5 Principles of Next Gen Healthcare Leadership in Our New Normal World

3 min

We are living in a time when leadership is at a premium. This is especially true as we adapt to a “new normal” in our personal and professional lives. In the healthcare arena, the premium on leadership is multiplied by several factors.

  • We have a costly, opaque, anticompetitive, and inefficient system.
  • Health care represents 1 in every 5 dollars of Gross Domestic Product and continues to grow faster than any other consumer price index category.
  • Like food, housing, and a means to support oneself and one’s family, health is a deeply personal necessity. Illness, injury, and disease compromise our ability to meet life needs. A lack of access to health care or to affordable health care compounds the consequences of personal and family health challenges.

These factors should elevate the expectations of next generation leadership in the health sector and hold us to higher standards in our current efforts and especially in our capacity to influence change.

It is not my intent to define leadership here. This has been done many times in many places. However, I’d like to suggest that as executive leaders within a healthcare ecosystem that needs great improvements, we should hold ourselves to next generation aims and actions. Here are some tenets that might help to keep us pointed in the right direction.

Leading Healthcare with Integrity
1. Do no harm.*

Questionable practices across stakeholders in the U.S. healthcare, pharma, and insurance systems have shaken the foundation of trust. Many “solutions” created by the legacy industry and new entrants inherit the current system’s ethical challenges, such as egregious billing and shared savings, hidden fees, and unscrupulous contracts.

Many are smaller versions of the same problems. For example, direct contracting meant to address valueless provider networks is often based on the same model of discounts off price-blind billing.

As next generation leaders, we need to ask, and answer, hard questions. Are we creating and delivering integrity-based products and services? Are our decisions and actions improving affordability? Lowering barriers to access? Increasing transparency? Creating more competition? Eliminating conflicts of interest? Making things better for patients, care providers, and payers?

* Contrary to popular belief, “do no harm” isn’t actually a part of the Hippocratic Oath.

2. The majority is almost always wrong.

This is the reason ingenuity, innovation, and positive change can take hold in the first place. Consolidating entities in a compromised system, like the unchecked hospital, PBM, and insurance carrier acquisition activity over the past decades, worsens existing problems, monopolizes thinking, and homogenizes behavior. This creates a spiral of further system regression, making change much harder.

Next generation leadership asks “If we could start anew, what would we do?”

3. Incrementalism is a way to avoid real change.

Incrementalism is an attractive proxy for standing still. In our current healthcare system, staying the same means getting worse by default. We see this in the form of minor tweaks staged as major advances, such as ACOs and value-based care attempts to blunt out of control fee-for-service.

A variant of incrementalism involves offerings designed to “manage the racketeering.” Examples of this include industries that have cropped up attempting to optimize PBM contracts or engage in an auditing arms race with hospital revenue maximization specialists and systems.

Next generation health leaders are not afraid to create much needed separation from the mainstream with offerings that will seem audacious to the status quo.

4. Look out-of-field for solutions.

This is a hallmark of innovation and invention across all disciplines. What can we learn and adopt from operational efficiency in other industries? From healthier buyer-seller-customer arrangements in unrelated arenas? From financial transaction reinvention in other sectors? Or from businesses that take care of people in spaces outside of healthcare? Importantly, what can we learn from those at ground level every day in the current system?

5. Take risks.

Outside of medical research, the established system is averse to risk and change. This prohibits progress. It requires courage from leaders who will embrace the unknown to step away from the majority and make real change happen through better solutions. We need leaders who are not afraid to ask “What if…?”

v2.0 Healthcare Leadership

In our new normal, we are at a time and place that is ripe for next generation health leaders who have the morals and courage to lead with bigger, bolder steps. If not us, who? If not now, when?

Patient Charged $809 for an $80 Item. Typo or Scandal?

< 1 minute

A woman in California received treatment for a broken foot at a reputable orthopedic facility. She was happy with their service until she looked at her bill: $809 for a plastic walking boot that costs about $80 on Amazon. She assumed it was a typo but after contacting the facility, she was shocked to learn the charge was correct.

To her credit, she raised her concerns about the astronomical 1,000% markup to senior administrators. Sure enough, there was an error: she should only have been charged $639. Really?!!

It’s no secret that the US health care system routinely gouges employers and plan members with inflated and nonsensical charges. Americans pay roughly double what those in other developed countries pay for care. But this situation demonstrates the degree to which outrageous greed has driven increases in deductibles, co-insurance payments, and ultimately, out-of-pocket costs for patients everywhere.

Since the industry won’t police itself, employers must take the lead in demanding transparent billing practices and fair market reimbursement. Employee health plans with clean contracting and pre-payment cost controls can help mitigate these abusive practices and protect employees from unexpected and outrageous charges. Employers need a plan that ensures situations like this simply cannot continue to happen.

How to Deliver Really Great Support to Health Plan Members

2 min

When evaluating a traditional employee health plan, employers and brokers typically focus on premiums, deductibles and co-pays, and the nuts and bolts of the plan’s coverage. Customer service is an afterthought. Historically, it has been enough that employees can call a toll-free number when they have questions.

Thankfully, the opposite is true when employers look at alternatives to these outdated insurance carrier plans. Instead of accepting the unacceptable status quo, there is growing demand for a significantly better member support experience. It’s about time!

A Better, More Compassionate Approach

There is no reason for employees to sit on hold waiting to speak with a random agent at a far-flung call center. Besides taking advantage of the many technologies available to connect and collaborate, members are better served speaking with a dedicated advocate who can guide them through the complexities of finding quality health care at a lower cost.

Health plans that prioritize the member experience help employees access more affordable health care, in all areas of care. Convenient and easy-to-use tools and personalized assistance ensure members (and employers) get the most value from their plan. This is as it should be, yet it is NOT what members get from a legacy insurance carrier.

Checklist for Better Member Support

Before renewing the current health plan, pause and seriously evaluate how well it meets member and employer needs. Apply these attributes to any plan under consideration and all stakeholders will be much better off.

  • Compassionate Advocacy
    Advocates are a member’s most important resource. Services should range from simple questions asked and answered, such as benefit verification, all the way to personal assistance in complex matters. When members need to access specialty care or find the physician or facility most capable of providing needed care, they deserve to work with a proven, trustworthy team that’s ready to jump in and advocate on their behalf.
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  • Flexible On-Demand Access
    While there will always be traditional phone support, a truly great support experience includes multiple platforms to simplify communication between members and their support team. Options should include in-app and online member portal messaging capabilities, online document uploading, and secure text messaging. This will encourage more and better communication by providing members with the platforms they are most comfortable using.
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  • Ongoing Education
    The more members know about their health plan, the more value they can realize. Most “education” takes place during the Open Enrollment period when members are inundated with flyers, fact sheets, and plan summaries. But it’s after enrollment that they really need help. Member-focused education provides readily available process guides, short “how to” videos, and regular communications throughout the year. It also highlights plan features to promote awareness and guidance on how to access them.

Members and their families benefit most from advocacy that supports them every step of the way. They deserve a trusted support team that is empathetic to their needs and is dedicated to removing barriers to needed health care

Comprehensive member support is a critical component of an employee health plan. And it’s what employers are demanding as they seek alternatives to legacy plans. With superior health plan alternatives available, isn’t it time to leave outdated insurance carriers behind and choose something better for both members and the business bottom line?
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As Managing Director of the Client & Member Experience at Vitori Health, Johanna Newsome is passionate about nurturing positive, lasting relationships and building teams with a client-centric focus to collaboratively facilitate a positive member experience.

Health System CFO is Fired for Trying to Fix Known Problems. Really?!

< 1 minute

Imagine you’ve been hired as the CFO of a well-known regional health system. You’re told during your interview that they’re looking for someone who can make difficult changes to address systemwide financial and accounting issues.

So, you dig into the known issues and find even more problems with inaccurate billing practices. You raise the flag about super-high error rates and the likelihood of repaying more than $5 million to correct the systemic errors. And then, BAM! You’re fired!

As crazy as this seems, it demonstrates how hard it is to change entrenched (and illegal) industry-wide practices that have thus far worked to your advantage. And give money back? Never! But there are things plan sponsors can do to start changing bad behavior.

The Value of Pre-Payment Integrity Controls

Employee health plans can directly combat egregious billing practices begin by knowing and validating care costs before paying any claim. They can eliminate price-blind buying and use transparent algorithms to establish payment rates that are fair for providers, employers, and plan members. And then they can scrutinize every claim to ensure accurate billing and reimbursement.

It’s time to change the buyer-seller relationship. We can’t rely on the industry to police itself, so buyers must align with a conflict-free health plan administrator who will fight on their behalf for transparency and payment integrity and take decisive steps to ensure they aren’t victimized by unfair billing practices.

Why Aren’t Providers Being Paid Fast, Accurately, and Fairly?

2 min

Payment disputes between insurers and providers are nothing new. Even with their secret, self-serving network contract arrangements, these relationships have been perpetually uneasy.

While insurers have billions of dollars in claims adjudication technology and staffing that should make processing and paying claims more rapid and accurate, they have always delayed payments to providers, sometimes as long as nine months or more, because every dollar they “float” for an extra day is to their shareholders’ advantage. But lately, this longstanding practice of delaying payment has worsened.

Kaiser Health News reports that the country’s two largest insurers are behind on billions of dollars in payments owed to hospitals and doctors nationwide. As of June 30, 2019, Anthem Blue Cross had not paid 43% of its medical bills. That figure has risen to 53% since the pandemic, and yet profits were $3.5 billion for the first half of 2021.

So why is this escalating? Some insurers point to the chaos driven by COVID-19. Others have introduced new and opaque reimbursement rules under the guise of cost-saving measures. Whatever the purported reason, these practices are indefensible in the face of ample resources and healthy bottom lines. More importantly, they are negatively impacting patients and providers in unprecedented ways.

According to VCU Health, an academic medical center affiliated with Virginia Commonwealth University, 52% of outstanding claims are more than 90 days old, despite a Virginia law that requires insurers to pay claims within 40 days. This delay has created “an unmanageable disruption” that threatens to undermine the financial footing of their teaching hospital in Richmond, Virginia.

Providers aren’t the only ones affected by egregious payment practices. Patients are reporting significantly more claim denials and prior-authorization hurdles than usual. The American Hospital Association asserts that insurer demands that go against the provider’s advice appear to be motivated by profit. Patients who receive recommended and routine treatments are now receiving astronomical bills when such services are deemed “experimental” and “not medically necessary.”

Doctors and hospitals appreciate knowing in advance how much they will be paid, and then getting paid quickly and accurately. Ethical health plan administrators who follow this practice, while still applying rigorous pre-payment scrutiny for billing fraud, waste, and abuse, are acting in the best interest of their clients and their clients’ members.

Welcome, Tim!

2 min

When your mission is to deliver a lower cost, better health plan that’s unsurpassed in the industry, you need a Chief Executive Officer who not only shares that mission, but has the experience and entrepreneurial mindset to shake things up and blaze a unique path.

Tim OBrienWe are therefore delighted to introduce our new CEO, Tim O’Brien, whose 25+ years of health and insurance experience will help Vitori Health continue transforming the industry.

Throughout his career, Tim has created innovative solutions that coordinate care, lower costs, and improve outcomes. He has also developed and implemented growth strategies and managed large scale operations, sales, and IT functions for global healthcare and IT organizations.

According to Tim, “The timing couldn’t be better for Vitori Health. We are uniquely positioned to deliver a comprehensive health plan that significantly lowers costs while providing members far better support than conventional health plans today. The Vitori solution has been incubated, tested, and optimized over several years with thousands of plan members. This gives us the confidence to deliver on our promise. It is a pleasure to work with such an experienced team and we are pleased to see incredibly strong market interest.”

Tim previously served as the Officer in charge of care delivery and strategic investments for Blue Cross and Blue Shield of Kansas City (BlueKC). He has developed national primary care solutions, multi-specialty surgery centers, and pioneered virtual behavioral health solutions. Tim served as the Chief Operating Officer of an integrated health care and capital management firm and delivered healthcare solutions in the UK, Middle East, and Latin America.

Tim is based in Kansas City where he will expand and strengthen our regional presence while leading the Vitori Health team to continue to serve clients nationwide. Please join us in welcoming Tim to the organization as we gear up for unprecedented growth and success.

UN-MINCED | Stardate 20210101

4 min

New Year’s Entry

There must be some kind of way outta here
Said the joker to the thief
There’s too much confusion
I can’t get no relief

       Bob Dylan (Jimi Hendrix cover preferred)

It’s 2021 and we find ourselves more than a fifth of the way into the 21st century. Let that sink in. That’s about 12,000 years or so into the Holocene or Human Era, the beginning of which roughly marks the point when we moved from casting about for food to planned agriculture and fixed settlements, working up to the most recent four decades during which we have made a stunningly atrocious mess of US health care, particularly at the ever more costly expense of employers and the sapiens they hire and provide benefits (we’ll get into the inanity and vexedness of this toxic quicksand in future posts).

Back To the Future

It’s the early 90’s and I’m sitting in the wood-paneled offices of Rick Wagoner, then CFO and eventually CEO of General Motors, one of the largest companies in the world at the time. I was part of an academic delegation from the University of Michigan* that had been summoned to Wagoner’s chambers to address a problem: GM was spending over $1,000 dollars on health care for every vehicle it produced. To hear it from Wagoner, they were “…spending more on medical stuff than we are on steel.” This didn’t sit well. In fact, GM, Ford, and Chrysler would be decried by Goldman Sachs as “HMO’s on wheels.” Worse yet, the multiyear cost trend was steeper than any of GM’s other expenses. By a lot. Keep in mind, this was at a time when Pacific Rim automakers were giving US auto companies fits. Wagoner was apoplectic and wanted answers. After polling my elder colleagues and wading through a litany of academic responses, he fixed his eyes on me and said, “Well young man, what do you think we need to do?” I glanced at my colleagues, who looked like someone had just placed a puppy at the steering wheel of one of GM’s cars. Looking back at Wagoner I said, “It seems like you need to get out of the health care business.” The room went silent and after what seemed like an eternity, Wagoner cocked his head, wryly smiled, and said, “That’s the best damn answer I’ve heard so far.”

The Firemen Are the Arsonists

I don’t juxtapose these time span bookends because my waning cerebral neurons can only recall the very recent or the distant past, although I’m sure some of that is happening. Nor do I mention this as a reminder that I was then, as now, a bit of a cheeky smart aleck. Anyone who has paid attention to the “health care“-becomes-“health business” saga of the US system and employer-sponsored health plans as a professional, or simply consumed the news once a week, knows all too well that only one thing has changed over this long stint: it’s gotten much worse. We have medical marvels of innovation wrapped in a stone knives and bear skins fragmented, inefficient, and ungodly expensive delivery system. In the employer health benefits arena, we have a plutocracy (kleptocracy is probably more fitting) of entrenched medical-pharma-insurance monopolies with vested interests who gorge themselves at the legacy economics trough. The collusion is deep and broad, functioning like a big time wrestling stage play with these actors pretending to beat up one another, feigning public good and allegiance to employers, while back-patting in the locker room as plan members and patients are ground in the gears of their collective machine and shareholders cheer from ringside seats. These oligarchs and cartels are plump and pleased and aren’t going to simply disintermediate themselves. As icing on this inedible cake, we have a longstanding disquieting co-dependency between employers and traditional brokers (who work as middlemen sales agents for the big insurance monopolies in a throwback to 1980’s manufacturer reps with their “books of business”) that anneals the status quo and retards change. One can almost hear this cabal of entitled industry stakeholders laughing all the way to the bank. But, it’s not funny, not funny at all, and we need to do something about this bullying and racketeering.

Patience (and Patients) Wearing Thin

As we go forward, we’ll examine the pathology of this juggernaut that continues to crush employer profits and employee disposable income and look at real opportunities for escape to a better place. And while it’s academically stimulating to think about large scale system solutions and health care as a basic utility in a first-world country, we are focused on less quixotic employer-sponsored health care solutions and take a SEALS approach; there are endless rescue missions to be run and we need to get ‘er done.

The name Vitori is a linguistic derivative of victory. It’s high time employers and their people moved from victim to victor. So, belt in buckaroos, there is a road less traveled that makes all the difference.

Let’s get after it.


* This is woefully ironic because, at the very same time, the University of Michigan Medical Center was becoming a “health system,” gobbling up physician practices and other hospitals like a black hole on amphetamines and raising prices with every expansion mouthful it could chomp. Sounds a lot like today’s sprawling health systems that are blocking out the sun as they buy their way across vast geographies, claiming bogus integrated efficiencies while continuously jacking up the cost of care and suffocating competition. Justice Department and FTC are you comatose???

A thought leader to the thought leaders, Neil Quinn has a very particular set of skills acquired over a very long career that make him a nightmare for the status quo.

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