April 8, 2021
Gary Bisbee 0:06
Healthcare leadership is hard work, but what if you could learn from the most brilliant and influential minds in healthcare and beyond? What would you ask them? Would you ask about politics, policy, or maybe leadership? On The Gary Bisbee Show I’ll do just that. You’ll hear from healthcare’s most successful leaders and those experts who they listen to, as together we’ll explore how the healthcare economy is transforming.
Mark Miller is Executive Vice President of Health Care at Arnold Ventures. Most of us recognize Mark from his 15 years as executive director of MedPac where he significantly influenced federal health policy. Before his leadership of MedPac, Mark held health-related positions at OMB, CBO, and CMS which provided him with an unusually broad and deep understanding of health policy and how the federal government works. During his 15 years at MedPac, Mark defined the position of executive director and substantially elevated the role of MedPac and its bipartisan source of in-depth and insightful research and policy positions. Mark currently has a very interesting platform from which to influence health policy at Arnold Ventures. For those not familiar with Arnold Ventures, you’ll find Mark’s discussion of his purpose and agenda to be both enlightening and refreshing. Mark holds a BA and MA from Old Dominion and his Ph.D. in public policy is from the State University of New York.
Good afternoon, Mark, and welcome.
Mark Miller 1:47
Thanks a lot. I appreciate you having me on.
Gary Bisbee 1:49
We’re pleased to have you at this microphone. We like to start with questions about the background of our guests, so what was life like growing up for you?
Mark Miller 2:02
I grew up military, so we moved all over the place. I lived all over the United States, I lived in Europe a couple of different times, went to three different high schools, that type of thing. A lot of movement.
Gary Bisbee 2:16
My dad was a minister and we moved all the time, too. They used to always say it was the PKs (a preacher’s kid) and the army brats who were coming and going all the time. Did you find there was any advantage to all that movement?
Mark Miller 2:33
As a kid, and this is probably true of you too, whatever is normal is normal. You make what you make out of it but, when I got to this area, what struck me was that kids had been together since elementary school and all the way to the end of high school. That felt very claustrophobic to me, so I’d seen a little bit of an advantage there, but who knows. It was very disruptive and hard on the family.
Gary Bisbee 3:07
That is hard. If you’re like I am, you’re good at meeting people, but you don’t have a ton of really close, personal friends because you didn’t grow up with them. In any event, you became interested pretty early in public policy. All of your degrees, your bachelor’s, master’s, and Ph.D. are in public policy. What led you to the public policy interests?
Mark Miller 3:30
As I went to undergraduate, I took government—but it was really a policy class—from somebody named Richard Skinner. He was a really good teacher, really engaging, and I think that was what flipped the switch there.
Gary Bisbee 3:46
Then where did the healthcare interest come from? It doesn’t sound like you were focused on health care early in your educational career.
Mark Miller 3:55
I would have a hard time answering exactly where that came from. As I was going through undergraduate into graduate, when I had policy papers I had to write, I gravitated to health. I’m not sure what the first attraction to it was, but I know when I got involved in it I was really taken with how complicated it was, how much it defied normal economics. So somewhere along the line, but I don’t know that there was a specific event.
Gary Bisbee 4:29
We’re glad you did decide to healthcare because you’ve had a terrific influence. Following your Ph.D., you probably had a choice of faculty or possibly coming to DC. What was the set of decisions you made there?
Mark Miller 4:44
That is true. The program I went to was focused a lot on methods and agnostic on the type of policy. I went off to Albany and wrote my dissertation on healthcare. That was my path. The majority of people I went to graduate school with were headed off to teach. There were parts of teaching I liked. I liked the actual classroom experience, but I felt very strongly about going and doing applied research and policy. That was something I really wanted to do. An ideal for me was to go to the Urban Institute, which I ultimately ended up doing. Something was said one night when we’re all talking about our plans. I was saying I wanted to go to Washington and work on policy and have an impact, or whatever you say when you’re graduate student. One of the other students said, “Well, I think teaching generations of students over time is also a really effective way to have an impact.” I always thought that was a really important point. One thing I’ve tried to do when I did get here, particularly when I started managing people, was to always try and bring people into their own careers.
Gary Bisbee 6:17
We were chatting briefly before that it’s not too late for you to go back to academia, perhaps to work at Arnold Ventures in academia. Any university interested in healthcare would love to have you, Mark, so maybe that’s your future. In any event, you came to DC, worked at the Urban Institute, then what got you into OMB? Was it at your first governmental posting?
Mark Miller 6:42
I had been at the Urban Institute for a number of years. I was doing the research and publishing. I always tried to drive my research in the direction of being policy-relevant. I did publish in the journals and so forth, but not the real academic things. Then the health financing branch at OMB was looking for somebody to run that. They reached out to me, so I went to OMB and worked there for several years. I was interested in the move because it was very policy-oriented and it was the first management experience I had.
Gary Bisbee 7:24
OMB, CBO, and then CMS. Was that the sequence of appointments?
Mark Miller 7:30
OMB, CMS, CBO, then MedPac.
Gary Bisbee 7:34
Before you got to MedPac, were there any fundamental lessons you learned from those three government postings that have carried on through MedPac and now at Arnold Ventures?
Mark Miller 7:45
There were a lot of similarities in the sense of trying to be the person in the room that worked off of evidence, looked for a logical policy, looked for a compromise, looked for a way to get things done. Differences between them: at OMB there was a lot of analytics. There was a very rigorous process of reach, say a position on the part of the administration looking across all the different agencies and pulling any information and pulling all that together to have an administration position. CMS was about implementation, a different role altogether, as opposed to just making policy coming to some kind of political agreement. It was actually operations, education, implementing the policy. Then CBO was much more analytic and exercised in influenced almost indirectly by saying, “Well, this is what the evidence is. This is how we think the world works, so this is how we would model or score this particular piece of legislation.” Of course, that had a big impact on what direction the legislation went in. Throughout all of those, the amount of dedication and professionalism of the staff in all three of those places has stuck with me. People who worked and gave large parts of their life to get things done. Working late, working weekends, working nights, that type of thing, and caring deeply about the mission of whatever of those three organizations. That was something that was really inspiring.
Gary Bisbee 9:35
That’s probably not universally understood by those of us outside government, so that’s good to know. What was the motivation to go to MedPac as executive director?
Mark Miller 9:48
I had these jobs and I liked these other jobs, I want to be clear, but I always had my eye on MedPac because I felt like it had a particular set of ingredients that were really attractive to someone like me and could be highly effective. Ingredients in the following way. It had a congressional mandate. It had stuff it had to do. It was a very pressurized environment. We had deadlines every month. It had to perform. The second thing is that, although it’s a creature of the congress, it’s independent and its job is to give advice to the congress. It’s also quasi-governmental in the sense that you have a professional staff there, but then you have this set of commissioners who are not of the government and some very explicitly from the private sector. It was small. In the end, it was a 40 person agency, so it was very manageable. You could get your arms around. I always thought, with the right approach, it could be an interesting and effective place to work. I had my eye on it so, when the executive director position opened, I wanted it.
Gary Bisbee 11:07
You were there for 15+ years and defined the agency and set standards for your research and analysis that stood out among those in government, so congratulations on that. How did you develop priorities? It sounds like some of them were required, but there are probably others you had some discretion to set. How did you define the priorities?
Mark Miller 11:36
Two other quick things before I segue. There was a real effort to remake the culture there and what the analytical principles and guidelines were going to be so the organization moved in a systematic way based on evidence and reaching policy conclusions, or at least policy recommendations. A second thing was to establish a tight relationship between the agency and the committee staff. When the committee staff thought of the word “Medicare,” they wanted them to impulsively reach for their phone and call us first. The way priorities were made, I wanted to respond to the congress and lead the congress. To get the congress to listen, you had to know what they cared about, which was part of the reason you want it to be very tight with staff, so you could respond to what they needed. Then the commissioners would come in from the outside and say, “Why aren’t we thinking about things like this?” You could have this balance of being highly responsive to what the congress wanted at that particular moment, but then you could incorporate ideas from the staff and the commissioners about where it should go and people would listen to you because you were right there when they needed you. When they picked up the phone, you were at the other end of the phone. It was a process that came from my staff listening to the hillside and then the overlay of the commissioners. Of course, the chairs are very important. I worked with Glenn Hackbarth for years and then Jay Krause who both have a lot of influence on the direction.
Gary Bisbee 13:19
How are the commissioners appointed?
Mark Miller 13:22
GAO appoints the commissioners. This is all part of enabling legislation for MedPac. There’s a certain amount of definition that goes into the composition of the commissioners like the law doesn’t want a majority of the commissioners to be providers who directly benefit from Medicare. They want input from providers so that, in designing policy, provider perspectives can be taken into account. There is some delineation of the types of backgrounds they want people to have, then GAO goes through a process of vetting people and then they make the appointments.
Gary Bisbee 14:04
Over the course of the 15 years, is it even possible to comment on what was the most influential policy issue that you worked on over that time?
Mark Miller 14:15
Probably not single most, but places where I felt like we had a big impact on the drug legislation and how the drug legislation and part D evolved were manage care policy, post-acute care, payment rates, and some of the redesign that is still going on. We also spent a fair amount of time around the physician fee schedule and the SGR. We had a lot of input on that. Those are some things that come to mind. There are specific issues that may be too detailed for this that I could delineate, but those were areas where I remember specific issues being played out.
Gary Bisbee 15:03
Is there any policy area you wish you’d been able to work on that you weren’t able to work on for some reason?
Mark Miller 15:10
First of all, every one of those policy areas has incomplete issues, so there’s that. What is it? “There are no new issues, just new analysts,” so those still have issues that would be good to complete. What was also complicated at MedPac is the whole dynamic of what policy and what kinds of consensus you could get on the commission. Then, of course, within the congress just to move Medicare. Then there were issues outside of Medicare that had a big impact on what went on inside Medicare that, as a matter of your congressional mandate, you couldn’t speak to. Hospital consolidation in the private sector had impacts on Medicare but it was out of our reach. What the FDA did about the issuing of patents and market exclusivities all would affect the drug markets but very much beyond our reach. There were things like that that you couldn’t get to because of the mandate of the commission.
Gary Bisbee 16:16
After 15+ years, why did you decide to leave?
Mark Miller 16:20
There are probably a few things. Part of the answer to that is in the question. It was 15 years. I want to be very clear: I really enjoyed it and the thing I probably liked the most about it was the crew that I worked with at MedPac. I’m going to reinforce this again. These are people who almost all of them could have gone somewhere else and made more money, but they didn’t. They cared deeply about the mission. They cared about getting the right answer. They, like some of the other people I’d worked with previously, gave up large parts of their life to execute the job. It was a very difficult decision because of the organization itself and the organization’s mission and that type of thing, but a very personal decision because of the people there that I had worked with for so long and had very tight relationships with. Some of it was 15 years, some of it was I felt like there had been a lot of building culture and methods pathways, whatever you want to call it, and the institution was working. As someone who leads, it’s absolutely important that the apparatus you set up can run without you. That should be an objective as a leader, and it was definitely at that point. Then I had a few conversations with Arnold’s and it felt like there were parts of the agenda that I just named to you that I could get to more broadly. After a few conversations, Arnold’s and Cali (who’s the president) and I got to a place where we had a shared view on what an agenda could be. The second thing is they were also pretty courageous. They understood that some of the issues they were going to take on not just with me but elsewhere but definitely with me it would get flack for it and they were up for that and that probably had something to do with me deciding to move. Then they wanted me to build something here and I liked that idea too.
Gary Bisbee 18:52
In a way, did you look at it as you could achieve some goals at Arnold Ventures you just couldn’t achieve at MedPac because of the charter of MedPac? Was that part of the thinking?
Mark Miller 19:05
That’s fair to say. Let me be bent around Washington not to know that it’s so hard to really move things, so I don’t want to overstate. Arnold Ventures probably gives me some more freedom to speak more directly at MedPac you could advise the congress but you couldn’t admonish the congress can do that now and also their sets of tools that you can be more aggressive in terms of the communication and pushing a message whereas, again, at MedPac you advise then you let the congress take its course and of course the people who didn’t want our policies to be implemented we’re actively lobbying and pushing their messages on the hill and that’s not a role that MedPac Really could play. In a sense, they’re sets of tools here that I didn’t have there. Then there were certain parts of the agenda. I named a couple I can still deal with Medicare stuff here, but I can also deal with the broader environment.
Gary Bisbee 20:15
You were there for virtually all of the George Bush administration, all of Barack Obama administration. This isn’t meant to be a political question, but more of a “how did the administration’s operate” type of question. Could you characterize the difference between the two?
Mark Miller 20:36
One thing that was interesting about both periods, and I remember: I’m in a legislative position at MedPac, I’m dealing with the Congress, and there would be changes in Democrats, Republicans movements there. But behind it, there would be the administration’s one thing that was really interesting to me. I don’t think this was accidental, because it was certainly part of my agenda was to always have a set of ideas that I could use, no matter what direction a piece of legislation was going. One thing I found is a good portion of the ideas that we put on the table, both administrations picked up and put in budgets, or both administrations would pick up as part of some legislative effort. And there was a lot of overlap between those two. And even though they would carry on and snipe at each other about their various positions, there were whole sets of policies that came out of MedPac that were always in both packages. But then where they would diverge would be the places where exactly you would expect if the republicans dominated or there was a Republican administration, it tended to always be seeking things that drove more in a market direction. The Democrats’ side would be more open to something that would be more regulatory. Of course, I always want to consider both because both are needed. But in a funny way, when they put their budgets or they tried to run their legislation through Congress are part of it was often the same.
Gary Bisbee 22:19
I think that’s a credit to you. You were always known when you were in that job as somebody who sought balance and didn’t overweight one way or another, so credit to you for sure. Let’s go back to Arnold Ventures. What’s the agenda now? Can you describe that for us?
Mark Miller 22:37
We’ve worked out or myself in the board worked out is the first thing, this is my portfolio. Now there are many other portfolios around the organization. Well, mine is about cost containment, reducing costs for taxpayer employer, the patient, and the people who pay premiums support public programs pay out of pocket, we have portfolios that are aimed at things that are prices, and things that are aimed at utilization. We have a huge portfolio of drugs aimed mostly at the prices of drugs. We have competition-based policies, research, and policies that are aimed at the middle man, the PBM, those types of transactions. Then policies that are very much aimed at trying to extract a better price. We have a portfolio built around the prices of mostly hospitals but increasingly physician services in the commercial sector. So the drug stuff is both public and commercial prices in the commercial sector. The story here tremendous amount of consolidation leads to higher prices. What do you do about this? By the way, one little spin-off issue on that was the surprise billing, which we are deeply involved with both on research and policy, and the most recent legislation that came out. Another portfolio is about low-value care. So there’s a lot of research that suggests not all the care is either helpful to a patient and in some instances actually causes damage or injury to the patient. How do you define that? How do you put it in front of the provider—first patient too, but probably the provider first—and then create a financial incentive to avoid it? Then complex care. Think of the 5% of the population that defined 35% of your spending. How would you manage care in that particular environment so you get a better spend for the Dow? That’s the broad stroke four parts of the portfolio. We fund research, we develop policy either with the researchers ourselves, we provide a tremendous amount of technical assistance. Then with other people in the organization, we engage in advocacy and communication.
Gary Bisbee 25:09
You mentioned the Arnolds are courageous people. With that agenda, particularly with drug pricing, I would say they need to be to make some progress.
Mark Miller 25:18
This is the thing about them, they have been attacked directly by the drug industry, and they have not flinched. They have stayed right on course, and there’s a lot of philanthropies around that wouldn’t do that take these issues on because there’s a lot of fun. Part of the reason that I wanted to position the Arnold’s in this particular way, and they were thinking along these lines to is there are other people out there who are very involved in coverage and quality and other sets of issues all find issues to be pursuing. But a lot of people don’t want to talk about cost containment, it starts to get uncomfortable because somebody’s got to get less and we don’t want to get into that. They were willing to go in that direction.
Gary Bisbee 26:06
Can we dig into complex care for a moment? My personal opinion is we don’t do enough in that space, generally speaking, so I think it’s terrific that you have that as one of your pillars. What kind of programming are you undertaking in that area?
Mark Miller 26:23
Mainly, our agenda today has been around the 12 million dual eligibles, Medicare and Medicaid eligible, gone in that particular direction, because it’s a lot of spend, it’s $300 billion, or north of that, and Medicare and Medicaid. You have two actors who care about it a federal government and state government. It’s expensive if you’ve got an incredibly vulnerable population. I think you’re right, and part of the reason that it’s so difficult to move and make progress in what we know. What we understand in that, as a matter of what works for the particular kinds of populations in question is directional, but not certain at all. It’s complex care, but it’s a fairly complicated topic.
Gary Bisbee 27:15
It is that. There’s a lot of human factors that come into play, too. It’s not the most attractive group to be studying, right?
Mark Miller 27:23
Yeah. People don’t pay attention to poor sick people, so yeah.
Gary Bisbee 27:27
I think that’s true. One overall question. You’re at Arnold Ventures, you work on something like surprise billing, I think you were pretty influential in that space. Generally speaking, how do you actually measure your accomplishments in areas like this?
Mark Miller 27:44
This is an awkward question of my bosses here. There are a few things, I’ll try and answer that question, just for the record. For my bosses, we’ve been wildly successful, let’s be honest, these directions that we’re trying to go in are extremely hard. There is a well-motivated, well-funded resistance to it, whether you’re talking about farmers’ resistance, or hospitals, or whatever the case may be. There are a few things and they think about things like this, but I don’t want to speak too much for them. One of them comes very much from a direction of knowledge and evidence accumulation. If you build as part of your portfolio, a set of researchers and a set of evidence that can then in turn drive policy, and then ideally, real change. One accomplishment is to have momentum and a set of actors and a set of research that’s coming out, and they very much come from a place of evidence matters. They see that as part of the accomplishment. The other part of the accomplishment is, but what changed. And that is, of course, the much harder one to extract. It can be something like surprise billing where it changed. We pushed very hard on it. To be honest with you the final legislation, it’s not the legislation, we would have read, there’s been some movement in the recent reconciliation bill, we’re very small one-off drug ideas are getting pulled into it. You might look at that as accomplishments, but what they really are looking for and what I’m trying to push for is I would like to see in a second reconciliation bill, as part of that, that more major drug legislation gets pulled along as part of that. We also work at the state level. You can see progress at the state level recently met it passed the drug commission then funded it overwriting a governor’s veto to do it and there are examples like that both on the drugs and on the prices side the commercial prices side peppered throughout the states where you can clearly point to pieces of legislation trying to move their way through the state legislature.
Gary Bisbee 30:21
Do you ever get discouraged? The preface is, healthcare is now almost 20% of the gross domestic product of the country. It’s huge. There’s a lot of money here. There’s entrench interest. There are people that have spent their careers pursuing a particular area. They don’t want to change, and you and all the colleagues you’ve worked with through the years are basically trying to reform things. Do you get discouraged that you have to take little bites here and there as opposed to some broad sweeping change?
Mark Miller 31:00
This could be the shortest answer yet. The answer’s yes. You see this overwhelming mountain or wall that moving through will be incredibly difficult. I don’t know how to say this. I’m trying in my head to figure out how to say it politely or professionally or something like that. I don’t know how much idealism I had to begin with but, if I did, I don’t know that there’s much of it left. It’s the unfairness of the situation that motivates me at this point. There’s so much that isn’t right and denies people access to their drugs, undercuts their wages because they have to pay premiums, they can’t meet their deductibles, whatever the case may be. If there was a truly innovative, high-quality reason to pay top dollar, there’s an argument for that, but so much of the money that’s moving through isn’t being driven. It’s just money coming out of households one way or the other. Yeah, I get discouraged, but it’s almost that that gives me an unwillingness to give it up.
Gary Bisbee 32:13
That makes good sense. The coronavirus pandemic pinpointed a number of gaps and inequities and unfairness as well. Any thoughts about that and are there any learnings about that that could enter into your agenda and Arnold Ventures going forward?
Mark Miller 32:31
I hope this doesn’t sound too pat, but it exposed so many of the things that we’re doing. The fact that you could be charged $300 or $3,000 for a test. The fact it would be covered or wouldn’t be covered. The fact that the disparities and the impact of the virus by race and nursing homes, talking about the complex care. The affordability of all of it comes into question. We’ve been carrying major debt in this country for years. A rant that I’ve been on for many years is that we can’t carry this debt because of its drag on the economy and because what if a real emergency happens and we need to anti-up? We have a real emergency and we need to anti-up, but it would have been better to start that in a much more fiscally secure position than at almost a dead equal to 100% of GDP and then just owe it out from there. If we had had a grip on our health spending problem, we might have had more resources than we could throw at it without having to go into debt. This is not my particular turf, but clearly we have not prepared in this country for a public health emergency. We don’t understand it, we don’t have the apparatus. That’s not something I’ve worked with, but that seems very clear.
Gary Bisbee 34:03
That’s very clear. Mark, we need to run you for office. What district do you want to run in?
Mark Miller 34:10
You don’t want me in office.
Gary Bisbee 34:13
I think that’d actually be pretty good. Public health has been a problem forever. We went through this 100 years ago with the 1918 flu and a lot of what we’re doing today is pretty much what they did back then right hopefully out of this will come a bit more financing and support for public health the apparatus the infrastructure definitely needs to tick upon the evidence base side the 1% steps for healthcare reform I know you know Ventures has been supportive of that initiative. It’s relatively new. Can you describe that initiative briefly for us?
Mark Miller 34:52
Zach Cooper from Yale came to us with this particular idea and it rang a couple of bells for me that I’ll get back to, but then notion that he believes economists have something to say and to help where health spending is concerned, that there could be smaller bites that could be broken down and more definitively defined, the savings that could be acquired, and how to communicate with the policymakers, I think was his thinking. For myself, the attractiveness of it is going back to MedPac. I always had a list of ideas, and they could be more market-oriented or more regulatory and they could be in different areas, managed care, post-acute care, whatever the case may be. I always had a list. Somebody was like, “We need offsets in order to do this thing we care about.” It’s like, “Well, you’ve come to the right place. Let me give you a list.” I saw Zach doing a version of that type of thinking, where he would develop this with his fellow economists and then package it in a way that is more consumable for the policy types. Quite frankly, kill staff is the way I would think about it. I’ve certainly tried to help him connect more directly with them. An important thing, even beyond the specific ideas, is the general attention it draws to the need and the opportunity for savings in the health environment.
Gary Bisbee 36:28
You’ve got a great longitudinal view of healthcare. The question would be, what do you think the major change of the last decade was in healthcare in a positive sense?
Mark Miller 36:42
In the last 10, the positive? Because I generally focus on all the problems. This is a very difficult question for me. I think my adversaries in the drug world will be surprised by this. I do think there has been true innovation in the drug environment. I do think there have been steps there that specific scientists, specific manufacturers should be proud of. There’s a lot of basic work that comes out of the NIH, but manufacturers do turn that into real products. There has been progress there. The organization of delivery systems and payment systems coming together in order to try and have a better focus on efficiency—cost on the one hand quality on the other, which efficiency is supposed to be—those two things and a real effort to try and bring those together and focus on it. I don’t know that it has been entirely successful, but the notion that that has become something that’s more of the coin of the realm is probably a positive thing. At great costs and in great pain, the recognition of the inequities that run through the system—the recognition, not the resolution, to be clear—recognition has been a good development for people to understand that inequities run throughout the system. The recognition of affordability as an issue for families is important. Those all are open-ended problems that are not solved.
Gary Bisbee 38:42
What do you think’s going to happen in this decade? You could think about it as Where are we going to be in 2030? What will the major trends be over the course of this decade?
Mark Miller 38:53
I don’t know that I can answer your question precisely, but I do think the affordability from the perspective of the taxpayer and employer, a family will be the defining issue, whether it’s the sustainability of Medicare, and even recently outrunning the Hei Trust Fund and the fact that part B draws from general revenue and how sustainable that is, the employers, if they ever would wake up and realize that this is something that they have to address that it’s eating their budgets. When you have 40% of American families unable to get together $400 in an emergency, we’ve got to do something because the way the health benefit is moving, because of the costs that I’m referring to. They’re pushing much more on the consumer through deductibles and co-payments that they don’t add, so that reckoning feels like it has to come to a head. The other thing that’s going to be in the next 10 years—and I hope we don’t have our usual amnesia in this country—is preparing for a public health emergency, which we’ve clearly ignored for decades and decades. Those are not like what will happen. Those are probably half wishes more than anything else.
Gary Bisbee 40:35
I think that’s probably the best you can do in that space. I agree affordability will be the issue of the decade. I don’t think there’s any way out of that. Looks to me like there’s a shifting of risk from the employers and the payers to the consumers and providers. Would you agree with that formulation or not?
Mark Miller 40:58
I do agree with that, and I think the way the providers have responded to it is to consolidate and extract in some instances where they can higher prices or to try and design payment systems that help them protect their particular revenue stream I think you’ve seen a lot of that in the alternative payment model process where particular groups of providers will come together and say well let’s build a payment model around what I do in sometimes I think it is well motivated and intended to result in a better product but I also think there are attempts here where it’s to build a moat around a particular set of revenue so yes I do think that things have become less affordable for the employers and there has been this redesigning of health benefits to push much more on to the consumer, but to the extent that they can do it, so I would agree.
Gary Bisbee 41:57
You made reference before, but the financing side coming together with the delivery side. Some call that the “new middle” or the “new financing metal,” and I agree with your point that we’ve seen some movement in that direction, but it’s going to have to be a lot more to really have a major effect. The question is, do you think the private sector can move down that path or is there going to have to be some legislation to push them in that direction or at least to offer an incentive to go in that direction?
Mark Miller 42:34
An alternative payment model, an ACO, managed care organization, or different permutations of a managed care organization. One of the reasons I think their performance more recently has not been that large of an impact is because our utilization has not been the same problem that it’s been. I’m an old guy at this point and I can remember decades where utilization was growing extremely rapidly. I find this very frustrating when I talk to employers or even insurers to some extent. You’ll talk about health care spending and they’ll immediately go to, “Yeah, yeah, we need to manage utilization.” I want to be clear: you do. You need to set these models up because we don’t really understand the waxing and waning of utilization. If it starts to accelerate again in the future, we should be positioned to do something about it or to curb it. However, particularly in the commercial sector, it’s prices that are driving the spending. There are several arguments that come into play. (1) They don’t understand the environment well. (2) They feel like they don’t have enough power as a single purchaser to do anything about it. There are probably some compromising positions in the sense that you’re in a community and you’re parts of boards and there is an employer on the board with the hospital and that type of thing. Ultimately, if nothing is done, that’s going to drive in government intervention. If people don’t take action and the employers, many would legitimately argue, they don’t have the market power to take an action. It’s going to drive government intervention, and that can go in the direction of curbing anti-competitive contracting behaviors, like in the Sutter case, but it also could go to say, “Look, when you start extracting payment rates at this level, you’ve begun to abuse the system because you have too much market power.” Will it take some government intervention? I think they need help because their problem, in some ways, isn’t solvable by that because they don’t have the reach to push back on a highly consolidated provider sector. I want to be clear, because the providers will get very angry about that. I stand by what I’ve said. You can also find markets where insurers are consolidated, but it is not the same problem, in my opinion, as the provider.
Gary Bisbee 45:23
The incentive positioning is certainly a key issue. This has been a great, great interview. I wish we had more time. Hopefully you’ll join me again. I’d like to ask one final question and that is, you’re a long way from wrapping up your career, but when you do, what would you like your legacy to be?
Mark Miller 45:45
In a funny way, it goes back to the head of the conversation. I hope there’s some knowledge base that I’ve left out there. I hope there’s some policy impact, but what I really hope is that there’s a set of people that I worked with over the set of years who feel like they had some kind of positive experience, some kind of learning experience with me, and then they continue to carry that forward.
Gary Bisbee 46:14
I love the answer. Thank you, Mark. This has been terrific. It’s been a real joy for me to conduct this interview, so thanks for being with us.
Mark Miller 46:24
I appreciate it. You take care of yourself.
Gary Bisbee 46:27
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