The rise of value-based care and the ongoing evolution of healthcare technology are just two of the many topics the new CEO of America’s Health Insurance Plans (AHIP) says are front and center on his upcoming agenda.
AHIP’s Matt Eyles takes a deep dive on those subjects and more while speaking with Rob Capobianco, the head of the Change Healthcare value-based-care analytics team, as part of the Change Healthcare Episode Intelligence podcast series.
Matt has more than two decades of healthcare experience in both the private sector and in government. Before joining AHIP, he held senior executive positions at Coventry Health Care, Inc., and Wyeth, and has been a consultant to some of the largest global and U.S. healthcare companies and organizations.
Matt began his career at the Congressional Budget Office where he worked on many issues, including healthcare, budget policy, and regulatory policy.
Rob and Matt cover a wide range of topics, including:
- The biggest differences in healthcare policy Eyles has seen in the past ten years
- Short- and long-term priorities for AHIP
- The future of value-based care
- The healthcare technology evolution
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ROBERT CAPOBIANCO (“CAPPY”): Welcome to Episode Intelligence, a podcast dedicated to finding the value in value-based care. I’m Robert Capobianco, Cappy for short, and I head up the value-based care analytics team at Change Healthcare. Today I’m speaking with Matt Eyles, the AHIP president and CEO. In our discussion today we’ll cover Matt’s background, and the depth and breadth of his healthcare policy experience. We’ll also discuss Matt’s vision for AHIP and learn more about AHIP’s key focus areas. Lastly, we’ll talk about Matt’s opinion on the direction of value-based care and his take on new research that was just published by Change Healthcare. Good afternoon everyone, this is Robert Capobianco from Change Healthcare with another podcast series, our Episode Intelligence series. And today I’m joined by Matt Eyles who is the president and CEO of AHIP. Matt, I want to first start out and just say thank you very much for giving us your time today. I’m sure your schedule is busy. We’re live from the AHIP floor. Incredible opportunity to interview someone of your caliber, your experience. I’m honored to have you as our guest.
MATT EYLES: Well, thanks for having me here Rob. It’s really great to be here. There’s so much interesting challenges within the healthcare system. So many interesting things going on. Great speakers here. So I’m really happy to talk about a couple of things that might be happening in the world of healthcare that are important these days.
CAPPY: Absolutely. So we’re going to dive right in and just start a little bit about you and your organization, sort of goals and accomplishments. But I’d love to introduce you to the audience and let’s just start out with, just tell me a little bit about yourself.
MATT: Sure. So I’ve been at AHIP now for about three and a half years. My career journey has been, I don’t want to say it’s interesting but certainly varied. I’ve worked in industry for more than half of my career, directly for companies. But at my heart, I’m a policy geek. I started back during the Clinton health reform debate at the Congressional Budget Office crunching numbers, doing analysis. And the very first thing that I worked on there was actually a paper related to the individual mandate and that was in ’94 back when it was a Republican idea and not a Democratic idea. So I’ve gone through a number of different twists and turns throughout my career.
CAPPY: Incredible. So very rarely do I get a chance to interview someone with that much policy background. So really, the first question to sort of dig into that extensive background around: What’s the biggest difference in healthcare policy you’ve seen over the last ten years?
MATT: I think healthcare policy over the last decade has probably got to be a bit more of a partisan exercise than it had been previously. And certainly there are a lot of different sort of reasons you can point to whether it was the way that the Affordable Care Act sort of moved through the congress. And just I think a broader trend towards more polarization that we’ve seen within politics more broadly and healthcare policy has gotten pulled up into it. You can look back in time, for example, the enactment of the Social Security Act that created Medicare and Medicaid, it was a bipartisan exercise, had broad support across the aisle. We haven’t seen that within healthcare. And even thinking about something like the Medicare prescription drug benefit which was created back in 2003 and got launched in 2006, that was largely a partisan exercise, too. The difference is that once Democrats got into control they implemented the law and they didn’t challenge it all the time. They might not have liked it so much, but they implemented it. And what we’ve see really as a result of the polarization is this really radical swing back and forth within healthcare. And it’s made it really difficult for entities that operate in the healthcare space whether you’re working in the health insurance industry, for a health insurance provider, whether you’re working for a pharmaceutical company, health systems, it’s made operations and planning so difficult because we’ve had these dramatic swings from one side to the next. I mean just think about what happened in November 2016 with the election and having the congress be in Republican control and the administration, you know a big swing from what we had seen just a few years back. And so I think it’s made it really challenging within healthcare to try and figure out, how do you navigate this environment because you can’t go too far left, you can’t go too far right. But we’re nevertheless impacted by these really large political swings.
CAPPY: Interesting perspective. Because I never thought about that policy actually improves when you sort of confront the pieces as they’re not working and try to remediate.
MATT: That helps when you have people who recognize that there’s a problem or a challenge that needs a solution. I think that’s how certainly we like to approach things. And historically, there are a lot of issues that have had bipartisan support. But really I’d say since 2010 with the Affordable Care Act where it has just been hyper-politicized. I think that’s probably the biggest difference and one of the biggest challenges that we’ve seen.
CAPPY: Interesting. So you’ve taken on a huge role as the new AHIP president. What are your top short-term and then long-term priorities? I’m sure there’s lots.
MATT: In healthcare, as everyone knows who works in it these days, there’s so many competing priorities but it’s important to focus. And we do as a membership organization that works across the entire spectrum of health insurance providers. So we represent plans in the commercial market, those that are on the exchanges, those that operate in Medicaid and Medicare, and also operate in non-major medical product space called supplemental. So dental and vision. We have a balancing act about how do we make sure that we’re addressing the broad needs of our membership. So, by way of short-term priorities I’ll identify a couple that we have. The first really is around the value of private health insurance and making sure people are clear about what it is that health insurers bring to the table in terms of improving affordability, reducing prices, ensure access to evidence-based care, and really having people understand health insurance is probably one of the most misunderstood products out there. It’s not like a lot of others that you can touch and feel and put in your pocket, except for maybe your insurance cards. So really having people understand what the value is of the private insurance system that we have here in the United States.
Two, focused on big government programs that are critically important to providing coverage. The Medicare Advantage program and really having people understand Medicare Advantage, which is a growing subset of the broader Medicare program. So Medicare Advantage plans now provide coverage for more than 20 million seniors and people with disabilities who qualify for Medicare. It’s a little bit more than one-third of the program’s enrollment and it’s growing rapidly. It’s growing this past year by more than 8%, at least in terms of enrollment. Because people see it’s a valuable option to the fee-for-service program because it provides better benefits, more coordinated care, out-of-pocket limits that don’t exist in the traditional Medicare program. Medicaid and Medicaid managed care coming out of the repeal and replace discussion, I think there’s been a really fundamental change with respect to how people look at Medicaid and the role of Medicaid in terms of being a safety net program for a very large portion of the American population. More than 70 million people are enrolled in Medicaid, and more than 55 million are in Medicaid managed care plans. And making sure that people understand the important role that Medicaid managed care plays in the broader Medicaid program.
Another area of course, the instability that we’ve seen in the individual market with premiums rising dramatically over the past couple of years as a result of policy changes and just the program not working exactly as it was originally intended and trying to move forward with a number of important fixes to that program. So those are sort at least beyond, one other one I should mention which is critically important too, is the employer market that are 180 million individuals who receive coverage through employer-sponsored insurance. And it has been overlooked a little bit in at least in terms of how it’s able to not just deliver high-quality affordable care but the types of programs and investments that employers are able to make in their employee populations because they tend to sticky, be sticky with them and stay with them for multiple years. So at least out of the coverage programs, that’s where we’re focused. And then there were a couple of other important issues that you just can’t escape. High drug prices and the challenges that we see there. What’s happening with the opioids epidemic and efforts by the health insurers to really be part of the solution and making sure people who need access to pain treatments have them. And in some cases, it might be an opioid that’s appropriate, but making sure that there’s also access to non-opioid treatments.
And then there were some other issues focused on premiums like the health insurer tax which increases premiums. We’ve been trying to get rid of that permanently. It’s been suspended for 2019 and we’re trying to get it suspended in the future because it adds an incremental three plus percent to premiums out there and given how expensive healthcare is today, anything that we are doing to add to it isn’t improving affordability. So that’s a long list. That’s sort of our short-term priorities. Longer-term it’s, we’ve been working as an industry group and membership group really looking out to the future.
So what is the ideal healthcare system look like? Again, if we just sort of get past the one or two year time horizon and even past the next election out to say 2025, what do we think the healthcare system should look like? And what’s the role of health insurance providers in that world? And so we’ve charted a course looking to the future, focused in three areas. The first one is around consumers and really making sure that our healthcare system is working to benefit patients and consumers and that they’re put at the center. And how can we make the healthcare experience for individuals and their families and caregivers so much more simple than it is today, because it’s extraordinarily complex. The second area we’re focused on is around partnerships, both public, private partnerships and partnerships across the healthcare system. So, for example, working with state governments, working with the federal governments, how can we work collaboratively together to improve the healthcare system. But then, working within the private sector too. So how can hospitals work with health plans, work with pharmaceutical companies to really have a much more effective healthcare system. And the third area that we’re focused on is around affordability and value. And it always has to come back to what’s affordable because to the extent that healthcare continues to rise at an unaffordable rate, we know that fewer people are going to have coverage. It’s going to lead to more uncompensated care. It’s going to lead to declines in health, greater mortality. So we really do need to grapple with the affordability problem.
CAPPY: Incredible organization. Incredible goals. You’ve covered a wide spectrum of that. I completely agree with you. Health insurance, one of the hardest products to actually understand as a consumer because we only use it at the time of need. But it isn’t a product that we go out and it’s not cereal or these things that become very commonplace for us.
MATT: What’s interesting about that point Rob, I think is that you want it there when you need it but that also because healthcare is an investment you want to find a way to use it while you’re healthy. And that’s an important, I think, shift, as our members are really trying to focus on well care and staying out of the hospital and not getting sick on access to preventative care and treatments and services and almost all the plans that are available now on the market today provide access. It doesn’t matter whether you’re in Medicare or you’re in a commercial plan, provide access to essentially free preventive care and screenings and getting your annual physical and really trying to shift towards how do we get people to use what they have so that we can avoid some of the bigger problems down the road?
CAPPY: It’s an excellent point, really highlighted in the kickoff presentation today about not just having a sick care system. Waiting until that point. A tremendous amount of effort going into the well care and the social determinants of care, and being as simple as just being able to get right food and act that way. Incredible transformation in the industry. I’ve been in it for 20 years so it’s exciting to start to see all this movement.
MATT: It is exciting to see that people are putting together pieces of a puzzle that had clearly been scattered around the room. And people like figuring out that some of these pieces actually fit very well together and are meant to fit together. You raised an important point around some of the social determinants of health and how do you provide access to nutrition, transportation, physical security, housing. I mean, all of these things are created and have as big an impact if not bigger than we know than the healthcare that you actually receive by going into the physician’s office.
CAPPY: Right. We’ve got to think about those, our basic need. Be able to supply to the basic need before we can get to the bigger problems. It’s absolutely true. Before we kind of move into some of the news that’s dropping here at AHIP, one of the biggest industry shows I’ve come to for over the last ten years, wanted to just one last question because you brought up the consumer-centric vision of the industry. What do you think about the technology evolution kind of going on there? Where is it? Where does it need to go to actually bring the consumer into the center?
MATT: Well, first thanks for coming to the AHIP Institute for so many years. It is a great conference. But coming to the issue of consumers and technology I think it’s important to recognize how consumers use technology and how we can create a system that enables them to use it the same way that they use it for in so many other aspects of their life. And there are ways that it can be used when an individual is acting as a consumer. There are times when someone’s a patient and having the technology probably isn’t something that’s really the most important, it’s just about getting well. But there are all different facets of technology that are really pervading in a positive way what’s happening in the healthcare system. And I think we’re really just starting to scratch the surface whether it be around things like telemedicine, apps that help individuals stay compliant with their medication treatment regimens, how can we make sure that people have access to technology that is going to make things simpler and easier for them? But there are a number of huge barriers that need to be overcome. Think about an issue like interoperability of electronic medical records. We’ve been talking about that literally back to the days of President Bush and saying how do we get a system where these electronic medical records can talk to one another? They’re interoperable. It doesn’t matter what platform you’re on. How can patients have access to their medical records so that they can be portable? I have a couple of colleagues that I used to work with who tell some really compelling stories about a very sick child with a very rare condition who, because electronic medical records are not interoperable, every time they go into a new hospital they have to give all their information over again. As they’ve traveled across the country at different times where something’s happened they have to do this over and over and over again and we just have to find a way to make the technology work to the benefit of consumers and patients and do so in a way that’s as friendly as it is in so many other parts of the healthcare system and our broader economy.
CAPPY: No. I absolutely agree. We can often get more about our automobiles or simple consumer services than we can about our own healthcare. It’s a great initiative. Fantastic organization. I’ve enjoyed the privilege of being able to come here for the last ten years and learn a lot. I wanted to step into a little bit about the value-based care study that was commissioned by Change Healthcare and performed by ORC International. We announced it at an appropriate venue here at AHIP where the right audience is. I think from the study itself, there were sort of, there were many findings but the three that sort of point out or poke out to me are that payers reporting success in reducing unnecessary medical costs all respondents claimed to be reducing medical costs, the average was right around 5.6%. In conjunction with that, and I think almost more importantly personally is that there also about 80% of the payers reported improvements in the quality of care, their provider relationships, and also patient engagement. And to me, that’s some way of looking at the medical cost is like trying to manage a result. It’s not managing the process and I think that’s the great part about the study is that we’re getting to the process, the relationships, the patient engagement, the quality of care. And then what surprised me out of the study, and I’m going to ask you questions about this in a minute, is really it’s the first time that we’ve seen the commercial lines of business start to lead in these efforts of value-based care where historically we’ve seen a little bit more involvement on the government lines. So with that as a backdrop, does the fact that payers are more active advancing their value-based care for their commercial lines of business over the government programs surprise you?
MATT: I thought it was a terrific study and a lot of really interesting findings coming out of it and great data that we can actually point to and say what’s working, what’s not, what’s really happening out there in the market? So I want to commend you for doing the study because as we try and move towards a much more value-driven system we need to make changes based on real-world data and real information about what’s working and what’s not. So that I think is an important takeaway as well from the study is that we have additional data now that we can point to. I will say if you think about the, if you step back for a moment and look at sort of what’s working in healthcare and what’s not, certainly paying based on volume rather than value that’s not working. We know that that’s not working. I think what’s really interesting about the growth in the commercial side I think it’s a recognition that that’s where so much of the cost shifting has actually occurred in the healthcare system because it’s pretty well known that Medicare and particularly Medicaid underpay relative to probably the cost of actually delivering services. So there’s like an urgent imperative in the commercial market to really try and find ways of paying based on value that work and that have results. Because when you have the average charge in say a hospital setting for a commercially insured individual being a multiple of what it is in Medicare or Medicaid it really creates this sense of urgency to act.
And then you can tie it also back to say the employer market where employers again provide 180 million lives worth of coverage in the United States, they’re paying the highest costs compared to Medicare and Medicaid and I think as employers are really scrutinizing their bottom line in terms of how they are providing coverage for their employees they want to make sure they’re getting the best value. They’ve been paying more than everyone else. So I think that might tell at least the part of the story in terms of why payers and plans are driving more even on the commercial side because they really need to get some results for their employer customers because as costs continue to rise, employers are spending more money on healthcare than lots of other services. And you know they would also prefer to pay their employees more rather than in terms of additional healthcare benefits. So I think that might be one of the reasons why we’re seeing this shift there versus what we’ve seen in Medicare and Medicaid which has been very, very active. I know our Medicare Advantage members and Medicaid Managed Care members are very active also in terms of this. But I think on the commercial side there might have been a fire that was lit under them by their employer customers saying we need to fix this.
CAPPY: And it’s like some point to tie back to your first comment around they also keep that employee for a number of years so they’re not just paying once, they’re paying over periods of years.
MATT: Over, and over, and over again. That’s right.
CAPPY: Excellent point. Great perspective. So why do you believe value-based care strategies are not more prevalent among I guess the health plans that haven’t started? Because to me, the wave is kind of come ashore and you need to be doing things. But from your perspective, what might be holding back some of those plans that maybe haven’t started?
MATT: Right. And I’d say the ones that haven’t started, I’d say there’s very few of them that haven’t started. It’s just a question of like evolved are they in terms of whether it’s the more sophisticated global cap model versus episodes of care, versus pay-for-performance. So I think there’s an evolution there and some are much more advanced than others. But the ones that are catching up I think really recognize that they need to invest in this and it’s an investment. And so if you think about a plan that has a national scale, that it operates essentially across the entire country. Probably has millions of covered lives in there versus maybe a smaller regional plan. And what was interesting about the study is that it tried to segment the size of the plan when you were asking questions in terms of those are the ones that probably have fewer resources to either devote towards trying to come up with these novel models but have recognized you know what, we’re going to be at a huge disadvantage if we don’t. And so they’re trying to play catch up as quickly as they can. And some of it is also just sort of a market dynamic. I think that was another interesting takeaway from the study is looking at what is the market dynamic. Is there a dominant payer? Is there a dominant provider? Health system? Is there one? Is there two? Are there no, is there no one that’s dominant? And I think some of those factors also play into how we see the world evolving with respect to value-based payments.
CAPPY: And I would say it’s interesting especially when you think about those characteristics. If it’s the dominant plan, it’s a great point, they have a little bit more wherewithal to sort of push the program out, drive adoption. In the provider markets where they’re dominant, they have a little bit more negotiation strength and power of membership.
MATT: Absolutely. That’s right. Now we’ve seen dramatic differences across markets and that’s one of the reasons why we have such enormous variation in healthcare spending across the country is because you can’t, you know if you’ve seen one market you’ve seen one market. I mean there are probably a couple of different archetypes where you can characterize those markets but nevertheless there are always sort of unique factors within any particular local market geography. Rural versus urban. Very big differences too. I mean in some places for example, you know in the rural health setting it’s really hard to put in these value-based payment systems just because the population isn’t big enough there in some of those cases and there may not be enough providers either in terms of trying to have something that works for them. So it’s important to look I think across different market segments to realize like where are these payment systems going to be most effective in terms of driving down costs and where’s the greatest market opportunity for these payments to results in the reduced costs like some of the percentages that you cited.
CAPPY: Absolutely. Thanks for the response. We did take sort of a focus on episodes of care and just particularly because of the high percentage of participation that we saw within the survey itself. So why do you think episodes of care programs are effective at savings costs and improving quality?
MATT: I think the episode of care is a way to look at the entire spectrum of treatments and services that an individual who has a particular disease-state or medical condition is going to experience. And in many cases, it’s easier to measure a start and an end-point. For example, I mean I was really interested to see the results around for example, maternity care in terms of episodes. But it’s evolving into those episodes too, now, that are chronic. I think it’s easier to start with things like joint replacements and again looking at the entire episode because you can see sort of where the start and where the end-point is and it makes it easier to measure quality, to measure outcomes, to measure cost savings, to say hey, this really works. Maybe we can apply it to another condition that we can get some similar results. And so I think it’s a nice way to look again at a total sort of spectrum of treatments for a particular condition, disease state that someone might get in. And it’s a lot easier to do than say for example, doing at a population health, a global level because you can do it. You don’t need to have that whole population health perspective again, but you’re able to still look across all of the care that someone’s getting and finding incremental ways to make it better, to make it less expensive, to make it higher quality.
CAPPY: Great point. I bring up some fundamental challenges that I think when people hear about episodes, I heard about them first from around 2006 when there were really only about six or seven available on the market. They were primarily within the orthopedic procedural practices. For the audience out there, I just want to sort of summarize that the episode gives you that disease context and then it does some fundamental things that I think we’ve been trying to achieve over a market for a long time, which is define that context that we can all agree on, and to your point set up a standard way or as much as the standards we can around utilization measurement, quality measurement, and being able to encapsulate the costs. So pretty powerful tool, but a great articulation of it. I wish you were out there with us sometime.
MATT: Well I think what’s really interesting in terms of like how you laid that out, is there is sort of a start and an end period? The challenge with an episode though is all patients are different. And so you might have someone with a particular disease state or condition that you’re trying to manage but you don’t know what other comorbidities or other conditions they might have. And so that adds in a layer of complexity where someone who has, who’s getting joint replacement but maybe has diabetes, hypertension, other factors like that it complicates matters. But it’s still an important starting point and a way to look across an entire sort of course of treatment over a specified period of time. Because you can sort of stretch these out I don’t want to say out into infinity, but for longer or shorter periods of time and still figure out okay if we include this episode say for a 90-day period versus a 30-day period versus 180-day period like what kind of changes do we see and what other information are we able to ascertain because that episode is either shorter or longer. So it’s a great way I think for all different types of payers and providers to at least start thinking about value-based payments depending upon how sort of advanced or whether they’re just sort of starting out.
CAPPY: I think it only gets better from here. But with consumer side devices and machine learning and AI who knows what the future holds. But I think it will incrementally keep building. That’s what we’ve seen in healthcare over and over and over again is we just keep taking the ideas farther.
MATT: I think that notion of incrementalism is really important as well when you think about healthcare because there are efforts out there and I’m coming back to the policy world for a little bit that would try and sort of fundamentally disrupt and change what’s happening within the healthcare system, whether it’s moving more towards a government-driven solution or sort of taking government out of it even a little bit more than it’s in there today. And that kind of massive disruption requires a lot of transition. That, it’s really hard to do that. And so thinking about incremental improvements whether it’s coverage expansion, ways that we’re improving healthcare is delivered, measurement quality, those are all really important and ways that we can make real progress over a finite period of time and see what’s working and what’s not. Because as we know, it’s been said before but I’ll say it here healthcare is complicated. So when you have that many moving parts probably an incremental approach is a lot more effective than trying to do a wholesale dramatic change. Despite all the disruption that we’re seeing now and all of the change whether it be on the technology side or what we’re seeing with Amazon and JP Morgan, Berkshire Hathaway, that they want to disrupt things as well. But it’s really hard to do it in a massive way in a short period of time.
CAPPY: Absolutely. Want to be cognizant of time. I’m sure you have way more meetings going out today and into the rest of the week. So for the audience here that doesn’t get the opportunity to speak to someone like you, just sort of any final words of wisdom for the audience? Things you want to leave them with?
MATT: I think it’s important to embrace the change that’s happening in the healthcare system. When I think whether it was my own personal journey professionally or the disruption that we’ve seen in different parts of the healthcare system if you’re able to embrace the change, sort of step back for a second and say okay, we’re going to figure this out. It might be hard. It might be really challenging. But we’re going to be better when we come out the other side because we will have learned something different. I think that’s a pretty important approach when you’re tackling big problems that are of the complexity that we see in healthcare. And don’t fight it because you’ll probably lose if you do. So you’re better off trying to figure out how can you work with the hand that you’ve been dealt, embrace the change, and try and make the system better.
CAPPY: Absolutely. Great. So for the audience what’s the best way that someone could learn more about AHIP and the work that you do?
MATT: So the best way is we have a pretty good website that talks about a number of the different issues that we’ve covered here today. Both our short-term priorities, our long-term priorities, who our members are, and most importantly what are the big issues that we’re spending our time on. So go to AHIP.org and you can probably find the information that you need. But if not, I’m always happy to talk to all people who are operating in the healthcare environment. I learn something new all the time. So open invitation for people to reach out to me and talk about what’s happening at AHIP.
CAPPY: Great. I want to thank you again for your time and too for your commitment to the industry. Again, AHIP has become a place where I’ve come in my career to come and learn just about every aspect of it from the member side to what technology is going on, policy movement, and come see some of the leaders of healthcare come and speak around the important issues. So really appreciate the time of coming out and I know that I learned a lot. I hope the audience does too.
MATT: Thanks for having me here today Rob. Really appreciate it. Thank you.
CAPPY: Thanks everyone. And that’s a wrap of this edition of Episode Intelligence, the podcast dedicated to finding the value in value-based care.
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