Provider Quality: Fad or Imperative in Driving Improved Health Outcomes?

Are provider quality scores just another healthcare fad, or are they a critical tool for driving better health outcomes and maximizing your organization’s investment in employee benefits? In this episode, we cut through the noise to help employers understand what these scores really mean, how to identify high-quality providers, and how leveraging this information can lead to measurable improvements in workforce health and cost efficiency. 

Join us as we answer the questions employers ask most:

• Which provider quality metrics actually matter for my organization? 
• How can I use provider data to improve employee satisfaction and health outcomes? 
• What are the pitfalls of relying on certain scores, and how can I avoid them?
• How have other employers successfully used provider quality information to drive results?
• What practical steps can HR and benefits leaders take to integrate provider quality into their strategy?

Whether you’re a benefits manager, HR leader, or executive, this episode will empower you to make informed decisions that benefit both your employees and your bottom line.

Transcript

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Welcome to The Pulse, where we keep pace with what's trending in employee benefits. I'm your host, Mary Delaney, managing partner of Vital Incite, an Alera Group Company. This series was developed to bring together nationally recognized subject matter experts from the health and pharmacy industry, as well as top academic and research institutions. Our goal is to provide unbiased information and offer scalable strategies that give you clarity amid the chaos and provide answers to your most burning questions. In today's episode, where we're diving into a topic that sits at the crossroads of strategy, health outcomes, and the evolving considerations

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provider quality. For years, organizations have wrestled with a simple but critical question: Are provider quality scores just another industry gimmick, or are they truly a lever for improving employee health and maximizing benefit investments? Today, we're cutting through the noise. We'll unpack what these scores really represent and how employers can use this information to drive measurable improvements in workforce health, engagement, and cost efficiency. And just as importantly, we'll explore where the current system falls short, because not all metrics are created equal, and misunderstanding or misusing them can steer organizations in the wrong direction. But before we jump into the panel, let's talk about one important reality – the pitfalls of today's provider quality metrics. Despite their potential, many of the commonly used measures suffer from significant limitations. Data is outdated or inconsistent. Quality ratings often rely on claims data, and that lags months or even years behind the current performance. Providers may have improved or declined, but the ratings don't always keep up. Another concern is metrics don't reflect true clinical quality. Some scores emphasize process compliance over actual outcomes. A provider can check every box or fill out every form, yet still struggle to deliver high-quality patient-centered care. Further, there are variations across carriers and measurement systems. Different payers use different definitions, weighting, scoring scales, and high-quality thresholds. This leaves providers confused and unable to focus on improvement and employers struggling to compare apples to apples across networks and markets. Then there's a concern related to risk adjustment that doesn't always go far enough. Providers caring for more complex populations may be unfairly penalized, making some high-performing clinicians appear lower quality on paper. And those providers who have effectively reversed diseases then are penalized by that patient being considered lower risk, where in fact it takes more provider effort to get to and support a person to remain low risk. And finally, a tendency to oversimplify. Reducing care quality to a star, percentile, or color code can cause employers to rely on a single number rather than a full nuanced understanding of the patient experience and outcomes. These pitfalls matter, because when employers use incomplete or misleading metrics, they risk connecting employees with providers who may not actually meet their needs. That's why today's conversation is so important. Our panelists are here to help us sort through the noise, and we're joined by two experts who live and breathe this work every day. I will start with Dr. Will Bruhn. Dr. Bruhn is a physician, healthcare researcher, and entrepreneur known for his leadership in price transparency and medical appropriateness. He previously served as a research fellow at Johns Hopkins School of Medicine, publishing extensively on healthcare quality and reducing waste. He co-founded GAM [Global Appropriateness Measures] , a physician consortium that develops data-driven, clinically sophisticated quality measures. His work helps organizations improve navigation of care, provider network design, and quality improvement initiatives. Dr. Bruhn, thanks for sharing what you've learned with us on this important topic today. Thank you, Mary. Great to be with you today. Great to have you. Next, we have Chris Hogan. Chris is a seasoned insurance professional with over 30 years of industry experience and serves as an executive vice president and principal at the Benefit Commerce Group and Alera Group Company. He works with employers to design sustainable benefit programs and alternate funding strategies that reduce costs and improve outcomes. His career includes leadership roles in product development, sales, and financial analysis at Cigna Healthcare and Great West Healthcare. Chris, we look forward to hearing your perspective. Thanks, Mary. Look forward to it. It should be a fun day. It will be a fun day. And I'm thrilled to have both of you gentlemen join us in this discussion. So with that, let's dig in. I'm going to start with Chris. I know that you believe that provider quality is a critical part of the strategy discussion. Can you tell us why you feel so strongly about that? Yeah, I just think it's been such a positive influence on the overall healthcare discussion. I think for years, the message that we have sent to – inadvertently, by the way – to the market is that the most important thing for anyone to contemplate when they're considering where to have care is what building. Or what suite number. Like as long as this health system logo is on the building, then that's where you should go. Or if it's on the office suite, that's where you should go. And it's not about that. It's about the quality of the individual provider, not where they work. I mean, there's variance in performance inside that building or inside that office suite, just like there's variance in performance no matter your line of work in any building or office suite. So I think this movement to try to really redirect people to the highest quality care is such a positive thing. And it seems so silly when I hear myself say it out loud, because it's so fundamentally sound, right? That maybe the most cost-effective care is the best quality care that gets it right the first time and eliminates all the expenses related to downstream complications. It's such a basic thing, but here we are. And I think we should celebrate that. Now that's great points. We've always talked about cost of care versus overall care quality and reducing overall cost. Dr. Bruhn, any thoughts? Yeah, I'm in total agreement. I really got into this world and became excited about it because of experiences that I had in clinical medicine where I saw a dramatic difference in the way that people approach patients within the same practice, within the same building. And a lot of healthcare has been advertised as these systems or these specific hospitals have the highest quality care because they're able to buy the biggest billboards on the highway. But in reality, you know, I've practiced and I've rotated inside of some of those really well-known hospitals, and based upon the doctor that you end up with within that hospital is really the biggest decision. And so we always talk about how quality has been looked at like a group or hospital level, and what we've really seen in, you know, my decade or so of research in the space has been it's that individual physician level quality variation that really makes the biggest difference when it comes to the care that's given to the patients. And so I love this space. I'm a total data nerd and it's been super fun to get into this last decade. Well, your data nerdness is what has connected me to be interested in your work. Can you tell us a little bit about in the research what you found and what really struck you in this realm? Yeah, a lot of what we started doing and a lot of my work initially started at Johns Hopkins, where I was helping lead a lot of research initiatives around how do you actually measure quality in a way that matters to patients? Because for most of history, quality measurement has been done where we only look at the outcomes of care after care is delivered. And so my research team and a large group of physicians, we started looking at what's called the appropriateness of care. And it's pretty staggering, you know, the difference in care that's delivered, like what we’re talking about at the individual physician level, looking at what percent of your patients end up going to surgery versus something more conservative like physical therapy. And what we've really found is the AD20 rule applies really well to this space, which is in most of our analyses that look at healthcare quality variation, there's about 20% of doctors that are giving pretty out…what we call outlier care, which is care that is delivered pretty far from what most comparable physicians are practicing as. But the reality is even just 20% makes up about 80% of the waste in the healthcare system. And so if you can really zone in and use good analytics to identify that bottom 20% to improve quality of care, to change behavior and also for the care navigation components, that can have a massive effect on the spend as well as just the quality of care that patients receive. So you brought up the, you know, going to surgery versus perhaps physical therapy. Can you give us a couple other examples like that? Because I think it would be good to really understand what identifies someone who is really not a high-quality provider. Yeah. The way I think about the quality domain is, the first question is, does a patient need the care? You know, really the appropriateness of care. Does the patient need it? And that can be an MRI, that can be a CT scan, that can be a prescription, that can be a surgery. And so when you look at the appropriateness of care, what you're really looking at in terms of quality is, is a physician routinely over-utilizing certain services like imaging and surgeries when it might not be needed. And even within surgery, are they doing the appropriate treatment within that surgery or are they doing the most expensive one? A really classic example is patients that need to get a lumbar operation done, you can do either a spinal fusion, which is super expensive, or oftentimes you can do a laminectomy where you remove part of the lamina of the spine. That laminectomy is about a third of the cost and typically has better outcomes for patients. But because we live in a fee-for-service model, a lot of physicians will go directly to that spinal fusion. Another example that's very relevant for employers is OBGYN care. You know, how often are low-risk deliveries ending up in a C-section versus a natural delivery? And so those are the types of ways that we think about appropriateness of care and measuring whether a physician is giving high-quality, appropriate treatment. Then I think the last leg of the quality domain is that outcomes component. When you do give the care to a patient, are they having good outcomes? Are they having low readmission rates, low surgical site infections, low complications, low re-operation rates? And so it's really those two domains that make up kind of the holistic picture of quality for a physician. That's great. Chris, I know you have studied this inside and out, so love to hear your feedback. Yeah, no, completely aligned. I think I was looking at some data recently, which would absolutely support that. But, uh, 3 of the biggest delivery systems in our market, I recently saw some data that showed the complication rate post-mastectomy for the surgeons that practice at each of those 3 delivery systems. And there was consistently a 3-4x variation from best to worst. Right? So think about that. Think about on the, on the member level, your everything in the health system, insurance and everything, is aligned to send you to that building or send you to that office suite. And we give very little thought to once you're in there, who should you see? But if you or a loved one had to have that mastectomy, I mean, the stakes couldn't be higher, right? To say, you know, if I go in this door, I'm probably going to be fine. If I go in that door, there's a 4 times chance I'm going to have complications here. That's just a huge lever – putting aside costs for just a second – on someone's life and the impact that quality has. And then the other piece of data that I saw, which was really kind of, you know, it’s like a thunderbolt hit me. I believe in transparency. We all believe in transparency and the transparency discussion has been in healthcare for a long time. The problem with the transparency discussion is it's always focused on unit costs, right? They go to this doctor because this is what they charge. Don't go to that doctor because that's what they charge. Well, this study that I recently saw was particularly compelling, because it was two doctors who practice out of the same office. So they work for the same health practice. They have the same contracted rate with all the carriers. If you look them up on a transparency tool, they will show as charging the same for a hip replacement or a knee replacement. But to Will's point before, this doctor is really good at his job and this doctor unfortunately is not. This doctor is delivering a total cost per episode of care that's 36.5% below the regional average. This doctor is delivering a total cost of care that's 115% above, all related to quality. Again, they charge the same to cut your knee open or to replace your hip. So the transparency tool says they're the same. If you look at the difference between down 36 or up 115, there's a $44,000 delta there. So that's where I think this is such a positive thing. We have to keep the discussion going. We have to keep the consumer-driven movement going to focus less and less on unit costs and more on cost per episode of care. So it's interesting. My brain, as you guys were talking, is going back to the evolution in healthcare that I've lived through, which is physicians owning their own practices and making their own decisions, and then now being bought by health systems. So in our data, we'll suddenly see a lot more C-sections in a hospital system and we'll reach out and say, you know, do you realize this is what we're seeing? And you know, we know there's motivation there, and now there's this AI thing that's gonna take place that's gonna help everybody upcode as much as possible. Not that we weren't already using coders for that. How is that gonna change this conversation? I'll tell you a scary story on that topic. We were meeting with a, uh, kind of a regional health system a couple of years ago and talking to them about this emphasis on quality purely from the perspective of their benefit plan, okay – not as what they do, but as their benefit plan. And we're focusing on all of that. They look at the relationship and the cause if we drive more care to the top providers, look what happens here. At one point in the conversation, someone from the health system interrupted us and said, “I just have to tell you, I would prefer you not refer so negatively to the lower quality providers.” I said,“What do you mean?” He said, “Well, we look at them as our rainmakers. Those are the ones that are driving most of the revenue for our health system.” And I was like, oh my gosh, like your value proposition is to keep the community you serve just sick enough that they keep coming back to you and just well enough that they can function? I mean, there's something really wrong with that, right? So that's a challenge, right? That…is the broader physician community really financially incentive to care about quality, when lack of quality can be a driver of activity, which is revenue generating for them? That's great. Now, Dr. Bruin, you were involved, I believe, with some of the research that led to Dr. Makary's book and talking about low value care. And I always find that fascinating. If you haven't read that book, you need to, because it's also about what we learn over time and how we make assumptions, and people who follow along sometimes are making bad choices. So any thoughts on that research and what that helped you understand about this system? Yeah, I love Dr. Makary – close friend, and we've been working together for about 9 or 10 years together. And yeah, he's one of those futurists. He just has like this unique ability to see what's going on, that's going to be happening in 5 years. And you know, our initial research within the space was actually a couple of years before the big opioid epidemic broke out in the country, he had the foresight to see, I think this is a big issue and I think that post-operative patients are actually one of the things fueling this issue, is people go to get a surgery done, they're an opioid naive patient, meaning they've never had an exposure to an opioid before. And they're going in to get, let's say, an ACL repair or a shoulder arthroscopy or a hysterectomy. And there was, we showed in the data, there's this massive epidemic in the country of physicians handing out hundreds of opioids after these surgeries. And so, this was one of the first areas that we did this work of kind of identifying appropriateness of care was, how do you actually define the appropriate amount of opioid tablets you should give out after surgery? And we did these large panels of physicians to kind of understand what they thought was the pain tolerance, and now we have these published opioid guidelines that I think, last time I checked, a couple thousand hospitals in the country were using to set standards on appropriate opioid tablets after surgery, which is significantly driving down like that risk of people getting hooked on those drugs. And so, he has a unique ability to be able to like see into the future and know what's coming. And sure enough, a few years after we started that research, that was when, you know, the big news headlines started coming out about this issue across the country. And so yeah, it's been great to work with him, and he has really a great ability to be able to zone in on how is the healthcare system broken, and bringing some transparency and light into that so that really the laws of market competition can flow and help drive down some of this issue, which, going back to what Chris said about transparency, I think to me, that has always been sort of the solution is, if we have good transparent data in front of patients, people can make good decisions. And I think the last 5 years have been all about price transparency. And I really see the next 5 years being about quality transparency. And you need both to make a good decision because even today, still higher-cost providers will justify their costs by saying we give high-quality care. And there's no way to measure that until this last several years, where different groups have been able to really quantify quality. And so I'm excited to see by 2030 where we're at as a healthcare system, and maybe having a very open, transparent marketplace for patients to be able to make good medical decisions. I love that whole story around the opioids because it absolutely proves why provider quality metrics that people pay attention to can help improve overall health outcomes. So you really changed the trajectory. We actually developed a report to identify opioid concerns, and thankfully we don't have to use it nearly as much as we used to. So it just proves it. And Chris, I know you told me a story about your philosophy and how you learned that through your P&C buddies. Can you talk about that a little bit? Yeah. So I don't have a P&C license. I've not spent a minute of my career on that side. I've always been on the employee benefit side. But I'm always fascinated to talk to my peers on that side. And I love having the conversation with my clients in manufacturing or construction or whatever about their safety programs and their philosophy. And it seems like every…it seems like that discussion goes something like this: I had a client, or I am an employer who is having some challenges with my insurance plan, workers' comp, or whatever it is. And the solution to that is I'm going to improve the quality of the risk. So I'm going to use data to identify the constituents I need to engage, and I'm going to come up with a strategy based on that. And I'm going to have mandatory meetings to introduce what that strategy is. I'm going to introduce non-optional behaviors that are kind of part of our core culture here at XYZ Company. And we're going to reward compliance. We're going to hold you accountable for non-compliance. And we're going to promote results and success and we're committed to that, and we're going to manage the risk. And when we manage the risk, we get a better cost, and we get a better cost, we get a better rate. And the discussion on my chosen profession side of the business is always sometimes, I have a client who's having some challenges with their insurance costs. Maybe I should find a cheaper rate. Why don't we focus on trying to manage the underlying risk, and have faith that the rate will be a representation of the risk, and rate follows risk. Risk doesn't follow rate. If I get a lower rate, that doesn't mean my risk improves. It just means I put a bandaid on something and avoided it for a year. So I think some of that mindset that they, again, are compatriots on the property and casualty side, I think would really, we’d do very well to emulate a lot of that on the employee benefits side. That's great. It makes my heart so happy to hear that story because when I first moved from the provider side to the employee benefits side, everybody was talking about percentage discounts and I'm like, how about a hundred percent discount? We could actually prevent disease from progressing and all of that. So this is a great conversation. And Chris, you brought up that, you kind of track, I think it was the National Business Group on Health and what they thought were priorities and how that's changed over time. Can you share that story? Yeah, I can. It's something that I think is really inspiring. And I think it's real, you know, kind of gives you faith for the future. So National Business Group on Health is kind of like a think tank. It's got great representation from the Fortune 500, and they meet and discuss best practices and priorities and things like that. And a couple of years ago, when you looked at their top 10 priorities, top 10 objectives for the new year, quality wasn't even in the mix. It wasn't even there. And the last two years, it's been number one. Like our top priority as an employer, as a member of the National Business Group on Health, is making sure our people have access to high-quality healthcare. So it's like, we all sort of woke up at the same time and said, you know, this obsession with unit costs isn't really getting us anywhere, right? We gotta look beyond…unit costs will never be unimportant, but it is not the be all and end all. The best unit cost is not the best total cost if it's accompanied by these additional expenses. Now think about the long-term impact of that as well. When I talk about this a lot with clients, one of the first questions I get back is, well, isn't it harder to get in to see better doctors? Isn't the wait time for a better performing physician much longer than for a not top-performing physician? And the embarrassing answer is it's not. And it's that way because nobody knows the difference between the two. But I'll give you, as this movement continues to grow and continues to really validate, and more employers embrace it and pass that on to their employees, and all of a sudden, the employees are now educated and incented to use the, to kind of migrate to the higher quality professions for professionals. What's going to happen? Yeah, there's going to be a supply and demand impact there. And there will be higher or longer wait periods for that. But here's the counter argument, which is really powerful. Those lower performing providers who are losing their customers because they're firing them to go and hire their better performing peers are now gonna have a decision to make. Do I get better or do I go out of business? And candidly, that's the decision that every one of us makes every day when we get out of bed, in business. And I think that's such a good thing for healthcare if providers have an incentive beyond just personal and professional pride to get better at their craft, because they know they'll get more business. As a result of that, that is such a, yeah, we talk so much about all the negativity in healthcare. What could be better than that? Dr. Bruhn, any feedback from that? Yeah, one of the things that I would add to that is, you know, our whole initiative is a physician consortium. And so we... One of things that I really believe in is sharing the data back with the physicians – giving that transparency, not just to the marketplace and the patients, but also to the physicians themselves. And when we were first doing this research out of Johns Hopkins, we did this study around Mohs surgeons, which is a skin cancer procedure where a specialized dermatologist resects a skin cancer with a small knife. They look under the microscope to see if they got the entire cancer. And what we found was a big area of overuse within Mohs surgery was that Mohs surgeons get paid per cut of skin they take out. So instead of taking out a cancer lesion with one or two cuts, which is normal and appropriate, we saw that there was physicians taking out 4, 5, 6, 7 cuts on average and getting paid a lot more for having an inappropriate practice pattern. And so what we did is we partnered with the American College of Mohs Surgeons, the specialty experts in that space. And we actually sent letters to half of the Mohs surgeons in the country, letting them know, hey, here you are on this quality measure that was developed alongside the ACMS. And then we did not send letters to half of them. And we did a trial to see, do physicians respond to seeing their data compared to their peers? We did this for 3 years in a row, sending letters once a year. And we found that 83% of outlier doctors corrected their own behavior just from receiving a 2-page PDF report on their practice. And that we, we calculated the savings was$93 million to Medicare just from reducing the amount of unnecessary cuts per case. And so I really believe that sharing the data back with the physicians and having transparency with them about how they're being measured is also a really important component to fixing this market. Because I think the reality is there's a lot of really good physicians out there that are just practicing in their own, you know, part of town where they don't have other people that they're practicing with. They don't know what the latest evidence might be. And they just need some education to get better at areas that they might be performing low quality care. So that's maybe just the only thing I'd add is giving that transparency back with the physicians as well. Well, that's good because that's part of the points that I made to start this off is that providers are confused by what they're…how they're being rated, you know, what scores are being used, etc. So given that, and you have such a positive attitude about this getting better – and I appreciate that, because we all need to have a positive thought about where we're going in healthcare– we did talk about all the pitfalls. So there's a lot of different companies out there, sources. One of you brought up the whole billboard thing. I have to laugh every time I drive down the highway that someone bought another billboard. I don't believe anything in the rating that's there. So what would you say, why don't you start, Dr. Bruhn, with what you think are the biggest pitfalls that you see in the quality ratings out there? Yeah, I think some of them we've already discussed, which is, a lot of ways that we're measuring quality actually just isn't true in reality. And part of that is missing the appropriateness of care component. If you're only looking at outcomes, which has been historically what we've done in quality, the reality is, if you're doing a lot of inappropriate care on patients, for patients that don't need, let's say, surgery, your outcomes oftentimes look really good. So you look like an amazing doctor because you're giving care to low-risk patients that probably don't need the care. And so if you're missing that appropriateness of care component, you're really going to struggle with getting at that true quality piece. And I'll also say the standard quality measurement sets that people think about out there, like the CMS star ratings and HEDIS and MIPS and stuff like that, I would just say those are pretty outdated generally. I've looked at every single government-level sponsored quality measurement out there. And I saw this study recently that showed it took, um, it took a couple of thousand physicians that have currently a board sanction for some type of malpractice or fraud. And then they benchmarked that against like the CMS star ratings. And they found that 93% of those doctors that have some type of malpractice suit going against them had a top tier rating on CMS. And so, that just kind of goes to show you that a lot of the ways that we've thought about quality historically don't actually match with what's going on in reality to the patients. And so, yeah, I would say those are kind of the main things that I see generally that are pitfalls in the way that people currently think about quality. Chris? Yeah, I would say kind of from the employer-sponsored plan perspective, I think the biggest pitfall is there are some plans out there who are very much guilty of promoting a practice as um high quality when in reality they're just owned by the insurance company. They're putting them in a category because they want all of us to use them so they can make money on both sides of the equation. So I think that's uh sort of the disingenuousness of leveraging this concept for selfish gain. Let's pause to thank our sponsor. This podcast is brought to you by Alera Group. Vital Incite is part of Alera Group, an independent financial services firm offering comprehensive property and casualty insurance, employee benefits, wealth services and retirement plan solutions to clients nationwide. Working collaboratively across specialties and across the country, Alera Group's team of more than 4600 colleagues offer unique solutions, personalized services and proactive insights to help ensure each client's business and personal success. For more information, visit AleraGroup.com and follow us on LinkedIn. I think you both have mentioned this previously in our conversations though, that there are some that you have to pay a fee to go through their credentialing, and um how that doesn't make a lot of sense because that's just another entity, and some great providers may not want to put the effort into it. So they may be considered lower quality. I will tell you that I have a very strong root in my healthcare community and I'll never forget the spine surgeon who…every doctor in the city, if you have a spine issue, you're going to go to this one guy. They were rated very poorly. And I finally reached out to him and he said, that's because this one carrier asked me to fill out so much paperwork that we finally said, forget it. Like, I don't need you to tell me I'm good. People know I'm good and I'm going to go with that. And I'm like, you know, that's what you want. And I also want to share that we recently had an onsite clinic provider try to state that they should be using a certain HEDIS metric as this outstanding quality. And that HEDIS metric is far below what you would clinically ever want to take care of that person with. But they use the word HEDIS, so the employer thought that was a great idea because why would you not trust that? But it is so outdated. Yeah, I'll uh commit a HIPAA violation against myself and share a personal story. About a year and a half ago, I found out during an eye exam that I had the very beginning of cataracts, and my eye doctor said, hey, good news for you. I have somebody on our team here who does the surgery. I can kind of get you over to him and no problem. And I used one of these emerging, know, quality transparency tools to look him up. And he did not score very well. And I found a surgeon who's about 2 miles from my house, he scored a 99, a really super high quality. And the initial…so I made an appointment with him and my consultation with this doctor was fascinating because he said, who referred you to me? I said, nobody. He said what do mean? I get all my business from customers. I said, well, I looked you up. And he goes, I don't participate in that. I said, well, that's why it works, because you don't know you participate in it. It's completely data driven. He's like, well, tell me more about this. What did it say about me? It was just this fascinating discussion of, to your point, it'd be completely invalidated. It was something I can pay to be in. We make a joke every year in my market. I live in the metro Phoenix area. Every year, Phoenix Magazine does their healthcare issue. And what a shock that the doctors being recognized as being one of the best in their practice on page 9 all have full-page ads starting on page 25! So I think just more kind of agnostic, purely data-driven is the best for all of us. That's a really good point about where people get this quality information from are absolutely critical. Dr. Bruhn, you were going to say something else. Yeah. The only thing I was going to add to that is just the antiquated approach to a lot of these standard quality sets. There's the average time from new evidence to actually implementing that in practice is 17 years on average. And I would say that also feels like it's true with our quality measures. Like it's like these things just do not keep pace with the emerging best evidence. And so there…I've seen certain HEDIS and mixed measures that are like recommending services and imaging and things of that sort that, 3, 4, 5 years ago, the society has made guidelines that actually don't even align with those things. And so it just goes to show, you really need…in this space, you really need to be working on a month-by-month basis of the best practices to make sure that the quality measurements align with what the physicians and the guidelines are saying. So given how complex this is and complicated, we've already talked about how much misinformation is out there. What do you think the most practical steps are that employers should consider as they're trying to encourage people to go to higher quality providers? I can start with that one. Yeah, I'd say the main things that I've seen working for self-funded employers, and unfortunately the healthcare industry is kind of stacked against the employers. Nobody is really aligned, the insurance companies and the providers themselves are not really aligned to give transparency on cost or quality. Even the insurance companies are not aligned to have prices go down. And so, I'm really excited over these next 5 years, like I was talking about with this revolution of quality transparency, because I think that's going to be the missing component in the market that allows this shopping experience that you can get in any other industry. You know, you go, you go car shopping, you go to Amazon, you go to grocery store, you can shop based upon quality and cost. And that's just historically not been true in healthcare. And so I feel really excited about a future where people, any everyday consumer can go on, understand objective quality, understand objective costs for healthcare services. And so the way that forms today is care navigation for employers. There's a lot of different groups out there doing care navigation type services. I think there's a lot of really cool work being done in the specialty space. There's a lot of vendors that are really doing a good job of looking at quality within a specific service line like MSK or oncology. And I've also seen some really cool work happening in the centers of excellence or networks of excellence space, you know, crafting your network to ensure that your patients are incentivized to go towards that high quality, lower cost position. And I think what all of that to me encompasses is this idea of healthcare moving towards the value equation, the value equals quality over cost. And I think these different vendors are getting bits and pieces of that, but I think in 5 years, we'll be at a place where there's a much more kind of unified, simplistic shopping experience, where I think the thing I hear from employers a lot is just vendor fatigue. It's like, I got somebody for oncology. I got somebody for CareNav. I got somebody for COEs and MSK and diabetes. And I think what we're moving towards is just better transparency to where hopefully we don't need 25 different vendors to give high-quality care. And instead it's all just a marketplace transparent shopping experience. Yeah, I just could not agree more. It's a topic I'm super passionate about. I think, you know, HSAs and consumer-driven plans were introduced with that objective, right? That if we, one of the many reasons why healthcare is expensive as it is in our country is this culture of the copay, right? If I have a $30 copay, for whatever doctor I use in network, there's no financial incentive in place for me to be a consumer. In fact, you could argue there's reverse consumerism, right? If Dr. A is $500, Dr. B is $2,000, and Dr. C is $5,000, I might immediately jump to the conclusion that Dr. C is the best because they're the most expensive. And if I have a $30 copay, I am more than happy to spend somebody else's money to access Dr. C. You could also argue that there's some mindset of, I'm going to stick it to the insurance company that charges me all these premiums by doing that. So kind of removing that and going to these consumer-driven models in theory was supposed to solve a lot of that. And it did in part, but totally agree with what Will said is the fallacy is, and it's embarrassing– we're 21 years into this, right? That the first consumer’s group reply was 21 years ago. The fallacy is that nobody knows how to be a consumer in healthcare. It's not like buying a mountain bike or buying a car or buying a computer. And here's why I'm a hundred percent confident when I say that. What the heck does anybody do when they're confronted with a reality about their health that requires the use of a specialist? Well, here's sort of the hierarchy I always go through. They call a friend or a family member. You know, I just, Hey, my daughter's pediatrician's moving. Do you know a good one? Or I just found out I need to have knee surgery. Didn't your neighbor have one a year ago? And do you like them? Well, it's usually based on like a random sample of one. I like them, so I know you will too. It's hardly the most data-driven thing possible. Two, maybe you try to Google who the best provider in your area is. Ever tried to do that? Good luck. It's all search engine optimization. It's all paid for, whatever. Maybe ask your primary care doctor, Hey, who's the best one for me to have? Guess who they're gonna send you to. Someone they're financially incented to send you to. It isn't to say that's bad. It's just it's definitely the best for them. It might not be the best for you. And the 4th one is the carrier. And this is the biggest joke of all. And it's not criticism of the carrier, it's more of a criticism of the healthcare system. Is if any of us – no matter who our carrier is – were to call and say, listen, I just got this diagnosis and I want to be really proactive in managing it. Who is the best specialist in your network for me to see that's in my area? The answer that any of us are going to get back is, here's a book. Here's a directory. Choose well. And the reason it's like that is the terms of the contracts between the insurance companies and the providers is the insurance companies say, if you join our network, we won't favor one provider over another. So they have all the data. They just don't tell you because it would violate their own agreements. Something really wrong with that again, right? That here I am at 21 years into the consumer-driven movement and I have no idea how to be a consumer. And this quality movement is really what's going to solve for that. You can't truly be a consumer if you don't have the insights on the quality. Again, that's, you know, think about in your own life, you don’t automatically buy the cheapest mountain bike, the cheapest computer, the cheapest car, because your transparency journey said this is the cheapest one. You did your research and you kind of matched up cost and quality, and then you made your decision. I can tell that's your soapbox, and I love it because it needs to be our soapbox for sure. So I appreciate that. Dr. Bruhn, I'm going to push back on you a little bit, but I think it's for you to give us a little more information. You said these networks, top-tier networks are being developed. I think what I see is the top tier networks can be developed from a carrier because they may have ownership in a provider group, or…you never know where the incentives are. I think you have seen something unique that's starting to develop. Can you explain what you have seen? Yeah, I think one of the big movements that we'll see over the next several years in healthcare is these alternative health plan models that are either cash-based or, uh, you know, you're even seeing more and more popularity with the cost-sharing networks. We're also seeing a lot of movements in the network list, like the no-network type of health plans. And so, I think those are all movements towards this same idea that we're all talking about, which is how do you give somebody a shopping experience where it's not tethered to all of the, all of the things that the carriers are, you know, constrained by. And Chris highlighted a very important one, which is a lot of these provider contracts don't allow them to steer within their own network. And so that right there removes any incentive to even think about quality because everyone is the same according to the carrier. And so I think these alternative health plan models that are launching, and I think we're going to see probably a lot more of those launching over the next 3 years. I'm interested to see how self-funded employers adopt those over the years to come by just fully dropping the main BUCA carriers and going with one of these alternative plans that don't have a network. Maybe it's all cash-based, no copays. I think that gets us closer to what we're all talking about here, which is a transparent marketplace. I'm kind of floored by that concept because it is so hard to turn this ship, but I can't wait to see it and see where it goes, so that's interesting. I have one final question for all of you. If, in our system, the primary care provider should function as a quarterback of care, Chris already mentioned that they could be owned by a system or they could be…and there could be other influences on that. It's critical that primary care, and we have had several podcasts now about this, is that it's critical for them to be able to identify risk early, to make sure they spend the time to really help people retain their health versus wait till they see them when they're sick. And then hopefully they're also guiding to higher quality providers. But I don't know that I've seen a lot of great information yet on primary care quality. And part of that is because we have such a crisis that we have so few primary care doctors to start with. And then, you know, we bring in all these different vendors that are trying to solve for this. It's almost like anything is better than nothing. Any thoughts or vision on, you know, how we can drive to better, higher quality primary care? Yeah, I don't mind jumping in there. Yeah, we've seen a huge surge in better measurements for primary care specifically. Surgery is a little bit easier to measure sometimes because it's like one encounter that you're looking at for like a knee replacement. Primary care is a little bit more complex. You really have to dig into multiple different facets of, you know, primary care has such a large breadth of services. And so going back to that framework of outcomes and appropriateness, there are now ways to measure quality and appropriateness of appropriate prescribing patterns. Are you doing the right imaging? Are you doing the right lab testing? Those are all things you can look at, but I would say more broadly for quality and primary care, it’s exactly what you said, Mary, which is, is this primary care physician acting truly as the quarterback of care, or are they just a referral center? And so that's one of the things you can look at is, for instance, one quality measure we oftentimes look at is, what's the mean number of specialists per patient within your primary care's office? Does your, do you have 12 different specialists per patient within your primary care practice or do you have like 3, just the necessary ones of the patients that need that oncology care or something else? And so there are actually really great ways to measure quality now. And that's one of the areas I'm most excited in the country right now is the advent and the surgeons of APC, DPC type setups, and I think having this quality information about who should be in those high-quality APC networks and specialists once they refer out is definitely a huge area of potential for the industry. That's great insight. Chris? Yeah, I think it's one of the big misses of the ACA is that we didn't include anything in there to reward providers for keeping their patients healthy. I can't help but think that that would have attracted more physicians to focus on primary care rather than specialty. And I would say, too, that it's always a little disheartening when you look at a utilization report and you see that 24% of the participating male employees went and got their annual physical. This is free, guys. Go and do this. It doesn't cost you a copay; it doesn't cost you a deductible. Go and do this. And every time I personally do an open enrollment meeting, I emphasize that we're gonna throw a lot at you here today, but if there's one thing I would ask you to remember is that your physical is free. Go get your physical. I can't help but think that so many of the large claim conditions that we've seen this past year, you could directly track back to noncompliance with your annual physical. And if we just solve that in some way, we could cut a big tail off of this healthcare cost monster. Yep, late-stage diagnosis. It is absolutely a problem because we've created such a crisis and concern. Yep. Before I close this up here, anything you think that wasn't talked about that employers need to hear today? Personally, I think it's just approaching your health plan with the same focus and discipline that you use in running your business, right? That when you have an important strategic initiative, you don't say, I want to spend as little time as possible on this and move on to the next thing. I mean, you get your fingernails dirty with the data and you come up with a strategy and be intentional about it. And I think there's some obvious awesome exceptions to that. But if I'm painting with a broad brush, I think there's a lot of exasperation and a lot of feeling of helplessness on the employer side that no matter what I do, it doesn't really matter. So why focus a lot of time on it? And, you know, the exceptions to that that you can validate are huge and inspiring. So I would say just run your benefit plan like you run your business. Because imagine if you did the opposite. Imagine if you ran your business like you're forced to in some ways, run your benefit plan, you'd be out of business. Nope. Very good. And I would just say my challenge to the self-funded employer space is to really dig into quality. Don't make it just a checkbox. There's a lot of ironically low-quality vendors and solutions. And you know, we've already talked about the pitfalls of some of the classic quality ways people think. And so I would just challenge, like make that something that's really important to you, and do your homework to make sure that whatever source you're getting quality from is something that seems to have some scientific rigor behind it, rather than just kind of the checkbox approach that I do think is pretty common in the industry. And so, but no, this has been great, and really appreciate the ability to start talking about this stuff, and love the fact that this is an emerging topic in healthcare, because I think it is super important. Yeah, you guys have made, you've proven to everyone that this is a critical emerging topic and something we need to pay attention to. I usually close with kind of recapping all the things you said. I have to admit, in the beginning, I was so enthralled with what you were saying, I wasn't taking good notes. But I do have a couple of things that I know that you didn't hit on just now that I want to make sure our listeners do pay attention to is that Chris started out by saying, we have to think differently about where we direct people. It's not what building or what practice you're going to, but what provider. And that, you know, Dr. Bruhn, then you said appropriateness of care and you brought that up several times. It is, you know, there's a lot of dollars and harm that are taken from people who do inappropriate care because care does have risks to it, too. So I think that's really critical. And you mentioned that it's really the 80-20 rule that about 20% of providers are outliers of care and do create that extra cost that is critical. We talked about how many measures were outdated and that we have to be careful and make sure that the measures used are refreshed rather quickly with updated data that, uh, I love Chris's conversation around the high-deductible plan and we expected everybody to be consumers and that's not what any of us are able to do. And we looked at cost instead of quality, and now maybe we're starting to be able to allow people to actually become real consumers in their healthcare like we do with everything else. Just, there's so much here. I know everyone who's listened hopefully has taken a lot of notes as I have. And I just really appreciate both of you guys in this conversation. Your different perspective helps us all formulate better strategies and hopefully moves us all in a better direction, which we absolutely need to do. And this wasn't an easy topic. So I appreciate both of you. Thank you so much. And to our audience, I hope you enjoyed today's conversation and it's given you valuable insight to reflect on your current strategies and perhaps even spark some ideas about where their next best steps can be. Thanks for listening to this episode of The Pulse. If you enjoyed it as much as we did, please be sure to subscribe so we can stay up to date on our most recent conversations. Share the link with others so we can all start to demand something new, and follow us on LinkedIn. The Pulse is produced by Vital Incite, a member of Alera Group. Alera is on a mission to help organizations identify medical spending waste through data-driven strategies, while helping to improve the health of their employees. If you want to make healthcare easier to understand and manage, and improve your organization's bottom line, reach out to us at vitalincite.com. I'm Mary Delaney. Thanks for listening.