The Circle of Money: What Physicians Need to Know About Health Plan Contracting with Dr. Jacob Asher

Jacob Asher: Welcome to Soundpractice, the business podcast for physicians and healthcare leaders, hosted by Mike Tsakopoulos and produced by the American association for Physician Leadership.

Mike Tsakopoulos: The Irish author Jonathan Swift famously said, a wise person should have money in their head, but not in their heart. This is the approach we hope to see in physicians working with commercial payers, balancing humanity and business realities, next on Soundpractice. My guest today is Jacob Ascher. Dr. Asher practiced as an ENT surgeon before transitioning full time into health Plan Management. From 2008 to 2022 he served as a California commercial market medical director for Anthem Blue cross, Cigna and UnitedHealthcare. Currently Dr. Asher is serving as a mentor for the Stanford University Master in Medical Informatics program. Jacob asher, welcome to SoundPractice.

Jacob Asher: It's a pleasure to be here.

Mike Tsakopoulos: Thank you sir. As you know, this is the podcast of the American association for Physician Leadership. Could you please describe your journey to becoming a physician leader?

Jacob Asher: Uh, sure. It's a bit of an odd story, but when I was uh, a staff head and neck surgeon with uh, Kaiser Permanente out here, I uh, ended up being elected to what's called the medical group's board of directors for Northern California, which is the governing body, uh, for the, I think it was 3,000, maybe now 4,000 physicians of the Northern California Permanente Group. And there was where the light bulb went on and I was exposed to the world of the business, of the provider side of healthcare predominantly, um, given the way Kaiser restructured insurance sales and some of those things that we'll talk about and that I learned in my second career, uh, were not primary but uh, it was really a wonderful 3 year experience working on learning benefits, physician compensation and something about the external forces. And then fast forward a few years. I no, uh, longer was enjoying my clinical life, uh, and actually my connection. I started taking some courses with the predecessor of aapl, the acpe, which was spectacular and wonderful, opened my eyes, was a great preparation, um, and enabled my uh, transition, um, wasn't the smoothest of transitions, uh, in retrospect, but I got through it, uh, and I really uh, ended up on the health plan, on the commercial health plan side, not as part of a grand strategic plan, but where uh, I added value and I ended up enjoying that second career very much. The simplest way to describe the position would be as the external facing business enabled medical director for the markets. I served in the commercial insurance business so I wasn't a full time medical director reviewing cases and saying yes and no. Uh, I was more partnering with the business leaders of the units, uh, I was in to promote sales, maximize retention, improve the quality of care and all the other external engagement projects that a health plan tries uh, to do to be good citizens and promote a clinical value proposition both to employers who pay them as well as to the communities they serve.

Mike Tsakopoulos: So you've been involved with the establishment of contracts between payers and providers. Talk a little bit about that. What is the contract between uh, a payer and provider?

Jacob Asher: Yeah, this was really a huge education and revelation in my second career where particularly in the non kaiser world which consists uh, of multiple providers of healthcare, uh, delivering services to populations that the insurance company has agreed to provide benefits for, money must be moved. Uh, the money starts actually on the employer side, uh, either in the form of a premium or a self funded option. But the insurance company stands as the fiduciary and financial intermediary and they need to be able to have uh, some control of the cost of services that will be provided over the insurance year to that covered population. And the way they do that is predominantly through what's called contracts with basically all kinds of medical providers who are then considered in network and the cost of each service down to the code, the individual CPT code is essentially fixed. Um, and therefore that enables the actuaries within the health plan, which is their business, to try and make accurate estimates of how much care will be consumed over the course of the year and at what cost and therefore meet the financial goals of the organization.

Mike Tsakopoulos: We're going to get into these contracts in more detail, but kind of a 30,000 foot view, uh, question. Uh, for me one of the basic assumptions of contract law is the freedom to contract. Do you believe that physicians have freedom of contract vis a vis third party health providers?

Jacob Asher: It really can be a complicated decision and is also market specific. So in markets where uh, there is great consolidation of providers on the physician, outpatient, surgery, lab, radiology or hospital provider side, those big buckets that people are

Mike Tsakopoulos: familiar with,

Jacob Asher: the individual practitioners tend to be a minority and they tend not to have as much negotiating strength against an insurance company in those particular markets. In other markets, uh, if they have particular market value or in smaller communities or if they provide, if they're the only game in town and the insurance company needs to have doctors in that town to treat employees of a client employer group, they may have more power. So there are a number of. Those are the kinds of factors that go into it. Um, uh, you know, local competition, uh, exclusivity, market power on both sides can sort of determine the weighting of that.

Mike Tsakopoulos: Do you believe that these contracts have uh, influenced or impacted uh physicians practice of medicine? And by that not so much what goes on in the exam room, but how they uh, aggregate together solo practitioners versus larger systems. It strikes me that it's very difficult for a 1, 2, 3 provider practice uh to be able to work their way through this type of um, uh

Jacob Asher: contracts that can be a factor. They can also have lower overheads and have a value proposition to an insurance company by saying we're a three person shop, we don't have a lot of buildings or bells and whistles. We have much lower overhead and we have data to show you that we take superb care of our chronically ill members. We have great data for our diabetics and our hypertensives and therefore we believe this is our fair market price and negotiate through it. But what people tend to forget is everyone has a margin. The providers, you know, everyone, all doctors, all hospitals, everyone sort of needs to take in more than they pay out in expenses. That's the American system in many ways. Um, and among your, your, your, your point is well taken. I think size matters predominantly frankly um, in particularly in the California market where I'm most expert. Um, but some of these alternative options uh, exist and in theory that's a grounds for innovation. And um, you see a fair amount of innovation and different kinds of practice models. The one medicals now with AI, who knows. But with all these it also provides ground for innovation interacting with that contracting model that um, capitalism seems to find value in.

Mike Tsakopoulos: What are the three major types of health care providers that payers contract with?

Jacob Asher: That's just at a. Yeah, at a very high level. I wanted to share that with the audience in the sense that there's the bucket of medical providers which is probably the number one thing people think about. Um, which is everything on the medical side. Hospitals, doctors, outpatient labs, nursing homes, rehab facilities. I'm leaving out. But all the clinical services to treat medical problems, behavioral services or mental health providers is a, essentially sold as a separate partnered benefit in the business. So it's in its own little silo. But all so mental health providers, drug detoxification, um, rehab facilities and even inpatient psychiatric facilities, let alone all the individual therapists, so forth and so on are a separate bucket. And then the third main bucket is drugs is the pharmacy. And the, and the pharmacy benefit manager world where the insurance company is seeking to uh, provide adequate drug benefits to the employer as part of the total health care package.

Mike Tsakopoulos: I find that really interesting that the Behavioral mental health component has been traditionally separate from other health care. And I don't think that it's just in the California market. I think that that's across the board. Do you have any idea why that was? And um, I mean I would assume that some would say that there is a tacit uh, prejudice against behavioral health or a stigmatization of it by separating it from other types of health. Do you feel that that's the case? Where did this come from historically?

Jacob Asher: I'm not sure I have an answer for you. I'm not sure the history of the development of the silos, uh, but now, uh, certainly in California, I don't know if it's federal, but there's mental health parity laws, um, which you could probably explain better than me. But essentially mandating now that whatever past imbalances, uh, there were, particularly in the benefits and the coverage offered to people for that realm of legitimate mental health disorders, it has to have a now a parity with the medical side. So in theory, uh, the past has been remedied. There are lots of issues with provider adequacy and network. Adequacy is a term we use where it's very hard to like. Child psychiatrists, for example, are very hard to find for various market reasons. You have to keep in network.

Mike Tsakopoulos: Understood. Dr. Asher, can you talk about the dynamics of the negotiation process between payers and providers that result in uh, contracted prices? Maybe give us a look at how the sausage is made.

Jacob Asher: Yeah. So this is one of the things that sometimes when I hear politicians, uh, and other folks who don't quite understand the insurance business, they tend to say things like as if the insurance companies have total price control over the price of services that are then that we all pay as patients, the hated bills and co pays and all that other stuff. And I'm not making excuses for the insurance companies. There's plenty of issues, uh, uh, and uh, consumer and this and that. But this idea that the insurance company is in this middle position between employers funding of health care. Again I'm talking commercial health insurance and the deliverers of healthcare and particularly in California. But in many markets the providers are quite powerful and consolidated so they have great market power and they know that if they are not contracted and therefore in network with a particular insurance company, uh, most local employers aren't going to buy the plan. So you pick your marquee medical system. It could be a Harvard Hospital or Mayo Clinic or Stanford. And this has nothing to do with the quality of their care. This is simply a business Observation I'm uh, making that major employers would when the insurance company is pitching them, huh, we want you to be your insurance company. And they'll say well what if I want to go to Mayo Clinic or Stanford? Is that in network? And if you say no, I mean if the insurance company happens to say well you know, we think they're very expensive, we think we can find equal quality without them. But you wouldn't be able to go to Stanford. That doesn't tend to be well received by the employer marketplace, if you will. And so the power of these systems can be consolidated medical groups depending on your market. It's not just, I'm not just picking on hospitals here, um, where the consolidation has left them as either a marquee name in a market or literally they have 80% of the primary care physicians in a particular market and therefore the insurance company has no choice. They have a great deal of pricing power is my only observation. I want to share with people. And so the insurance company yes is trying to get the best price but it's not like the dynamic is more complicated than the public often understands.

Mike Tsakopoulos: Maybe talk a little bit about the employers or the companies that are purchasing because um, it seems to me oftentimes uh, they're left out of the discussion. But they must be very important.

Jacob Asher: Sure. No, this is all again this is the primary focus. Uh, they are the client in the commercial insurance industry. So my job was to support the account teams, the sales teams and it was a bit of a revelation. You know, I would go to meet the employers for both new business pitches and, or retention of existing pitches. And so we would make presentations and I would be responsible for the clinical side and to be sure they are absolutely want to make sure their employees are getting the promised benefits with the least amount of friction and abrasion possible and that the promises of it might be added on services or case management services on the clinical side are being met. But by and large it's the cost of care that uh, is a primary. So don't forget for most employers after salaries, their health benefits I think are their second biggest overhead expense. And that's our system. It's not rational, it's not how you would design it from scratch. But the employer funded system has a tax deductible advantage for benefits that are provided for healthcare and employers therefore in theory should be all over it more than they are frankly. But it's been for so many years that it's been this no alternative challenge I think and they know that uh, and so it's all about how much is it going to be next year versus how much is it this year. Because they need to make their financial plan and they need to understand what their employee costs are going to be. Uh, and those tend to be the predominant uh, drivers of the relationship. So if the insurance company says we think you know your trend, we call it your, it never health care never goes down. So it's how much is it going to go up? So you know, the insurance company might say we think you know, 4.2%, you know and set the prices and so forth and that and the expectation of the premium or the self funded option. And then six months in there's been premature babies, there's been unexpected COVID epidemic, there's been GLP1 drugs come on the market. This is the risk part of the insurance business where despite your best effort to actuarially estimate what's going to happen in that population, stuff happens. And suddenly the employer is uh, on the premium side. If it's an insured product, they're protected, they're done until renewal.

Mike Tsakopoulos: Mhm.

Jacob Asher: So in other words if you write a premium to the insurance company, that risk, financial risk becomes shifted to the insurance company. And it was my problem in a sense for our bottom line to manage that as best we could. But for renewal they would say well next year we need to charge you more because we had a bet you had to recapture. Um, uh, and so that, that tends to be it. Ah, the other big issue is, tends to be the disastrous rare cases where things unfortunately go badly or there are tragedies or you know, terrible cancers or and ah, if in particularly if it's with you know, C suite relatives, things like that, those can be factors that are I think can be also drive wedges between insurance companies and um, insurance and employers. But 90% of it is really about is the money I think.

Mike Tsakopoulos: Let's talk a little bit about reimbursement models. I think most providers feel like they provide a service, mark the super bill and they're paid that way. But there are a number of different models out there, are there not? Um, for employers maybe that are paying for their uh, their employees healthcare.

Jacob Asher: Uh, it's actually the employer doesn't see that that's all handled by the insurance company basically. Okay, so the, I mean the insurance company can pick different kinds of products where the reimbursement might have a different network of medical groups that their employees can go see. But the choice of moving the money around between the premium dollar and the providers Is the insurance company's call essentially with other market forces. And this does get jargon heavy. But the classic foundation of our system is what's called fee for service, where each service has a code and a fee. And sadly, the more services are provided, the more fees are charged, the more income comes into the provider. And whether you're a nonprofit provider or a for profit provider, like I said, uh, everyone's got margin. And also hospitals are incredibly complicated multi billion dollar businesses now and have all kinds of other factors driving their financial margin, their issues. So that's the system that we're sort of living in. And the incentives from both a clinical um, and a cost control perspective are backwards. Most health economists been saying this for years. It's just paradoxical. And we don't incentivize prevention and outcomes and quality of care as well as total cost of care in a particularly meaningful way. Some of the alternatives that have been developed for that, the biggest difference is something called capitation, which is what Kaiser permanently pioneered and some other places across the country where a, uh, provider says, I'll take a fixed amount of money, usually a medical group, but it can be a hospital system and medical group, and I'll take care of paying everyone underneath that. They become sort of the sub insurance company, if you will. But the capitation incentive means that they now are incentivized to subject to very scrupulous regulation. Because now in theory you have the reverse incentives. In other words, if you deliver less care under capitation, in theory you would have higher profits, which is if you're denying needed care is immoral. So subject to very scrupulous regulation and oversight. It tends to align with a different approach where avoiding costs in a medically appropriate way is your main driver of margin. Uh, in hospitals there's two main buckets of, uh, reimbursement. One is called per diem, which is literally Latin for every day. So every day you're in the hospital, the meter runs. And then Medicare pioneered and some commercial hospitals take it as well, something called diagnosis related groups or DRGs, which most doctors are very familiar with, which tries to put a sort of a capitated or a fixed amount around specific diagnoses again to incentivize a package price for a service, to encourage efficiencies associated, uh, with good outcomes without imposing undue risk on the hospital. So, you know, you don't want to, I mean, you know, your hospital's not going to say, I'll take X amount of money for somebody with pneumonia, but what if they get A stroke while they're in the hospital and stay two months. Obviously they're entitled to be reimbursed for catastrophe, like that kind of thing. So they're. There are the contracts have those exceptions to make sure that people are made whole. So the issues have to be. Those are the big, the big differences where you're trying to either align incentives a little better, um, and uh, and, and still maintain margin for both sides in the equation.

Mike Tsakopoulos: Very, uh, very, very interesting. Do you see one reimbursement model, um, being more popular than another in recent years?

Jacob Asher: I think it's pretty, I mean there's been endless. We've been talking about this in my whole career, basically about um, fee for service versus capitation and perverse incentives in health care and poor control of healthcare inflation. Um, and we don't even get to the drug companies, which is a whole nother world of pricing. But, um, the pendulum, it's very hard because like I said, everyone has a bottom line. Everyone is subject to overhead and financial pressures on the provider side, um, nonprofit versus for profit status on the hospital side, in my experience, didn't drive radically different behaviors on their cost of care and pricing stuff. It's really complicated businesses and really complicated financial management for them. So the short answer is no. I think, um, Kaiser Permanente on the west coast remains, uh, the pioneer and an exception. But it really is, you know, national observers often say, isn't it interesting that it really hasn't spread? You know, they have made expansions. They actually are doing some major expansions now I think in Pennsylvania and somewhere else. But by and large it's been this west coast dominant thing where it's incredibly well run and successful and uh, and seems to be able to meet all the business and clinical needs very well. Um, but getting doctors who want to practice that way can be a political issue. And then to manage the risk, like I said, a capitated provider is taking on some of the risk and that risk is real. So back in the Hillary Clinton, um, Medicare medicine stuff, there was this wave of medical groups that thought it was easy to be a capitated medical group. And they said, sure, we'll take on risks. And boom, you know, premature triplets happened and you have a $15 million bill. So the risk is real on capitation and you need to. So that the. It's um, you tend to need to get mass and a big population quickly to handle the financial, uh, issues, if you're following me. So, uh, capitation tends to be that. So the short answer, I think I'M not aware that there's a radical shift. I think fee for service is probably still by the vast majority of the country it has regional variation. Like we said California is different but Southeast is probably all fee for service. There are different parts of the country have different biases.

Mike Tsakopoulos: Many citizens patients are distrustful of their third party payer. Uh, the welling up of support for the shooter of the United Healthcare executive in New York ah city last year was certainly disturbing to many of us. Can you discuss the widespread dislike of third party uh, payers both by patient and also providers?

Jacob Asher: Yeah, this is the problem the industry hasn't really solved. Uh and um, I've been trying to explain what the financial drivers are in the insurance world and uh, sadly there's great variation in how well they administer what's called managed care. So the defense of managed care which is the term used to say no essentially that is there evidence based medicine to support uh, everything that a particular provider wants to offer you. And in reality often there isn't. But the system that has been set up doesn't work very well, is not consumer friendly or physician friendly or hospital friendly, has a great deal of abrasion into it which leads to the stories you talk about. It doesn't justify in any way what happened to this poor zick.

Mike Tsakopoulos: No, absolutely not.

Jacob Asher: You know, that's crime. Um, but the different uh, insurance companies have varying cultures and just the complexity of it all also leads to these isolate, you know, leads to these terrible examples of the complexity of paying claims and analyzing claims. Let alone, you know, that was the clinical teams. Uh, insurance companies invest a ton of money in clinical teams. I managed one of them and I thought they were really diligent and they were really trying to do the right thing and they would say to the doctor, I really want to approve this for you but you need to give me these four pieces of clinical data that say that it's medically appropriate, done ethically and efficiently and quickly. That system could work quite well. But it's very hard to manage phone calls to busy doctors and back and forth. Um, uh, and then you get life threatening and emotionally laden cancer things. So um, I don't have a good explanation for adds a tiny bit of value in my experience. But the accounting for all that. Interestingly can you prove that how much denials of this or that are adding to the bottom line are actually providing as little complicated. But the problem for the insurance companies is and it doesn't need sympathy but the total cost of care is unit cost of a Service times the utilization of that service. And as I tried to explain, their whole business is monitoring the total cost of care during the year to see how it's going. The prices are fixed by the contract. So until the contracts come up for renewal, there's nothing to do about that. So the focus tends shifts unfortunately, or for whatever, it shifts to clinical utilization. And so that is the tool and it requires very scrupulous ethical management to make sure it doesn't slip over and do the wrong thing. And most of the time I was very, I was very supportive of my team and they were trying to do the right things. But mistakes happen or poor communications happen and terrible, there are terrible stories that are not a credit to the industry. They ideally should be trying to do much more about that in some way.

Mike Tsakopoulos: But it also seems a bit unfair that the third party payer takes all of the heat when much of the reimbursement is being forced by employers for lower rates. Right. I mean, I don't hear much outcry with, with individuals about how their employers are not paying enough for their health care. It seems like the intermediary takes all the heat. Um, would you agree with that?

Jacob Asher: Yeah, I think it's a fair statement. I think this employee, you know, I have adult children who are working and they asked me to help them choose their benefits at work and it's impenetrable. I can barely get through it. But in terms of uh, what's called cost shifting and the trends, I think we're seeing the politics of this become more acute more recently is I think the employers have really been trying, have uh, not had a good strategy, but instead have been trying to shift more of the cost onto their employees. You have these frightening stories of still paying 30 grand a year for a family's insurance company and having a $20,000 deductible. And it like, how is that insurance? You know, in other words, you have to spend 50 grand before you get any care on a middle class salary in America strikes me as a pretty serious failure of any kind of value proposition. So I think uh, the employers, um, probably don't get enough attention from their employees just because it's so opaque. Most people just see that deduction on their paycheck and they choose once a year their benefit package. Um, and they don't quite make the connection, like would I have gotten a bigger raise if my health care premiums were less. Those kinds of broad, interesting questions. So you raise. I think it's a very fair point. There are some, particularly the bigger Employees in America who are self funded, in other words, they take the risk themselves and just pay their cost of care right out of their checkbook. They tend to be very engaged and motivated and they use their market power and they have been the source of some interesting innovation experiments. Some do what's called director provider contracting, bypassing the insurance company and so forth. But broadly speaking, for the megatrends that you're sort of referring to with increasing dissatisfaction, I'm not sure that you hear a lot from the employer associations, Chamber of Commerce, whoever represents them, that they probably mean well, but they don't think they have a good toolbox that anyone's offered them.

Mike Tsakopoulos: Well said, Dr. Asher, let's shift gears. Um, I was interested to see that you are a mentor for Stanford Master in Medical Informatics program. Tell me about the program and what you do with uh, that program. Uh, sure, yeah.

Jacob Asher: I got uh, after I retired and was looking to keep my hand in the field and share some of the stuff I learned. I was connected with these folks and it basically is a uh, dedicated program to mastering the world of clinical data because basically health insurance companies are gigantic data management firms. You just can't imagine thousands of contracts, thousands of codes, millions of members, millions of checks going in and out. Their IT stuff platforms are sort of their core issue and they're immensely uh, complicated. Um, so these folks are looking to add to their, they can be business or clinicians in the program. So some of them are going into the biomedical field, some of them are doctors adding their business experience. Um, so some of the projects they work on, um, you know they have different, they uh, do. It's a one year program and they have a practicum and do a project. So I'm available if somebody's interested in a project on health plan data and I offer this kind of talk basically, you know, I mean I offer my expertise and suggestions on what, you know, where, that, what kinds of data they might look for, what are the current data, what were the current data sets that I tried to deal with even though I'm not a data analyst. But you know, I had support uh, in the industry and that kind of thing and there. And I enjoy working with folks at the early in their career and sharing uh, my expertise.

Mike Tsakopoulos: Well, sounds fascinating. And it leads me to inevitably AI. With AI certainly comes hopes of tremendous advancements in medicine. However, some fear the loss of art and humanity to the practice of, of medicine. What are your thoughts on AI's future impact upon the practice of medicine?

Jacob Asher: Yeah, you know, I'm not practiced. I haven't practiced in a long time. So I'm sort of like most people reading smarter people smarter than me. Uh, Robbie Pearl is a one doctor I read on LinkedIn who writes a lot about who used to be the CEO of Kaiser. Very, very smart guy about the clinician side and certainly the business implications are manifest on the health, uh, insurance side. Um, I'm not pessimistic about it yet. Um, I think that um, one of my pet peeves is not peeves but um, primary care physicians get all this responsibility and demands in the system, in our system currently, and they're underpaid and have tremendous professional unsatisfaction, dissatisfaction. And the model hasn't changed. I have some optimism that AI tools could help um, relieve some of the stress from them. I think it has the chance to increase efficiency on all kinds of administrative stuff from note taking to just lean processing and stuff which has the potential to reduce the cost of care. Uh, and on the clinical side, as long as it's monitored for quality and error rates and so forth, it's perfectly reasonable that um, it could fulfill the potential of the electronic medical record where you type in stuff and you're entering this data and you put down your impression and suddenly AI says no. Actually here's four articles and three this. And uh, those kinds of scenarios I think imagine could happen in the not too distant future. And as long as the doctors remain in charge, not the AI, it can be. I think I'm not, I'm not panicking yet about that. I think that um, for certain kinds of problems, I think some people might be very happy to. If I can get in and talk to a good AI that's supervised by a human and get my, you know, my sore throat, my earache, my sprained ankle dealt with quickly and efficiently at a reasonable price. I don't see a human being, I can see that evolving as a possible new kind of provider if you will. But those are just, I'm not pretending to be expert at all on that.

Mike Tsakopoulos: No. But let's hope that as you point out, many of these third party healthcare insurance firms are really data analysts and it would seem like AI would be a tremendous tool to. Maybe I'm being Pollyanna, sure. Or overly optimistic, but to help uh, reduce uh, reduce costs while keeping the quality of medicine.

Jacob Asher: Yep. I think on the sgna, you know, the administrative overhead side and certainly the, the what we were talking about before, the reviewing the prior authorizations and all this, the M. Managed care stuff now that causes so much friction. I agree with you. AI has the potential to uh, reduce the administrative cost of that and it can only help improve both the user either side's experience of the review process. In my view.

Mike Tsakopoulos: Correct is our time together draws to a close. I'm interested in what's next for you. As a physician leader. You've done such interesting things. Do you have anything on the horizon?

Jacob Asher: You know, I'm open to it. I'm thrilled that I was able to connect with aapl and I realized looking back that I don't recall someone like me. Uh, the insurance medical director role was not often. I don't recall this. It's been a while obviously. But it is a career that has its pluses and minuses for physicians seeking alternative careers in their life. And I'd be happy to be a resource to help guide that. Um, I think my main interest now is sharing some of this reality of the basically I call it the circle of money. But we've talked about this. That like them or hate them, but this is how the business operates. And no one's going to be able to come up with a better solution with innovative solutions if they don't start by understanding everyone's role in the system and the fact that everyone has margin to meet that. Price control is a huge unaddressed issue for the reasons we talked about with the contracting with marketing and we really didn't get to drugs which is, you know, basically has patent protection for pricing so that they have a whole different business model that is far more profitable than the insurance company model. Um, and to try and support people, um, who are trying to think about new ways to address the biggest industry in America. I guess that clearly could still has not achieved the outcomes we deserve, uh, at a price that is, uh, people consider reasonable.

Mike Tsakopoulos: Well, it's certainly. You're certainly an important voice and bring um, good information and perspective to the discussion. And on behalf of aapl, thank you very much for your time. Um, my guest has been Jacob Asher. Dr. Asher, thank you so much for being on Soundpractice.

Jacob Asher: I've enjoyed the conversation. Thanks for having me.

Mike Tsakopoulos: My thanks to Jacob Asher. Dr. Asher has worked aside of the managed care equation that is all too often opaque. His time and thoughts on such an important topic to physician and patient alike are greatly appreciated. My thanks also to the American association for Physician Leadership for making this podcast possible. Please join me next time on Soundpractice. We release a new episode every other Wednesday.

Jacob Asher: You've been listening to Soundpractice, the business podcast for physicians and healthcare leaders. Check out the show Notes for this

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