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Enabling Health Value: Episode 5 | Navigating Headwinds and Capitalizing on Industry Inflection Points: Driving Collaboration with Value-Based Care, with Ben Grabski and John Fryer

June 18, 2024



In this episode, Dr. Eric Weaver interviews Ben Grabski, CFO of Lumeris Group Holdings Corporation and CEO of Essence Healthcare, and John Fryer, Chief Growth and Corporate Development Officer at Lumeris.  

This episode delves into the challenges and opportunities in the Medicare Advantage landscape, highlighting the importance of collaborative payer relationships, consumer-centric innovations, and care delivery transformation. Ben and John share valuable insights on leveraging AI, navigating strategic inflection points, and building a win-win model to empower health systems and providers in achieving value-based care. Don’t miss this enlightening discussion on transforming healthcare and driving better health outcomes for all! 

Episode Bookmarks: 

2:00 Introduction to our guests, Ben Grabski and John Fryer 

4:00 “…a transformational cultural shift for better care for all.” 

4:45 The personal side of VBC at the intersection of finance and health. 

6:00 The founding story of Essence Healthcare, a fully insured 5 Star MA plan in the St. Louis area.  

7:00 How Lumeris was borne out of best practices in payer-provider collaboration in VBC. 

7:30 Having the North Stars of patient outcomes and provider experience to see VBC through multiple market cycles. 

8:30 A comprehensive overview of the headwinds facing Medicare Advantage. 

10:00 Nearly half of health systems are considering dropping Medicare Advantage plans (reference) 

10:30 How bad behavior in MA is leading to decreased funding and benefits. 

11:15 “Many in our industry see changes in risk adjustment as an existential crisis.  And they should in those businesses because value-based care isn’t just about the coding.” 

11:45 Inflation Reduction Act changes to the Part D prescription drug program. 

12:00 The Two Midnight Payer as a prime example of payer collaboration in the policy arena. 

13:00 The hostile climate for Medicare Advantage today is like what we saw during rollout of ACA in 2010. (It didn’t kill MA then, when market penetration was only in 20s – not the 50s like today.) 

13:30  Taking the long view on the role of MA in value and realizing that adjustments will be ongoing. 

14:00 Headlines about health systems terminating their entire MA book of business is just clickbait! 

14:30 Health systems are strategically deciding on collaborative payer partners for the future. 

15:30 Current headwinds provide opportunities for carriers to redefine how they work with their care delivery partners. 

16:00 MA is a foundational pillar of value-based care, but it’s not the only program that offers advanced risk sharing models. 

16:30 Enabling provider delivery systems to transform how they provide care to all communities. 

17:30 The explosive growth trajectory of MA and its high market penetration in the dual-eligible segment. 

18:00 Consumer-centric flexibilities are inherent to MA plan design. 

19:00 The “white glove” curation of the clinical model in MA drives better patient outcomes. 

19:30 Reinvestment of savings in the form of supplemental benefits to members.  

19:45 How the “arms race on benefits and consumerism” has gotten out of control (e.g. MA plans buying golf clubs for members). 

20:30 Retrenching back to basics (investing in more traditional ancillary benefits like food as medicine and pharmacogenomics).  

21:30     Aging baby boomers driving exorbitant levels of spending to capture market share. 

22:00     A different foundational philosophy is required to thrive in this emerging era. 

22:30     A level playing field: the growth of MA has provided underserved communities with more equitable access to care. 

23:30     Public earnings reports from large carriers foreshadowing exits from rural, underserved communities which are less profitable than major metros. 

24:30     Building winning payer-provider relationships in value-based care. 

25:30     Downward pressure on Medicare FFS reimbursement coupled with shifting demographics (aging population). 

26:30     VBC and collaborative payer partnerships as the answer to navigate into a new model. 

27:15     Don’t give away all the winnings to the payer by investing in value before getting VBC contracts. 

28:30     “Systems can no longer continue to afford to build new assets and or keep up with their existing physical plant and property within the reimbursement environment that exists today.” 

29:30     Critical strategy decisions (e.g. planning for VBC over a long-term time horizon, consolidation approaches to sustain) 

31:00     Building a comprehensive managed care roadmap with inputs from actuary data science and underwriting. 

32:00     The fallacy that you must take early losses in risk arrangements before you are ready to manage outcomes. 

32:30     Matching risk contracting with network maturity benefits both parties in a collaborative payer-provider relationship. 

34:00     Shifting to full-risk capitation amidst macrotrends such as AI and payment model innovation.  

35:30     Finding strategic inflection points in your business (referencing “Only the Paranoid Survive” by Andy Grove) 

35:45     The modern-day technology curve (LLMs, generative AI, advanced models of data synthesis) will allow us to deliver personalized care in an efficient manner. 

37:00     Inflection point for data liquidity (a 5-year time horizon for full maturation) 

37:30     The perverse incentives of HMOs in the 1990s that pre-dated sophisticated data management capabilities. 

38:30     How the HITECH Act and Affordable Care Act better positioned industry to manage total cost of care. 

39:00     Effectuating change with generative AI — leveraging digitized information and predictive insights to accelerate value transformation. 

41:30     How Lumeris provides infrastructure and expertise to support enterprise value transformation. 

42:30     The importance of aligned economics to co-create solutions in an enabling partnership. 

43:30     Lumeris’ purpose-built technology for the sole purpose of driving better health outcomes.  

44:30     Supercharging technology with the emerging computing power of generative AI. 

45:30     Empowering partners with people, process, and technology (using just technology to solve problems will never be successful) 

47:30     “Our collective future in healthcare delivery depends on those who wake up every day with an innate passion for improving our healthcare system. While I think value-based care may not be the only answer, it is definitely going to be playing an integral part in redesigning and guiding us towards a future healthcare delivery model that benefits all populations, benefits all of our families, and ultimately benefits us as individuals.” 

48:30     “Value transformation is a really important place to get our best and brightest in the country. And I think if you can challenge yourself as the status quo of fee-for-service is unacceptable. We need change, and with new drugs, new technology, new treatment plans, it’s never going to be static. We need our best thinkers looking at this on an ongoing basis. It’s a massive service to your community and to your country.” 


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Enabling Health Value: Episode 4 | Revolutionizing Healthcare: Generative AI and the Future of Medicine, with Robert Pearl, M.D.

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Enabling Health Value: Episode 3 | Scaling Innovation in AI, Interoperability, and Health Equity, with Micky Tripathi

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Enabling Health Value: Episode 2 | Determining Your Medicare Value-Based Strategy for 2025 and Beyond, with Joe Satorius, SVP, Risk Based Medicare and ACO Programs at Lumeris

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Find out why health systems and physician groups across the country partner with Lumeris.​