, listeners and viewers here. I’m a proponent of prior authorizations because I do think they have somewhat of a role, right? I do believe that as a health care system, we need to sort of You know, make sure that the services that are being delivered are actually needed.

Marc Ryan: And I know that’s controversial with some providers, but I do think there’s a proper role for P. A. But I also feel like plans sometimes take that way too far, right? They create huge burdens on clinicians [00:06:00] and um, That’s a huge problem today in the provider world, right? The huge administrative burden of not only prior authorizations, but we’ll probably get the claims a little later.

Marc Ryan: And so I do think that there’s a way to make this a lot better. So on one hand, uh, The AMA and the AHA, the hospital and the doc lobby, I have to give them hats off. They’re probably the best lobbyists on health care out there. They have really spent a lot of time at the state and the federal level lobbying to get some restrictions on prior authorization.

Marc Ryan: And so that’s one external trend we see there. And for example, they’ve also lobbied CMS. To have some restrictions in Medicare Advantage, and those just went into effect on one one twenty four and essentially you have to follow the fee for service rules related to whether a service should be given compared to, you know, applying plan [00:07:00] rules as an example, but also I think we’re getting to a happier medium.

Marc Ryan: I know docs probably won’t immediately see that, but the reality is with these external restrictions. Uh, plans are beginning to reassess prior authorization. Will we always have them on inpatient expensive services? Yes, but in other areas, they’re beginning to say this is pennies on the dollars when I could focus my effort on saving dollars rather than pennies.

Marc Ryan: And they’re starting to pull back on their prior authorizations. They’re looking at automating prior authorizations without using AI in a bad way, sort of in a good way. And so there is a positive trend out there. It’s going to take a while for it to emerge, but I think we’ll get to more of a happy medium where.

Marc Ryan: PA is being used reasonably. And again, I think there is reasonable use, but we will be lifting the burden on providers. And I think that’s a great thing too, [00:08:00] right? Because we know what it takes today to be a provider. And unfortunately we’re losing a lot of independent providers to corporations and things like that, because the cost, the sheer cost of running a practice and a lot of it administrative is, is just amazing right now.

Erik Sunset: It is. And, uh, you know, I would tend to agree with that sentiment that there is certainly a reason that prior auths are needed and exist. You look at how an insurance carrier operates as a business, they need a check and balance. I think it’s really the weaponization of the prior authorization to say, we’re not going to pay for that. Putting you through that, that paperwork burden at the practice and at the provider level that folks take issue with. Is that, is that a fair shake?

Marc Ryan: Absolutely. Right. And we got to remember that, um, you know, often you pivot, uh, you know, you, you have health plans and providers sort of in this confrontation relationship, right? That’s probably not a good thing for the health care system, right? I think over time we [00:09:00] can get to a better place and recognize everybody’s burden.

Marc Ryan: Both are running businesses. And that’s free market. That’s free market economics in our country. I think it’s a good thing, but we have to recognize both have to run a business and make money.

Erik Sunset: And in the same boat, this, uh, weaponization of claim denials as a way to maybe get off the hook, and this is conjecture and I’m going to get out of my depth here really quickly, but on the, on the insurance side, on the payer side, Um, if you are routinely denying claims contractually, you are obligated to pay, but rather than just pay it for whatever reason, you’re asking the practice to go back, work this denial, resubmit paperwork, resubmit the claim, resubmit medical necessity, All of these things we hear from providers, I even heard it this week at the New York Society of Ambulatory Surgery Centers conferences.

Erik Sunset: That on the ASC and facility side, they are taking it, you know, straight to the face that we’re having to resubmit claims that we got paid on for last week and nothing [00:10:00] changed.

Marc Ryan: Yep. I, I think that’s where providers really have a beef, right? Um, you know, I, again, I’m going to say that claims scrutiny by a health plan is a core function of what they do and you have to, you know, guard against fraud, waste and abuse and things like that. But you’re absolutely right there. Claims denials have really gone way too far on the part of plans.

Marc Ryan: And, you know, there are some big controversies in lawsuits out there that providers have filed related to sort of a I used to deny claims without ever a medical practitioner looking at that claim for medical necessity and things like that. So really, plans sort of went way too far on this. You know, And, you know, I think they have to be held accountable for that.

Marc Ryan: Again, proper use of claim scrutiny, use automation in a good way rather than a bad [00:11:00] way. And I do think that the regulatory oversight and the provider pushes on this is a good thing. Because again, there’s a happy medium there where the burden on providers aren’t there. And I think one of the big things we forget is it’s not only the absolute claim denial, But the cost, the administrative cost of the provider having to wait months, uh, and fix quote unquote the issue for the plan and then the revenue cycle management impacts that are there.

Marc Ryan: It’s it’s just a pretty, pretty major burden. And so again, Sometimes in my writings, people will think I’m a little more sympathetic to the plans and claims denials, but clearly, uh, you know, things have really gone a little too far. Plans have millions of dollars of resources at their disposal. They can fix this.

Marc Ryan: They can get to the happy medium, and they really need to, because this is what is part of the major consternation between [00:12:00] plans and providers. It’s got to be fixed.

Erik Sunset: Well, and to that exact point, you know, if we can get to this happy medium, and I would agree with all of your points being made that it shouldn’t be one end of the spectrum or the other, you know, it needs to be in the middle, both. with parties involved and even the third party, the patient. They re not operating the business, certainly the practice or the facility is, as well as the insurance carrier.

Erik Sunset: Uh so the truth is somewhere in the middle or the best outcome is somewhere in the middle that claim denials are going to happen and claims are going to be scrutinized. We see how much fraud, waste and abuse happens in health care, but even just that administrative burden. That’s something like a quarter of the cost of our total healthcare spend when you add it all up, and that’s unacceptable.

Erik Sunset: There’s just a better way.

Marc Ryan: Yep, you’re you’re absolutely right. And I like the fact that you use the quarter, right? Traditionally, people talk about 10 percent as the benchmark. But truthfully, when you look at everything, fraud, waste and abuse, you’re absolutely right. It’s 25%. So I’ll [00:13:00] always defend a health plans right to scrutinize claims, but they have to do it correctly.

Marc Ryan: They have to do it timely, and they shouldn’t be impacting providers the way they are.

Erik Sunset: Yeah, and just, this is a little bit of a tangent, but as a healthcare consumer myself, like you are, like we all are, I want my carrier scrutinizing claims, because if they don’t, and they just pay out every single sheet of paperwork or electronic document that comes in, I’m gonna pay more. I need some level of scrutiny, but we’re at a, kind of in a silly place, it seems.

Marc Ryan: No, absolutely. And again, you know, I’m going to go back to my health plan routes here and I will say back to the PA and back to the claims denials and that scrutiny, the level of scrutiny of services up front or for claims payment in the fee for service system is not good. That’s not good for the health care system overall.

Marc Ryan: Some of what MA is doing is good, but there’s far too much of it as well. And you mentioned the consumer, [00:14:00] you know, we have the no surprises act now, and that’s done a great deal of things, but it hasn’t stopped all surprise billing. Part of these surprise billings are related to conflicts between payers and providers.

Marc Ryan: If too much time goes by on a claim denial, really the provider sort of has no, you know, they have to go and bill the provider, uh, the pet, the. Client the patient because they don’t know if they’re going to get paid. Now, sometimes providers may do that too early and we should stop that. But, uh, that’s where the consumer or the patient gets in the middle of these claims denials and it’s unhealthy for the system as well.

Erik Sunset: Indeed, and this is again a little bit of a tangent, but memory serves back for my, I’ll flash back to my revenue cycle management vendor days like you’re flashing back to the health plan days. It doesn’t seem that the adjudication process for these no surprises act issues between the provider and the insurance carrier offer a [00:15:00] very robust solution and you can speak to that in much greater detail than I can, but is there an improvement that could be made there to streamline this for everybody?

Marc Ryan: Yeah. Again, I think the no surprises act was a good thing for consumers overall, right? It took them out of the middle. Of a lot of surprise billing, not everything. But the construct we have now is not working. The caseloads for the arbitrators within the no surprises act are huge. And one area that I will be a little critical of on the provider side, and this is sort of a subgroup of providers.

Marc Ryan: I think a subgroup of provider entities, largely run by private equity firms, have created a way right now. That I think they’re a bit abusing the no surprises system. I think in the end, everybody, you know, you might argue whether the regulation is exactly right the way it’s been set up, but [00:16:00] we shouldn’t have a small group of entities abusing the system and not allowing it to work correctly.

Marc Ryan: And they’re responsible for a lot of those caseloads. But. Good law, very important to help consumers, but I do think we need improvement along the way. You know, we may not always agree on exactly what the last best offer should be as an example, but I think there are ways to refine it. The Congress has to relook at it in a much better way.

Erik Sunset: I’m with you there. Hard to argue with a good point there, Marc. And then coming back sort of to our focus here around Medicare Advantage and all these CMS plans. Word on the street is that open enrollment may be a little tougher than expected for members. Is that due to a reduction in benefits or what’s the word on the street there?

Marc Ryan: Yeah, I’m calling it sort of the October surprise for people that don’t aren’t aware of that. You know, in elections, you always fear in [00:17:00] October surprise. I’m from politics way back. And I think there could be a little bit of an October surprise where beginning in October, people start enrolling for 2025 benefits.

Marc Ryan: And there are a number of trends, the return of inflation, the return of utilization post pandemic star ratings. We won’t go into that, but they’re lower right now than they should be for plans, which costs them revenue. There is a risk scoring modeling change not to go into details there. But that means revenue is a lot less.

Marc Ryan: And that has made me a little bit upside down on their margins. And the truth is ma plans also should get some of the grief a little bit too, because in the heyday of the pandemic, they weren’t paying attention to things. They were getting big rate increases, big star scores, and they just went. out of control on benefits.

Marc Ryan: They put too many benefits in there. [00:18:00] So the combination of all these factors will drive up premiums and M. A. It will drive down benefits, and it will also mean some geographic contraction. I will also tell you that there’s again a provider payer dispute where some, uh, Payers or providers are backing out of contracts with MA hospitals, for example, because of the claims and the prior off controversy.

Marc Ryan: So all of this is going to be a little bit upsetting for consumers. They’re going to be seeing major changes. I still think MA will grow just because of that value against fee for service, but some of your docs are probably going to have to hear from their patients about. Are you still in my plan? Um, I’m worried about my benefits.

Marc Ryan: What do I do? Right? Docs are often, uh, social workers for patients, right? They trust their docs and so they’ll probably hear some of this. I will also tell you there were some [00:19:00] Part D drug changes in Medicare. It’s being championed as great things about lowering out of pocket costs and things like that.

Marc Ryan: But the truth is that law also drives up premiums. So you also have that issue, whether you’re in fee for service or an M. A. That the part D premium component will go up. So a very complex issue. But to go back to your question. Yeah, we’re going to see reductions and it’s probably going to hit people by surprise.

Marc Ryan: It’s really going to hit those fixed income, those low income people that many of your docs serve, and they may be knocking on the door saying, what do I do here? Right? Because they’re going to be in a bit of a predicament.

Erik Sunset: Yeah, yeah, that makes sense with all of the layers that we have governing health care and insurance plans and everything in between that end up impacting the patient. If there was a single flip, single switch to flip rather, I know we would, but it is just such a [00:20:00] complicated endeavor.

Marc Ryan: Absolutely.

Erik Sunset: And then looking, uh, Looking a little more closely at Medicare Advantage, there is a little bit of a stir, uh, from what I understand that CMS starting to sort out what are going to be the implications of that.

Marc Ryan: Absolutely. Yeah. So I’m a big defender of M. A. As you probably have figured out here. I think it’s the best system private delivery for for us as a nation. I argue in my book, it’s it’s the way to go. But I also believe in accountability. I want the federal government to sort of oversee the system and allow innovation on the provider side and the payer side to bring The level of efficiency and quality you need in the system.

Marc Ryan: This is one area again, where although I’m a defender of MA, I believe MA may have it too good. They may have too much of an advantage over the regular system. And I think some [00:21:00] players in MA, not all. But some players have sort of abused the system and caused some of these controversies. So there’s sort of three big ones out there.

Marc Ryan: One is the overpayment issue. I discount a lot of what some of the opponents of MA say about selection and why certain risk scores may be higher in MA versus fee for service. But they do have a point. On some players, some plans out there driving risk scores up way too much, so much so that they may use health risk assessments and chart reviews from providers, theoretically, where these diagnoses are never ever reported on a claim.

Marc Ryan: My belief is you should be able to report on a claim if somebody has a diagnosis, if you want to get paid for it. But there’s a lot of bad actors and bad activity, uh, you know, where some part of that overpayment argument is [00:22:00] absolutely correct. So I think there needs to be reform there. And I think CMS will go down that road.

Marc Ryan: The other big controversy is supplemental benefits. So when an MA plan puts in a bid, they tend to be able to do it well below fee for service. Because fee for service is more inefficient, they get a portion of that difference back to offer supplemental benefits. These are the goodies that help a lot of people afford health care that they otherwise wouldn’t be able to do.

Marc Ryan: But there’s big reason to believe that supplemental benefit utilization is not where it should be. And therefore, what plans are saying it costs. is not really what they’re spending. And I think it’s a good point. CMS is beginning some reforms to drive better utilization and to ensure that all of those supplemental benefits are submitted as encounters.

Marc Ryan: So it’s accountable and we know. And then lastly, there’s some marketing controversies. Um, I was a [00:23:00] big believer in CMS’s rule that basically ruled out extraordinary compensation between these. Big third party marketing organizations and plans, which essentially steered consumers to a given M. A. Plan because of that extraordinary compensation.

Marc Ryan: These backroom deals that they struck as opposed to what’s in the best interest of a consumer. Most agents are good, credible, independent guys or smaller brokerages, and they’re doing the right thing by their patients, much like a doctor wants to do, but others took advantage of the situation, and the reform was great.

Marc Ryan: Unfortunately. A court struck it down and said that, uh, the agency did not have the authority. You’re going to hear a lot of that moving forward based on a Supreme court decision, but Congress should get together with CMS, [00:24:00] explicitly lay it out in a law because that reform is good. But those three things, overpayments, supplemental benefits, and marketing tend to give MA a bad name.

Marc Ryan: But I do think that CMS and Congress are going to deal with some of those areas.

Erik Sunset: Well, that’s something to keep our eye on. Obviously, that’ll be a positive development, especially the extraordinary compensation that falls, at least in my mind, pretty squarely into the fraud, waste, and abuse bucket of driving costs without a real reason to do so. I see. We don’t like that

Marc Ryan: Absolutely.

Erik Sunset: and we’ve already invoked, uh, COVID 19 in this discussion.

Erik Sunset: So let’s, uh, let’s, let’s poke at that a little bit as well. You know, you think you’re finally through with the COVID headlines, uh, reading the news outlets, Beckers, what have you, but it’s, it’s still there. Um, still continues to have an impact on providers, on healthcare organizations that are, you know, they’re still taking the financial hit as it were.

Erik Sunset: Is our federal government doing anything to respond to these concerns? And we [00:25:00] mentioned our multi layered system. So then let’s tack on, what about the States as well?

Marc Ryan: Yeah, absolutely. Um, you know, so when we think about the COVID pandemic, obviously huge displacement within provider entities and even within plan entities. Um, we were already seeing more and more independent docs being gobbled up by hospitals, health systems, other firms, because they just could not make a go of it.

Marc Ryan: And, um, That actually began to accelerate once we started coming out of the pandemic because of the real impact on revenue cycle management and utilization within the office and things like that telehealth made up a little bit of that. And that was helpful. But now you’re starting to see some telehealth get reined back in because, uh, both the government and even health plans have felt maybe it went a little too far.

Marc Ryan: Um, so providers are really still dealing with the impact of COVID. [00:26:00] Now COVID is going to become endemic as opposed to pandemic moving forward. That’s sort of a good thing in some ways, because I think people will now begin. To adapt to, uh, going back and gaining utilization from providers. We sort of saw 22, a start of the comeback a little bit in 21, but really in 22, 23, we saw more, but we’re still not back at.

Marc Ryan: The utilization levels that you would expect, right? And so on the provider side, that will be a good thing, right? We’ll start to see everybody really start to come back into the system on the health plan side. As I noted, it’s a bit of a negative because they’re now seeing some medical expense issues there and margin issues, but we’ll start to see that come back.

Marc Ryan: But the reality is that the dynamics of what’s having in healthcare, whether it’s the pandemic. Utilization so far coming back or [00:27:00] even reimbursement to providers. It’s a huge struggle for providers and I’m very sympathetic here on this issue. Not so much to hospitals. I think they can get far more, uh, they can get far more efficient, but the primary care docs are terribly under reimbursed.

Marc Ryan: Uh, even some specialist areas have problems if you look at Medicare fee for service reimbursement on which much of the M. A. rates sometimes are, are, are built, um, they have not had a reasonable permanent solution for doctor payments for decades. And I don’t understand why CMS, CMS and Capitol Hill can’t get together.

Marc Ryan: Whatever it’s going to cost, it’s going to cost, get the right formula, make it permanent. Do not create these huge cliffs where providers are waiting months and sometimes [00:28:00] years to get a solution about what the reimbursement is going to look like. We know that Medicaid is a historic underpayer. Uh, some states have driven primary care rates up there a little bit, but Medicare hasn’t solved it.

Marc Ryan: And that’s a big utilization driver in the system, and we need a permanent solution there. I think some health plans have tried to do a better job on provider payments, but not all, depending on their lines of business. So, um, all of this is sort of coming together to create huge issues for providers. And that’s why today more than 50 percent really 70 percent when you think about docs owned by health plans as well as private equity.

Marc Ryan: Now it’s actually probably closer to three quarters, but we really only have about 25 or 30 percent of independent physicians out there. And again, some of your folks may disagree with me, but I believe independent physicians [00:29:00] are very important to the future of health care, because I do believe, and it’s not to say that a doc isn’t gonna, you know, do the right thing for his patient, but there starts to be some built in conflict of interest when you are working for a hospital or a health system or a private firm that isn’t really there as an independent physician.

Marc Ryan: But again, I think docs act with integrity, but I’m just a little bit worried about the erosion of independent practices and what it really meant to our healthcare system. Historically, it was the bedrock of what we did in healthcare and that’s sort of being changed a little bit here as well.

Erik Sunset: We’re worried about it too. And I think as a, as a patient, uh, you ought to be concerned by this as well. You know, you look at all the data around physician burnouts and. Listeners of the show will be familiar with our, with our thesis and really with the reality that burnout, and this is not a thesis, but reality burnout is causing [00:30:00] physicians to retire much earlier than anticipated.

Erik Sunset: And certainly individuals have the right to do what they think is best for them. But when you look at the numbers, we’re going to be faced with a massive physician shortages. Some areas in the country are already experiencing that. And what you just described, that lack of autonomy. Physicians want the best outcomes for their patients, that goes without saying.

Erik Sunset: But if you’re working for a health system, or for a large group, and your treatment protocols are X, but in my private practice life I know that Y works just as well at a lower cost and faster, or whatever the case may be, and that treatment mechanism is either taken from you or delayed, Things like that are what’s driving physicians and nurses and all members of health care to retire too soon.

Erik Sunset: And that’s bad for the system. I think, uh, unequivocally bad. And I’ll, you know, put my name on that. So I couldn’t agree more.

Marc Ryan: You’re, you’re absolutely right about the shortage. It’s going to be a killer. And frankly, I think that’s where really state and federal [00:31:00] governments have failed. They have a duty to make sure our healthcare system is robust. I’m sort of a smaller government guy, not a small government guy, but a smaller government guy.

Marc Ryan: But public health infrastructure Is hurting terribly in our country compared to some others and other developed nations. I view the physician’s shortage as part of that public health infrastructure. And we as government should spend dollars to solve that problem. But there’s no plan, literally no plan at all.

Marc Ryan: Uh, there’s a couple of innovators out there at states and there’s a couple of healthcare systems and things like that that are doing it. And I applaud that, but we don’t have a national, uh, you know, policy or agenda about how we’re going to solve that. And again, It is actually happening in every developed world just because of trends and things like that, but I think it’s going to hit us the worst.

Marc Ryan: Right? We also tend to have an over [00:32:00] specialization in our country compared to others, which essentially steals dollars from primary care in favor of specialties. No offense to specialists. They’re needed. But there’s also that imbalance that also is part of that overall physician shortage too.

Erik Sunset: I’ve talked to a lot of smart folks like yourself, Marc. And I ask the silly question, like, If you had a magic wand, how do you fix this looming shortage of physicians? And even here, I’m in South Florida. We certainly don’t have the shortage of physicians. Physicians by number, but access to physicians has been more difficult to come by every month and year that passes.

Erik Sunset: So if you, I’ll pose the question to you, if you had a magic wand type fix, what do you do?

Marc Ryan: Well, it’s a difficult thing, right? Uh, and I really believe that we need comprehensive healthcare reform in part to solve that. So I believe we have to pivot from Uh, you know, pivot from what we always did on prior authorization to wellness [00:33:00] prevention and care management, which would free up a lot of dollars to reimburse better and things like that when you reimburse up front, better in primary care as an example.

Marc Ryan: You see evidence of real change and prioritization, right? There should be policy that drives better care management and wellness and prevention, but reimbursement would help a great deal, I think there. But I also think part of it, of this is cultural. At one time, uh, being a doctor was pretty lucrative, almost in all cases.

Marc Ryan: And people were seen. As very important in society, and I’m not saying docs aren’t seen importantly. I think they’re very well respected, but there’s been erosion of what I would call the prevent the profession of medicine right in favor of all sorts of weird economic issues and things like that. And I think we got to change that paradigm as well.

Marc Ryan: We [00:34:00] need to spend money convincing people that being a primary care physician is probably one of the most important things you could do in the medical world. And we have to lift the burden on physicians so that when you’re making that decision to go to medical school, Uh, you feel like you can be successful.

Marc Ryan: And again, I say government should have a role in that. I don’t have a problem with subsidizing medical education, uh, so that somebody can have their lifelong dream of being a pediatrician accomplished rather than paying off student debt by being a. Specialist, right? I think we have a duty to craft that solution.

Marc Ryan: I think, I think we have a lot of that putting it together. It’s going to take a little more brain power, a little more money, but that’s money well spent in my view. Otherwise, we’re really going to crash here. We’re headed for a crash. And that’s what we really have to think [00:35:00] about. So I didn’t quite answer your question, but, uh, I hope I gave you a couple thoughts there anyway.

Erik Sunset: No, you did. It was a comprehensive magic wand because it’s two parted. You need to keep physicians happy being physicians now, keep our doctors employed, our mid level providers employed now and satisfied with their work. But then that medical school throughput, but That’s, that’s tough because you’re looking at an eight year lag if you could wave the magic wand and start that today between medical school, your residency, your fellowship, and then being able to treat patients.

Erik Sunset: That’s what scares me. We have magic wands at our disposal for right now, but a decade from now, things are going to be really different with access to healthcare.

Marc Ryan: Yeah. And just as a side note there, I was, I’m a former hospital board member of two hospitals. One, it was an academic health center. I think we really have to focus in on the costs at these academic health centers, uh, direct medical education, graduate medical education, how we think about new [00:36:00] ways of financing medical education, just given the sheer cost.

Marc Ryan: Because many of those health centers, as much as they want to do the right thing, it is so costly, so burdensome that that has really broken as well. And so that’s another part of it that you raised in my head when you talked about that. So.

Erik Sunset: I’m with ya. I haven’t found a point to disagree with yet, and I would if I, uh, if I did. One of the, um, one of sort of the shining examples though in healthcare now, or maybe not a shining example, but a step in a very positive direction is around value based care. And some of the, some of the feedback that I’ve heard around value based care is sort of tongue in cheek, like, I’ll talk about it, but what do you mean?

Erik Sunset: What is value based care? Because I can’t, uh, get a consensus on a definition. So where, where do you see us going, uh, as a country with value based care

Marc Ryan: Yeah, I totally if you talk to one person, you’ll get a definition of value based care. And then you talk to 10 others [00:37:00] and suddenly you probably have 20 definitions, believe it or not. Right. But, you know, value based care. I still think. is a concept right now, right? I think it’s a good concept. And the tenants of value based care are sort of sitting out there, but we haven’t yet mastered what it means.

Marc Ryan: And we’re really sort of in the infancy of value based care. And I’m one of these guys that says these complex things are going to take years to really develop, right? I sort of split value based care into two things right now. You have sort of value based payments where a doc, a provider group, uh, uh, in a, an ACO even, or, or others are being paid for a service on a value based payment basis, or even for an episode, you know, we see knee replacements and things like that in the commercial and the Medicare world now that are going down that road.

Marc Ryan: So these value [00:38:00] based payments. are starting to chug along. I, I believe that in many respects, I’m not sure that the regulators know enough about them and the fallout on doctors to make them terribly effective. They are also very expensive. A lot of these pilots are very expensive. These value based payments.

Marc Ryan: So, uh, and there are so many out there in many cases, these pilots and value based payments that, uh, Doctors are confused by what this pilot value based payment really is, and again, they can go from, you know, payments for one service or even payments and reconciliations like in an ACO that are based on quality and savings.

Marc Ryan: So. My view there is again, I applaud. I’m a big defender of CMS. I think they innovate reasonably well, and they’re trying to change the system. But if I had one message for CMS, I would get [00:39:00] rid of most of the pilots focus in on two or three that makes sense, educate providers, get pie in and And then you might have more success on the value based payment world, right?

Marc Ryan: And you’d reduce a lot of admin on the doc side and the hospital side, as well as on CMS side, a lot of the, uh, congressional budget office reviews have sort of shown that with admin, we’re not really saving money now. Sometimes that’s okay. At the beginning. But we need to start saving money in these programs.

Marc Ryan: Then we talked about sort of the provider payer relationship. And this is where it’s getting again. It’s in its infancy, but it’s growing. And this is where payers and providers are entering into risk arrangements. It could be. Capitation with certain rewards, but it’s also partial risk on services or global risk on services, depending on how mature and large that [00:40:00] organization is.

Marc Ryan: I come from the Miami and in South Florida world where a global risk and partial risk has been part of that dynamic for decades. There are many metro areas where that’s the case, but more and more you’re starting to see those risk amate. Risk arrangements grow. And I think that’s a good thing. I think rewarding physicians through risk arrangements on quality and cost reduction is a good thing.

Marc Ryan: It emphasizes hopefully the need to do both reduce costs and drive quality. And I think that’s a good thing. But again, in some, this is going to take us decades to get there. And I do believe that part of that paradigm, Is getting to true interoperability without the right data or the right information of VBC and VBP are going to be somewhat limited in in their success until then.

Erik Sunset: before we, before we touch on interoperability and that’s like a dog whistle for me having spent [00:41:00] 15 years in EHR land with the advent of meaningful use, uh, stage one, stage two, all the way through now to MIPS. Um, but before we, before we go to interoperability, uh, I wanted to touch on one thing with value based care that some of the physicians we speak to and have as clients are all for it, would love to be compensated for delivering true value to the patient, to the system at large.

Erik Sunset: You mentioned it’s going to take decades for this to be reality, I guess I’ll put words in your mouth a little bit. I think based on the feedback that I’ve heard and just understanding human nature and Americans as consumers. It seems like there will need to be a little bit of a shift towards more individual accountability for one’s health, despite social determinants, despite household economics, despite all these headwinds for value based care, and despite What, you know, I love about our country is that if I can fix a problem really easily, something like a GLP 1 agonist like Ozempic, if I can get an [00:42:00] injection and just overnight become healthier, I’m gonna do that.

Erik Sunset: I think that’s positive overall, but that makes things like value based care, you know, significantly more difficult. What’s your take on that?

Marc Ryan: No, I think you’re absolutely right. And let’s be really honest. a Republican, but I’m sort of a moderate Republican. I’m a pro coverage Republican. And therefore I believe in things like the Affordable Care Act and things like that. I believe that investing up front, uh, in coverage. will save us down the road no matter what we spend in subsidies so much more than having this emergency room inpatient undiagnosed cancer type of thing that we have.

Marc Ryan: I do think social determinants are real, right? And it’s very hard when you do have major social determinants to drive personal responsibility. So that’s where I think providers and [00:43:00] plans and even the government have a duty to try and overcome that barrier. The other thing I would say is I think Republicans fall back way too much on the issue of personal responsibility.

Marc Ryan: And the reason I say that is I’m a big believer in it, and I think we can get there, but when you have a system that is so expensive and really means that people. cannot access the system because of price, it’s hard to make personal responsibility a real thing, right? And so that’s an important point. And that ties into the SDs. I will side with the Republicans on one thing, personal responsibility, as we reduce the cost of Is a very important thing. We cannot ask doctors to be social workers. We can’t ask health plans to be social workers over time. People do have to take responsibility for their own health. And when we [00:44:00] make it more efficient and less expensive for people, and there’s no Barrier to obtaining care because the cost is not an issue for that person.

Marc Ryan: I think there should be penalties as well as incentives, uh, to encourage personal responsibility. So again, I’ll put it in there as a good piece of what we do in some ways, until we sort of reform price and things like that, sort of takes a little bit of a backseat because you’re fighting an uphill road.

Marc Ryan: Now, some people will accuse me of being wimpy on that issue and things like that. But if you start looking at price and why many people don’t activate care or delay it, it really is foundationally on price.

Erik Sunset: Well that, and that’s a good segue into discussing the Affordable Care Act a little bit, better known as Obamacare. Uh, absolutely indisputable success for getting coverage to Americans that either weren’t able to get it, [00:45:00] weren’t able to afford it. Um, on the flip side, slightly contentious that just because you have the coverage doesn’t mean you’re ever going to take advantage of the services or the care that are now available to you, either for economic reasons or otherwise.

Erik Sunset: Let’s dive in there. What, what better time than now?

Marc Ryan: Absolutely. So again, I told you I’m in favor of Obamacare. Um, I’m part of that small cohort of Republicans in Congress that, you know, believe it was a good thing. Um, you can always argue about the excess. Of a given program, right? And I do think there are some excesses in the Affordable Care Act. If I were to sort of remap everything, I might have the benefits be a little less generous, right?

Marc Ryan: I might redo the subsidies a little bit. I will tell you that I think. Middle income people deserve more of a subsidy because paying eight and a half or 10 percent of your income [00:46:00] before you get a subsidy is huge, even for a family of four at a hundred and some thousand. And I might take away a little at the bottom because maybe it’s disincenting that personal responsibility.

Marc Ryan: We, we talked about that might actually begin to become something if you’re paying very little, but in the end, Setting aside that the Affordable Care Act is a good thing for the nation because it begins to prioritize universal access and it begins to get people covered up front and it gives us the ability over time to pivot to care management and things like that.

Marc Ryan: And I think that’s absolutely essential. My big fear about the Affordable Care Act is that we just made huge, uh, You know, gains, uh, again, Donald Trump sort of was anti ACA and sort of tried to rein it in as much as possible. Biden came [00:47:00] in and he really did two things. He made major investments in it, which is really important to health plans.

Marc Ryan: The health plans make decisions as much on economics as what the public figure is saying about the program. It was hard for, uh, a money making venture to make an investment. In the health, in the exchanges under Trump, when he was constantly bashing it and the Republican controlled Congress was bashing it, it’s no mystery that when Biden came in and made some investments, uh, that you saw enrollment go up to record levels and plan participation and network coverage go up to.

Marc Ryan: Great, great levels, right? And this is coming from a Republican. I’m just sort of trying to give you the reality. Then of course you had the premium subsidy enhancements. And again, personally, I would argue they’re probably too rich. And [00:48:00] should they be P be permanent? They were probably good for the pandemic, but are they too rich?

Marc Ryan: Right. Is the question. And again, I would say you didn’t make middle income, uh, rich enough. And I would argue the middle income guy is always getting hurt. Right. But would I re up at least for some time, the current version of premium subsidy enhancements? I would, because it’s done a couple of things. It drove enrollment up by millions of lives.

Marc Ryan: It’s stabilized. Uh, the exchanges in the Affordable Care Act and plan participation and things like that are a record high. You’ll see an erosion. Now, should we make it permanent at the current levels? Perhaps not extended relook at what you want to do moving forward. Uh, but I think taking it away at this point would be a bad idea.

Marc Ryan: I heard an interesting thing the other day from the Paragon Institute, which is generally an opponent of [00:49:00] these kinds of things, which said, uh, there’s some fraud in the system, which we should worry about. Maybe you grandfather the current people, right? So those are some of the ideas that I think should be done.

Marc Ryan: Um, but it is in danger, depending on what Congress looks like, whether Harris is president or Trump is president. Um, it may not. Re up itself, right? That could be a huge problem for the system that has really gained a lot. Now again, it’s very expensive. There’s still a lot of issues, but we’ve gotten to a point where people have coverage, and that’s probably the most important thing.

Marc Ryan: And

Erik Sunset: that Obamacare, uh, didn’t get more people covered. It absolutely did. No, no two ways about it. Um, so that’s a good first step towards, uh,

Marc Ryan: I would say, uh, uh, you know, Medicaid expansion was also very important. Medicaid is perhaps the single [00:50:00] cheapest way to get people coverage. I know that there are access issues and other things there, but if we sort of made some additional investments in rates and things, that’s the single best, most stable way to get people covered.

Marc Ryan: I don’t understand the philosophy of 10 states that have not been It’s a bargain at any price. I think it’s philosophical inclination that has stopped that. I find it fascinating that I’m of pretty good means. And my daughter found herself as one of those millions of people. that were in that coverage gap because we live in one of the 10 states, Florida that has not passed Medicaid expansion.

Marc Ryan: Her employer didn’t offer it. So what did I have to do? I had to buy a policy for her. I was lucky enough to be able to do that. And my daughter had some expensive things because of a brain condition at the time, but not everybody has that luxury and [00:51:00] millions of people are in this coverage gap. And to me, it’s almost sinful that politicians have not reacted to that.

Erik Sunset: Yeah, again, coverage is the first step towards a healthier nation, and then we can look at the, you know, more exotic levers to pull light value based care and incorporating that personal responsibility and really getting us on the right track from, from all ends of the spectrum. And I pivot us pivoted us towards Obamacare, um, at the expense of our interoperability, uh, points that we wanted to make.

Erik Sunset: And like I said, What a dog whistle for me, having been around at the outset of Meaningful Use. And we’re going to get everybody digital. And that’s the first step towards nationwide interoperability. And I can still hear it. If you get in a car wreck, God forbid, in Maine, and you live in Florida, that doctor’s going to know all about your records.

Erik Sunset: You won’t have to tell them anything because it’s just going to be there. And we’re not, we’re not really all that much closer than we were in 2009. Now in [00:52:00] 2024, um, so what’s new on the interoperability landscape?

Marc Ryan: sure. Just just to say you’re absolutely right. We’ve made very little progress. We’ve passed some funding and some rules, but so far we really haven’t even gotten there. And the thing that worries me most is there are some rather progressive states that have had some pretty good successes. They actually have functioning regional health information exchanges, right?

Marc Ryan: It’s nascent still, but at least they’ve made that move. But if you go to another state of the nation and we won’t use words there, but, uh, they couldn’t even tell you what an HIE is, right? So, uh, our nation is sort of hobbled by the fact that we are a bit of a 50 state Autonomous type of nation, and depending on whether your state makes it a priority, your road to interoperability could be far longer than it might be in, say, a [00:53:00] California or in New York or some other states.

Marc Ryan: I do, though, think the latest rules. Are going to probably begin to have some benefits. So I do believe the fact that we’ve now gotten to dictating a standard, which, for the most part, you’d call the fire standard is a very good move, because before that, we didn’t we had some sort of meaningful use and interoperability standards.

Marc Ryan: But at least now we have the fire standard that I think, again, it’ll take a decade or more. But we’re starting to go down the road of having a standard to use now, when we introduced HIPAA many years ago, everybody thought that was going to be, you know, one HIPAA file for each of the areas. We know that’s not true, right?

Marc Ryan: A HIPAA 837 and a HIPAA 834 can be as different, but at least it is a standard, and I think FHIR will get us there as well. [00:54:00] I will tell you, I think the biggest challenge, even with the standard, is providers and payers talk different languages. Yeah, they deal with diagnosis codes and things like that. But if you dig your way into an E.

Marc Ryan: M. R. It looks a lot different than the terminology that plans are using. And you also have the issue of how old the data is in the E. M. R. And really, how actionable is it? So we’re going to hit those barriers even with the standard. But over time, I think smart people and good plans and provider groups and things like that are Are sort of going to work it out.

Marc Ryan: The other encouraging thing about interoperability, I think, is the electronic nature of PA. Right? We have that in the retail world already with the NCPDP submissions and e prescribing is a majority of what’s done today by docs. And I think it’s pretty well accepted. We’re going to get that in the medical world too with EPA as well.

Marc Ryan: I think that might be a [00:55:00] little easier to deal with than the care management data that you have to make a lot of decisions and understanding about. But I think the standard is good. The mandate to tell plans they got to move forward is good. I still feel like what we’re missing on the provider side. Is there are probably two things, especially for those that maybe aren’t part of the health system or something like that.

Marc Ryan: Resource is a big issue on the provider side to get, uh, in resource, you know, in budget is, is going to be a problem there. And I think knowledge and expertise is also a problem. So it’s 1 thing to pass these. Rules, but I also think you need to have some money on the provider side from the federal and state governments, sort of like we did with E.

Marc Ryan: M. R. Meaningful use way back when, because providers can’t afford it. They don’t have the expertise, the time or the [00:56:00] money to get there.

Erik Sunset: I would even take that a step further, things like FHIR standards and being able to utilize APIs to interchange data meaningfully. Shame on health IT at large, um, that there wasn’t a bigger, bolder move towards APIs and legitimate interoperability.

Erik Sunset: Whether that’s because battle lines were drawn and we’re not going to share our clinic data with this guy’s EHR, we’re not going to do it. You need to be in our ecosystem. That may even be worse than just a willful, uh, ignorance of API utilization for lack

Marc Ryan: I think you’re absolutely right. And your last point is good. E. M. R. Entities. Companies have a duty to really open up, uh, and be in that ecosystem. They see it as a threat to their viability, but I think that’s a long way, old fashioned way of looking at it. Right. I think openness will actually probably give them more [00:57:00] opportunities.

Marc Ryan: They’re just afraid of losing what they have. Right. So I think that’s a great point as well.

Erik Sunset: This is a, this has been fantastic. And as a way to sort of wrap up, Marc, I ask all of our guests of this show thoughts on AI in healthcare. And this is, the question is stated exactly how I want to ask it. Very broad. What are you seeing? What are you thinking? Wow.

Marc Ryan: is incorporating a lot of AI into its platform as well is we really believe that our artificial intelligence is going to create efficiency and find things, frankly, that, you know, a human mind can’t find. And I think that’s absolutely correct, right? Some of AI Even that we’re doing will be just fairly, you know, looking at document scanning and going into those documents and finding it much faster.

Marc Ryan: Right?

Erik Sunset: Love it. What a great way to cap off our episode, Marc. [00:58:00] As, uh, as folks have listened and enjoyed, uh, hearing you speak, how, how can they connect with you? Are you big on any social medias? Where can they see your work?

Marc Ryan: Yeah. I sort of limit my social media to LinkedIn. I’m on Twitter, but I don’t really use it much, but you can always go to my healthcarelabyrinth. com website. Again, a newsfeed five days a week. a blog twice a week, a podcast once a week. I’m also like you on leading podcast apps and sites. Um, and again, you can subscribe there if you want to, to the blogs and newsfeeds and podcasts.

Marc Ryan: Uh, my company again with two co founders, which I’m delighted about is called lilacsoftware. com. We also run some, uh, star and quality improvement in medical economics blogs on that site. So healthcarelabyrinth. com. And then also, uh, lilacsoftware. com. And then on LinkedIn, just search for Marc [00:59:00] S. Ryan, and you should be able to find me there.

Erik Sunset: And we’ll make it even easier than needing to be found. We’ll get all the links to those, uh, URLs into the show notes. Marc, thanks for the time. This was a great episode.

Marc Ryan: Thanks so much. Love to, uh, love doing this and, uh, really, uh, would love to come back at some point in the future to talk about any new things as well.

Erik Sunset: Oh, you’ve got a standing invite. And on behalf of the entire DocBuddy team, thank you for listening. Be sure you’re subscribed on Apple podcasts, Spotify, and YouTube. We’ll talk to you on the next one.