Jennifer Colamonico
On today's episode of Vital Viewpoints on Healthcare, we are joined by two managing directors from HMA Delivery Systems practice, Robert Ross and Warren Brodine. Together they bring deep experience shaping care across hospitals, physician practices, federally qualified health centers and safety net systems, showing us that health care delivery is about much more than hospitals alone. Rob Ross has led hospitals through financial turnarounds, mergers and system integration, all while improving patient experience and quality of care.
His leadership spans from Montefiore St. Luke's Cornwall Hospital in New York to MedStar Washington Hospital Center in DC, where he advanced patient safety, streamlined operations and strengthened behavioral health services. Warren brings decades of experience guiding FX's IPAs and safety net systems. Warren has helped design whole person care models that address social determinants of health, achieving major cost savings while improving outcomes and engagement.
Warren also serves as a national voice for payment reform. Together, Rob and Warren bring perspectives from hospitals and community based care. The two parts of the system that must work in concert to create sustainable and patient centered health care. Thank you both for joining us.
Robert Ross
Great to be with you, Jen.
Warren Brodine
Thanks for having us, Jen.
Jennifer Colamonico
So let's start with this concept of interdependence. Traditionally, we think of health systems as hospitals. And doctor's offices and community care as clinics and other sources of care in the community. But altogether, our total health care delivery system includes all that. And more places where people get care, behavioral health care, even in jails. So when we think about the broader definition of our care delivery system, how does this help frame our national discussion around health care access?
Robert Ross
The way I look at it, many people look at as far as access, it's really having the right care, in the right location, at the right price that can be easily accessed by the patient. And if we really focus around that, we start to look at the definition of health care access throughout the United States and where the most appropriate place, for patients to access our care.
We all tend to look through our lenses, you'll hear through our conversation and more. And I joke with each other on a regular basis, being hospital centric versus being clinic and health center centric. And so we tend to look through our lenses. But if we can pull the lens back and really look it from the whole system and really look at really what's the right location and the right cost and the right care, I think we can start to frame the conversation better.
Warren Brodine
Well, we'll start off with a point of what do they call it, violent agreement, the right of care at the right place with the right provider at the right time. Yeah. What I think about what is going to make health care more sustainable, leaning into the no wrong door approach to health care is really the right answer. Wherever a patient is poised and ready to receive the care that they need, then that's the right place for them to get the care.
And and marrying this concept of the care that the patient needs in the setting that is appropriate at the right price point, across all types of payers, whether that's the patient paying out of her, his own pocket or an insurer or some kind of other risk bearing organization that is managing the total span of the health care, in a way that's culturally competent and appropriate and accessible to the patient, are really the pieces that come together to get the care delivered and get the outcomes that we need.
Jennifer Colamonico
So people talk a lot about, you know, meet people where they are. And I think that's really what you're talking about. But, you know, we have a very fragmented system and, we know that. And, so, you know, how do you bring those pieces together? You talked about payment. You talked about, you know, no wrong door.
If you had a blank slate, what would an ideal, kind of partnership look like between health systems and community health providers?
Warren Brodine
The right blank slate in this environment, to me, is one where the incentives are actually correctly aligned to where everybody has, piece of the action, so to speak, in terms of managing total cost of care so that, all providers of all types are rowing in the same direction to maximize outcomes while minimizing costs and making sure that the patient remains at the center of it.
As long as we have fractured and incentive systems and fractured payments, where everybody has the ability to sort of go in and negotiate for their own bigger slice of the pie. The more we're going to have providers sort of tackling each other to get to the patients, rather than being truly focused on meeting all those right care, right place, right time, right cost kind of things that Rob and I laid out.
Rob, what would you change?
Robert Ross
From my experience and for what we've seen both in my experience prior to consulting and in consulting, it's really to sit down and understand the organizational missions of both and acknowledge that there are different, there are different payment structures and different funding mechanisms for both. There's different organizational missions for both. And so therefore they're coming at the healthcare system from different perspectives.
Neither one is right or wrong in understanding. And that is really, you know, the foundation to building that relationship. I'll give you an example from my career of that. There was enough shock in my community, and I was running a, safety net community hospital, and we kept going to the FQHC saying, why are your patients showing up in the emergency department?
And the FQHC was saying, why are you taking all our patients in an emergency department? And what we ended up doing after we sat down and really discussed it, is agreed that we would put a case manager, from the FQHC in the emergency department. And that began to help both of us understand why patients were choosing care in the emergency department, which may or may not been appropriate, or the FQHC which may or may not been appropriate.
And then we can adjust our services appropriately. And so I think it really is sitting down, understanding the perspective of each and then focusing on what's best for the patient.
Jennifer Colamonico
You were just talking about a safety net hospital and an FQHC and that sort of, you know, interrelationship. There's probably the same type of a conversation between, you know, a general physician practice and a non safety net hospital. But I'm like, how do we even think of safety net these days? I mean, is it kind of segmented by type of reimbursement, lack of reimbursement?
You know, some of those safety net hospitals in the FQHC's are, they're getting their funding differently. And so you don't necessarily have to have insurance. But I just wonder how we think about safety net these days as incentives kind of start to meld and merge and evolve. And, you know, how does that, lead us to think about overall sustainability between these systems?
Warren Brodine
If we had to characterize the safety net today, you know, what you have is, it's a mission commitment to taking care of individuals and a and an organization is this principle that taking care of folks who are recipients of Medicaid and analogous types of coverage, as well as care to the uninsured and underinsured, is really a hallmark of that.
And a true safety net institution has that at its center, not in its margin, and is organized around making sure that the entire community gets care and not just individual patients. There's no one definition of safety net to me, but there are some characteristics that you find across the safety net.
Jennifer Colamonico
Well, that's interesting when you think about the population health, right. In theory, our non safety net quote unquote hospitals leaning into that space too. I just wonder how blurry those lines are.
Robert Ross
The lines are very blurry. And the definition of safety net is to Warren's point. Depends who you ask. And when you ask it, you'll get different definitions. And there's formal definitions and informal definitions. And they all they all differ. But I think Warren described that, perfectly. It's core to the mission of a safety net to serve a population that may be underserved.
There may have challenges in getting access to care, for a variety of reasons. It could be insurance, or lack of it, but there could be other barriers to care. And a safety net at its core is seeking to reduce those barriers and, allowing for easier access to care for the entire community that's served.
Jennifer Colamonico
Yeah. And I feel like that's sort of, like, culturally specific, depending on what community they're serving. Right. There are different barriers to care in different, you know, communities. I mean, one could argue that many people with even decent insurance have some barriers to care. And I think it's interesting just to think about what sustainability looks like. In a time right now we're recording this when, you know, we have lots of potential cuts coming.
So maybe let's talk about financial stability a little bit, and payer mix changes that we're facing. So, Rob, you've led hospitals through these types of financial turnarounds. Talk a little bit about, you know, payer mix, different revenue streams. You know, how does that all play a role in financial sustainability and specifically right now about Medicaid cuts?
Right. Some people, I think, think Medicaid cuts affect only people who have Medicaid. We know that's not the case. So talk a little bit about kind of payer mix and what that means for overall sustainability for any of these organizations.
Robert Ross
So I mean, the first question that, anybody asks the hospital when they're talking about their financials, the last the first question being payer mix and that's being the core to a hospital's sustainability is what's its payer mix? How much of it is commercial, which is a higher rate of pay? And if the percentage of commercial is too low, they're going to struggle to have, financial sustainability if they rely too much on Medicaid, which is generally a lower pay or Medicare as middle of the road, and also the percent that are uninsured.
So payer mix is the key we're seeing in hospitals, kind of the, widening. So the hospitals that have been doing really well are performing better, and there's a larger gap, and then there's the hospitals that are performing poorly. And that gap is growing due primarily to payer mix. So for a hospital being sustainable, there's two overall two key levers.
And it's the way our system works. Hospitals drive their bottom line through payer mix, having, more lucrative commercial insurance contracts and limiting to the degree possible for the community they serve, Medicaid, uninsured and Medicare. And the other is the complexity of care. The more procedures that are done, surgical or cardiac procedures, the higher the reimbursement, the more sustainable.
So if you look at those two levers for a hospital, that's really where you see, financial sustainability and is we advise hospitals, we look at payer mix, we look at what their service mixes and, see where they can make, gains in that in the future so they can remain sustainable.
Jennifer Colamonico
So we think about, you know, Medicaid cuts in light of that. You know, Medicaid typically reimburses at a lower level, as you point out, compared to other payer types. And so, you know, hospitals are kind of in the conundrum, right? Where they've, obviously you want to maximize your commercial reimbursement. But also, you know, there's been a lot less uncompensated care with Medicaid expansion.
So how do you see these Medicaid cuts really affecting hospital operations for everybody, or do you.
Robert Ross
Significantly, you know, the Medicaid cuts will have a and it comes in two forms. One is reducing the number of people who are eligible for Medicaid. So you'll shift more people from Medicaid to uninsured, which puts pressure on a hospital's bottom line, as well as clinically, which I'll talk about in a moment. And the other is the cuts that are coming in a couple of years to what they call state directed payments and provider taxes, and that going down.
So the amount that hospitals are being reimbursed for each episode of care will get reduced. So there's pressure on both sides. Fewer Medicaid covered patients and more uninsured, which generally means that, you're providing free care or almost free care. And then also Medicaid reimbursement you're currently receiving is going to go down. So there's going to be, at least as of the laws are written right now.
And what each one has, it'll have a significant impact on hospitals. And those hospitals that I mentioned before that are already struggling will be even more of an issue for them.
Jennifer Colamonico
So when you think about the patients that sort of drop out of those systems, Warren, do you see, I mean, is that when folks get more busy, you know, do those patients find their way to clinics more often.
Warren Brodine
Because of the way that community health centers folks are compensated for Medicaid and Medicare? The hospitals worst payer is the FQHC's best payer. And so, because the systems were constituted to do this, population health in the community for low income individuals, there's a special reimbursement mechanism on a prospective payment basis that exists for community health centers, FQHC'S, whereby all the costs, theoretically, of providing these extra social supports to reach patients are compensated through that rate.
So the answer to your question is kind of it depends. Because the level of care that's offered in an emergency department or in an inpatient setting is not typically replicated within an accuracy setting. Typically speaking, what we have to handle and all of this is that right care in the right place at the right time. Question that Rob and I kicked off this conversation with.
And so part of the challenge that Rob is referring to is that because we have a fractured health care system, people seek care in hospitals that they should seek in community health center environments. And it's very costly to provide that care with in a hospital setting. And it's a better supported patient experience and social determinants lift in a community based setting.
So part of this coming together and where in payer mix does play a role in this. But part of this coming together is around getting the system to properly and appropriate Lee apportion out the care to the right location so that the right payment is following the right set of services. So you know anyone who's had an Ed visit, you get evaluated for a lot of different body systems, and you get a lot of tests and a lot of X-rays.
And, you know, if you think about it, sometimes comes one of the biggest challenges to the health care system today, from a financing perspective, is people seeking outpatient, regular doctor office kind of care in the hospital with all the costs that that brings along with it. So while, yes, hospitals get strapped and stretched, the nature of the beast in a hospital is that they're always there and available.
So people continue to seek care there even though it's more expensive. So I'd amend your question. The clinic environment should get busier, but whether or not it does is a matter of a question. And this is really the crux of our work. Rob and I are trying to organize systems of care in communities and with communities to help them get to that right care at the right place at the right time.
Yeah. You know, Nirvana. And we're looking forward to, you know, to to living in I want to address the, the point of payer mix, too, because what ends up happening is, you know, everybody is a business here. So everyone needs to...is focusing on their income stream and their bottom line. And they've got baskets of services and community benefits and, and participation that everyone's looking for in the health care sector to provide and hospitals seek.
As Rob pointed out, they seek the largest and biggest payer mix that they can gather in sort of market share within that commercial environment. You know, it does have an interesting ripple effect on care for uninsured and for others. So while no hospital can limit, say, for instance, labor and delivery by paramedics, right. That that's the empower active somebody is an active labor.
Then they have to be cared for. And that's a wonderful feature of our system, that we need to preserve. But you'll see hospitals right. We sort of forge partnerships that push up that commercial mix of their cases is their dream state, is that they're full of commercial patients, so can't accept Medicare or Medicaid, uninsured because they just don't have any room.
And, you know, we allow things to sort out that way within our communities. So if I really saw this through to the end, we would have a lot of ability to sort of work as a community of care and a community of providers to make sure that we're helping people access the care that they need at the right setting, so that we're using the dollars in the most effective way possible, so that we're doing primary care in a primary care setting, that we're helping patients address their social factors of health within that primary setting, you know, and frankly, not doing a $200 outpatient visit in a $1,200 hospital setting.
And that's really the bottom line.
Robert Ross
And just to add on to that, Warren, and you talked about and Tyler, being a feature is also a bug of the system because that is truly the less safety net. Hospitals do have to by law, accept every patient in the emergency department. And just like you said, it's, both, clinically and certainly from a cost standpoint, it's not the ideal location of care, but where the hospitals and the folks can work together is exactly what you said.
Bringing them together, having primary care, being seen by primary care providers and the FQHC, but also easing the access and the transition when a patient needs that specialized care, to have that ease of access that the hospital is and the providers at the hospital and the specialists that patient can have that ease of transition and access. We've all navigated the system in of work referrals.
It is difficult even for us to understand the system. Nevertheless, you know, people who are less savvy with the system. So it's a comfort upon us as providers, whatever part of the system, Ron, is to reduce the friction in moving through the system.
Warren Brodine
The greatest features often are the biggest bugs in any system. We need to emphasize the features and de-emphasize the bug wherever we possibly can. Really successful communities and communities of care. Arguing strong patient and community education about how to seek care at the right level and at the right time, and making services available. Available, you know, around the clock, through telemedicine and some of those things.
You know, the Covid pandemic did one amazing thing in the Medicare and Medicaid market, which was actually equalize it to the commercial market in terms of telemedicine access. And I mean, as a person who's been covered by private commercial insurance for my entire life, I have always had telemedicine access. How many of us have picked up the phone and called our doctors and gotten a prescription called it.
So that's par for the course, right? In almost every commercial paying system and in every capitated system where providers are allowed to work at the top of their license, you know, they don't need to bring someone in for a prescription if they don't need to. And, you know, but those systems didn't exist and there was no support for that in Medicare and Medicaid prior to the Covid pandemic.
And our speaking on a day where it's in limbo because of, of the shutdown, September 30th was, was the last day, and it has yet been reauthorized. So, telemedicine flexibilities are currently in a state of flux. And I know providers are continuing to serve people with telemedicine, but those are those are some of the ways in which we can permanently improve the system by having really great call and op lines and Teladoc lines, so that all of our patients of all types can be seen appropriately and have clinical evaluation, you know, and especially if you think in the overnight hours when, you know, costs are exceptionally high and access is particularly limited.
Jennifer Colamonico
As they say, people don't only get sick between, nine and five. Right. I wanted to talk a little bit about folks as sort of innovators. I had an, I'll never forget somebody I met who was sort of a very, thoughtful, you know, a thought leader, really, in the value based care movement here in New York.
And I remember he told me this was somebody who had access to very, you know, high levels of insurance and commercial insurance. He sought out his care at an FCS. See intentionally the coordination that he was getting. This is somebody who is sort of a big proponent of value based care. It was, you know, it was coordinated.
It was efficient. He was getting the follow ups. He was, you know, they were coordinating through different services. It was kind of that model of integrated, coordinated care that, you know, the private system, if you will, has been trying to create. And it somewhat exists in FCS and so I was just, you know, curious. You talked about telemedicine, obviously, that's another place where, you know, we've had innovation for a bunch of reasons.
And now we can learn from that. Why, you know, are we learning from folks in terms of best practices? You know, can we be learning more? Why aren't we learning more? It seems like there's some really good models of what that kind of level of coordination can look like to help people overcome challenges and get the care they need.
But, you know, are we learning enough from FQHC's?
Warren Brodine
Maybe not just because I've made my career in community health? Do I think you're exactly right? I think for a minute with an objective lens on, you know, the your local community health center is likely a one stop shop. It's organized that way somewhat by design, because the community based patient governance of efficacy ensures that the organization is being really supportive and is engaging in the kind of activity that the community itself actually needs.
They're doing the local needs assessment, and they're not they're not making their care deployment decisions based on, you know, we can get reimbursement of X number of dollars if we have a 64 slice CT scanner. They're making their investments based on saying, wait, the epidemiological data show that 40% of our community faces hypertension. So we need to add cardiology and nephrology into our scope of service to keep our patients healthy and to make sure that we're addressing all the causes of hypertension and bringing the average blood pressure down in our community.
That is a dimension the integration of behavioral health and dental care, which, you know, the other great outcome of Covid is people checking in on one another's mental health in a way that never existed prior to 2020. I remark all the time, the number of people that we come in contact with every day who are just checking in with each other, in a way that was quite rare, in fact, before the pandemic.
And, you know, this I think has highlighted behavioral health for medical providers, for internet speed iterations, family medicine docs, and and the apps who surround them in a way that's just totally different than it was before. And then, you know, dental care is always been at the forefront. So many areas of oral health actually affect physical health that having a dentist, dental capacity onsite in the building and able to be seen same day in case of need is really important.
Often dental issues are one of the top ten diagnoses, is taken care of in emergency departments. And you know, that's something that we're clearly regular. Maintenance care can be really important in improving.
Jennifer Colamonico
Dental and and mental health. Rob, and I know you're working a lot in that space around trying to bridge behavioral health and hospital systems. So, what are your, what's your take on that, really?
Robert Ross
I think you bringing in the innovation and getting to the behavioral health side, there's a lot that others in the health care system can learn from earthquakes on what the innovation is and not just looking at FCS, as, you know, the clinics in the community, but really looking at, a center for innovation. I was talking with someone who was a national expert in patient engagement, and his view was the innovators in patient engagement are actually FCS.
He's seen far more innovation there than you've seen in hospitals and health systems. And it was an interesting take, on it. And behavioral health is a great example of that. Innovation is truly integrating primary care and behavioral health. We tend in health care to silo patients by diagnosis. And nobody comes with a single diagnosis. We all have multiple issues that we present with.
And frequently there's behavioral health issues that go along with that. And looking at that patient from a whole patient perspective and treating both the immediate emergent need, but also what might be underlying and going on with the patient and integrating behavioral health with regular care is vitally important. And hospitals are doing a lot of that work. And I think more partnership with FCS makes a lot of sense in that, because there's expertise that the folks have in behavioral health.
Certainly, you know, in areas like Warren mentioned, in dental and even in labor and delivery, which is a core, and obstetrics is the core service that, that folks have. And there's great opportunities for, for that integration and innovation.
Jennifer Colamonico
I guess maybe, you know what? What gives you hope? Where are the opportunities for greater alignment, I think is really the question I want to ask here. Is it data is you talked about aligned incentives. So obviously money is important. But like what else needs to happen to create this kind of, alignment? Is it, you know, is it technology, is it data?
You know, what else? What else could it be there?
Robert Ross
I know it's not just money, but frequently. That's the driver. And interesting. It might be the lack of money, going forward, as you talked about before with Medicaid, that might actually bring DFCs and the hospitals together because they're both having to take care of the population of patients. It's both going to it's going to become more difficult potentially, to do that.
And I mean, hopefully my hope, in this is that it can bring them together and say, okay, we have a community to care for. The patients have needs. They're coming to us regardless. Let's work together to figure out the best way to provide that care. So, you know, I think it comes down to the financial, but it also comes down to just that core mission of serving the community and serving the patients.
And, you know, if we can get those, align the financial incentives with the core mission, that they both have, you know, we're moving in the right direction. Warren alluded at the beginning to innovative payment models. So the CMS, the head model, which is a global payment, which means hospitals will receive a global payment for the community as opposed to on each episode of care that hopefully will drive the hospitals to look at what am I, community partners because we need to distribute that.
There's also a team model of certain diagnoses now that Medicare is paying a bundle payment for, regardless of what services there are. So that'll lead. The hospital will go outside the walls and say, I need to partner with others so that we can deliver this care in the most efficient manner, but also in the highest quality, and make sure that patients recover and stay well and don't come back to the hospital.
So I think there's there are financial models that are beginning to bring the pieces of that together. The hope and the fear together is we tend to have models and we don't follow through on them. Hopefully some of these get follow through and continue on.
Warren Brodine
I agree, I think there's just a couple of areas that we could expand. You know, that includes the regulatory framework. So much of what happens in health care is not allowed to be sort of satisfied by a partner. From a regulatory perspective, I think if we can get to a point where you have, we talk about the team based model of care inside the walls of a health care provider, while there's a team based model of care that unifies all kinds of different providers for that community.
And, you know, we we need to have or figure out the regulatory structure that protects patients, protects providers, but also lets people truly work together to integrate data and, you know, use and use the tools at our disposal to make sure that we're hitting that right, care at the right place at the right time. And, you know, someday soon there will be a good chance for, I think, to play a role on this, too, especially helping us do a sort of retrospective review to tweak and improve our systems development.
So often, regulatory compliance becomes the hammer that prevents innovation. And, you know, we we must take advantage of an opportunity to remake the regulatory structure in a way that fosters the collaboration and in a way that allows all provider organizations in the community to be an extension of one another within, within that system of care. I think when we start getting to that, the promise of data, liquidity and data fluidity over time.
I mean, we've been talking about this since the late 1990s and getting the data in line, and now we have, what's bigger than a terabyte? We have we have tens of thousands of terabytes more data available to us. And still, I don't think we really know what to do with them to make the life of a patient better.
Sometimes there there are some great examples of, you know, discharge data and things like that. That's a good that's a good flow. But we're living under a mountain of data that so far is not helping most patients get in and out of systems faster and with more efficacy. So, and a lot of that is because of the regulatory environment where every time you walk into a different tax ID number, you have to sort of reregister and establish everything, everything together.
And we don't have the navigation, tools available to us to help us, you know. Yeah. Take a file from the hospital and transfer it to the chassis to send it to the lab to go over to, to the radiologist, you know, so someday we'll get there.
Jennifer Colamonico
If you had a magic wand and you could redesign one aspect of sort of how these systems work together, or rather, maybe don't work together today, what is the thing you would change first, and how do you think that would transform care for patients?
Warren Brodine
I would start with the incentives. I change the incentives instantly to where to make sure that all the different sectors of care are sort of required to integrate and work seamlessly with one another, and that there would be incentive penalties if they didn't.
Robert Ross
And I would agree that it's driven by the incentives. But it's really making sure those incentives reduce the friction in our system. And it's just friction that providers have within the system. It's friction that patients have to access the system. If you think about what it takes just to get an MRI and you know what insurance companies have to do and how much money is spent on that, and doctors have to do and patients have to do, that's all cost.
That's all barriers to access. We got to reduce the friction and get the care of the patients going back to the beginning, the right place, the right time at the right cost. But it all starts with the incentives. And, the incentives come from how you pay for healthcare.
Jennifer Colamonico
Oh, that little thing. How you pay for health care. Well, I appreciate both of your time today and, really appreciate the work that you're doing. And, and sort of the partnership that you're building is really a model for how systems should work. We're, we're sort of building it internally and, and reflecting it externally in the work that you do.
So I appreciate you both very much. And thanks for being with us today.
Robert Ross
Well, thank you.
Warren Brodine
Thank you.
Jennifer Colamonico
This episode of Vital Viewpoints on Healthcare is sponsored by HMA Information Services. HMAIS is a subscription based service that provides state level data on publicly sponsored programs like Medicaid, from the latest managed care enrollment, market share, and financial performance data to up to date RFP calendars and state by state overviews, HMAIS has all the information you'll need to power your initiatives to success.
This podcast was produced by myself, Jennifer Colamonico along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.
