MEDICAL ECONOMICS & BUSINESS OF MEDICINE
Reflections of the Inaugural Chief Medical Officer
of the Mashantucket Pequot Tribal Nation
by Setu Vora, MD
Editor’s Preface:
Dr. Setu Vora is a multitalented physician, a superb
pulmonologist and intensivist, an expert in coagulation and
thrombosis prevention, and an equally superb physician
leader and educator. Dr. Vora accepted the job as Chief
Medical Officer at the Mashantucket Pequot Tribal Nation to
embrace new challenges and to expand his horizons. I asked
Dr. Vora to reflect on his experience as Chief Medical Officer
and share his insights with the William W. Backus Hospital
staff. He kindly consented.
- Dennis Slater MD
I just completed my first year as the
inaugural Chief Medical Officer of the
Mashantucket Pequot Tribal Nation
(MPTN). My role is to be the steward of
healthcare. I report to the Tribal Council
led by Chairman Rodney Butler, in active
collaboration with the Health Care
Advisory Board and the Health and Human
Services Committee, Human Resources,
Risk Management, Occupational Medicine,
and Worker Compensation over at Foxwoods Resort Casino. I work
closely with and oversee Pequot Health Care (PHC) - a leader in
self-funded health plans. We manage the health plans for about
15,000 individuals, including many commercial businesses that offer
self-funded health benefit to their employees through us at PHC.
We offer various carrier networks and although we have our own
dental network. As CMO, I also oversee the Tribal Health Services,
Behavioral Health Services, Child Development Center, Nursing, and
Community health grant projects. Together, we are building a culture
of resilience and innovation. And through this we aim to improve
clinical care, community health, and company growth.
Q
WOULD YOU HAND OVER A
NO-LIMIT CREDIT CARD TO ALL
YOUR EMPLOYEES TO KEEP AND
USE AS NEEDED EVERY YEAR?
If you are providing a fully-funded health benefit to your family and
employees through a carrier, such as Blue Cross, United, Cigna,
Aetna, or Humana (BUCAH), that is exactly what you are doing.
Unlimited credit card!
24 THE OPEN JOURNAL
Physician practices and businesses are under stress in Connecticut.
Physician-Employer sponsored health benefits for the staff are
driving up the cost of running a private practice. The small group
market for fully-insured health plan is very expensive. Every year,
the premiums go up and to keep it from rising too much, brokers
push a high-deductible health plan that many physician practices
grudgingly embrace. Between 2000 and 2013, the direct health cost
to employees increased over 60%, while take-home pay increased
only by 3%. In 2017, the average annual premiums for employer-
sponsored health insurance were $6,690 for single coverage and
$18,764 for family coverage. This is outrageous, and even large
employers such as Amazon, Berkshire, and Chase have had enough!
This unsustainable health insurance cost is a challenge that is
common to physician practices and other small and large employers
including Mashantucket Pequot Tribal Nation. We have to stop
writing a check every month to the BUCAH (Blue Cross, United,
Cigna, Aetna, and Humana) for a “fully-insured” health plan. They
are not the payers, we all are.
HEALTHCARE WASTE IS THE ENEMY
As physicians, providers, and as businesses, we expect to be paid
fairly for our services, but we all know that our enemy is waste in
healthcare cost. 1 out of every 3 dollars spent on healthcare [$750B]
is on waste - unnecessary services, excessive administrative costs,
inefficient care delivery, inflated prices, fraud, and prevention
failures. You may have heard of the recent case of a teacher with
myocardial infarction that had a stent placed at a Texas hospital.
For months, this hospital hounded this teacher to pay up $108,951-
nearly double his annual pay, as a balance bill for ‘out-of-network’
service. It took publication of this story by Kaiser Health News and
NPR for the hospital to accept $782 instead. How about the fact
that a dose of Rituxan costs the manufacturer $300, but hospitals
pay $3,500, and then charge $13,702 to the patient? How much
price variation is reasonable for the same surgery in the same
city? We hear of a total joint replacement varying from $26,000 to
$87,000 in cities such as St. Louis, Missouri.
IMAGINE THE POSSIBILITIES
Imagine this: what if you and your business could finally have a
clear view of both the medical and pharmaceutical claims that you
are paying when you ditch the ‘fully insured’ opaque BUCAH health
plan? Wouldn’t it be great to have a better handle on your total
healthcare cost? It is possible when you participate in self-funded,
partially or fully self-insured health plans. Imagine how you can
reduce the risk by having appropriate ‘stop-loss’ insurance to
protect your business against catastrophic medical/pharmaceutical
Continued on page 25

claims. Wouldn’t it be meaningful to design health benefits for your
company that actually led to better health, while not ruining its
financial wellbeing? We know that struggling school districts and
town municipalities would appreciate that saving and maybe hire
more teachers at better wages, invest in technology, and retain top
administrative talent to deliver better services. What would you do
with all the cost savings?
Q HOW CAN PEQUOT HEALTH CARE
HELP YOU CUT HEALTH WASTE?
WASTE 1: UNNECESSARY SERVICES
RX: HEALTH WASTE CALCULATOR
At Pequot Healthcare, we are testing the MedInsight Health Waste
Calculator from Milliman, a management consulting company.
We have learned from the analysis of Virginia All Payers Claims
Database that low cost, high volume health services contribute the
most to unnecessary healthcare spending, for example MRIs for
acute back pain, annual nuclear stress tests, preoperative excessive
testing, annual mammography and PSA testing, etc. A self-funded
health plan knows where such major waste and unnecessary
services are being delivered and reduce it.
WASTE 2: EXCESSIVE ADMINISTRATIVE COSTS
RX: DIRECT CARE CONTRACTING
Health insurance carriers, hospital systems, pharmaceutical
companies, Pharmacy Benefits Managers, healthcare IT companies,
physician multispecialty groups- all have increasing administrative
complexities and number of executives. Administrators are not paid
to reduce spending. Most of their pay comes in the form of vested
stock, so they do whatever it takes to make that stock go up. Drug
price gouging, selling more medications, marketing and doing more
profitable procedures (think joint replacements, cardiac procedures),
getting more people into the hospital owned primary care and
specialty practices all serve to drive up ancillary, downstream
‘revenue’. Health policy experts believe that the opposite would
benefit the broader system: lower prices, eliminating unnecessary
care and drugs, and coordinating better care.
At Pequot we believe direct contracting will become more
commonplace and accessible, even when you are self-funded.
Direct primary care and direct specialty care models are attractive
to large employers that self-fund employee health plans. Direct
contracts with select centers of excellence, and even high value
hospitals, will be offered to reduce the excessive administrative
costs associated with the status-quo arrangement between the
large hospital systems and BUCAHs. The providers can jack up the
charge master, but as long as they offer sizable ‘discounts’ to the
carriers, the BUCAH carriers can proudly sell it to the employers
that they offer 50% savings off the charged amount! But hospital
list prices on charge masters have no link to true underlying cost
or what patients actually pay. Princeton healthcare economist Uwe
Reinhardt called hospital charge masters, “chaos behind a veil of
MEDICAL ECONOMICS & BUSINESS OF MEDICINE
secrecy.” What if the providers were paid fairly quickly with minimal
disruption, and no prior authorization requirement, directly from the
self-funded health plan that actually rewards the provider with more
volume of patients? Imagine the hours of time and money saved!
WASTE 3: INEFFICIENT CARE DELIVERY
RX: DIGITAL HEALTH SOLUTIONS
Are hospital-based ambulatory medical centers or physician office
based infusion suites the best places for infusions of certain
expensive injectable biologics? At Pequot Health Care we look at
not only the indication, dosage, units, and step-therapy, but we
also pay attention to the site of care. Many injectable medications
can be given safely, conveniently, efficiently, and with much less
expense if given at home.
Do all these mushrooming urgent care centers, walk-in clinics,
convenient care centers co-located with emergency departments
provide the most efficient care? Industry estimates suggest that
30% of all ambulatory care visits and as many as 80% of all
behavioral health office visits are treatable by telehealth. At Pequot
we believe that we need a combination of High Touch and High
Tech™ resources for our members. We offer Teladoc free of charge
to all employees, including their entire household. The antibiotics
prescription rate is lower than face-to-face office visits. Adoption
is slow, but we expect it to rise as members experience the
convenience and care.
At MPTN we have on-site chronic disease management coaches,
wellness programs, nurses, occupational health, and physical
therapy for the team members, along with primary care, behavioral
health, community nursing, pediatric nursing for the tribal members.
Along with these High Touch resources, at MPTN we are actively
exploring, testing, and deploying High Tech digital health solutions
to address member engagement/health literacy, reversal of type 2
diabetes, smoking, and behavioral health. By researching, adopting,
and proving the value of these emerging digital health tools in our
own population, we are positioned to guide our other self-funded
commercial clients for success.
WASTE 4: INFLATED PRICES
RX: REFERENCE BASED PRICING, RX
STEWARDSHIP, & TRANSPARENCY TOOLS
Every facility that participates in Medicare and Medicaid is required
to file their actual cost with the Centers for Medicare and Medicaid
Services (CMS). According to the author Dave Chase, CEO of Patient
Relationship Management company, Avado, the 2 largest hospital
systems in Charlette, NC file their cost for a CT scan as being
between $75 and $90. Their average billed charge to a health plan
was between $1,800 and $2,700. Is a 2,900% markup reasonable?
Continued on page 26
FALL 2018 25
 MEDICAL ECONOMICS & BUSINESS OF MEDICINE
Every quarter, CMS publishes the Average Sales Price (ASP) for
drugs and the allowed payment for said drugs based on information
submitted by the manufacturer. ASP uses manufacturer sales
information that includes all manner of discounts (i.e. rebates,
volume discounts, prompt payment, cash payment, etc.). At Pequot
Pharmaceutical Network of PHC, we are a prime vendor and can buy
medications at the discounted Federal Supply Schedule rates. Our
clinical pharmacy doctors have a proven, sophisticated Specialty
Drug Management program. We have an Academic Detailing
program that saved both the members and the plans hundreds
of thousands of dollars on an annualized basis within the first 6
months of launch. Modifying just 1 prescription of a biologic drug
Stelara (ustekinumab) for psoriatic arthritis helped save tens of
thousands of dollars for a self-funded mid-size company’s plan.
Our team provides a full range of vaccination services and also an
increasing number of Medication Therapy Management programs to
the members. We pattern drug costs to ASP.
We benchmark providers and choose the highest quality providers
that are preferably closest to the Medicare like rate (MLR), or
alternatively to the FAIR Health average value for our commercial
members. FAIR Health is an independent nonprofit that collects
data for and manages the nation’s largest database of privately
billed health insurance claims. HAIR Health is also entrusted with
Medicare Parts A, B and D claims data for 2013 to the present.
At Pequot Health Care, we empower the members to be in charge.
We give free digital, smart phone app-based access to a healthcare
value transparency tool called Real Time Choices, powered by
Healthcare Blue Book. If a member is, say, thinking about getting
a colonoscopy, the app guides them to the Green Providers aka
those who can provide their services with excellent quality at a
reasonable cost. If they choose a high value provider for elective
procedure such as a colonoscopy, we actually reward the members
with $100. Members who make good high value choices for elective
surgeries, CT scan, MRI, stress tests, echocardiogram, sleep studies,
etc. will likewise be rewarded. All of this is part of our plan to
expand our preferred Centers of Excellence programs.
WASTE 5: FRAUD
RX: PREPAYMENT DETECTION
USING ANALYTICS & PROSECUTION
There are bad apples that give all of us a bad name. Deliberate
over diagnosis, over-treatment, too frequent episodes of services,
unbundling, waving co-pays, are among the many examples of
fraud that we detect at Pequot Health Care. To combat this we
are streaming pre-payment claims data through algorithms and
analytics to detect Fraud, Waste, and Abuse [FWA]. Routinely
testing our claims process through both internal audits, as well
as independent external audits, facilitates our commitment to
continuous improvement.
26 THE OPEN JOURNAL
With in-house expertise in TPA, claims processing, data intelligence,
stop-loss, medical and pharmacy best practices, auditing, risk
management, and health care law, Pequot Health Care is well
positioned to reduce FWA for its own health plans and outside self-
funded health plans.
WASTE 6: PREVENTION FAILURES
RX: HEALTH COACHING & MEMBER
EMPOWERMENT
Is it better to detect a stage 1 colorectal cancer or find out at stage
4? How may we get to know the patients with chronic severe
asthma and then ensure that they are taking the correct medications
to prevent acute exacerbations? Would you want to run a preventive
vaccination campaign where you work? Pequot Health Care can
help.
We know the target population, and we can identify the gaps
in care. By connecting with the members where they want to
engage - either in person, mail, email, IVR, home landline, personal
cell phone, or SMS text-messages - we aim to build a trust based
relationship to help and empower members to take healthy actions.
There is so much more to learn and work on together.
I am thankful for the opportunity to work with all of my colleagues
at MPTN and in Indian Country. I do miss the daily interactions with
the patients, families, staff, and colleagues at my old pulmonary
office and at the William W. Backus Hospital where I served full
time as a private practitioner and a physician leader from 2005-
2017. Nonetheless, I am maintaining all 4 of my board certifications
(Internal Medicine, Pulmonary Diseases, Critical Care Medicine, and
Sleep Medicine), and have dedicated 1 day a week for continued
clinical practice.
I can be reached at svora@mptn-nsn.gov for any comments. n
Editor’s Note:
The breadth and depth of economic inefficiencies in
medicine are mind boggling. But Dr. Vora has clearly
exposed the multilayered problem of fraud, waste and
abuse. Do we providers have the courage to recognize our
own contribution to wastefulness? Self-funded medical
insurance sounds like a good option for physicians to focus
on health, conserve resources, and save money, but likely
not a panacea. As a physician employer in private practice
I would be interested in methods to mitigate catastrophic
risk. Nevertheless, self-funded medical insurance might be
the right start. Hopefully Dr. Vora will come “back to Backus”
soon and save us from ourselves.
- Dennis Slater MD