Pay for quality. I am a big believer in value-based care. We’ve been working towards this ideal market for years, and we are making some progress. For example, the state of Massachusetts, where I have been working for almost 20 years, has launched several initiatives that have been successful in driving employer and health system responsiveness. These efforts have shown that a lot can be done at the state level if the state embraces the value-based model.
As a part of our interview series called “5 Things We Must Do To Improve the US Healthcare System”, I had the pleasure to interview Eric Schultz.
Eric Schultz is president of FluidEdge Consulting and EVP of CitiusTech, and has over 30 years of experience in the healthcare industry. Prior to joining FluidEdge and CitiusTech, Eric was president and CEO of Harvard Pilgrim Healthcare Inc. for eight years. Under his leadership, Harvard Pilgrim was consistently ranked among America’s highest-rated health plans by the National Committee for Quality Assurance (NCQA).
Eric has also held executive positions with CIGNA Healthcare and Prudential Healthcare, and has also served as Medical Group Administrator for Nashville Healthcare Group. He currently serves on the boards of the Kenneth Schwartz Center, America’s Health Insurance Plans, the Massachusetts Association of Health Plans, the New England Council and the Worcester Regional Research Bureau.
Eric holds an MBA in Healthcare Leadership from Yale University’s School of Management, as well as a BS degree in biology and a BA degree in economics from the University of Connecticut. In 2009, he received an honorary PhD from the Massachusetts College of Pharmacy and Health Sciences.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
When I was younger, I wanted to be a physician. My mom and sisters were nurses, and I was genuinely interested in healthcare. Pursuing the goal of becoming a doctor, I attended the University of Connecticut and began in their Pre-Med Program. I ultimately chose to complete my Biology degree and also pursued a degree in Economics, because at that time, U.S. healthcare spending was increasingly put under a microscope. I was fortunate to start my professional career at Cigna Healthcare, where I applied my biology and business education as a medical claims processor and also gained a strong understanding of health insurance fundamentals. I had a wonderful physician mentor who later invited me to be a physician group practice administrator. While I came to the position thinking I knew a lot about how healthcare worked, the role showed me how much I didn’t know. I was able to shadow physicians during patient visits, and these encounters revealed how insurance can have a positive or negative effect on a patient’s care experience, course of treatment and relationship with their provider. Those six years as an administrator did more to shape my perspective and career than almost any other point in my professional journey. It allowed me to see the critical connections between clinical care delivery and insurance coverage and reimbursement, and it was during this time I came to realize that if you don’t understand the nuances of care delivery, you cannot execute the processes surrounding insurance and care payment effectively.
What do you think makes your company stand out? Can you share a story or tell us why?
In my experience, I’ve found the most successful businesses are those that do two things exceedingly well. First, they clearly understand the business and market they are in and remain committed and focused on their mission, goal and purpose. The second is that they truly grasp and excel at the basics of their business and do so consistently.
Too often businesses lose focus of top priorities and pursue the next big thing, whether it’s a piece of groundbreaking or life-changing technology or a “million dollar” idea, but in doing so, more often than not, customers suffer, business costs increase and eventually, they fail.
CitiusTech is fully committed to healthcare — and part of that is remaining dedicated to bringing exceptional and consistent service and value to our customers. I was in a meeting recently with a smaller health plan customer along with the CitiusTech’s co-founder. The customer experienced some obstacles on a project and was concerned that they might not receive the attention they needed because it was a smaller-scale project. The meeting went well and we agreed to create a plan to address their concerns. However, what impressed me most was when the co-founder reassured the health plan’s senior executive that CitiusTech is equally committed to all its customers, no matter the size, or scope. This was further reinforced upon learning that the two of them regularly connected over the following three months after that call took place.
Are you working on any exciting new projects now? How do you think that will help people?
In January 2021, CitiusTech launched a new product, Stars Decision Engine, a unique AI-based solution for Medicare Advantage plans that drives performance improvements in their CMS Star
initiatives, which can impact who signs up for their plan and their reimbursement levels. In addition to providing rich insights to positively impact quality performance across all contracts to help health plans drive sustainable value, it utilizes in-built data science models to accurately project end-of-year Star scores and recommend key measures for ROI-based performance improvement.
CitiusTech is also constantly perfecting its Provider Performance Management solution, which enables caregivers and administrators to effectively measure and improve clinical quality measures and deploy solutions to optimize patient outcomes and cost of care. Equipping today’s providers with the best and most proficient performance tools and analytics to further drive clinical, operational and financial results will not only help close care gaps but ensure organizations are set up for future success.
Thanks for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the U.S. healthcare system is ranked as the worst among high-income nations. This seems shocking. Can you share with us three to five reasons why you think the U.S. is ranked so poorly?
Let me preface my response by saying that it would be easy to speak solely about the many ways the U.S. healthcare system is failing. However, I would be remiss if I didn’t acknowledge a fundamental tenet of U.S. healthcare that is something of which we should be proud. In this country, we have a culture of providing access to care to everyone — and that is not a universal approach across the world. In the U.S., if you show up to an emergency room seeking care, you will receive it, regardless of your location or ability to pay. Even though this idea is commendable, it is currently just a small seed of potential progress that has been left largely unattended. It is our job as providers, payers, employers and government agencies to work collaboratively to grow that seed into something that can thrive long term.
Now to answer the question you asked. There are myriad reasons why the U.S. is falling short in healthcare. One is that we have a major chronic illness problem that is exacerbated by a variety of factors. Rising obesity rates; care inequities and disparities based on race, ethnicity and sexual orientation; and broader societal issues, such as inadequate food and housing, are all fueling chronic conditions and a lack of proactive health management. Before we as a nation can see meaningful improvement in health outcomes, we must find ways to better manage and limit chronic disease.
Another issue is the imbalance between the amount of money the U.S. spends on research and development and the financial support we receive from other countries in this effort. A great example of this is the difference in the cost of drugs here versus Great Britain, India or Australia. The U.S. is spending substantial amounts of money to create new drugs, and, for a variety of reasons, the drug makers are establishing prices with other countries that are far less than what we pay. I recently saw a report from 2018 that stated the average global payment for drugs is about 55% less than that of the U.S. This not only applies to pharma but to technology as well. Our relatively high spending number is inflating the denominator of the healthcare spending equation, which does not allow us to make accurate comparisons to other countries. Moving forward, we need to find ways to reduce how much we are paying for pharma and technology and make contributions more equitable around the world.
U.S. healthcare also has significant room for improvement in the area of behavioral health. With the exponential growth in opioid addiction, suicide rates and other stressors, there is an urgent need for mental health services. At the same time, we are seeing a societal change that is removing some of the stigma around mental health treatment. This confluence of factors is driving demand, and we currently do not have an adequate supply to meet it. As a country, we are not effective at providing easy, affordable access to mental health services, and the need for this type of treatment is only going to grow — making it one of the more pressing issues we face.
You are a “healthcare insider.” If you had the power to make a change, can you share five changes that need to be made to improve the overall U.S. healthcare system?
There is a wealth of potential changes we could make, and they all could bring value, but no one strategy is a silver bullet. That said, here are five changes that could move the needle toward a safer, more cost-effective and equitable healthcare system.
- Pay for quality. I am a big believer in value-based care. We’ve been working towards this ideal market for years, and we are making some progress. For example, the state of Massachusetts, where I have been working for almost 20 years, has launched several initiatives that have been successful in driving employer and health system responsiveness. These efforts have shown that a lot can be done at the state level if the state embraces the value-based model.
- Increasing transparency around quality. In addition to being paid for quality, organizations need to be transparent about the quality of care they provide. Although the focus over the past five to 10 years has been on promoting cost transparency, this shouldn’t be done without offering clarity around quality performance. It’s relatively easy to come up with a software solution or app that lets consumers know how much a service is going to cost, especially for high-volume, discreet services, such as a spinal MRI or a normal vaginal delivery. However, when providers share cost comparisons, they may not be communicating the full story. Most consumers believe that if something costs more, it’s better. As such, cost comparisons on their own may encourage patients to go to a more expensive provider, which may not be the one producing the best outcomes. When providers close the cost-quality information gap, patients can be more aware of what they’re paying for and make decisions based on complete information. Unfortunately, providing quality transparency is harder than cost transparency because it’s more challenging to devise comparative quality measures that consumers can use confidently. And yet, I think as an industry we can come up with at least 20 measures to start, which would help us to move in the right direction. For example, these measures could include high-volume services that offer easier comparisons such as total knee replacement, deliveries, back surgery, etc.
- Make payment for R&D more equitable. This may be more of a hope, but one I’m passionate about. Getting control of pharmaceutical spending and making the whole pharma environment easier to navigate is essential. There are many hands in the pot right now, and I think it’s important to pursue a strategy that simplifies and creates a more sustainable, predictable research and development spending situation. I don’t think we can do that without dealing with the current inequities surrounding global pharma therapeutic pricing.
- Promote primary care. I’m a big proponent of using primary care professionals, including primary care doctors, internists, nurse practitioners and physician assistants to maintain wellness, improve clinical outcomes and enable more effective chronic care management. Several years ago, Medicare revised its system of relative value units (RVUs) to assign greater value for years of education and technical skills. This has resulted in specialists getting paid much more than primary care physicians. And since what Medicare pays often drives what commercial payers reimburse, the industry as a whole has started paying specialists more. An unintended consequence is that fewer medical students are opting to go into primary care. Medical students have a lot of bills and loans, making the higher specialty salaries more attractive. There are also competitive pressures. Pediatrics, internal medicine, and family practice are not always perceived to be as prestigious as specialties like neurology, cardiology or orthopedics. In some cases, students think that opting for primary care is “settling” as opposed to other specialties that are thought to be more rigorous. These dynamics have contributed to a shortage in primary care. With primary care specialists performing much of the wellness care here in the U.S., we need to stop undervaluing the field. If we truly want to become more proactive about chronic care management, we need to consider realigning RVUs to more accurately reflect the value these providers bring to clinical care.
- Set up an infrastructure for frail seniors. Given the fact that our population is aging, and that existing and emerging technologies are helping us live longer, we are going to face a substantial rise in the number of frail seniors in the not-so-distant future. Generally speaking, frail seniors are nursing home eligible. The Program for All-Inclusive Care for the Elderly (PACE) provides comprehensive medical and social services to certain frail, elderly people (participants) still living in the community. Most of the participants who are in PACE are dually eligible for both Medicare and Medicaid. Some of the services this program offers include adult day care, meals, PT/OT, counseling and transportation. As of now, the program is only available in certain states, but we should work to make it universal across the country, so that services are available as the frail elderly population grows.
Ok, it’s very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
We all have a role to play, whether at the state or federal, payer or provider, employer or individual level. Improving the healthcare system is not one person’s or someone else’s issue. It starts with me doing the best I can to be healthier and actively work to make good choices. In the same way, payers, providers, employers and government agencies need to ask what they can do to help the communities they serve to be healthier. How can we as entities make things more accessible, affordable and equitable? A primary focus should involve moving the dial on social determinants of care, such as food insecurity, lack of affordable housing and inconsistent community support. In my opinion, healthcare payers should take the lead on this initiative. I believe insurers are well positioned to measure these factors and influence change to boost health outcomes for everyone involved.
We also need to continue to remove the stigma around behavioral health and find ways to better connect behavioral and medical treatment. A key component in managing chronic illness is addressing the mental health aspects of disease. Depression and anxiety go hand in hand with chronic illness. By ensuring mental health services are affordable and accessible, payers and providers can take a significant step toward more proactive chronic care management and more positive clinical outcomes.
A big trend that will likely evolve over the next months and years is the smarter use of artificial intelligence (AI) and machine learning to improve healthcare delivery and operations. And we all need to search for opportunities to leverage this technology to gain insights, make predictions, improve efficiencies and reduce waste. Take telehealth, for example. There was huge growth in telemedicine due to the pandemic. The question is whether that growth will continue as the vaccine is distributed and life begins to return to normal. And if the use of telehealth goes down, how far will it drop? At CitiusTech, we’re in the process of running data through AI to assess how telemedicine was used during the last year and pinpoint opportunities for improvement. For instance, there seems to be a positive use case around adolescent behavioral health. Oftentimes, teens don’t want to go into a waiting room for their counseling appointment and may shy away from in-person visits. With telemedicine, they can chat with a provider from the privacy of their own room. Not only can this help overcome some of the roadblocks to adolescent behavioral health, it can also reach patients in rural areas where access to care has traditionally been inconsistent.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
A quote that seems particularly timely comes from Napoleon Hill. “Within every adversity is the seed to an equal or greater benefit. “ No matter what happens, I try to look at how I can collaborate with others to create something better and learn from the experience. Sometimes it’s hard to say this quote when an adverse event occurs, and it’s nearly impossible to see a potentially positive outcome. However, I firmly believe there is value as leaders in pausing after negative events and thinking through how we can use the experience to make something better, even if it is an incremental step in the right direction.
How can our readers follow you online?
Please follow me on LinkedIn. To find out more about CitiusTech visit, https://www.citiustech.com/default?location=worldwide