Driving demonstrable improvements in population health
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Re-Imagining How Healthcare is Delivered with Robb Cohen, VP, Government Affairs at PopHealthcare was automatically transcribed by Sonix with the latest audio-to-text algorithms. This transcript may contain errors. Sonix is the best way to convert your audio to text. Our automated transcription algorithms works with many of the popular audio file formats.
Welcome to the Outcomes Rocket podcast, where we inspire collaborative thinking, improved outcomes and business success with today’s most successful and inspiring health care leaders and influencers. And now your host, Saul Marquez.
Saul Marquez:
Welcome back to the Outcomes Rocket. Today, I have the privilege of hosting Robb Cohen. He is currently a community volunteer and serves on a number of nonprofit boards. Robb is a health care executive with over 30 years of experience in health care, management, policy and finance. He was a Co-Founder and Senior Executive of XLHealth, which has found that as a diabetes disease management company became the nation’s leading Medicare Advantage Chronic Special Needs Plan and was acquired by United Healthcare. Robb was part of the founding management team in 1998 and stayed through the sale to United Health Care in 2012. Robb was an advisor to the State of Maryland and the design of the Maryland hospital payment system and was the former founding CEO and Advance Health Collaborative, a network that includes seven health systems with 10 hospitals. Robb is also CEO of a founding and founding partner of the Phoenix Healthcare Consulting. Robb has payer, provider, investment banking and consulting experience with his MBA from the Wharton School of Finance and Health Care Management. He’s a regular speaker at industry conferences. He’s a graduate of the Wexner Heritage Program and GBC leadership program. He has served in leadership positions on many nonprofit boards, including the Jewish community for the ADA and JDRF and at his children’s schools. Robb is married, has two daughters and is an outstanding contributor to this business. I’m excited to have him here today. Robb, so glad you made it.
Robb Cohen:
I’m very happy to be here. Thank you for having me Saul.
Saul Marquez:
Absolutely, Rob. So let’s dive into it. What is it that got you into health care?
Robb Cohen:
I’d say what got me into it is it was a family business, if you will. My dad was a health care economists, my mother is a nurse. So it started there. And my wife is a physician. My sister is a social worker. But it started with my parents who were health care economists and a nurse.
Saul Marquez:
Very cool. So really, it was kind of like everywhere you looked, people were doing it. And why not you?
Robb Cohen:
I grew up around it. And when you graduate from college and you’re looking for a job and your folks say, hey, call this guy. And I say that tongue in cheek. But I became more entrepreneurial, more finance. So I think like many of us, we we get a foot in the door, but then we make it our own.
Saul Marquez:
Right.
Robb Cohen:
And I think that’s kind of what I did. So, yes, it was a family business. But, you know, like many of us, I also carve my own path and did things a little differently.
Saul Marquez:
And you put your own fingerprint on the work that you did throughout your career, focusing on chronic disease management, particular type 2 diabetes. I love to dive into some of that story. And then also through some of your thoughts in health care in general. So what is it that you believe needs to be front and center on health leaders agendas today?
Robb Cohen:
I believe, as I said when we talked earlier, we all have our blinders, all our channels in which we focus. I believe population health, value based care, focusing on the 20 percent of the people that cost 80 percent of the money, predicting where the risk is, looking for areas where you can both improve quality and reduce costs at the same time. I’ll come back. I think the first one I said it was population health. So a lot of people think about care management. They think about, say, re-admissions. Well, what about preventing the first admission that that type of thing? You know, people with CHF that could get admitted six times in two years, but yet none of them qualify as a readmission. So how do you keep people healthy and out of the hospital to begin with?
Saul Marquez:
That’s key. And so we think about these things is sort of the genesis that that began the business that you started and then sold the United X-File Health. Tell us a little bit about that and, you know, how you saw the opportunity and how it created results?
Robb Cohen:
Sure. Well, it started it was a number of clinician’s were the initial visionaries, a cardiologist, a primary care physician, endocrinologist, podiatrist, so people that we’re all seeing diabetes and its co-morbidities and complications from different angles and said, hey, we can make this better. Initially, they were focused on reducing amputations because people with Type 2 diabetes, you know, they get lower extremity wounds. It can lead them patients and folks eventually pass away and not a fun manner. And we wanted to back up and stop those problems early on so that the complications never happened. And so we started focused on diabetes, lower extremities. But then you realized people with diabetes have lots of other complications. Plus they have the you know, as folks get older, they have the same health care issues that everyone else says falls and frailty. And so we became a more holistic care management company. And then I would say that what really opened the door for us. The turning point, if you will, was when the Medicare Modernization Act came out in 2003, it created Medicare Advantage special needs plans. Plus it put in place a payment model, a risk adjustment system that enabled you to focus on enrolling the 20 percent of the people that cost 80 percent of the money as opposed to where most in health, most health insurance companies want to enroll all the healthy people. And we wanted to enroll the people with problems. But that only works if it’s properly risk adjusted. So the Medicare Modernization Act created the ability to have a Medicare Advantage plan. It focused on certain beneficiaries. You could pick your diseases and it also created the risk adjustment model.
Saul Marquez:
There was a reason for the really the foundation of the business and why you guys were able to scale it, you know, it wasn’t automatic, though, right? You guys were able to connect the dots and and be able to to build a business model around that. Well, could you share with the listeners about maybe one success and one setback that you had during that process?
Robb Cohen:
I would say one success we had was that we had the vision that it was created at the Medicare Modernization Act was the end of 2003. The risk adjustment system phased in over three years. So it wasn’t fully in place until January 1, 2007. And so I think we smartly said we have this three year path to plan for this, to build our networks, to get our infrastructure in place as a health plan and to launch January 1 0 7 in a big way. And so we were the largest I think we were the largest Medicare Advantage launch of all time across 700 counties. That’s just unprecedented. One setback we had is that although the Medicare Modernization Act created this new risk adjustment system, it wasn’t perfect. And so and even today, it tends to overpay the healthy and underpay the sick. And there’s ways around that. But so we were successful in that. We had division in the planning to do this great launch and we managed through it operationally with tremendous growth. And a setback was the payment model. You know, I don’t know whether I. We all have blamed the actuaries ourselves. It wasn’t perfect. And so that was challenging at first. And then we worked our way around it.
Saul Marquez:
Definitely. You can imagine it wasn’t easy to do. And now want to give you big kudos for seeing it being able to strategically plan and then navigate the the boulders and the in the water, so to speak. What would you say is one of your proudest leadership moments in your business career?
Robb Cohen:
Hm, the proudest leadership moment, I think being an evangelist, if you will, for focusing all on sort of having the courage, if you will, to be a health plan that went after the people with the chronic diseases. So like I said, I think I as mentioned before, you know, many health plans. Have the intention, the goal, they set up systems to honestly recruit the healthy, recruit 80 percent of the people that cause 20 percent of the money to buy, then get paid at the average. So at the end of the day, if you’re getting paid at the average and recruiting healthy people, then, you know, it’s kind of easy to make money, if you will. And I think we had the mindset and the goal. I mean, yeah, yes, we wanted to make money. And yes, we saw there was a path to make money, but it’s a it’s a hard path. And we were willing to do it. And we convinced a lot of people that it was the right thing to do and had a lot of people follow us. As a result, we improve people’s lives and improve the system at the same time.
Saul Marquez:
And I would say that’s a very admirable thing to do and creative way to reach for a niche that not a lot of people wanted to go after. So certainly a lot of kudos. And you guys obviously built the business that you’d know later. Well United acquired. Tell us about that and how that.
Robb Cohen:
Sure. So I mentioned before that one of our challenges was that the risk adjustment system overpaid the healthy and underpaid the sick and that there was this new risk adjustment model, and one of the things about this new risk adjustment model is that it tags chronic diseases it has so every single Medicare beneficiary every single year gets marked with I’ve lost track now. A few years ago it was about eighty binary toggles. So in other words, does the beneficiary have diabetes? Do they have heart failure? Do they have rheumatoid arthritis? Do they have, you know, every all these conditions and they all have a coefficient, a risk factor associated with them. So the beneficiary premiums, how much a health plan would get paid per year if it enrolls a beneficiary is calculated at the little level of the individual. Think of it as every single Medicare beneficiary has like a sticker on their forehead with what the health plan would get paid if they enroll them for that calendar year. And the payment is based on the data in the big Medicare system in the sky from the prior calendar year. And so one of the reasons that the healthy are overpaid and that the sick are underpaid is that the big computer doesn’t know all the chronic diseases a person has. And not only that, but every December 31 at midnight, it resets, it wipes the slate clean. Every single chronic disease in this country is cured in a sense. And it’s got documented during the year, it’s gone as of the next year. So amputations go away. Heart failure disappears. All all these chronic diseases disappear unless they get re-documented and lots of them don’t. And because we were the largest chronic special needs plan, we were the health plan in the country that had the highest concentration of sick people. Which meant if we can do something about it, we were effectively the most underpaid health plan in the whole country. Now, the flip side of that is if you go out and identify the chronic diseases, you do quite well. And we because we were starting with our head further below the water than anywhere else, we figured out how to document those chronic diseases and we are very good at it. For our hundred and seventy thousand members at the time that we sold the company and UnitedHealthcare recognized us as the best in the industry at doing that. And I can’t speak for them. They brought the company, so they do with it what they want. But I think it’s fair to say they wanted to take our Know-How for what we were doing for our hundred and seventy thousand people and do it for I forget what their numbers were at the time. It was in the to millions out so scale our what we called housecalls program across their 2 million beneficiaries. So they weren’t they weren’t in a sense of buying are hundred and eighty five thousand members. They were buying our know how to roll out that housecalls program to their 2 million members.
Saul Marquez:
I love it. It makes a lot of sense, Robb, to think about the model that you guys built and how scaling it could give them incredible efficiencies and help their patient base and profit base.
Robb Cohen:
Yeah. I mean, I think it’s it’s worked out well for them. They have they have in fact, scaled that to a core piece of what they do in Medicare Advantage. And it’s and it’s also a key piece of care management. I mean, you know, it’s not just to identify the diseases for the sake of getting paid. It’s to to use that data to know the health care status of your beneficiaries. So you can appropriately apply Care management.
Saul Marquez:
So, RoBb, tell us a little bit more about an exciting project or focus you’re working on. I know you’ve taken some time off and potentially you might be getting back in.
Robb Cohen:
I mean, one thing that has crossed my mind lately, this might come off as a bit of a tangent compared to what we’ve been talking about, but I’m from Maryland, you may or may not be aware that some of your listeners may or may not be aware that Maryland has a very unique hospital payment system. We operate under what’s called an all payer waiver. There’s a hospital rate setting model dates back to the early 70s. Many years ago, there were there were at the most there were four states with all payer rate setting models, Massachusetts, New Jersey, New York and Maryland. Maryland’s been the only one left. For decades, it was a kind of precursor to the DRC payment system, which all hosts all other hospitals in this country are on for Medicare. And then more recently, the Maryland model went from a cost per case system to a globally budgeted system. So all Maryland hospitals are told at the beginning of the year how much money they’re going to get. So they’re not paid fee for service. They’re paid a global budget and their incentive to manage it. They’re like these little community based insurance companies. And so I would say two things about the Maryland model that I think have relevance for the national debate. And, you know, that’s always been the purpose of the Maryland waiver from the federal government’s perspective is to. Learn for the nation is one learning would be this tofino sort of the total cost to care nature of our model. So incenting providers to manage total cost of care, not just be paid fee for service. And the other thing is the all payer rate setting nature that on the hospital side rates are set and everybody pays those rates, whereas in the rest of the country, while Medicare and Medicaid do rate setting, if you will hospitals around the country and providers around the country charge what they want insurance companies negotiate. But I believe that in many cases, those charges are set so high that it ruins the nature of negotiations and resumes and in payments at a level that are not reasonable. Because when your charges are so high, it prevents the party on the other side from being able to negotiate. And I think there’s some national learnings in that you you may or may not have. I’ve been seeing it in the news lately. Why? There’s some buzz around this. And I think the learnings from our Maryland system could contribute to that debate. And I think the learnings from our Maryland system could contribute to aligning incentives between providers and payers and patients to do better care management.
Saul Marquez:
That’s a very interesting idea and very fascinating to learn Robb, I didn’t know that’s the way that Maryland was set up. And it’ll be interesting to see what happens in this debate and what gets adopted nationwide.
Robb Cohen:
Yeah. I mean, certainly those we have a lot of good in our health care system in this country and at the same time there’s a lot of things I think we could do better.
Saul Marquez:
Totally agree with that, Rob. Now, what would you say is your favorite book that you recommend to the listeners?
Robb Cohen:
I think she qualifies as a book. It’s not not not a book in words, but I’ve been listening lately to Malcolm Gladwell’s revisionist history as a podcast and I think it’s excellent. So I’ve been listening to podcasts recently and I think that’s a really good one. I’m Malcolm Gladwell, certainly written a lot of good books. I’ve read some of his books. They’re really good. But I’ve been enjoying his podcasts revolutionist history lately.
Saul Marquez:
You know, I’ve had a chance to listen to it and I really enjoy it, too. I think it’s a great recommendation and always questioning what’s at the surface, which I think is pivotal to to having success, whether it be in care management, population health, etc.. I think it’s a great recommendation, Robb. Thank you for that.
Robb Cohen:
I think you tie that up very nicely in terms of not just the episodes, but sort of the observation that not just taking what’s at the surface for granted. Yes. I couldn’t couldn’t agree more.
Saul Marquez:
The one that I remember and I’m speaking of is the one that he did about memory. You know, he he talked about memory and he went back to 9/11 and asked people how unreliable our memory could be.
Robb Cohen:
I thought that was fascinating. And it’s not that people are lying. It’s it’s genuine memory. And I thought the way he analogize it to the court system was just fascinating.
Saul Marquez:
It is.
Robb Cohen:
Yeah.
Saul Marquez:
Yeah. So anyway, there’s a little sneak peek, folks, if you have a chance here already on the podcast app, listening to us in your type in a couple of keys. Revision is history. Definitely one of my favorites as well. Glad you recommended it, Robb. This has been a great session, folks. I mean, Robb is a health care veteran. He’s been there, done that, created a company that added so much value to that 20 percent that needs most care. He took a risk. He got rewarded, wasn’t easy, but we had a chance to hear his story here today. I love Robb if you could just before we part ways, share a closing thought that the listeners could take on with them.
Robb Cohen:
Closing thought. I mean, I have had so far a tremendous 30 year career in healthcare. And I would say I never had a game plan. I just did what I loved. I found it enjoyable, I think with. With work best thing to do, it’s to find something that intrigues you and is fun, where help is needed and to. Be flexible, be willing to take risks. And I find this amazing how big an industry health care is that you can be in a dinner party and three people say, can you say, I work in health care but yet none of you have ever heard of what the other one does. Bit the tangent that I just find that interesting, just just sort of in the sense that it’s a big industry that needs a lot of help. And you’re listening to this podcast. You may well be in health care, so I hope you enjoy it and have fun with it and follow your passions. And if you work hard and put an effort, I’m sure you’ll find success.
Saul Marquez:
Without a doubt. And so, Rob, really appreciate your your words of wisdom here. And looking forward to staying in touch. Thanks so much for your time.
Robb Cohen:
Saul, thank you very much. And have a great day. And I do enjoy learning about Outcomes Rocket. Thank you.
Thanks for listening to the Outcomes Rocket podcast. Be sure to visit us on the web at www.outcomesrocket.com for the show notes, resources, inspiration and so much more.
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