As part of Pearl Health’s Drive for Better Care, we recently had a chance to sit down with Dr. Lee Fleisher, Principal and Founder at Rubrum Advising, Former Chief Medical Officer for the Centers for Medicare & Medicaid Services, and one of Pearl Health’s Top 50 Value-Based Care Thinkers of 2024.
Join us as we discuss the importance of aligning value-based incentives across primary care providers and specialists, the evolution of quality measures, the importance of interoperability, the role of community health workers in patient engagement, and more.
Jen Rabiner: Hi everybody, my name is Jen Rabiner. I’m the Chief Product Officer at Pearl Health, and am thrilled to be here today with Dr. Lee Fleischer, one of Pearl Health’s Top 50 Value-Based Care Thinkers for 2024. He is is a national healthcare strategist and the principal and founder of Rubrum Advising, a consulting firm that advises clients on innovative solutions to improve patient outcomes and reduce the total cost of care. He has spent two decades at the University of Pennsylvania School of Medicine as a professor of anesthesiology and critical care, serving as the chair of the department for nearly 17 years. Dr. Fleischer has vast clinical experience in care quality, most recently as Chief Medical Officer and Director of the Center for Clinical Standards and Quality at the Centers for Medicare and Medicaid Services from 2020 to 2023, where he was responsible for executing all national clinical quality and safety standards for health care facilities and providers.
It is great to be here with you today to chat about your career, care quality, and trends in value-based care. So my first question: I think I only really scratched the surface with my intro about all of the different things that you’re involved in these days across policy, quality and care, and value-based care, and would love to hear a little bit more about what you’ve been up to.
Dr. Lee Fleisher: Thank you. It’s really a privilege and an honor to be part of that Top 50 from your company. When I left CMS — which I left because I continued to live in Philadelphia, my spouse continued to live in Philadelphia, and the commuting became more difficult — I got great advice from Governor Leavitt, the former Secretary of Health, who said: do well and do good. So I do advising, and we can talk about that, but I also continued to work with a lot of the D.C. groups, having had the privilege of working at CMS as a senior career official. I was not a political appointee, so therefore worked under two administrations, and I got involved with Duke-Margolis – an institute that does health policy – as a visiting fellow. I also got involved working with the Bipartisan Policy Center as a senior advisor, as well as FasterCures, part of the Milken Institute. I’ve worked a lot around digital health and artificial intelligence as a member of the Health IT Advisory Committee of the National Coordinator, as well as the Coalition for Health AI, as well as the National Academy of Medicine.
It’s really been fun to take my learnings as a doctor — and I still practice on Fridays, giving anesthesia — my learnings as someone who was part of the regulatory state at a very unique level, during a unique time — the pandemic — and now applying those learnings to give insight into how CMS and I thought, but also how we can use the levers of government to really drive better care for patients.
Jen Rabiner: Wonderful, thank you. We just talked about what you’re doing now, but I’d love to start at the beginning. What drove you to pursue a career in medicine, and in anesthesiology in particular?
Dr. Lee Fleisher: Oh, going back to when I was probably five, my grandfather was a pharmacist, my uncle was a physician, and I loved science. I still remember creating my science presentations in the fourth and fifth grade. I started doing research when I was 15 back down at Jefferson and I continued doing research. I thought I was actually going to be a surgeon because I had done immunology research, but I didn’t like it. I did love taking care of surgical patients, so when I was in a surgical internship, they said: Lee, go be an anesthesiologist and then come to critical care. I just never took the last step of getting into critical care because I love doing anesthesia and I began doing research when I was in my anesthesia residency looking at: how do we make sure patients with heart disease undergoing non-cardiac, non-heart surgery do well? I got involved in guidelines and that’s really how I got involved in policy, believe it or not.
Jen Rabiner: That’s so interesting. When did you make the leap into policy and regulatory?
Dr. Lee Fleisher: I was writing guidelines on pre-op evaluation for the American Heart Association, the American College of Cardiology, as well as other groups. I started to realize I needed to understand health services research better and worked with a brilliant health services researcher, Jerry Anderson — who, ironically, my son got his master’s degree with — and we used to go to CMS and visit. He taught me something really important: you can do research, but if it doesn’t help regulators in pulling a lever — in helping them think through how they can actually implement it — it’s just another paper in a medical journal. It doesn’t actually lead to better patient care. I was very fortunate that when CMS developed the first quality reporting programs for hospitals, which was part of the Surgical Care Improvement Project back around 2002, I was one of the 14 people in the room who got invited to join them.
And because of that, I started getting very involved in the National Quality Forum. In fact, before I came to CMS, I was treasurer and really helped think through the right quality measures in all the programs at NQF, being a member of the Consensus Standard Approval Committee and the Measures Application Partnership. So I kept thinking that when I finished my tenure — because there are set terms as chair of anesthesia — I would go to CMS and work at CMMI to develop some value-based programs. I was talking to them about that when my predecessor at CMS — Kate Goodrich — decided to leave. Two months later, COVID hit, and two months after that, the agency said: several people have nominated you, please apply for the position that I was eventually chosen for.
Jen Rabiner: Tell me a little bit about that experience. So you’ve been doing all this research on the guidelines. You’ve seen this evolution at that point — about 18 years between 2002 to 2020. How did the pandemic change what you intended to do at CMS compared with what you needed to do during the pandemic? Tell me a little bit about how that changed priorities around things like safety and quality standards, because people’s health status was still the same regardless of a pandemic.
Dr. Lee Fleisher: As a chair of anesthesia and critical care, I had the privilege of standing up the response to COVID. I was very fortunate. I actually had faculty from Wuhan and from Milan, and they were giving me intel way before we really recognized how bad it was. So I had about four months of working on the COVID response as a doctor, and I really came to CMS because of all the things they did to allow the healthcare system to continue to run. When I went into the agency, I still remember: I said I needed a month to transition, and the administrator at the time — Seema Verma — gave me a week because the nursing homes were literally on fire. And what became clear was the first question: how did we respond to the nursing homes? How did we actually deliver care that was safe, but where we didn’t have family members who could say: we need to worry, they’re getting a decubitus? How did we help articulate some of the issues that the family members frequently address in these settings?
We also saw hospitals saying: we’re not going to focus on worrying about these quality measures. We’re going to focus on delivering care. I could see it in real life. There were two things happening: one was, how do we deliver safer care to our nursing home residents? That was CMS’s charge by the White House. And two was, how can we make sure we don’t forget about safety and quality? We didn’t want to forget about delivering high-value care, but we also wanted to make sure that the clinicians focused on what was important, which was delivering care, period. I frequently say thank you to the clinicians of this country. People forget that they came in and were risking their lives. I had faculty members who wouldn’t go home, would stay in hotels, would go to their basement, take showers, and not be with their family. So I think it was really balancing that.
When things started to get better, I collaborated with Michelle Schreiber, who oversaw the QMVIG, which is the Quality Measurement Infrastructure at CMS, and Denise Icardo and Arjun Srinivasan, colleagues at CDC. e wrote a paper that I think has been quoted frequently in the New England Journal about the fact that quality had deteriorated and we needed to recommit. We needed to develop a more resilient system. Acknowledging that safety had deteriorated significantly, and as the pandemic went on, we needed to say: that’s not good enough.
Since then, I’ve articulated in a piece in The Catalyst, as well as others, that we need to rethink safety because the ecosystem has changed. We have lots of traveling people, and many of our providers were trained when there wasn’t direct patient contact. During the beginning of the pandemic, people were standing further away. I think it’s really important, and you could see it in the inpatient prospective payment system rule that just came out where there is a structural patient safety measure for hospitals.
Jen Rabiner: When you think about that continuum of safety — where the origins of a lot of quality came from — evolving to the more preventative and proactive kinds of quality measures that we have today, do you feel like we went back a little or do you feel like safety just evolved into something taking a different role?
Dr. Lee Fleisher: We all want to get to high-value care. Value-based care means a lot of things to a lot of people. In my mind, it’s ensuring that patients get the optimal care, and that total cost of care is actually either fixed or reduced, which would be the best. The goal we need to work toward is to get better measures of care. I think one of the areas that fits into your continuum of value-based care is diagnostic excellence. It’s one of the areas that Michelle Schreiber and I really focused on. It was an area that the Moore Foundation was very interested in for a while, and certainly the National Academies is. Getting to more accurate, faster diagnoses for patients, with more appropriate treatment, is something that we haven’t measured well, but we need to. I think we’ve got to recommit to high quality safety measures again, because patients demand that. Avoiding preventable harm in our hospitals, which we still see is a major problem, but also delivering care that gets to the right answer, quicker, with the right treatment.
Jen Rabiner: What do you think about how we pay for health care and how we make sure that quality is high — whether we’re talking about increasing the safety standards, or about preventative care, or about speed of diagnostics to treatment? You mentioned fee-for-service before. How does it help or hurt?
Dr. Lee Fleisher: We get what we incent and pay for. I think that has led to a certain amount of overutilization, which in a total cost of care payment model would hopefully be reduced if the incentive is delivering the right care, and we have the right metrics for the lowest cost — the definition of value-based care. I had to oversee programs like hospice and home health. There are such great opportunities to use that effectively, but in fee-for-service, we really need to think a lot about program integrity. When we stood up the acute hospital at home program at CMS , the thing we had to worry about was, is this home health on steroids, or is it really the evolution of the hospital given technology to bring it to the home? Which in my mind isn’t the ideal situation. When you look at the positive aspects of hospital at home, you can see that patients get to stay in their home, rehab in their home, and actually use less post acute care. But how do we create the right payment models to do that? So I agree entirely that fee-for-service has not achieved what we want, and we really need to think about other payment models. For example, at CMS we were always proud of the Medicare Shared Savings Program (MSSP) and the other ACO programs. They incentivize the right thing — that care coordination. The issue is that specialists are rarely in those models. How do you integrate primary care versus specialty care?
Jen Rabiner: And then versus a hospital.
Dr. Lee Fleisher: Absolutely.
Jen Rabiner: So when you think about how we make policy, do you think there should be different types of policies for these different settings? How do we make sure there’s that alignment across different settings with totally different jobs and incentives?
Dr. Lee Fleisher: So that was the genesis of thinking about CMMI, or the CMS Innovation Center, as I think it’s now termed. They had the authority to do things. Fee-for-service Medicare is a defined benefit, and you can only pay for certain things, and it became very clear to me that with the social determinants of health, patient activation is an important challenge that’s difficult to address in fee-for-service. I still remember a story: one of my medical students had gone up to the Bronx and had a patient who became a diabetic and they said: do not drink sugared drinks. The patient kept coming in and her diabetes was out of control, and my medical student said: we told you not to drink sugared drinks. And she said: yes, I stopped. I switched to juices. So to her, sugared drinks meant sodas. She didn’t understand.
Now, whose fault is that? It’s really the system’s for not meeting her where she lived — for not understanding that her education did not allow her to do that. So the idea of community-based health workers is important, but we couldn’t pay for them in fee-for-service — although CMS is starting to develop plans to pay for them — and in CMMI models, we could.
Jen Rabiner: Yeah. Well, like you said before, you get what you incent, and so it’s hard to talk about how to change without thinking about how we fund.
Dr. Lee Fleisher: You know, one of the things we pushed during my tenure at CMS that I was proud of was the queries on the social determinants of health. I’m sure your team is very familiar with that concept, as are the listeners. We told hospitals to ask them, but there’s a downside to that. If you keep asking them every time you have a patient encounter, but then you don’t do anything about it, it really gets people angry.
Jen Rabiner: Yeah, because it feels like a rhetorical question.
Dr. Lee Fleisher: So the question is, what’s the third measure? One is, did you screen? Did you screen positive? What should we hold the health system accountable for? Is the hospital accountable to make sure you’re fed well? Is it accountable for referring you to a food bank? Is it accountable for you going to the food bank — not just referring you — and making sure you are driven there? These, I think, are the questions that policy makers need to answer. People who would be listening to this podcast on value-based care, you understand this is really the thing that’s going to make the difference.
Jen Rabiner: Yeah. It’s kind of the root of public health:there are a lot of different things you need to address to actually improve health over the long term. Do you have an opinion on how far the responsibility goes for primary care providers, for specialists, for hospitals?
Dr. Lee Fleisher: You know, we started doing really interesting studies right before I left. I hired a medical anthropologist and I put him in the surgeon’s office when they were doing informed consent. We found out that by the time patients got to the surgeon, it really wasn’t informed consent. The patient already had a fixed idea and the surgeon either affirmed it or, with difficulty, moved them. Think about the power dynamic between a patient and a provider. I was very fortunate to have lunch with Daniel Kahneman — the Nobel Laureate and behavioral economist — before he passed away, and he would say to me that even he had difficulty negotiating with a doctor. You know how many times I went into the hospital for a diagnostic procedure and everything was fine, but then they just hand you the consent forms and talk quickly? Even I do it when I’m practicing medicine on Fridays and it’s like, is it real? Is shared decision making the way we do it truly real? The issue is that patients in the United States are a little different than those in Europe. They want what they want, and they have beliefs and they get that from a lot of information, not just from physicians. It takes more work to get people to change their mind and you actually have to think of best case, worst case scenario. So keeping all of that in mind, I think primary care and coordinating care is incredibly important. I think primary caregivers do an amazing job. Patients frequently want to go to a specialist, and the ability of the primary care provider to control what happens once they leave that office and go to that specialist — especially in fee-for-service — is incredibly difficult. So I don’t know the answer. But I think that’s one of the key questions we have to figure out is, how do you make the primary care and the specialist coordinate together?
One of the reasons I got involved in CMMI is because I thought a lot about pain management. Being an anesthesiologist who had a pain management part of my department, I asked: how could we coordinate with primary care so that the specialist would just intervene occasionally? So that most of the care would be given by the primary care provider and there wasn’t an incentive to do more procedures unless it would make a big difference? But who was gonna pay for that new model?
Jen Rabiner: Out of all the models that have come out of CMS, out of CMMI, are there any that you feel have held particular promise to inform where we go next?
Dr. Lee Fleisher: MSSP is a great model. I do believe strongly in the primary care ACO concept. But the biggest issue that I learned about is they’re not all on the same EHR.
Jen Rabiner: That is true.
Dr. Lee Fleisher: NAACOS used to talk to me about the difficulties created because many of their members would have multiple EHRs, and I think that needs to be solved. Interoperability holds the promise.
Jen Rabiner: It does. It’s hard to talk about all of this without even talking about the data side.
Dr. Lee Fleisher: Exactly. In addition, the Kidney Care Model is really interesting because I think there’s a lot of positive aspects that I can see going forward. But, as we know, a lot of people and many of the models are too isolated. They really need to work together.
Jen Rabiner: We often find primary care doctors are confused by how many models there are, and which one is going to be better because there are multiple options.
Dr. Lee Fleisher: Before coming into the agency, I remember a lot of debates at the National Quality Forum focused on: do you adjust quality for the percent of duals for your socioeconomic area and the implications of that? I had done research and a lot of people had done research that showed that you could improve the quality of care, particularly acute hospital care, for people who are in poorer or more disadvantaged areas, but it costs more because you had to keep them a little longer to overcome some of those social determinants of health. So REUP and Doug Jacobs — a senior advisor at the Center for Medicare — wrote a great paper on this in the New England Journal of Medicine. The idea that instead of adjusting up for social area deprivation index or one of the other markers, you actually pay more if they achieve high quality. It’s not paying more for lower quality, but if they can get higher quality, there are more incentives; that’s the REUP model.
Jen Rabiner: And is that implemented now?
Dr. Lee Fleisher: It’s starting to be implemented in ACOs. You can see where providers get upfront payments, particularly if they’re smaller, if they have a higher percentage of dual eligibles, etc. That is the idea.
Jen Rabiner: You touched a little bit on data. I would love to dig in a little in that space and on all the quality measures. I’m sure you’ve written and read many of them, and sometimes you say: yes, exactly, we should be doing this; this is a good thing for patients; this is what we want to measure. Then we get into the implementation, where everybody’s on a bunch of different EMRs that have varying levels of capabilities to capture all of the data that’s necessary for the quality measure. Where do you see those loops of learning, where we write the right thing that says: this is what should really be happening in the execution, but it’s either very administratively burdensome, or we’re not able to capture all of that data. Have you seen that process improve over time?
Dr. Lee Fleisher: I have, and I give us a B to a C. How are we improving? I was shocked at how much CMS cares, and is required to care by the Administrative Procedures Act, about public comment. I think the public — i.e., the physicians, but also the advocates and others — could do an even better job at providing the feedback that CMS has to listen to. I still remember that for every quality measure rule, AMA and others make lots of comments, but we really need everyone. For example, on a coverage decision around Alzheimer’s disease, CMS got 9,700 comments. For the physician fee schedule, they get tens of thousands of comments, and those help the team think things through. There’s requests for information right now on patient safety, as well as on other questions of: should the readmission measure now consider emergency room visits? Should it consider observation stays to be a better measure? So I think there’s an important opportunity to help iterate.
And then, on the other side — and CMS always was interested in listening, at least when I was there — on the other side, the Office of the National Coordinator is really pushing the EHRs to truly be interoperable. I always ask the question: why do we have what we have? If you’re an EHR company and you’re not interoperable, there is a business model for that, but I can assure you that Micky Tripathi, who’s the National Coordinator, is really pushing for interoperability and the use of USCDI — the core data set — to really allow things to be reported on more easily.
Jen Rabiner: I’ve certainly seen that evolution as well. I’m interested in your thoughts on how that landscape has changed over time? Do you see the focus areas changing from those core clinical guidelines in 2002, when you were starting to write, to today, where even the ACO REACH Model has three clinical quality measures that are really all just about keeping people out of the hospital? It’s a very different landscape than it’s been, at least in some of these experimental models. I would love your perspective on that.
Lee Fleisher: Thanks. It’s interesting: we started with structural measures because nobody wanted to be measured on outcomes. There was a lot of pushback because outcomes weren’t properly risk-adjusted, and they were all valid. There were some methodologic issues.
We moved to saying everything should be focused on outcome measures, but under the current administration we moved back to some structural measures, and we also moved to a Universal Foundation. We need outcomes measures, and we need better ones. However, they’re very expensive to create, we had too many measures, and we had too many non-harmonized measures, which led to the creation of a national quality strategy at CMS. Jon Blum, the Principal Deputy, really forced us to say we’re all going to try to use and harmonize the measures, and I think that’s a good thing. That became the Universal Foundation, but it needs to keep evolving. I think the entire team would agree with that. Moving to electronic quality measures — so reducing burden — is really important. Although the Administrator, Chiquita Brooks-LaSure, does frequently say you don’t want to move too fast and leave behind groups that are not on the newest EHRs, or not on EHRs at all.
Lastly, it became clear that going only to outcomes would miss certain things that are not yet ready for outcome measures, but should be measured. The classic example is maternal health. There’s now a “Birthing-Friendly” designation from CMS — which says you participate in a collaborative program — as one of the measures around improving maternal health. That became so important because we don’t have the outcome measures yet. They’re being developed, but we know that healthcare equity, disparity, and issues around maternal health are huge, so it became important to implement.
Jen Rabiner: Yeah, almost like a leading indicator.
Dr. Lee Fleisher: They are the leading indicator. Well put.
Jen Rabiner: You and I were chatting a little bit before about how you participate on a committee and have an interest in how AI is being applied to healthcare. We’d love to hear a little bit more about what you’re working on in that space and any thoughts you’d like to share about where you think it has promise and where it has risk.
Lee Fleisher: Everyone said it’s going to be utilized first for back-office issues. It’ll be utilized to synthesize clinical notes. Well, that’s moving a little bit into the clinical area. It’ll be utilized for decision support. I think AI has an amazing ability to assist clinicians, but we have to make sure that we keep learning as we use it, and that there’s appropriate quality assurance and performance improvement around it, and that there’s feedback shared with the developers to avoid issues. For example, if you use AI to synthesize your clinical notes, depending on some of the phrases used, it could introduce a lot of bias into the notes you’re taking, and that could lead down strange pathways. Some of the work we’re doing with the Safety Commission and the Coalition for Health AI is really about that governance: about making sure an anesthesiologist doesn’t have the ability to order oncology drugs, about making sure that there are the right safeguards, the right oversight, and the right feedback mechanisms if harm is incurred. If harm occurs because bedrails are not adequately put up, what’s the process to make sure you do it right the next time? So I think we will start to see diagnoses potentially faster, but the other thing we need to do is teach people how to use a tool that gives you less noisy advice.
Jen Rabiner: Yes.
Dr. Lee Fleisher: So you know where I’m going, because, in fact, there have been several studies that say: let the AI tool do its work in something like radiology and it’s great. Humans do great. But if you put them together, you actually do worse, because people start to question when the AI tool is not right. So I’m a Bayesian. I think people have to learn how to use AI tools for the information they give you, and I think we need to teach that in medical school and nursing schools and all our clinical schools.
Jen Rabiner: How do you feel it should be or will be regulated to ensure safe use?
Dr. Lee Fleisher: Stay tuned: there will be something coming out in JAMA Health Forum. To just give a preview, I think that some of the ways we regulate other medical products are available to CMS. One of the key things I’ve been thinking about a lot is: if we use a medical device or a drug, there is the FDA indications for use, which is what it’s actually been developed for. As you use things in hospitals or in your practices, you should really understand the transparency of who this has been developed on and how it should be used, and you should put that in place to determine how you’re going to use it. If this was developed — I took a law course on this — in what they would call the Global North, but your population is really an immigrant population from South America, it may not behave correctly.
Jen Rabiner: That’s a great point. Lots more to come in that space, I’m sure, and we’ll look forward to reading soon. Zooming back out to value-based care. Everybody defines it a little bit differently. So a couple of questions here: number one, there is a lot of excitement these days around value-based care. I think you’ve said it’s at a tipping point right now. I am curious because it has been a phrase that we’ve been using for over a decade now and, with various models, what do you think is different about this moment for value-based care compared with the last 10 to 12 years?
Dr. Lee Fleisher: Both in a positive and negative way, I still think the term is embraced by both sides of the aisle because they can interpret it however they want on a political spectrum. That’s a positive. But what we’ve seen is that a lot of models don’t work, and that patients, doctors, nurses, and clinicians are not satisfied with the care being delivered right now. So what you have is a certain level of frustration and people thinking: when we go into the hospital, it’s not the same as 10 years ago. That may be the bye bye birdie effect: they’re growing up not the same as us, so people are looking for that higher quality care and I think there are more tools available now — the tools that the insurers and CMS have given, tools like what Pearl Health and others have provided to help deliver a more holistic way of getting to better health. I think the fact that the fee-for-service system of CMS and the federal government didn’t do some unique things during the pandemic closure to keep physician practices alive, and that another public health emergency may topple the system, has led people to recognize that having a total cost of care model has some advantages.
Jen Rabiner: I find a lot of conversations in healthcare make it feel like a zero sum game. If one person wins, the other person loses. And in reality, I think for a lot of things, if we did them right, everybody wins. The patients win, most importantly, with getting the right care at the right time. Physicians win if they are also incentivized to do all of those things, which are usually the things they want to do. And the system wins, because we do save money as well. What is your perspective on that?
Dr. Lee Fleisher: Yes and… Consider the physician fee schedule. It’s a fixed pot of money. So if we increase E&M codes and care coordination codes, the proceduralists lost and that’s what we just saw. That’s why you keep hearing about the doc fix, because they added a new code for care coordination. It was the right thing to do, but the problem is that the accounting is very siloed within hospitals, and between hospitals and physicians. That was the goal of the Innovation Center, and I think it’s still the goal: how do you share the total pie? Until that’s figured out even better — where people can see the total cost of care, which includes the patient’s costs — we still have a ways to go.
Jen Rabiner: Speaking about that, thinking about the coordination of primary care and specialty care, what does that ideal world look like to you?
Dr. Lee Fleisher: I think you have to embed models within models. As I said several times, MSSP is a great model. It works, but there has to be better alignment on how to share the wins. I know there were hospitals at the beginning of value-based care that would provide second opinions before surgery and, frequently, they would determine that a patient didn’t need the operation. I’m a huge fan of physical therapy whenever possible to avoid surgical interventions, especially in orthopedic care. But how do we actually have it so everyone wins? That was the model that I was planning to work on when I came to CMS back in 2019, and who actually owns the model became one of the key issues. Should it be owned by the surgeon so they would feel that if they actually said no — and I remember they did this at the University of Utah — they still won, or at least got a piece of the pie, for not operating when it was the right decision? We’re still working to get the right financial models to incent so that everyone wins.
Jen Rabiner: Truly outcomes-based care is maybe a specific way to say it. And it looks like you also teach courses right now on value and care and quality and care. Is that something you’ve been doing for a while?
Dr. Lee Fleisher: I started a class for medical students about 14 years ago, and then I transitioned to the masters of healthcare innovation where I teach a different version of that. I still very much enjoy it.
Jen Rabiner: How has the curriculum of that course changed over the last 12 years?
Dr. Lee Fleisher: It changed a lot when I went to CMS, and it changed a lot actually in part because of the advising business. We now advise companies who have products or services that improve patient outcomes — otherwise I won’t advise them — and what we have found is that they don’t understand the levers to get their products accepted. They don’t understand if the hospital pays for it, or if it’s paid for within the hospital DRG, or if it’s paid for by an extra payment from CMS’ new technology add on, or if it’s paid for separately. So what has changed is that, as I talk to these innovators, I’ve tried to teach them to think about who the stakeholders are who would either pay for this or accelerate its change. What are the quality measures that they could drive — which is something new I’ve been thinking a lot about — that would increase adoption? And how do they correctly talk to the right people?
I enrolled in a Master’s of Law and just completed it. Part of the advantage of taking that was learning how other disciplines think. Regulators think differently than members of Congress, who think differently than lawyers, who think differently than doctors. Even doctors think differently versus other clinicians and versus health or public health officials. So how do we make sure that our language is the same? We use that to actually get great ideas adopted.
Jen Rabiner: That’s so interesting. We’ve touched a few times on the role of the patient in achieving health outcomes. So when you are advising companies or when you’re teaching in your course, patients are maybe the biggest stakeholder that we’re talking about in order to actually change some things. Have you seen anything that has been particularly successful in helping change patient behavior?
Dr. Lee Fleisher: I’m a huge fan of patient activation. Before I even went to CMS I was working with the patient activation measure. I think patients have an incredibly important voice and tell us so much. And what people don’t tend to do when people are yelling at them or advocating strongly is listen. They miss the 20 percent that’s critical because of the 80 percent that’s packaged in: you’re doing something wrong. What I’ve been trying to do is two things, with listening being the first. One particular example: when I was at CMS, the newspapers would talk about all the things CMS was doing wrong, about oversight, but there’s some really important stuff in there that we could change.
The other is telling many of those stakeholders: help me help you. omeone recently came up and said to me: you know, it’s funny, we were in this meeting and you finally said, okay, so here are the levers I have. Tell me what I can pull to achieve that goal. So I think one of the things that we in healthcare really need to do is, when we listen to our patients, we also need to give them information on the tools we have at our disposal so we can help them help us. We can ask: how can we use those tools to be more effective?
The Secretary of Health kept saying to us, I want things to be culturally and language appropriate. And I did not really understand what he was talking about. And at one point Secretary Becerra said: my father is American born, but speaks almost only Spanish. So when he goes to his physician, the cultural barrier is so great that he doesn’t always tell the physician what he needs to do to help the physician take better care of him. So I think it’s really important: we need to be better listeners for our patients, to understand the differences we have, and try to help them articulate what they need. And that’s why I think the community health workers are phenomenal in helping us think through these issues.
Jen Rabiner: We talked about all these different things that we need the medical community to evolve to support. How do you think that should or will change medical education? We’re asking them to be small business owners, to understand many different components of patient needs on top of all of the clinical training that they need in medical school.
Dr. Lee Fleisher: That’s a really difficult question because lots of people are saying: you know, we got to get back to the basics, but the basics do require understanding the environment our patients live in. We have great students coming in with really interesting backgrounds, so I think we’ve got to stick with them understanding the basics of how to do whatever they’re trained in. But I also think ee need to bring in other disciplines more. Our nursing colleagues teach us so much about how to listen better. We talk about a team-based approach, but I don’t think it’s there yet, and that’s what is going to be critical.
Jen Rabiner: Including those community health workers.
Dr. Lee Fleisher: I’m a huge fan. I used to do tours when I was at CMS, and, we’d go to some of the hospitals that were less resourced, where I really liked to work. And that’s where I saw some of the novel programs; I still remember going to Chicago to visit a hospital, and they talked a lot about including those community health workers, and having equity dashboards, and how that made a big difference. The community health workers started teaching the medical students how to have better conversations, but you’ve got to be open to it.
Jen Rabiner: Absolutely. Wonderful. Final question for you: with your new venture, and Rubrum Advising, and all of these other roles that you have, what are you most excited about that you see in the world of innovation and as you’re working with these different companies and regulatory bodies? What is most exciting and inspiring — that gives you the hope that we’re moving forward?
Dr. Lee Fleisher: I believe the technology that is evolving is phenomenal, but technology alone won’t solve it. So I think we need to combine that with some of the innovative ways that we’re paying for other individuals to surround you. What I’m seeing from the best companies is really understanding that if it’s in the interest of patients, there are great levers to use to get those things adopted, and what we really need is more evidence of what works, how it works, and what is the infrastructure you need to surround it. And that’s why I created Rubrum: it’s all about creating the evidence to help companies show the value of their products.
Jen Rabiner: That’s exciting. Wonderful. I can’t tell you what a pleasure it was to get to know you a little bit better. Thank you so much for spending time with us. And again, congratulations on being one of our Top 50 Value-Based Care Thinkers this year.
Dr. Lee Fleisher: Thank you so much.
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Top 50 VBC Thinkers 2024
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Top 50 VBC Thinkers 2024