Scott Webb (Host): Today I'm joined by Montez Carter. He's the CEO of Trinity Health of New England, and he's here for a lively conversation about Health Comes First, which is a campaign to raise awareness about the importance of fair and equitable reimbursement from commercial insurance companies for healthcare providers.

 This is Transforming Your Health, the podcast from Trinity Health of New England.

I'm Scott Webb, and today we're talking about the campaign to raise awareness about the importance of fair and equitable reimbursement from commercial insurance companies for healthcare providers. And so it's great to have you here, Montez. Welcome to the podcast.

Montez Carter, PharmD, FACHE: Thank you. And I appreciate having a chance to discuss this important topic with you today.

Host: Yeah, it's always nice to have the CEO of an organization on to answer these types of questions. And Montez, I know when it comes to the cost of healthcare and health insurance payments and coverage, it's confusing. It's a confusing topic with many contributing factors. One of the key factors is the dollar amount or percentage commercial healthcare insurance companies pay a healthcare provider to reimburse them for a service they provided to a patient with that insurance coverage, right? We've all been through this, right? People who are listening are nodding their heads saying, yeah, this is a bit confusing. So just wondering if you could break it down for us a little bit more and help us understand how it all works.

Montez Carter, PharmD, FACHE: Yes. And you know, Scott, it's very interesting, right? Because whenever you talk about costs, it actually depends upon whose costs you're referring to. So there are different lenses, even when you say the word healthcare costs. So if you are a patient, healthcare costs are what you pay on a monthly basis for your insurance, when you do seek healthcare services, what is your deductible, your co insurance, your co pay, all of those things in terms of patient responsibility. That's the lens by which most patients think of health care costs. If you're an insurance company, health care costs is based on how much do I pay providers or hospitals for services that are rendered.

So if someone's getting a CT or MRI or has to have surgery or has a heart attack, pneumonia, insurance companies lens is how are health care costs relative to services that we're paying for. If you're a health care system like us, a hospital, a provider, our costs around health care is how much do we pay for salaries for our colleagues, how much do we pay for supplies, medications, the light bill, maintenance on our buildings and things of that nature.

So for us, our healthcare costs are around the inputs that it takes for us to deliver services. And so a lot of what we'll be talking about today is particularly from our vantage point as a healthcare system. How do we take the costs that we have and that we have to do business and then how is that adequately offset by the reimbursement that we receive from different forms of payment.

And just to try to simplify it, even though it's not necessarily just as simple, but it's pretty accurate. You know, we get paid in about four different ways, in terms of depending on what types of patients in general that we care for. So, there are patients that have no insurance that come to us that we care for them and, and we're able to deliver their services, but they may or may not have an ability to pay. And that's part of our mission is to care for vulnerable populations. So for those patients that come to us, we have financial assistance programs, which may result in us getting little or no payment for their services, regardless of the cost to provide that care.

Then we have government payers and they're kind of two buckets Medicaid patients, Medicare patients. They come to us, receive the same care, and we get paid a percentage of our costs relative to the services that we provide. If you look at some of the more recent data from the American Hospital Association, for instance, they estimate that for a Medicaid beneficiary who is treated in our hospitals, that we get reimbursed about 62 percent of our costs.

If they are a patient that is on Medicare, that we're reimbursed about in the mid 80% of our costs. So, from a cost perspective, payment perspective, we consider Medicaid and Medicare, as under reimbursed types of patients we care for. And then we have the commercially insured patients, which pay us a cost of care plus some sort of a margin.

And so as you put all of those together, all of those patients that we're caring for, whether they're no insurance, Medicaid, Medicare, commercial insurance, all that are meeting the needs of the community, then at the end of the day, we collectively have to be able to care for them given our costs and then receive reimbursement that at least covers our costs, but then also exceeds it so that we can continue to reinvest in our colleagues. We can continue to reinvest in our facilities and our evolving cutting edge technology that patients explore.

So it is confusing because when you say costs, it depends on whose costs. And then even when you get into the various commercial plans, how we get paid, what services are covered, depending on what type of plan an individual patient has, it varies. So there's a lot of complexities that have really been built in over the last 40 to 50 years. And it does make it confusing from everyone's perspective.

Host: Yeah, it certainly helps to have you break it down like that. And as you say, you know, you have just obvious anyway, that you have a lot on your mind from the big to the small to keeping the lights on and all that good stuff. So have a little better sense anyway. And I know that earlier this year, Trinity Health and Trinity Health of New England launched a Health Comes First campaign. So I want to know more about that. What does that mean?

Montez Carter, PharmD, FACHE: Yeah. So that's really, I think for us bringing to light, that we have to continue to put the needs of our community, in terms of our ability to provide services for all, for those who have, those who don't, and to be able to do that in a sustainable way. And so as we are going through the normal negotiations that we go through with commercial insurers, there's a lot of discussion around making sure that our reimbursement is fair and equitable so that we can continue to advance our mission.

You know, one of the things that many people who are not in healthcare business may not ever think about is that, contracting around commercial services is something that happens generally every three years or so, on average. And as part of those discussions, you would think that if you had an insurance company that had a contractual relationship with providers or hospitals in a community, that what they pay those providers in those hospitals in a certain pretty small geographical region, at least, is pretty equitable.

But the reality is that it's not, right? There's an imbalance in many instances, particularly in communities that we serve as well, whereby there's payments that for the same patient in the same community needing the same level of service that can go to two different organizations and what they pay one organization versus what they pay another could be off or could be different by 20, 25, sometimes 30%.

And so when that occurs, then it really creates a challenge for organizations such as ours to continue to carry out a mission because the expectations of those patients that are commercially insured is regardless of where they go, there's a consistency around safety, there's a consistency around service and quality and access, and in order for us to be able to do that in a consistent way, in comparison to others, then we have to also have fair and equitable payment that covers our cost of doing business, but also allows us to continue to reinvest into our mission.

So we really are, have been highlighting that need, because in the past, I believe that many organizations such as ours, as we go through the normal negotiating process, patients have prioritized the needs of those patients to get the negotiation done, even if it was not fair and equitable, because we've always been concerned about patients being displaced if we go out of network or having a disruption of service.

And so even though that continues to be a concern of ours and we continue to be mindful of it and do not take that lightly, we also understand that as our cost of doing business continues to go up in a way that we can't control; then we've got to be able to be financially stable and sustainable.

So as we're kind of going through that process and the public is hearing about some of these negotiations that start off private, but may become public if we can't get to an agreement that they kind of understand the why from our vantage point that it is happening and kind of why it's necessary for us to advocate for fair and equitable payments so that we can continue to be here for many, many years to come.

Host: Yeah, you're so right. It is important to understand the why, and you mentioned there, you referenced it as a negotiation, but it also really kind of sounds like a partnership. So, just wondering, how do you partner with these commercial insurance companies to ensure that fair and equitable payment?

Montez Carter, PharmD, FACHE: You know, Scott, I thank you for bringing it up because in an ideal world, it should be a partnership, right? I think that we all agree that we want to have the right care, for the right patient in the lowest cost environment. I mean, that is an aspiration that we all have and that we all share.

I do think for us to come in an agreement in terms of how do we get there is where sometimes we get into a point of disagreement. There's, in some instances, insurance companies you know, a couple of tools that they have to be able to keep healthcare costs down is to set up things like, prior authorization processes to where they get to review before a service is rendered whether or not you really need that service or if you can have a service that's lower cost.

 And then denial of payment if they feel like the service that was offered was not done so in the best interest of patients consistent with their plans. And so for us, you know, one of the things that we, we like to work with them on is to say, listen, we should not have unnecessary care being provided, but by the same notion is that if our providers deem that there's something needed for the benefit of a patient, and then we go and deliver that service to the patient, then it should not be a case to where the insurers insurers can just deny payment after those services have been rendered because we've already delivered the cost.

The patient's had that surgery, they've had that medication. And so it is about us collectively work together to say, how do we put the right care at the right place for the right patient, but at the same time understand that when patients need service, that we have to be able to be adequately reimbursed for that service so that we can continue to provide access to meet community needs.

Host: Yeah, it really sounds like, you know, when we think, no pun intended, but when we talk about the bottom line, the bottom line here is really the financial stability of all hospital systems, of course. So let's drill down a little bit more and talk about why these fair and equitable payments from commercial insurance companies are so crucial.

Montez Carter, PharmD, FACHE: You know, they're crucial for multiple reasons. So, you know, we not necessarily for our time together, but there's a lot of discussion nationally, is healthcare a service? Is it a right? You know, and how it's provided. And you think about for us as a nonprofit organization, really our mission is how do we continue to be sustainable to meet the needs of the community? You also kind of on the flip side of that, look at many of the commercial insurers that not to say that they're not concerned about health care in the community, but they also have an element of their business that is about returning value to their shareholders.

Whether you agree with it or not, we understand that that's a priority that they have to balance in terms of returning value to their shareholders and anyone can look at quarterly earnings statements to evaluate how well those companies do that or not. But from our perspective, it is about us generating a sufficient model to be able to give our employees raises on an annual basis.

You know, there's a lot of great things with artificial intelligence and medical developments that are really leading to great technologies and treatments, but those things cost money, right? I mean, it's no different than for some of us who are old enough now to have bought our first cell phone 25 years ago. And now we go and buy a new cell phone. And what those two costs are. They're a lot different, right, over time. And the same thing with the technology. And we have to be able to invest in that technology to keep up with the times in terms of the care that we're able to deliver, which in many ways does improve outcomes for patients.

And unless we advocate and fight for fair reimbursement, we're not able to do that. So the consequences, either those patients that we're serving, you know, are going to kind of fall behind in terms of having the latest, greatest cutting edge technology, what they all deserve, regardless of their ability to pay; or we're going to be able to be an organization that is healthy, thriving, and still willing to partner, you know, with the commercial insurers and patients to provide the lowest costs of care for them so that their costs can go down.

Host: Yeah. I was just thinking about all the things you're talking about AI, we could probably, Montez, do an entirely separate podcast on the future of AI and healthcare, uh, but just thinking about, you know, everybody wants minimally invasive surgeries and you need robots to do those things. And I know how much roughly a DaVinci robot costs, right?

So, you know, just thinking about how to provide the best care for patients and their families and all of that. And it just really seems, Montez, like, everybody is facing financial challenges. So maybe give us a sense just to understand kind of the commercial insurers side of this, what are some of their financial challenges?

Montez Carter, PharmD, FACHE: Well, I'm not sure about their financial challenges. You know, if you look at earning reports, I don't know that it's necessarily a challenge. I mean, maybe it's not meeting targets that they're going for regarding the kind of return, you know, for shareholders. But I'll say again, the over utilization of health care services is always a concern of the insurers, ensuring that we have quality outcomes in terms of whether it's health care acquired conditions, whether it's our service scores, whether it's us preventing unnecessary medical errors, I mean, that's part of what they're concerned with and where care is provided, right, so that as many things that can be done in a community based setting versus a hospital based setting are done in a lower cost environment.

Even saying all of that, right, we as a hospital, for instance, we have to be available 24/7. You don't know when someone's going to have a heart attack or a stroke or a car accident. And so it's, it's great that we have areas and avenues to where if someone needs to have an outpatient surgery, they can have that done in a community based setting.

But that does not take away that we have to still be here for our communities when they need us. Right, and we just saw coming out of a pandemic how important that is to have healthcare infrastructure when things happen that none of us anticipate. And there has to be a degree of funding to make those things accessible when they are needed because our employees want to continue to make more money to keep up with inflation and technology is getting more and more expensive. For us to go out and build facilities or just maintain ones that we have; those costs are not going down just like no one else's costs are necessarily going down at home.

So it's really important for us to receive fair and adequate payment. And again, the fairness point is when we know that in our same communities that there are others that they're paying more to, than we're getting paid, we're definitely as part of our negotiation saying that cannot continue to happen because there's no difference in expectations between our institutions and other institutions from safety, quality, service, and access.

So we really are challenging insurers when they are asking us to take less when the expectations are not any different.

Host: Right. As you say, the biggest part there is just the fairness, right? And I'm thinking about patients. I'm thinking about who's listening to this podcast and just in general, what they would get from this. So we think about from the patient's perspective, you know, these fair and equitable payments from commercial insurance companies. Why is it so important to patients? How do patients really benefit?

Montez Carter, PharmD, FACHE: Well, I think the patients benefit because they have options based on their preference in terms of who they have an access to care, because there are more institutions that are healthy and viable to be able to meet their needs in a more immediate basis. They're able to make decisions in terms of based on quality and based on safety and based on service on which organizations or which providers that they want to receive care from.

So it's healthy for patients to have choice and that choice to not be influenced by one organization that is more financially capable than an other to be able to offer services and, so that, you know, I think benefits patients to have opportunities to have access to high quality care.

And definitely for us as an organization, we are advocating for those vulnerable populations who don't have choice necessarily because not every provider builds their business around taking care of Medicaid beneficiaries or taking care of patients with no insurance.

And so it is important for our community to have organizations such as our ministries that really have a focus and an affinity to care for all of the community, whether you're a commercial insured patient or you have no insurance. And so that in terms of our state, in terms of our society is part of what we're called to do and fair and equitable payments are a huge contributor to our ability to do so.

Host: Yeah, right. Today we're talking about, you know, finance and money and payments and all that, but what it really comes down to is people, patients, the community. Let's finish up there, Montez, and just, you know, talk about fair equitable payments and how it really impacts the entire community.

Montez Carter, PharmD, FACHE: Yeah, so, you know, our mission is to be a transforming, healing presence in the community which we serve, and that is mission that really stands on the shoulders of a legacy of many of our religious congregations, where sisters came into communities all over the world, particularly even here in Hartford and Waterbury in Mass. And they, really came to our communities because they saw a need. And out of that need, sometimes hospitals were born, sometimes schools were born, sometimes other things were born. And so as we continue to serve in that spirit, in terms of really working with and meeting the needs of the community, the entire community, even as times change, then we have to be financially stable to do so. And so even though it is about the patient, it is about care for the patient, we can't do that if we're not able to continue to be in business for the future. So, it's important for us, and they don't have to be mutually exclusive, right? We can do both. We can continue to meet the needs of the community, advance our mission, but then also get adequately paid for the services that we render and that is the fight that we're in to make sure that we have that balance so that we can continue to live out that mission that the sisters started, so many years ago that we now are taking forward in their legacy as good stewards of that mission for the future generations.

Host: Yeah, that's perfect. You know, I've been reading about and done a few podcasts on sort of healthcare deserts, if you will, you know, and many of these you know, community hospitals and systems, just not having the resources, not being able to keep their doors open, having to turn people away and having patients have to go much further for care. And we definitely don't want that. And so this negotiation, these partnerships of fair and equitable payments. All really important stuff. Really educational today. Thank you so much.

Montez Carter, PharmD, FACHE: Yes. Thank you. I appreciate the time and appreciate the conversation.

Host: That's the CEO of Trinity Health of New England, Montez Carter, and to learn more, go to healthcomesfirst.org. I'm Scott Webb, and if you found this information helpful, please share it with others, especially on your social media. Thanks for listening to the Transforming Your Health podcast from Trinity Health of New England.