‘It’s a big ship to turn, but if you don’t have the at­ti­tude in place, you’ll never change’

Modern Healthcare - - Q & a -

HHS Sec­re­tary Alex Azar in early March chal­lenged the in­dus­try to move quickly to be­come more trans­par­ent about pric­ing. And if it doesn’t hap­pen, he said, the

Joseph Fifer, gov­ern­ment has “plenty of levers to pull to make the change.” CEO of the Health­care Fi­nan­cial Man­age­ment As­so­ci­a­tion, agrees that health­care has been slow to adopt mean­ing­ful trans­parency poli­cies, but he be­lieves that is chang­ing. Fifer, who took over the HFMA in 2012 af­ter 11 years as vice pres­i­dent of hos­pi­tal fi­nance at Spec­trum Health in Grand Rapids, Mich., says in­dus­try lead­ers are start­ing to do a bet­ter job of lis­ten­ing to con­sumers. Fifer re­cently met with the Mod­ern Health­care edi­to­rial team to talk price trans­parency, pa­tient-friendly billing and other top­ics. The fol­low­ing is an edited tran­script.

Mod­ern Health­care:

What’s the big­gest change you are see­ing in the CFO’s role?

Joseph Fifer: All the CFOs I talk to are ab­so­lutely right in the mid­dle of strate­gic devel­op­ment of their or­ga­ni­za­tions.

Some­times we talk to our CFO mem­bers about things that are core to what the HFMA does, like rev­enue cy­cle or just pure fi­nance is­sues or ac­count­ing stan­dards, and they’re not all that tuned in be­cause they’re fo­cused so much on the strate­gic di­rec­tion of their or­ga­ni­za­tions.

So that has all kinds of im­pli­ca­tions for a CFO’s role to­day. And I think that’s go­ing to con­tinue.


How much are you work­ing with mem­bers on the is­sue of trans­parency?

Fifer: We con­tinue down this path of price trans­parency and pa­tient fi­nan­cial com­mu­ni­ca­tions, which we started back in the mid2000s. We started talk­ing about price trans­parency be­fore it was cool. We had a con­sumerism re­port out in 2006; we had a re­port on pa­tient-friendly billing and on pric­ing. It re­ally started to call into ques­tion how or­ga­ni­za­tions set their charges.

A cou­ple of years ago, we had our price trans­parency re­port and we pulled to­gether a coali­tion of or­ga­ni­za­tions, in­clud­ing Amer­ica’s Health In­surance Plans and the Amer­i­can Hos­pi­tal As­so­ci­a­tion.

With the an­nounce­ments from the cur­rent ad­min­is­tra­tion about trans­parency be­ing a fo­cus, our eyes and ears are wide open, and if there’s a way

for us to par­tic­i­pate in the di­a­logue about these top­ics, I don’t think there’s any­body more ex­pert in the coun­try than we are.


Has the in­dus­try gone about trans­parency in the wrong way? Do we re­ally know what a con­sumer thinks is trans­parency and what they want ver­sus hav­ing to be an in­dus­try-led con­ver­sa­tion?

Fifer: I’d like to an­swer that with a story about what we did with our price trans­parency coali­tion. We pulled to­gether some large health plans, we had some large health sys­tems, we had other as­so­ci­a­tions. But we also had a pa­tient for part of the time. It was a woman who was in New York and there was a se­ries of ar­ti­cles in the New York Times about her. She was be­tween jobs, she didn’t have in­surance, this was be­fore the Af­ford­able Care Act and she was preg­nant. She was look­ing for price and qual­ity in­for­ma­tion about where to de­liver a baby. And of course the ar­ti­cle was not very com­pli­men­tary about her suc­cess in find­ing that in­for­ma­tion, so there was a se­ries of ar­ti­cles de­scrib­ing that ex­pe­ri­ence.

She was an at­tor­ney by back­ground, not a health­care at­tor­ney, but ob­vi­ously un­der­stood com­plex con­cepts and was used to study­ing, but not an ex­pert in health­care. We’d be talk­ing about all these things and every once in a while she would raise her hand and say, “I don’t know what you guys are all talk­ing about, but here’s what I was in­ter­ested in find­ing out when I was do­ing this.” And it grounded us in a nanosec­ond. It took us right back to the roots of what we needed to do.

So that’s a long ex­am­ple, but it’s so im­por­tant for or­ga­ni­za­tions to do that, whether it’s through a for­mal de­sign think­ing process or just pay­ing at­ten­tion to the con­sumer’s needs. I am see­ing more and more of that but it was a slow up­take.

MH: Given that there seems to be so much dis­par­ity from state to state and even health sys­tem to health sys­tem, do you think there needs to be more of a federal pol­icy that sort of stan­dard­izes the in­for­ma­tion that ev­ery­one pro­vides?

Fifer: We are po­lit­i­cally ag­nos­tic. We don’t put to­gether guid­ance to de­fend against leg­is­la­tion; we don’t put to­gether guid­ance to pro­mote leg­is­la­tion. We put a guid­ance to­gether that says, “This is how it should work.” And the idea is that or­ga­ni­za­tions can rally around that.

If there is go­ing to be leg­is­la­tion or reg­u­la­tion, there’s a blueprint that folks could use. It re­ally is hard to come up with federal laws or reg­u­la­tions that work re­ally well in such a di­verse in­dus­try across 50 states.

MH: Since the HHS sec­re­tary didn’t of­fer any specifics, does that af­ford you an op­por­tu­nity to go in early and say, “Here are some ideas of what we think we could do,” or are you still go­ing to take a step back and wait un­til they pro­pose some­thing?

Fifer: Maybe some­thing in be­tween. We con­tinue to make it pretty clear that we’re avail­able for any­body who wants to talk about these is­sues. We have a body of work that we think ap­plies.

I don’t mean it to sound pas­sive, but we just don’t have the in­fras­truc­ture to re­ally en­gage in that kind of a cam­paign, so we’re not go­ing to do that.

MH: The in­dus­try still strug­gles greatly with con­sol­i­dated, pa­tient-friendly billing. What’s it go­ing to take to get to a point where the ma­jor­ity of the bills are some­thing that the reg­u­lar con­sumer can un­der­stand?

Fifer: There’s some in­her­ent struc­tural com­plex­ity in our in­dus­try that other in­dus­tries don’t have. When you buy a car, you’re buy­ing some­thing that many peo­ple may not un­der­stand. I don’t un­der­stand the in­side of a car. But when you buy a car, you’re not deal­ing with all this frag­men­ta­tion.

Health­care has all this frag­men­ta­tion that makes the en­vi­ron­ment much more com­plex than any other in­dus­try.

That said, we could do a lot bet­ter, but if I’d had this ques­tion two years ago, I prob­a­bly would have given you a pretty dis­cour­ag­ing an­swer, be­cause I didn’t think that we were mov­ing fast enough as an in­dus­try.

Over the past year to two years, I have sensed a much higher aware­ness of re­ally lis­ten­ing to con­sumers and de­vel­op­ing tools that will make it eas­ier for them. I’m en­cour­aged by that.

MH: In terms of the cost­cut­ting ques­tion, what do you think of what Ama­zon, JPMor­gan Chase and Berk­shire Hath­away are do­ing?

Fifer: So many times, some­body from out­side the in­dus­try thinks there’s a sim­ple so­lu­tion to some­thing, and there’s not. This is a very com­plex in­dus­try, and every sin­gle thing you do has mul­ti­ple in­flu­ences and mul­ti­ple im­pli­ca­tions.

But it sounds to me like they’re go­ing into it know­ing that this is not a sim­ple thing and that they can’t just wave a magic wand and fix it.

The ques­tion will be, are they will­ing, as em­ploy­ers, to make fun­da­men­tal changes in their ben­e­fit plan struc­tures to change the di­rec­tion of their health­care spend? And I’m sure that’s what they’re try­ing to fig­ure out. So many times we want to change part of our in­dus­try, but don’t rec­og­nize just how frag­mented it is.

We’ve all contributed to get us to this point. It’s silly to think that one or two of these seg­ments, if they just make a change, will fix it.

MH: What about the ag­gres­sive moves by CVS Health, Aetna, Op­tum and Wal­greens?

Fifer: I’m watch­ing those just as much as I am the Ama­zon-Chase-Berk­shire news. Those or­ga­ni­za­tions have a dif­fer­ent set of data that they’re go­ing to be able to mine and do some­thing dif­fer­ent with and I think they’re each fas­ci­nat­ing. The Aetna and CVS deal is par­tic­u­larly fas­ci­nat­ing to see what that will do on the con­sumer end.

There’s a move­ment to­ward do­ing a bet­ter job of pay­ing at­ten­tion to the con­sumer and that’s what is driv­ing this sen­ti­ment. It’s a big ship to turn, but if you don’t have the at­ti­tude in place, you’ll never change. And that’s the optimistic part that I’m see­ing now. I’m see­ing a dif­fer­ent at­ti­tude about it.

I’ve been a critic of our in­dus­try be­cause it starts with at­ti­tude.

“So many times, some­body from out­side the in­dus­try thinks there’s a sim­ple so­lu­tion to some­thing, and there’s not.”

MH: What are your thoughts about cen­tral­ized ver­sus de­cen­tral­ized boards and what that does for fidu­ciary re­spon­si­bil­ity?

Fifer: Two things. If we’re go­ing to be­come more ef­fi­cient, we need an abil­ity to make de­ci­sions in a more cen­tral­ized way. Ob­vi­ously with any model, there’s a right way to do it and a wrong way.

The other point is, we need to come up with dif­fer­ent lan­guage than say­ing, “We’re go­ing to close the hos­pi­tal.”

If you think about a small ru­ral hos­pi­tal, rarely would some­body say that we’re go­ing to close this hos­pi­tal and not have any ser­vices in the com­mu­nity at all. I think it’s a re­def­i­ni­tion of what it is to be a hos­pi­tal in those com­mu­ni­ties. And I’m not just play­ing on words here.

I’m not just try­ing to cam­ou­flage what’s re­ally hap­pen­ing in these com­mu­ni­ties. Us­ing cur­rent tech­nol­ogy, there’s a dif­fer­ent level of ser­vices than just hav­ing an in­pa­tient hos­pi­tal.

Some parts of the coun­try are do­ing this re­ally well, like Alaska and the up­per Mid­west states, where they’re us­ing telemedicine and other tech­nol­ogy to de­liver ser­vices dif­fer­ently in those re­mote ar­eas.

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