Mike Mardini is founder and CEO of National Decision Support Company of Madison, WI, which is part of Change Healthcare.
Tell me about yourself and the company.
I’m a healthcare IT veteran. I’ve gone through three companies in the utilization management and documentation space. We were acquired by Change Healthcare about a year ago.
How will the acquisition change your business?
We had been working with McKesson for two years and they were acquired by Change. We had a good relationship. We knew what we were getting into when the conversation about them owning us started. We knew the people and we knew what the synergies were. We lived together before we got married. That was a big advantage, not only for us, but for them, too. It happened the right way.
It’s content integration and connectivity to impact care. To share data between providers and payers. A lot of assets come together.
How do you balance the big picture of growing the business, raising money, and considering who might acquire you or who you might acquire, all while you are still running the company day to day?
I’ve done it three times and I’ve asked myself that question. Each time was a little different. The first time was the first time. The second time, the strategic buyer was different. But it is a balance. You have to be true to the company and the company’s mission as opposed to a personal type of mission.
Some would say it was harder or easier for me since I never raised money. I never had a bank or a VC dictating what they wanted out of it. It was always personal. Whether it’s running the business or finding a partner, you’re in it every day. You have to be true to the mission of the company and to evaluate how the company is better off, whether it is run independently and we keep on going, or whether we’ve found the right partner to advance the mission. It becomes easy.
Change wasn’t the only one that wanted to us. From the day that we got started, I would say inside of a year, we were courted. We found the right partner.
CEOs have told me that instead of the champagne corks flying once the deal was done, the due diligence was like a colonoscopy and then it was second guessing about whether it really is the right partner, the right price, and the right thing for the company and its employees. Is it hard to balance the negatives and positives of multiple offers?
It was a lot easier this time around than the other two times, whether it was experience or that we had been working with them for two years. It is difficult. It is the colonoscopy. It’s all of that. But this time around was a lot smoother. We knew what to expect, we knew the people, and everybody’s heads and hearts were in the right place.
How hard would it be for a health system to set up and maintain ordering appropriateness checks on their own?
It’s a huge project. They all have a few dozen alerts and advisories. When we install our imaging product, it’s 15,000. Maintaining and managing with native EHR tools is a huge task. That’s why they only do dozens. All the content is managed locally.
Governance is an issue. Tracking the impact and the effects. It is a huge undertaking for sites to do it alone. I’m not sure they even realize how big the problem is. But as the market starts to evolve, they’re starting to ask all the right questions. We want an enterprise partner. We want to understand your analytics. We want to understand all the components, not just whether you put this alert in my EMR.
How do doctors react to that extra level of review or entry that is required to ensure clinical appropriateness?
The docs who are complaining about alert fatigue are primarily correct. When you install your EMR, you have people putting all these alerts. There’s not a lot of thought that goes into it, and even if there is on the front end, there’s not a lot of thought on an ongoing basis. They’ll add five alerts, then two years later, they add another five without taking a look at the original five. A doc does something in the EMR and three boxes pop up with kind of related, yet unrelated alerts. All they do is X through it. There’s no response, there’s no impact, it’s just these things that pop up and they pop up all the time. Nobody says anything, because they’re just X-ing through it.
Thoughtful implementation of guidelines to where they really have an impact, and putting them in place where we’re using the data from the EMR to fire guidance when it’s appropriate. When the end user connects, you understand what the value of it is.
That being said, we still see see doctors who don’t want to see them because they don’t want to see the EMR. They don’t even want to work inside the EMR. There needs to be an improvement in the thought process and the implementation of these advisories to ensure that they’re optimized so we’re not wasting people’s time.
The “revenge of the ancillaries” must play a part, where anyone in any department who wants to collect more information or make their own job easier dumps a new documentation requirement into the newly installed EHR. Is it easier to sell the idea that your recommendations were created by the societies to which those physicians belong?
It all depends on the use case. Sometimes the information is from societies. Sometimes it’s a local rule that a facility wants to implement. Sometimes it’s a payer rule. We try hard to make sure that the guidelines that are actually put in are relevant and respected by the end users.
Imaging is particularly hard. We took on the absolute hardest part of it. An entire service, in some cases 3,000 orderables, 7,000 clinical reasons for why you would want to use those 3,000 orderables, as well as variants used by every specialty in healthcare. It’s not something like, let’s put an alert in there for blood management if the patient’s hemoglobin level is above seven. Everything that we do beyond imaging is much easier for us to hit the target.
Why does CMS keep pushing out the mandatory date for implementing advanced imaging appropriateness rules?
This next date is set in stone, short of a big lightning strike. But I think the market is constantly making CMS aware of just how huge this implementation is. Everybody orders imaging, so they are communicating to CMS that it’s going to impact everybody. They’re getting a lot of push-back. They’re getting a lot of blowback from the market. They want to get it right.
It’s not just that they pushed it back, they have refined it, too. It is not all imaging, it’s certain clinical scenarios. But beyond just that, it’s figuring out how the data gets on the claim forms. There’s a whole process, not just on the provider’s interaction with CMS, but how all this data is going to flow and how they’re going to keep track of it all.
Do I think that they could and should have gotten this done faster? Yes. Am I surprised that it has taken this long? No.
Hospitals get paid well for imaging that best practices say it is inappropriate. Are they interested in ensuring the appropriateness of imaging until CMS forces them to?
That is almost the norm. They want to use it for the stuff that they’re at risk for, but they’re not as excited about it for the stuff that they’re not at risk for. We have seen that.
But the market is moving in a different direction. As the risk shifts to providers, this concept of a standard of care and making sure that there is no waste becomes tantamount. Not just to patient care, but to profit as well. As the risk shifts, everything looks like a DRG. Everything looks like a bundle. We are starting to definitely see a shift in wanting to adopt more and more as this risk shifts. They start acting like payers.
How is Choosing Wisely, which is endorsed by Consumer Reports, being implemented and what results are we seeing?
It’s another set of criteria. Some of it is really good. Some of it is impacted by evidence. The single greatest thing that Choosing Wisely did was create a market awareness that it’s workable to put guidelines in place to impact decision-making. It’s possible and it should be put into place. It has created an awareness.
Many of the Choosing Wisely guidelines are obvious. There’s no debate on them. So it has done a great job of creating an environment where the market is willing to accept putting guidelines in work flow to impact decision-making. The guidelines themselves are good, some better than others, but the awareness that it created is the impact that it has had.
What causes the gap between what a competent practitioner wants to order versus an insurer or hospital that thinks they need to tell them they might be wrong?
There is new data out there that docs may or may not be aware of. The average CME credits that docs get every year can’t begin to cover and keep docs updated with the latest knowledge. One of the points of implementing an EMR is to solve this gap in data. This ability to shed a light to docs on data that is available that would help them in their decision-making. I don’t think anybody could reasonably argue that doctors can’t benefit by being made aware at clinically relevant times that guidelines out there are proven or should be followed. It’s not for every case, but this is science, and information is being found all the time.
We talked about how risk shifts. Let’s go to the extreme and say you have a full-risk model on a provider’s side. Now, when a third part is paying, it’s the third party’s money and they are trying to save on unnecessary testing. Once the risk shifts to the provider, the issue is reversed. How do we prevent the provider from cutting corners? How do we prevent the provider from doing things to save money? It’s not based on bad things or evil or greed. It’s about keeping the lights on.
The only thing that protects providers from liability around cutting corners is to reduce variation in care, to establish a standard set of “this is what we do in this clinical scenario.” It doesn’t mean that somebody can’t veer off of it if there is a variant that exists. But it’s a standard that everybody follows. That ultimately will have to happen to give the provider not only protection from liability, but credibility. Why should the same type of patient with the same scenario walk in and get two different protocols?
Do you have any final thoughts?
I want to go back to the synergies with Change Healthcare and what we’re actually doing here. NDSC came to the table with a content management solution that is designed to deliver provider-focused guidelines seamlessly integrated into EMRs. In a standard way, extract data, calculate that data against guidelines, and then send that clinical data wherever it needs to be sent. We have a large provider footprint and success in the market. Change brings a host of criteria through its InterQual asset, a dominant product in the market that is used by health plans. They also have advanced business intelligence, a large investment in AI and machine learning labs, and a very large network of payer connections with a whole host of claims information.
We are working together to close the loop on delivering guidelines into the physician workflow, then being able to share that information with payers or whoever is financially risk to insure that the right things are done and to mitigate waste.