Ep #473: Illuminating the Healthcare Sector: Transparency and Data-driven Insights - with Keith Somers

David Saltzman: 0:05

It seems like a big no-brainer. If you need medical care, you want the highest value options in your area. The question is, how do you find those? We'll find out on this episode of Shift Shapers.

Host: 0:21

This is the Shift Shapers podcast, Connecting benefits advisors with thought leaders and entrepreneurs who are shaping the shifts in the industry. And now here's your host, David Saltzman.

David Saltzman: 0:34

And to help us answer that question, we've invited Keith Somers. Keith is co-founder and CRO of HealthCorum. Welcome, Keith.

Keith Somers: 0:41

Thanks for having me. Great to be here.

David Saltzman: 0:43

It's our pleasure. Tell us a little bit about your journey. How did you get to be doing what you're doing today?

Keith Somers: 0:47

You know, I actually came at it from the patient perspective, so I've been in technology for many years. I've also been a founder of other businesses. I just so happened to be experiencing some of the you know things that are troubling in health care in my personal life family, dealing with wasteful spending and low-value care and it got me interested in potentially helping to solve that problem. So that's where my journey began. I was also fortunate to meet my founding team, who has been in this space for decades doing work around provider level analytics and circling on some of these same problems, but just not doing it in the way that we've now come to market as a company. So we have a really awesome experience team and I've been basically getting them growing in the right direction towards this goal of helping to improve health care.

David Saltzman: 1:43

That's awesome. So, at a 10,000-foot level, what's the problem? What's the challenge?

Keith Somers: 1:49

The challenge is pretty straightforward, in that there are best practices and ways that are universally accepted as how you should be treating patients. 99% of doctors will agree on these things. There are many, many different sources, and they vary by specialty. So, while those exist, the wasteful spending and the low-value care persists year over year. It just keeps happening, and it's really a percentage of overall spend. So the issue is really as health care continues to become a greater percentage of GDP, the waste keeps going up as well, and we're far and away nationwide worldwide, I would say the most expensive place to really receive care. So that's a problem and it takes a lot of minds working together to try to solve it, and we're not the only ones tackling this issue. I think the angle we're taking and the approach is one that can be really effective, though.

David Saltzman: 2:52

But, at the end of the day, the patient, the one who's receiving the care, is really in the dark, aren't they?

Keith Somers: 2:57

Typically they are. I know my personal experience with trying to navigate the healthcare system. It's a lot of calling friends and family asking do you know somebody that you would trust in the particular specialty? Let's say, if I go on my provider search tool through my insurer today, I have no indication of who's a high value, high quality provider and who's not. And if I ask my primary care provider, I hope that they're leading me in the right direction. But a lot of times referrals are based on deep-seated relationships and so do they even have the right information to be steering you, the patient, towards those appropriate providers. So let's level set.

David Saltzman: 3:40

Can you define those two things for us what is high value and what is high quality?

Keith Somers: 3:45

Sure thing. I would say that in order to deliver high quality, you have to be focused on value. So that's one of the core tenants here is, when we analyze how a physician or even a facility or a group compares to other similar ones, we're looking at the proportion of care they're delivering and how much of that is low value or high value. So what does that mean we're looking at ultimately? Are they judicious in their care? Are they delivering care that's necessary in the first place? So you might have a surgery that is, on paper, it looks like it has a great outcome. There's maybe not any readmission events, but if it wasn't needed in the first place, then that's falling into the low value care bucket. So a lot of what we're doing is trying to get to that not. Was it a successful surgery or did the patient have a good outcome? Necessarily, that's a piece. But more importantly, was it even needed and is it potentially wasteful, adding to complications that wouldn't exist in the first place if nothing had been done?

David Saltzman: 4:55

How do you educate patients? Because right now, and probably for a good long time to come, you have this white coat authority. When a doctor says you need this, you go OK, cool, let's go get it done, or no, I'm not having it done. How do you educate patients to understand that there's more to the decision than just, as you point out, a referral from a friend or someone who's had a good experience with Dr A or Dr B or Dr C?

Keith Somers: 5:21

I think that, inherently, patients are going to trust the provider. It's ingrained, they know best and oftentimes they do so. Our approach is less about trying to get every single patient to understand the nuances of clinical best practices and rather what we're doing is trying to get them in front of and steer utilization towards those providers that tends to deliver higher value care. And what we see is that if we have more people seeing more of those high scores, those high value folks will have reduced total cost of care while not sacrificing on quality, on outcomes, on really delivering medicine that's successful.

David Saltzman: 6:06

So do you provide folks with a dashboard that gives them that information and they look up a condition or a surgery they need, or what's that going to look like as consumers come out of the yes, doctor, or whatever you say doctor mode?

Keith Somers: 6:22

Right. So there are a lot of point solutions out there, provider search tools where patients have access. Our philosophy is we want to get this in the hands of as many people as possible. So we've made this strategic decision not to be gatekeepers and say you need to use our front end, our search tool. Rather, we plug in a lot of different places. So oftentimes you'll see overall score, overall value score, overall quality score, powered by health quorum, and that will be your experience as a patient. On the back end, it's our data that's powering the display and, ultimately, the ranking and sorting that they're able to do in their search. But on our side we're agnostic, I would say, in terms of how this is deployed and actually gets in the hands of patients.

David Saltzman: 7:14

I think one of the long held consumer beliefs is that if something's more expensive, it's better, and that's true with a lot of things, but it isn't really true with healthcare, is it?

Keith Somers: 7:25

I would say no, I would say that sometimes it can be and I would think that for our experience, for particular very complex surgeries, let's say you may want to have one done at a academic facility, a teaching hospital, that's on the cutting edge of certain therapies. That's all well and good. But in general contracted rates very rarely have a direct correlation to quality and to outcomes. So I would agree with your assessment that you don't want to go to the cheapest or the lowest cost provider necessarily. What our scores help do is give that other element so you're able to see what does the cost potentially look like here, but also what does the quality and the appropriateness of care and how effective is that provider.

David Saltzman: 8:18

So what do you attribute that? Is it just that certain physicians or surgeons or practitioners do a lot more of a given procedure? Is it just raw skill? Is it a mixture of all those things?

Keith Somers: 8:32

depending on what you're doing, and I would say in general, skill is no question a factor. If you're a skilled practitioner, you're generally going to have better outcomes and so forth. That said, a large piece of it does have to do with just your mindset around treating patients and what really should be happening at which frequencies. So a provider that's really jumping into expensive procedures and surgeries etc. Prescribing brand name drugs when maybe there's a generic alternative available, those types of activities, without having a second look, can really add up and become problematic. So it's almost this process of retraining some of maybe some bad habits that have formed over the years.

David Saltzman: 9:27

So one of the things that obviously using the data and being aware of this stuff as a consumer is that it can lower costs. Tell me how that happens based on making decisions based on data.

Keith Somers: 9:42

So, as a consumer, there's the macro understanding that if I am being a better steward of my company's healthcare program or whatever plan you're on, you'll help reduce the pressure on increased premiums year over year. That's a little bit tough to wrap your head around. And there is that issue of well, I'm paying for this insurance so I want to utilize as much as possible, so it's getting buy-in there. But really the way to, I think, be most effective is follow the money. If you're able to incentivize members to see those high performers, those high scorers, and you do the math in the back end and say we can offer X amount, we can waive a copay, a deductible, all these things to get someone more incentive to see the high scorer, those can be very effective.

David Saltzman: 10:39

We found Do you find that TPAs and others that are using these data sets are creating alternate networks or concentric networks, or some of each?

Keith Somers: 10:51

There's the use of narrow networks, as there's some times referred to.

Keith Somers: 10:58

There's also tiered networks, so you might have one tier that you have to pay more out of pocket, let's say, than for another tier, but really it's not. You don't even have to do all of that complicated work. It can be as simple as just sort ordering providers based on their score and that's put in front of a member, and research shows that most people aren't going to page five. They're going to see those first handful of choices and make decisions there. And I think what will start happening is, as what we're doing and others in the industry gains more and more prevalence, there'll be that almost that buy-in from the provider community as well to really pay attention to this. Now, what I think we do that's unique and really much needed is that we offer full transparency into our process, so there's no black boxes over here. We give that granular picture of why is a scorer the way it is, what's causing it, and we have those conversations with providers all the time and give them that insight which I think is sorely needed in the space.

David Saltzman: 12:11

To that point. You mentioned readmission rates. What are some of the other factors that go into you guys determining quality? What are the other things that people need to look for and know about?

Keith Somers: 12:21

So there's readmissions, complications, adverse events, rates. There are other outcome-driven measures that we include that are we call them indirect. So it's tied to where that provider is practicing and if we see that at their facility level there tends to be some poor performance, then we can draw that connection. We also take that broader view of quality right. So it falls in our process under appropriateness of care. But it's very close and again, that's looking at actual low-value care detection that we do on our side, where we look at what's something appropriate in the first place. So it's a little bit of a broader view of quality than maybe what someone might be used to, I would say.

David Saltzman: 13:15

What kind of feedback do you get from the provider community? Are they in favor of this? Do they see it as intrusive? What do they tell you?

Keith Somers: 13:23

Yeah, you know, I think anyone who's being evaluated, if they're, if they're ending up on the right side of things and they're high scoring, then they're going to be happy with it, and if they're not, then they'll take issue. You know it's always going to be the case, right? But I think what's important is giving that level of transparency to them, and so, while there might be, you know, a little, a little bit of someone taking issue with having a low score, at least we're able to point to the specific reasons why. The other thing we do, which is very important, is risk adjusting for the relative sickness of their patient panel. So we're doing all of these things. Risk adjustment is one of them, but it helps us create this apples to apples comparison of providers, and we're going at this totally unbiased approach. It's just what the data shows us. We have no preconceived notions on. You know who's the most popular and you have a market, right. We're just saying, relative to your peers, the data tells us X and that's what we put forward.

David Saltzman: 14:30

Do you have any sense of? I mean, there's two things that people look at right it's lowering costs and improving outcomes. Do you have any sense of what the delta is on the cost, if somebody's using this kind of data and using it intelligently, or what it could be?

Keith Somers: 14:44

It can be massive. I'll give you an example. We were working with a health plan that had around 100,000 members so you know relatively small regional size plan, right. And we dug in and we did this assessment where we looked at just 2,000 of the providers that they were working with, that's out of maybe 60,000 in their market. What we saw was that, with that population and just focused on that segment of 2,000 providers, they had around $60 million in potential savings that they'd be able to achieve if they just had steered their members in the direction of those high scores. Obviously, you're not going to capture 100% of that and it'll be steps over time to get there. So even 10%, right, that's still $6 million that can help either reduce the cost of care or be used for other high value activities that will help improve overall satisfaction and health for the patients.

David Saltzman: 15:49

So that was $60 million. Over what total spend? What percentage would that $60 million represent if they were able to capture all of it?

Keith Somers: 15:59

Out of all of their spend. You know I don't know offhand, to be honest, and that was, again, only across 2,000 providers. So it was a small slice, but the takeaway there was that even just looking at, you know, 17 providers in one specialty and, you know, shifting towards the high scores, can really, you know, make a significant difference out of those. You know that delta that we're looking at, and you know the other piece, improving outcomes.

David Saltzman: 16:27

I mean, if I'm an insured patient, at some point I'm spending other people's money. I don't really care, I just want to get well and have the best care. What do we tell them about improving outcomes? What does improving outcomes look like at the street level for a patient?

Keith Somers: 16:42

Yeah, I think people don't want to be doing services and going through the hassle if it's not needed for them. So a good outcome for a patient can be, you know, going to the doctor and not having something done right. It doesn't necessarily mean that they had to go through with whatever they had in their mind when they went into the visit. It can also mean that maybe you needed something and it was. You know it was necessary and you had it done cleanly. You didn't have to go back for additional procedures or you didn't have to get admitted again. So I think it can mean different things, depending on that key question. You know, was this necessary in the first place?

David Saltzman: 17:30

We've got about a minute left. Where do you see this all in a year or two, or five?

Keith Somers: 17:36

So the biggest development over the past year that will lead me to this answer is price transparency and that legislation around plans having to publish their prices for popular procedures, starting at 500 codes right now, and it's moving up With that said, it's somewhat akin to what we saw in retail 10 years ago, where price suddenly became really easily searchable online and suddenly the quality of the goods was front and center. So I think that our scores and what we're doing, combined alongside with that price transparency data, is really an incredible one-two punch that can empower consumers and drive a lot of this forward. It's only going to get better. The data is messy right now, but we see a lot of promise there and it's really a perfect use case for what HealthCorm does.

David Saltzman: 18:36

Well and, as that develops, we hope you'll come back and chat with us again. Keith Summers, co-founder and CRO at HealthCorm. Keith, thanks for sharing your knowledge with us.

Keith Somers: 18:46

Thank you so much, appreciate your time.

Host: 18:51

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