Lisa Farren (Host): Hello everyone, and welcome to Crushing Healthcare, where we explore diverse perspectives regarding the state of healthcare today, and gutsy visions for a more affordable, accessible, equitable, and sustainable healthcare model. My name is Lisa Farren. I'm your host today. So in recent episodes, we have had a variety of guests talk about such things as clinical integration, particularly with regard to value based care and population health.

Most recently, we talked about the role of data in healthcare to inform decisions and to improve outcomes. Building on that discussion today with our guests, we'll examine healthcare through a financial lens. I'm excited for our guests today, both of whom have extensive experience in this area. Trudi McKenna and Stephen Rolfsmeier, both with Southern New England Healthcare, also known as SoNE Health.

Trudi is Chief Financial Administrative Officer at SoNE. Trudi is an industry veteran with more than 25 years of experience in finance and healthcare, including extensive experience in strategic planning, finance, operations, administration, health system integration, and transformation.

In her current role at SoNE, Trudi has optimized the financial performance and growth over the past nine fiscal years to generate positive bottom line results. She has led the MSSP ACO entity, which has produced shared savings totaling 50 million since 2020. She was integral in the initial development and infrastructure build of SoNE Health as a clinically integrated network.

Working closely with Trudi at SoNE, we also have Stephen, Vice President of Medical Economics. Stephen has extensive experience in leading risk measurement teams and innovating and automating sustainable, multifunctional financial infrastructures. His career spans Medicare, Medicaid, and commercial lines of business with breadth and depth of experience in healthcare analytics from both payer, insurance company, and provider vantage points.

 So we have two great guests. With that, Trudi and Stephen, welcome to Crushing Healthcare. Thanks for joining me.

Trudi McKenna: Thanks, Lisa, thanks for having us.

Steve Rolfsmeier, FSA, MAAA: Thank you.

Host: I'm looking forward to diving in to the financial side of health care today. So we all interact with the health care system, whether directly ourselves visiting a physician or perhaps accompanying a child or another loved one to an appointment; health care touches us all. And like most everything else these days, we're experiencing rising costs.

More and more patients are approaching healthcare with a consumer mindset. So with most other purchases a person makes, think maybe buying a car or even just going to the grocery store to buy food, consumers have the information and the ability to compare prices and base their purchase decision on those, from that information.

They have a sense of value associated with cost, but I would argue for most of us, healthcare costs and value are shrouded in mystery. We don't know how to make those decisions. So today, we're going to try pulling back that curtain a little bit, and I look to both of you to share your experience and expertise in that.

So let's start on a very high level. As I mentioned, costs are going up, everything in the healthcare realm, from premiums, deductibles, and prescriptions. They're getting more and more expensive year over year. Why are costs on the rise?

Steve Rolfsmeier, FSA, MAAA: So let me put an exclamation point on that too. Every year there's a number of industry reports that come out about this time. With respect to those most recent industry reports, we're seeing trends are going to be higher than they've been in about 10 years, reaching seven and a half to eight percent. And at its core, these are always driven by increased utilization, more expensive services, increased costs. And what we're seeing driving those, the increased utilization generally over the long term is that we, we do have an aging population and that aging population has increasing rates of the chronic condition epidemic is being pushed down to lower age groups, lower age brackets,

We are seeing increased chronic conditions, but on the cost side, we're also seeing new technologies and drugs driving increased costs. So we've seen gene therapies,

that are really miracle cures. Recently they can cure certain types of cancer. We've never had that before, but also we're seeing increased utilization of other miracle drugs that are, driving, say, anti inflammatory drugs. And, I guess most recently probably everybody's aware about the GLP 1s.

Which were primarily used for diabetes, but now are being used for weight loss and, and even cardiovascular, and as time goes on, probably more and more indications; they'll be used for more and more indications. And there's some other dynamics that are happening in the industry as well, such as provider consolidation and workforce shortages that are driving up wages.

Host: Sounds like there's a lot of factors. It's the perfect storm, if you will.

Steve Rolfsmeier, FSA, MAAA: That's right. So given that these trends are high, the highest trends that we've seen in years, it's important that we ensure every dollar spent on health care is high value. And what that means is that we're achieving high quality care and high outcomes, good outcomes for our patients. That means that we need to improve the health status of our patients and reduce the cost of and trend at the same time. And we can achieve that by reducing the A1C in our diabetics, the A1C markers in our diabetics, making sure that patients keep their blood pressure under control,

making sure that patients seeing their PCPs and getting their preventive screenings as needed.

Making sure that patients

don't always go to the hospital to get their surgery. Maybe they can go to a lower cost site of care to get a surgery, like an ambulatory surgical center or a freestanding surgical center. Maybe going to the urgent care instead of the ER. All of these things can help. Reviewing medications to make sure that they're still necessary and appropriate. So, these are the things that we can do to increase value. And if we do that, everybody ultimately wins.

So, we're talking about the doctors win,the patients win, the payers win, whether it's Medicare or it's the insurance company. Everybody wins, but most importantly, the patient can win because it'll hold the premiums in check. It'll keep the out of pocket expenses in check and they'll have a better patient experience overall. I guess most importantly, the health status will improve and the quality will improve.

Host: That's great. That's ultimately what we, I think we all want, is we want positive health outcomes. We want to live a long, healthy, active life. And of course, the idea of driving down costs. So, I think that, that would resonate with everyone. So, I think that's great. I'm curious, so, can you speak a bit about how it is exactly SoNE Health is helping to rein in these costs?

Steve Rolfsmeier, FSA, MAAA: Yeah, so, basically our team, what we do is we essentially, we leverage vast amounts of data and evaluate this data to compare what we're seeing in our specific data, whether it's at the patient level or if it's an aggregate. It can get fairly granular. But we compare this data against industry benchmarks. And that helps us set expectations to see kind of where our outliers are. Are the patients keeping their blood pressure in check? Are we performing to the best standards that are available? We use that data to do those things. And then we identify trends, we identify high cost areas, and we work diligently, basically, to keep those trends and costs in check.

Host: So it sounds similar to a recent episode we had speaking about data in healthcare, where, as you mentioned, the outliers, so you can identify the areas outside of where you want them to be and then take remediation action to help the population at whole as well as more granular on the individual level. Is that correct?

Steve Rolfsmeier, FSA, MAAA: Yeah, and then once these issues are identified, then we basically work with the population health team and the broader network, informing them of what we're seeing in the network. And then we devise strategies to keep those costs in check and increase our quality.

Trudi McKenna: Yeah, I'd like to say, Lisa, that you know, it takes a village to look at this, and so what Stephen's team looks at all of this data, and there's a ton of it, and then we utilize that, we kind of cull it down, if you will, so that it's actionable, and then useful for the population health team and the providers in the network so that they can be identified where there are opportunities related to their patients that are at high risk or are just missing care gaps, right?

So that's really something we focus on after we look at all of this data so that we can help drive this industry trends or try and stay ahead of them, if you will.

Host: Thanks, Trudi. Yeah, it's good to hear that as patients, I don't think we realize that all this is sort of happening behind the scenes or can even be happening behind the scenes. It's good to know that there's the data, there's the tools, and then the team behind it to really wrap around the patient to support the providers, and work toward better outcomes. As I mentioned, that's really the, the ultimate goal, right, is a positive health outcome.

So these sound like really good approaches and strategies to bend down and stabilize healthcare costs. Are there any, I'm thinking of this through the patient lens now; are there any action items that we as patients can do to assist in lowering costs overall?

Trudi McKenna: My first comment would be, talk to your providers, right, to understand. Sometimes as you said, it's an unknown, right? And from a patient perspective, you, we live in the healthcare world, but we don't always understand it from a patient perspective, how it all fits together, right? So I think it's really important to ask questions when you go to see your providers, so that they can help you identify if there's a lower cost opportunity, or you're looking at all of the different options that may be relevant to your care.

Host: So for example, would a question be such as if somebody needs surgery, as Stephen, you mentioned, not necessarily, the hospital may not be the best location to have that surgery. Perhaps, a surgery center would be a better cost. Is that the type of questions you mean? Like asking, where can I have this? Why are you suggesting the hospital? Those types of questions?

Steve Rolfsmeier, FSA, MAAA: You should definitely ask, but they should also stay informed, too, because sometimes maybe the provider assumes that the patient wants something that maybe is not cost efficient for the patient, but maybe the provider is assuming that they want to have a, have a surgery in a particular hospital because it's known in the area or something like that, but there is a lower cost option available. Just having the information, asking good questions will help direct that.

Trudi McKenna: And as you started the podcast, right, Lisa, as a consumer, it's not like what we do with everything else that we might purchase, and you know, I think that's important to have the patient advocate for themselves and research and understand, because they would do it with another purchase in their lives, right? So I think it's something that people don't always feel comfortable or understand to ask those questions.

Host: That's a very good point. Absolutely. And you know, what it makes me think of is in previous episodes, we've talked a lot about one important aspect of value based care is really the physician-patient relationship and that it's a collaboration, it's teamwork, it's forming a trusting relationship.

So I think that's a bit at the root of it is, is patients need to build a relationship with their primary care provider so that they feel comfortable asking the questions and having these discussions, particularly before a chronic episode happens so that they understand that they can ask questions and it's a team approach.

Trudi McKenna: Definitely.

Host: So can one of you share SoNE Health's results in this area and the work you're doing?

Trudi McKenna: Sure, I'll do that, Lisa. So, SoNE as an ACO, as a clinically integrated network, has really been performing well over the past five years, seven years. So we've demonstrated within Medicare Shared Savings Program, which is a CMS program for Medicare, traditional Medicare patients. We've generated over 50 million dollars in savings across our region, which is Connecticut and Massachusetts. That represents approximately 380 dollars per member per year. So that's a patient and savings for each of the members that SoNE manages. So typically, if you say have a patient and they're unmanaged, their care could be much more expensive.

And so that's something that we do. That's something we utilize the data to understand that and see how we can do better. We've been one of the best performing ACOs across this timeframe in both Connecticut and Massachusetts markets, even during the COVID years. And we expect to continue to do, have that same success and results for 23 and 24.

We also recently did a survey, an analysis, I should say, with an industry consultant and they've demonstrated that our SoNE ACO performance is more regionally efficient than others across many states. So that means that we, SoNE, is helping to save CMS about 15 percent more than other ACOs. And we see that across, we're in multiple health plan ACOs beyond Medicare. So we see that result continuing across all of those different value based care arrangements, and helping for saving the money related to the patients and then the providers overall so that we have the improved results and maintain quality and care.

Host: Those are impressive results. Wow, thank you for sharing that. So, SoNE is really, it seems, the recognized leader in this area, in your region.

Trudi McKenna: Definitely. We really are. And I think it's continuing to show that. I think as we continue to grow back our lives, we'll continue to see that, that still improved results.

Host: It's good to hear that there is work being done in that area, and as patients to understand that yes, there is work being done to drive down costs and help improve outcomes. So I think that's awesome. Thanks for sharing those stats. So I'm curious as patients and health care consumers, we have a role to play. What can we do ourselves to help in this area?

Steve Rolfsmeier, FSA, MAAA: I'd say first, we really cannot emphasize prevention enough. So there are a number of things a person can do, but most of them really do boil down to prevention. And at kind of at the top of the list, every patient really should have a PCP, a primary care physician. When they have a primary care physician, then they can get advice about prevention.

They can identify, that PCP will help them identify issues earlier, if there are any. If surgery is needed, or if some other lab test is needed, that PCP can help direct them to not only a high quality place, but a cost efficient site of service. And there's other things that the PCP can provide advice on, but that I would say near the top of the list is that they would, they should have a PCP and then communicate with that PCP about their health conditions.

Host: Yeah. What, what you're saying definitely resonates as previous episodes we've had various other guests and that was a common theme is really the, the idea that nothing is more important than the physician-patient relationship, and that it really needs to be collaborative. And working together as a team in the patient's care, needs to be a trusting relationship, one with open communication. So it's definitely a theme that I see, a recurring theme when we speak about this and value based care.

Steve Rolfsmeier, FSA, MAAA: And of course, once they have their PCP, they should also get their screenings. Make sure that they've had their breast cancer screening, their colon cancer screenings, that all of their health metrics are in check. We talked about blood pressure and A1C metrics earlier. Making sure that they're taking their medications as prescribed and following their regimen. At informing themselves and asking questions to their PCP about cost and quality questions, if there are any. So, they might ask about the cost of a treatment or whether or not the treatment is even necessary. Is there a lower cost site of service that they could go to? Maybe they should be using an urgent care instead of an ER, for example.

Host: So it comes down to, I would say, similar to every other industry, is really, we need to be informed, we need to ask questions, and we need to do our research.

Trudi McKenna: And at the end of the day, live a healthy lifestyle if possible.

Host: Yes. Absolutely. Well, all right. I've ended previous episodes saying maybe that's the takeaway today. And I'm going to say it again. Maybe the takeaway is for those out there listening who have not visited their primary care physician recently or had a good conversation, maybe that's the start is make sure you do that today and make sure you have your, your physical and start the conversation.

Thank you both for joining us. I think it was a good discussion. I think it really helps us understand a bit about the mystery behind healthcare costs. And it's good to know that we as patients, healthcare consumers, that there's actually action we can take to be a part of that and help drive down costs ultimately.

So thanks again, Trudi and Steven for sharing your expertise with us today, helping us better understand this very complicated topic. I appreciate it. I thank everyone out there who's listening, thanks again. I want to remind you that we all have a role to play in healthcare transformation. So please join us in Crushing Healthcare.