Should you enroll enhanced benefits yourself, or can a professional enroller help to create clear communication while maximizing enrollment and delivering better client satisfaction – and what are the financial considerations of that decision?

That is the question that Allison De Paoli discusses in this episode. Her firm, De Paoli Professional Services, specializes in becoming an extension of your office, enabling a more direct and in-depth communication about employees’ enhanced benefits in an effort to maximize participation.

We explore whether (in some situations) using benefits enrollment software makes more sense than doing in-person enrollments. Allison also explains that success in this practice area represents a combination of art and science – exactly the kind of nuance needed to help employees make the best choices for themselves and their families.

Finally, we discuss how some employers are making the choice of baking enhanced benefits into their plans, and what that means for advisors.

What You’ll Learn From this Episode:

  • Why you can’t simply use benefits enrollment software on its own.
  • What market sizes can benefit from professional enroller help.
  • Whether advisers should handle smaller cases themselves, or send someone from their office to manage them.
  • How much of enrollment is “art” and how much is “science”.
  • Why some employers are baking enhanced benefits into their plans.

Featured on the Show:

Listen to the Full Interview:

This Episode is Sponsored by:

Enjoy The Show?





Episode Transcript:

David:     How can using professional enrollers help increase revenue and client satisfaction? We’ll find out on this episode of Shift Shapers.

Change either paralyzes, or energizes. The choice is yours. You’re listening to the ShiftShapers Podcast. You’re about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change that you want to see. Here’s your host and chief transformation strategist, David Saltzman.

David:      This episode of the Shift Shapers Podcast is brought to you by Captivated Health. A captive insurance arrangement, that helps small and mid-market companies escape the fully insured marketplace, and deliver stability, control, and savings, without watering down employee’s benefits, or increasing their premium share. If you have clients in the Educational Institution, or the Engineering Vertical, go to our website at, or click on the company logo on the Shift Shapers website.

For a lot of really interesting reasons, there’s been a renewed interest in enhanced benefits, and there’s always the question when you talk to Benefit Advisors about that. About what the best way is to enroll folks to be both effective and efficient, and our guest today, Allison DePaoli, who’s the Founder and Benefit Enrollment Expert at DePaoli Professional Services, practices in this area, and has studied extensively, and we thought that Allison could help us answer some of those questions.

So, with that welcome Allison …

Allison:       Thank you, pleasure to be with you today.

David:        There are lots of Benefits Administration Systems, and some of them have pretty decent decision support tools, but you still counsel that one on one enrollment is best. Why is that?

Allison:       I do. One on one enrollment is best for a few reasons. First, it is still the crème de la crème of communication. There is nothing that beats a person sitting with another person to have a full explanation of their benefits. Today, forward thinking brokers are talking more and more about medical management, cost containments, scheme-e networks, RX discounts, where you go to get the best care. That is a lot for a C-Suite to absorb, let alone a regular employee. Even mid-level and senior level executives. Most people spend about 10 minutes a year on their benefits, and when you start to insert services like this, they do require a fair amount of communication, not just on a one on one basis, but in a variety of manners.

So decision making support, in an online benefits enrollment, an app on your phone that will help you find a provider, regular communication from HR, as well as the traditional group meeting. So, when you piece it together, one thing at a time, if you’re getting to six or seven forms of communication, you’ve fully addressed the communication needs of the group.

David:        So it’s not an either/or? It’s kind of more of an “All of the above?”

Allison:       I think it’s an “All of the above.” I worked for a gentleman who I just loved, who gave me the rule of 8’s, when I was teaching a group of people something new, and I’m not an overly patient person, and I was not allowed to express my impatience until I had explained something 8 times. Once I explained it 8 times, I could lose my patience. Rarely, did I get to 8 times.

So when you’re communicating in a variety of fashions, and over a period of time, people start to absorb what they need to do better, most people want to control their cost, they want the best care, they want to pay the least for their prescription drugs, they want to know what to do, when they need to do it, and they need to know how to piece everything together.

So, the more tools you give them, the easier it is for your employees to appreciate the benefits that you’ve worked on.

David:        That makes perfect sense, now are there certain market size segments that lend themselves more to one on one enrollment, as opposed to other methods?

Allison:       Traditionally, there has been a lot of public sector and large employer focusing on one on one enrollment. A lot of that has been product driven, sort of in the enhanced benefits arena. That is changing. With the advent of so many new tools, and so many different kinds of ways to piece your benefits package together, it is becoming a more holistic communication mechanism, so when we send a team, or when the industry standard now for sending a team is that they’re going to communicate all the benefits.

They’re going to get your medical questions answered, they’re going to refer where you need to go to find this piece of information, they have their own tools to make sure you understand how to use an app, or an advocacy line, or an RX discount plan. So, it’s much more holistic, and as that becomes more prevalent, you see more and more employers engaging in that service. So, used to be 1,000, maybe 500. Now you’re dropping that into the 500, the 200, the 50, and for small employers it’s always been more personal. Maybe you weren’t talking about a whole host of products, but if you have an employer with 20 or 25, or even 40 or 50 employees, and it’s been your case for a while, you know who those people are, and they’re going to come to you with questions.

David:        Would you recommend in that kind of situation that the Benefit Advisor do that enrollment themselves, rather than sending somebody from their office because they are so visible and so familiar to the case?

Allison:       I think that all Benefits need to be sold, not in an uncomfortable high pressure way, but I do think that they require some explanation, and sales education are very similar tools. You are explaining something to somebody so that they see the value in it. I think a professional salesperson is best suited to that, and I think it also allows that professional to see what is actually happening, and what people like, what they don’t like. If you don’t do that, there’s a lot of miscommunication, or misinformation, and you can solve a lot of problems in that sort of one on one environment, or a small group meeting environment, when it’s a small employer.

David:        So, if I understand you correctly, what you’re saying, especially in the smaller segments, is for advisors who are being asked to do more with less, who’s staffs maybe have gotten paired back a little bit because of commission compression, it’s critically important for them to do those one on one’s, because they will ultimately lessen the service burden of their office staff?

Allison:       I think it does lessen the burden of their service staff. It also gives them a pulse on what is happening, and I know it can be a little scary to do a one on one enrollment yourself, you can hybridize that, you can do some one on one, benefit platforms are getting more and more user friendly and useful for smaller case sizes, you can introduce that into your case as well. That is a great opportunity to grow the benefits package.

David:        Is this one on one enrollment, is it art or science, or some place in between?

Allison:       I think the technical aspects are science, but I think there’s a lot of art to it. I think it’s a sales process. The best sales processes are structure and personal delivery, and personal delivery is all art. I think it’s very important to know and to be able to read your audience as to what is important.

There’s a lot of research about the generational differences, and how people like to be communicated to. The reality is that the baby boomer generation, and the forgotten generation, as well as the millennials, they all want information, they just want to receive it differently. But when they want a question answered, they want a question answered by a person. They don’t necessarily talk to artificial intelligence or into a chat box, they want to talk to a person who can explain it fully.

David:        So, would you change your approach having the same conversation with a boomer vs a millennial, even though ultimately you’re going to deliver the same information?

Allison:       I think you should always tailor your communication to the person sitting in front of you. I think one of the big misconceptions is that older people and younger people have different risk tolerances. The millennial generation actually has a risk tolerance that is much more similar to the greatest generation, than to my generation.

David:        It’s interesting, because they’re also savers like the greatest generation.

Allison:       They are.

David:        As they’re becoming more and more part of the middle of that bell curve of the workforce, that’s becoming more and more apparent, and it’s fascinating that you make that connection as well, in terms of risk.

Allison:       Yes, they are very risk averse, for the most part. Not every person. They are also very interested in understanding what they have. I think it’s really important to explain it to them.

David:        Now, a word from our sponsor.

Captivated Health is a single source solution for your clients and prospects in the Education and Engineering Verticals. The Founders of Captivated Health have 35 years’ experience, working with healthcare and benefit clients. Over that time, they’ve developed a keen understanding of the unique problems mid-market clients experience.

Frustrated by a lack of control, the unpredictability of ever increasing healthcare costs, and the pressures and regulations of the Affordable Care Act, these groups have been adrift in the fully insured commercial market place, until now.

Captivated Health has built a program that solves those problems, and does so with virtually no disruption to employees, while saving clients millions of dollars. We wanted you to be among the first to know that Captivated Health is building a national distribution partner network, so you can bring this cutting edge solution to your education and engineering clients that you advise.

To learn more about Captivated Heath’s Solution, go to our website at Or click on our logo on the Shift Shapers website.

Now, the personal responsibility amounts on all of the plans that are being sold these days are going up. Is that driving a particular set of enhanced benefits, a particular set of products that you’re seeing more interest in, than we might have five years ago?

Allison:       Absolutely. Gap insurance is becoming more prevalent. It’s becoming more something that the employer might pay for, or there might be a cost sharing arrangement between the employer and the employee. That will help alleviate some of the out of pocket burden. Accident and critical illness are still the standards, and if you bake those into the planning process, so when you’re sitting down with your renewal, and you’re deciding how you’re going to manage for the next year, if you’ve got a good accident product, and a good critical illness product, you can eliminate risk for a significant number of medical events, and a good Gap or hospital indemnity plan depending on what your clients’ needs are, will help eliminate a little bit more of the risk.

It can be a real challenge to be a young family, and starting your family. You know, newly married, and starting your family, and your maximum out of pocket is $4500 if you want to have a child. That’s a pretty big hit. So, baking the Gap plan or the hospital indemnity plan into the coverage can help eliminate that.

David:        So, when you say baking in, is it kind of an opt out situation? Everyone is assumed that they’re going to get this? Or is it everybody gets it, whether you want it or not?

Allison:       I think it can be either. In some situations you want a Gap plan that’s baked in, and everybody who goes into the medical plan gets that, and then that needs to be discussed in your group meeting, and your one on one follow up, but it doesn’t have to be particularly for smaller employers.

What offering a Gap or hospital indemnity plan on a voluntary basis allows, is for the employer to have a little more flexibility to increase their deductible, or their out of pocket, and offer this alongside. I think it works best when those decisions are made when the plan designs are being reviewed, and the funding is being reviewed as well. Then you know how you can pivot, and how you can move, and to be truly effective, it’s helpful if you can watch that plan develop over 3 to 5 years, so don’t plan just for this year, plan for next year, and the year after, and 3 and 4 years down the road.

David:        Does the culture of a particular employer pay in to the decision of how those baked in benefits are offered?

Allison:       It absolutely does. Most employers really try to do the right thing by their employee. Employees are a valuable asset, and they really do try to do the right thing, and they may not understand how to both do the right thing for their employee, and do the right thing for their operating budget.

If you have all this on the table to start with, you have more flexibility in both situations.

David:        In your practice, do you find that, can you generalize?  Are there certain types of employers that tend to go one way vs certain types of employers who maybe tend to go in another direction?

Allison:       More forward thinking employers tend to look at a more holistic package, and employers and industries that are very competitive for talent look at more holistic benefit packages, and what they can add that will attract or retain an employee. Talent can be very difficult to keep, talented employees, you want to keep them. It costs 20% on the low end to replace an employee if they leave. It can be a substantially higher cost for a more high level employee, so you want to do what you can to retain them, and by enhancing your benefits package, you have an opportunity to do that.

The other thing that I’d like to point out, employees don’t necessarily expect an employer to pay for everything, or even to contribute to everything. Particularly with younger employees, they want to know how many dollars they have to spend, so more like a defined contribution, or defined contribution for this, you’re going to get that, and the other things they will participate in them or not, whatever it is that works best for their situation. Not everybody’s the same, but everybody wants a benefits package that works for them.

David:        Of course, and what I’ve started hearing, especially millennials, are keen on tailoring that for themselves. Would that be an accurate statement?

Allison:       Absolutely. Much more so, than older generations.

David:        So, is this like an awful lot of other employer based initiatives? Would it be fair to say that communication and education, even prior to enrollment, are really key in a commitment from the C-Suite?

Allison:       Commitment from the C-Suite is the most important indicator of success.

David:        Fascinating. So, if you’re talking to a Benefit Advisor, long before the enrollment happens, how do you counsel them? What’s that conversation like? What should they be talking to those C Level folks about?

Allison:       They should be talking about benefits packages as a capital expense, and not an operating expense. For the most part, employees are considered a capital expense, and not an operating expense, and benefits packages need to be managed. Every process in most businesses is managed. Everything you buy, everything you sell, has a purchase price, a value, everybody’s looking for how to reduce their costs. How can I buy it more effectively? How can I use it more effectively? How can I buy it more inexpensively?

By considering benefits to be a capital expense, you put some of that thought right into the process. You’re starting there. It’s not coming later. So you want your unit cost to be as low as possible, by considering it a capital expense, that is a C-Suite understanding of what that is. Oh, I should look at it as a business expense, how do I manage it?

David:        It’s fascinating that, back in the days when I was selling, it’s fascinating that employers will spend months evaluating a $200,000 piece of equipment, but they don’t want to spend more than more than an hour, talking about their $4,000,000 medical plan.

Allison:       Correct. That $4,000,000 medical plan, if it’s not being managed can probably be delivered for a significantly lower cost.

David:        Absolutely. So, back to advisors. Some advisors have a perception that using an Enrollment Firm, using Professional Enrollers is too costly, but if a one on one enroller is more productive, where is that cross over point, and where do they figure out where that line is?

Allison:       Traditionally, enhanced benefits have been used to fund a one on one enrollment. There are some costs, and there are some risks. You do need buy in from the C-Suite, there does need to be a commitment to making sure that every employee is communicated to on a one on one basis. So, there is some skin in the game for an employer. There’s some time, there’s some making sure people get through the enrollment, so the cross is, how effectively do you need your benefits to be used? How much do you value how your employee is using their benefits?

If an employee can feel more satisfied in their job, because they’ve had this experience, which realistically takes about 20 minutes per employee, and that increases your retention by 3%, 5%, 8%, what is that worth to you? What I think you’ll find is that, that cost, at one on one enrollment, is well under that in cost.

David:        One of the things that you’ve been nice enough to do is provide for Shift Shapers listeners, a link. If listeners click on the link to your logo, that’s on the left hand side of the Shift Shapers online page, or they look in the show notes there, you’ve made available a couple of calculators that will help advisors figure that out. Can you talk a little bit about those two different calculators, and why you use them, and how they help?

Allison:       Sure. There’s two calculators there as you said. One is for use if you are conducting your own enrollment, using enhanced benefits, some traditional products like accident or critical illness, that have a fair amount of heaped first year commission built in, and you can see what revenue you can drive, and that will help you determine how much expense you want to use when you’re doing your one on one enrollment.

The other calculator there is for if you’re using an enrollment partner, to help you with your enrollment. The commissions are lower if you’re using a partner, but those dollars are completely expense free. So, if you’re looking at increasing your revenue about 15 or 20%, that is revenue that will go directly to your bottom line.

If you prefer to do it yourself, there will be some costs. There will be some time out of the office, you will probably need an online enrollment platform, those are very cost effective and becoming a standard of business like good customer service. Whereas, five years ago that was a newfangled toy, and you might need some of your own staff out of the office for groups that are a little bit larger.

Your call. You may want to mix and match that up. You may find that with this group of employers, you want to use that yourself, so you’ll understand how much revenue you’re driving for yourself, and there may be other instances where you want to use a partner for that, and you’ll see how much the enrollment actually costs, because there is a commission split built into that, and you’ll see how much revenue you’ll drive directly to your bottom line.

David:        So, at the end of the day, it’s really a balance between being effective and being efficient, right?

Allison:       Correct. Isn’t it always?

David:        Well, Peter Drucker thought it was, but other folks not so much. You know, Benefits Advisors, one of the nice things that I think is happening, if you can say there’s a nice thing that’s happening from the commission compression that’s going on, and from being asked to do more with less, is that I think a lot of Benefits Advisors are really starting to look at their businesses as a business, rather than just going out and dropping product on folks.

I think ultimately, that’s a very good thing. But this notion of being effective and efficient, hasn’t always been part of the calculus of all Benefits Agencies, as you know, and today I think it’s more. I presume you’re seeing that as well in your discussions?

Allison:       I am seeing that in my discussions, and I think in every market there are some brokers that are more forward thinking, and thinking more like businesses, than about just running an insurance agency, which I agree with you, has often not run as a traditional business.

David:        So, we have about a minute or two left. We always like to wrap up our interviews by asking our subject matter experts, where do you see the future? What do you see happening with enhanced benefits, and then how firms such as yours, and other in the industry interact with Benefit Advisors?

Allison:       I think one of the most important things to understand about enrollments, is there are basically two parts. There is the project management. How do I execute, and deliver this project? You know, I need a timeline, I need materials, I need some structure, and then it’s a communication piece. How am I communicating to all of the different parties? Because there’s the C-Suite, the HR Suite, there’s an employee, there’s a management staff, there’s on the other end, there’s carriers, how am I getting this information back to carriers?

So, there’s a whole host of tools that you can play with. To me, that’s the interesting part. There’s apps now, where you can provide advocacy service, and you can provide access to medical management, to telehealth, to drug discounts, where is the most effective place for me to get my drug? My ID cards can be in there, you can do a text messaging campaign, “Hey everybody, wellness fair is next week, please come we’re going to make sure that your wellness benefits get filed.”

Those are all different kinds of tools, so the fun to me is integrating them all together.

David:        It looks like there’s going to be a lot more fun, as we get deeper and deeper into this world of enhanced benefits. It certainly has become something that for all the reasons we discussed, is becoming more prevalent, or there’s a resurgence I guess you might say, in that area. But a great place to leave our interview.

Allison DePaoli, Founder and Benefit Enrollment Expert at DePaoli Professional Services.

Allison, thank you so much for sharing your expertise with the Shift Shapers audience.

Allison:       Thank you for having me, it was a pleasure.

The Shift Shapers Podcast is a production of Strategic Vision Publishing and David Saltzman. This podcast may not be reproduced in any form, in whole or in part, without the express written permission of the producers. All rights reserved.


Deb Ault and some of her fellow RNs were against managed care when they were working at patients’ bedsides – but now she thinks it could help innovate and improve care while saving money.  

Nurse Deb is the President of Ault International Medical Management and a pioneer in the medical management field. As an advocate of proactive and predictive case management, she helps patients and their case managers navigate the diagnosis, treatment, and financial aspects of healthcare.

Deb defines and discusses the four types of medical management and explains why she thinks predictive management is the model of the future. She shares how she realized care management could both improve care and reduce costs when done correctly. Deb also emphasizes the importance of employer engagement in health plans, and why they must balance the cost of care with the health of their employees.

What You’ll Learn From this Episode:

  • Why Deb had a change of heart about medical management and how she discovered its potential.
  • The four types of medical management and which Deb finds most effective.
  • The monetary advantage of each type of case management.
  • Why it’s difficult to lead Americans with a carrot or pay them to behave the way you want.
  • How to get employees and employers alike more engaged and compliant in healthcare.

Featured on the Show:

Listen to the Full Interview:

This Episode is Sponsored by:

Enjoy The Show?





Episode Transcript:

David:      How can understanding the four modes of medical management help you to deliver exceptionally better value for your clients? We’ll find out, on this episode of Shift Shapers.

Change either paralyzes, or energizes. The choice is yours. You’re listening to the ShiftShapers Podcast. You’re about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change that you want to see. Here’s your host and chief transformation strategist, David Saltzman.

David:        This episode of the Shift Shapers Podcast is brought to you by Captivated Health, a captive insurance arrangement that help small and mid-market companies escape the fully insured marketplace and deliver stability, control and savings without watering down employee’s benefits or increasing their premium share. If you have clients in the educational institution or the engineering vertical, go to our website at or click on the company logo on the Shift Shapers website.

We often think about medical management as something that’s kind of a behind the scenes activity, but it’s starting to move to front stage and for some very, very good reasons. One of the people who’s making that happen is our guest on this episode of ShiftShapers – Deb Ault, otherwise known to those near and far as Nurse Deb. Deb is president at Ault International Medical Management and so with that, welcome Deb.

Deb:           Thank you for having me.

David:        It’s our pleasure. You’ve had an interesting path to get to where you are today and I think that informs a lot of our conversation. So if you wouldn’t mind, would you spend a minute or two talking about how you got to where you are?

Deb:           Well sure, I’m happy to do that. I am first and foremost a registered nurse. That’s how I started my career at the bedside. Worked in the ER, ICU, critical care kind of areas, moved around as a lot of nurses do exploring other areas, home health and doctors office. Landed at a telephonic nurse on call program, which was kind of good because it gave me an opportunity to further my education. It also was my first experience of working with patients over the telephone and I was always intrigued with the kind of impact that you could have not being face-to-face with patients. So that’s how I wound up on the telephone side of working with patients.

I got laid off from there unfortunately when some cost-cutting initiatives came into play. You guys probably remember that time of the market when all of the big hospitals were having all these great big consulting companies come in and show them how to cut their costs. At that point in time, I was very convinced that managed care was the reason that cost-cutting was necessary on the provider side. I was very vocal about it and was involved in the nurses’ union. I had been interviewed for television, spoke with many politicians about the cost-cutting that hospitals were doing, and became more and more dissatisfied at the bedside because of that, and feeling more and more pressure like a lot of nurses do to compromise patient care. So I was very anti-managed care, but then when I got laid off, having been so vocal about the cost-cutting that the providers were doing, I found myself having difficulty getting a job at any of the other large hospitals in the city.

So my husband pushed me to apply for managed care position. I kept telling him, “No, they’re the evil ones. They’re the reason were having to cut all these costs.” To make him be quiet, I applied. Fortunately, I wound up at a company that was nurse-led and they were following the teachings of Catherine Mullahy and were doing good case management. The problem that they were having was that they were having difficulty explaining to the bean counters, especially in the self-funded major medical health plan world which is where I am, how that was having a positive financial impact for the plan.

I’d continued my education, and I’d gotten my bachelors in business with a minor in math and statistics. So they hired me essentially to learn case management because of that math background and being able to come in and define savings and explain how getting the right patient to the right care at the right time in the right place would naturally result in the right price for the health plan. So that’s how I started my career in managed care and have the typical spinoff sell merger acquisition moving around in different roles in the managed care industry.

Then about 15 years ago, we had gone through one of those buyouts by venture capital and said to my husband, “This is crazy. These guys are not the kind of people that I want to work for. I’m going to have to look for another job.” He said, “No I think it’s time that we do this for ourselves.” So he convinced me to open AIMM about 15 years ago. We’ve been working in the self-funded major medical health plan arena ever since.

David:        To level set a little bit, you break managed care down into four different types. I’d like to take a moment and explore each one of those. The first one is reactive. What does that mean?

Deb:           Reactive is what we kind of traditionally think of when we think case management. So something happens. A patient becomes ill, has a catastrophic condition. They’re diagnosed with something or they’ve had a huge amount of claims spend happen. Then a case manager steps in to react to that. I affectionately call this also a “paid historian” model, because once that diagnosis has already hit, once those claims have already arrived, it’s very difficult to do anything that’s going to be impactful on the clinical quality of care or on the financial control side. So reactive is kind of responding to things that have already happened, often very far back in the timetable.

David:        The next piece you talk about is real-time. What is that and how does that differ from reactive?

Deb:           Real-time hit the market about 20 years ago. It was predominantly nurses who were doing case management who were frustrated with reactive and who were saying, “Listen, I need to get out in front of this. I need to be able to respond right away.” So as soon as somebody gets diagnosed with cancer or MS or any kind of life altering condition, I want to get involved real time at that point in time. That was more effective than reactive, but not still not everything that it possibly could be.

Reactive – when I think of the reactive model and the impact that it’s going to have on clinically a patient, it’s minimal. The horse is already halfway across the stream; telling them to change paths is difficult at that point. It’s disruptive in a negative way. They’ve already established relationship with care providers. Financially, what you see happen in groups that have reactive case management is they follow trend. If the trend increases 8%, they’re going to financially perform at 8%, 9%. If they’re really lucky, maybe 7%.

When you get into real-time and you start getting engaged with members at the time of diagnosis, then you can begin to have an impact clinically because you’re educating them. At least getting them to understand what questions they need to be asking their care providers. You’re also able to have more of a steerage in that which specialists are going to be chosen. Yes, maybe the doctor who diagnosed them with cancer told them a doctor he was going to refer them to but they haven’t seen that doctor yet. So if there’s another option that they need to be thinking about, they’re more open and receptive to it.

It also has a better impact financially. So those groups typically are going to beat trend not by a huge amount, but they will come in a couple of points under trend in comparison to everybody else in the market. So it does have an impact. It’s better than reactive, but it’s still event-driven.

David:        Then there’s proactive, which I guess means what it sounds like, but how does that happen in practice?

Deb:           So proactive is, if you remember a couple of years ago, we went back to expanding the list of things that require precertification. So there’s been this big back and forth and back and forth in the market for things like imaging studies. So maybe you get a pre-cert request for somebody who’s going to have an MRI and that MRI is highly suspicious of a catastrophic diagnosis. At that point, you get the member engaged. Start having conversations with them and say, “Hey I have gotten your precertification completed. When will you get the results back?” You’re building rapport much earlier in the course of illness.

Now, of course, sometimes those will come back no big deal. It was negative. Everything is benign. It’s fine. They’re not going to need any treatment. So, yeah, there is a little bit of “waste” there, but the benefit of doing it that way is in those instances where it does truly come back important, catastrophic, serious, you’ve already got rapport built with the patient. They already know that you’re there to help them. Making sure that they’re getting the right care, making sure that the timing is flowing smoothly, making sure that they’re getting care in the right place.

So because you’re able to do that, you’re able to have a more active role in helping them get the care that’s right for them. Doesn’t always mean that they’re going to do what I would do or what you would do David, but they’re going to make an informed decision. They’re going to have all of the tools and resources and support and guidance at their fingertips to help them through that. So you’ve become proactive because you’ve gotten in front of that date of diagnosis. Something is suspicious, there’s a high likelihood. There’s a potential coming down the pike, now we’re being proactive about getting that person engaged.

David:        Now a word from our sponsor.

Captivated Health is a single source solution for your clients and prospects in the education and engineering verticals. The founders of Captivated Health have 35 years’ experience working with healthcare and benefit clients. Over that time, they’ve developed a keen understanding of the unique problems mid-market clients experience. Frustrated by a lack of control, the unpredictability of ever-increasing healthcare costs and the pressures and regulations of the Affordable Care Act, these groups have been adrift in the fully insured commercial marketplace – until now.

Captivated Health has built a program that solves those problems and does so with virtually no disruption to employees while saving clients millions of dollars. We wanted you to be among the first to know that Captivated Health is building a national distribution partner network so you can bring this cutting edge solution to your education and engineering clients that you advise. To learn more about Captivated Health Solutions, go to our website at or click on our logo on the ShiftShaper’s website.

So then we go from being in front of the date of diagnosis to actually in front of the diagnosis altogether with the fourth piece which you call predictive.

Deb:           Absolutely. I love predictive and I think that it is where everybody should be and probably everybody will be before too much longer. There are great tools out there and have been for quite a while. The problem has been that not a lot of people have wanted to adopt them. Some people are averse to the cost even though it’s a minimal cost to do any kind of claims data mining or predictive risk modeling. There’s been questions about, “Is this clinically valid? Is this mathematically valid?” I think we’ve overcome all of those hurdles with a couple of products in the industry. So you can now begin to actually do predictive risk modeling. Guess what? You can initiate case management based on prediction.

Again, is every person that you predict is going to spend $25,000 in claims next year, definitely going to spend $25,000 in claims next year? No. Nobody has got a crystal ball that’s 100% accurate, but it’s worth the time and energy to invest in doing predictive risk modeling and the medical management that goes along with it. That’s really where you can begin to have a maximum impact on people’s lives, on what happens to them clinically and what happens to the plan financially.

So with the proactive model of medical management, we talked about where a group is going to perform in comparison to trend. You can really begin to have a good impact on spend. If you do predictive, then you can not only have the impact of proactive which will continue, but you can also flatten that trend out long term. So if you think of reactive as being right about trend, real-time slightly below trend, proactive cutting trend off, cutting that in half or stopping the flow of dollars, and then predictive as leveling that out long term.

David:        You say there’s products that are out in the market that do a pretty good job with predictive modeling. I remember years ago when I was with Humana. It was one of the things we chased and the number we always looked at was R squared – more colloquially I guess, how often you predict correctly. Where are those numbers at today? I know there’s a lot more data that’s flooded into those models that should have increased that.

Deb:           So it depends on whether you’re looking at clinical prediction or financial prediction. Most of the ones that are really worth using are going to be at least 80% accurate both clinically and financially. There’s always going to be that 20% the guy who drives his Lamborghini around the curve too fast and ends up in the side of the mountain that you can’t predict. At least 80% accuracy should be the threshold that you’re looking for as you’re shopping for those.

David:        So one of the things we talk about a lot on the podcast – and you may have heard us talk about it – is compliance, and how you get folks to actually engage. I know that you feel that Americans are kind of unique in that they don’t really respond to carrots. So that being the case, what do you use? Sticks, or orange sticks, or some combination of the two or…?

Deb:           It’s different from group to group to group. I think that’s one of the key characteristics. If you want to be successful in continuing to provide health benefits, but being able to do that in a financially feasible way, you have to understand your population and what works for them. Don’t get me wrong. I’ve got a group or two that their members will respond to a drawing for a $5 movie coupon. But those are pretty few and far between. Generally speaking, as Americans, we’re pretty affluent. Even offering somebody a big-screen TV may not be enticing to them. For the most part, you’re not really able to buy behavior. You may be able to buy participation, but participation isn’t going to generate the outcomes that you want if people don’t change their behavior. So it’s a real challenge.

I think the only thing that has truly worked in my experience… what I’ve seen work is an intensive education campaign and a culture shift within the organization, the employer organizations, since the employer is the one that’s providing the health plan. When you begin to get that happening, then your engagement rates go up. Engagement results in behavior change. Behavior change results in cost reduction. So it’s really appealing to the nobler motive as Carnegie would say. That seems to work best with the most of our groups or most Americans.

In other countries, things are different. As we travel the globe, we find that different cultures have different motivations. Most of the people that I work with…again, I work in a self-funded major medical health plan arena. So these are all people who are gainfully employed and they can pretty much afford the things that you would offer. Although I will tell you that I have seen groups be very successful, especially with the younger generation….so if the population of the plan is very young, offering incentives for things like extra days off, because we find that a lot of people in that millennial generation are seeking better work life balance, but again that’s not always as effective at getting the behavior change which is the real outcome that you’re striving for.

So it really boils down to education and changing the culture of the organization. It really has to start at the top of the organizations. So the C suite has to be on board and they have to be focused on this. They have to be focused on a combination of a couple of different things. They have to be focused on how do we improve the health of our members and simultaneously control the cost of our health plan. So that’s a balance that they have to be focused on. If they focus just on cost, we’re back in the old HMO world and that’s not going to get us where we want to be.

If they focus just on health – especially if the tenure of the population isn’t a long one – they may be investing in making that person healthy for their competitor when they leave and go to work for somebody else. So there’s a real balance there. The C suite has to be involved in setting up what that balance is going to be for their organization.

David:        There’s a lot of conversation going on around a topic that you may have bumped into called noncompliance. Where do you stand on noncompliant and working with noncompliant individuals as a tool to help move trend and to move claim spend?

Deb:           So that’s an interesting topic because as nurses we work with patients. The whole noncompliance issue is continual. You have to really step back and start thinking about things like Prochaska method and where somebody is on the stages of change scale and those kinds of things. There’s noncompliance for a lot of different reasons. We have to determine whether that noncompliance is what I call the result of free will. “I’m fully educated about the ramifications of my choice but I’m going to make this choice anyway,” versus noncompliance that comes from a position of lack of knowledge.

When it’s coming from a position of lack of knowledge, there’s a lot that can be done, by case management and in particular, medical management, to make sure that that person is equipped with all of the information, resources, support, guidance that they need so that they can make the best choice possible. I talked a little earlier about the HMO world. Most self-funded health plans at least don’t want to dictate treatment. They don’t want to be in the business of practicing medicine for their employees. They’re in the business of making widgets or whatever their core business is. They do want their people to have the information to make the right choices for them.

So distinguishing noncompliance into two different categories, the categories I call it a free will versus lack of information and education and then applying Prochaska method and motivational interviewing techniques and things to make sure that that patient has everything that they need.

David:        So we’ve got about a minute or two left. We always like to wrap up by asking our guests where they see the future. You certainly are out on the edge and doing some things that other folks maybe haven’t embraced yet. Where do you see your field going? Where do you see the future?

Deb:           I really feel like we’re at a great crossroads right now. I’m not sure that everybody in the industry recognizes it. I think especially with everything that’s happening politically, one of two things will happen. Either we, meaning those of us in the industry, will step up and revolutionize healthcare or we’ll end up with a single-payer nationalized healthcare kind of system. I think were at that point that in the very short term we’re going to have to make a decision as a country and go one way or the other.

I think that we as an industry have the capability. We have the tech. We have the mind power. We have the resources to truly revolutionize healthcare. I think that the tools are there. The question will become whether those who are providing health plans, the employers that are sponsoring health plans will get on board with it and will grasp it, and whether the big carriers will embrace it or not. Whether the big hospital providers will embrace it or not. I think that’s yet to be seen. I think we’ll go one of two ways. We’ll either revolutionize it and it will be a beautiful thing or we’ll end up in a nationalized system.

David:        Well that certainly is a stark choice and we’d love to have you back as that unfolds and talk to you more about where the direction is. Deb Ault, president at Ault International Medical Management. Nurse Deb, thanks for sharing your expertise with the Shift Shapers audience.

Deb:           Thanks for having me. I look forward to talking again sometime soon.

The Shift Shapers Podcast is a production of Strategic Vision Publishing and David Saltzman. This podcast may not be reproduced in any form, in whole or in part, without the express written permission of the producers. All rights reserved.


We spend a lot of time and effort on enrollment, but how can we use the other 364 days to gain engagement and create health care consumers?  

That is the question Justin Holland, CEO and Founder of Healthjoy will help us explore on this episode of Shiftshapers. HDHP designs have shifted more of the financial burden to employees, but that shifts a great deal of the knowledge burden to them as well.  As always, the question is how to engage employees.

We discuss the addition of artificial intelligence via chatbots and other techniques such as push notifications and video offerings in addition to the more traditional concierge-type call-in model. Justin offers his experience with those techniques and tools and more, on this episode of the podcast.

What You’ll Learn From this Episode:

  • Strategies for educating and engaging employees after initial enrollment.
  • That consumers actually care about their healthcare options.
  • What role artificial intelligence and chatbots will play in personalizing the user experience.
  • Why quarterly newsletters and posters in the office are not delivering enough information.
  • Where telemedicine is going and how utilization will evolve for the average consumer.
  • Why push notifications can help create constant consumer engagement.

Featured on the Show:

Listen to the Full Interview:

This Episode is Sponsored by:

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Episode Transcript:

David:       How can service at the point of question help to create cost containment and provide benefit satisfaction? We’ll find out on this episode of ShiftShapers.

Change either paralyzes, or energizes. The choice is yours. You’re listening to the ShiftShapers Podcast. You’re about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change that you want to see. Here’s your host and chief transformation strategist, David Saltzman.

David:        On this episode of Shift Shapers we’re speaking with CEO and Founder or HealthJoy, Justin Holland. They’re doing an awful lot of interesting stuff in the employee engagement space and helping folks become consumers, and Justin’s done an incredible deep dive into this, knows more than pretty much anybody I know, and so we’re honored to have him on the program to talk about where this entire field is going. With that, welcome Justin.

Justin:        Yeah, great David. Thanks to you for having me on the show. I appreciate it.

David:        We appreciate you sharing your expertise with the audience. Let’s start at kind of an interesting level set. We spend an awful lot of time in our industry focused on enrollment, but that’s a day or two or a week. It leaves an awful lot of time where we’re not really doing a great job engaging consumers. What’s the opportunity there? Why is that space important?

Justin:        Yeah, so what we’ve seen, or at least what I’ve seen from the space, at least when I say that’s more from the venture side of the business, that a lot of basically venture money, private equity money, has been really focused on the bed administration, the enrollment side, of getting people in an insurance. So really focused really only on that 15 minute period of time when a person is trying to elect for their benefits for the year.

I think when we look at it, kind of the main reason for that was the advent of the ACA and Obamacare where we were just showing, “Hey, there’s this massive opportunity. You have 20 million people. They’re gonna be coming on board and sign up for insurance for the first time.” So it kind of made sense that there was a lot of focus on, “How can we get people actually enrolled in insurance?” I think what ended up happening was that they thought that it was kind of the same paradigm that the carriers had been working under for the last 40 years was, “Okay, well let’s just get people on insurance, and that should be enough for the year.” If they log on once a year into their portal on the carrier or the payer site, then that should be enough for them effectively to satisfy the need of the insurance carrier.

But what we saw was that as this paradigm shifts to these high-deductible health plans and more burden’s shifting to the employees, that one-time-a-year login wasn’t enough to actually make them utilize their plan in a successful way. So we saw this as an opportunity with this tectonic shift in the market to say, “Look, the consumer wants to be more involved with accessing their benefits.” They’re not on these $500 PPO plans anymore where they’re just signing up and effectively they don’t have to make a decision. All they had to do before was go to the doctor, and they’re effectively … they’ve hit their deductible, and then they’re just utilizing the care on their plan for the rest of the year.

But when you’re having to spend $2,000, $3,000, $4,000, or even more for the plan through the year, the consumer was just kind of left to their own devices. They were left in a desert to go navigate to find water and to go find shelter. So we saw this as a massive opportunity for us, and really for the industry, to come in and say, “Look, people actually care about using their plans. People actually want to be consumers, because this is the first time that they’re actually looking at their pocketbook and they’re trying to make a good decision across all these myriad set of opaque, different options that they had across the space.”

So we saw that as the opportunity of, “How can we be there? Those are the 364 days a year, where you may have spent only 15 minutes making that plan decision, and how can we really focus on hand-holding, be helpful, and attack all those different pillars of cost that go into utilizing healthcare in our country today?”

David:        Part of the tectonic change, to use your phrase, that’s happened is because of the increased personal responsibility amounts because of the advent of consumer direct plans; we’ve had trouble as an industry actually connecting employees to the cost of their healthcare. You know the old saw is that, “There’s a whole swap of folks who think that an office visit actually costs $20, or whatever their co-pay is.” If you don’t connect them to the cost of their healthcare, how can they become consumers and what do you do to get them connected? How do you get over that hurdle?

Justin:        Yeah. The first way is obviously shifting the burden to them, right? That was kind of step one. We look at the last 40 years of health planned design changes. Really it’s just been a continual movement towards, “How can we put this burden back onto the employee or the individual?” from a cost perspective. That’s step one, right? Step one, they have to feel the pain. If you don’t feel pain, it’s very hard to get any disruption in any space. That’s kind of the same for really any industry.

Now that they have the pain, they still feel lost. So they have to have tools. They have to have the services in order to actually become a consumer. They have to have … And that starts with transparency. It starts with access. It starts with good data across the board. Without those things, it makes it very, very difficult to actually be a consumer. If you’re … It’s like going to the grocery store and there’s no prices inside the grocery store. You might have access to the grocery store, but if you don’t know what stuff costs, it’s hard to make a decision across any of those.

I think that the pain is very clear. The pain is something that is talked about … From the media perspective and from a government perspective, we all know there’s a pain. I think that we’re just starting to see now in the last three to four years there’s a lot of new companies that have come up that are starting focus on, “How can we give tools so that people actually can be a consumer today?”

David:        But among all the bewildering stuff, we’ve given people tools for a while now. You know how it goes in open-enrollment meeting. If I’m an employee I’m focused on, “What are the plan changes that are happening this year? How much more am I gonna have to out of pocket, and how much is my premium going up?” I walk out of that meeting, and if I remember those three things I’m a superstar. So now the year goes on, I don’t remember all these tools and things that I have, and I have a healthcare event, or I need to encounter the system in some way. How do we help them get through that maze and get them back to the tools that they need and help explain how those operate?

Justin:        Yeah, that’s a good question. That comes down to education and engagement, right? If you’re not able to … This reminds of most of the carriers that we work with. They have great programs and services that can do a lot of these different things, but there’s a little consumer DNA to actually get people to understand and how to use those programs and services that they have. Being top of mind, making sure that you have your program or your service or your strategy, is constantly communicating to those people.

Because the issue is, healthcare is such a funny thing, where I’m selling you this basket of goods at the beginning of the year, and most likely you’re not in a situation where you’re actually utilizing care at that point, right? At the first of the year or mid-summer of whenever your enrollment period is. Then three months down the line, or six months down the line, or however far down into the year, you’re expected to remember that 30-minute webinar that you had with HR going over what your benefits were for the year. That’s just an unreasonable expectation, and that’s why it’s so important that it’s constantly communicating and constantly educating on those plan … on that program design that exists.

That’s really the only way that it happens. There’s no magic bullet. It has to be a constant set of, flow of data and information to the employee or the individual about what they have. Communicating through quarterly newsletters or office posters isn’t enough. It’s not gonna help just putting your nurse hotline poster on the fridge inside your company’s bathroom, or company’s kitchen. It’s just not enough. They have to be constantly aware of what they have. So when that time, let’s say 2:00 a.m., or if it’s they’re having a pregnancy, or whatever they’re going through, they need to really have it top of mind so that it’s present to them when they actually have to make that decision.

David:        And yet, in the rest of the consumer universe, we don’t keep stuff like that top of mind. I agree with you that education and communication are critically important during the course of the year, but with all the communication that we’ve been doing, if you look at … I think it was last year’s Kaiser Family Foundation study about healthcare literacy … most folks still can’t explain what a deductible or a co-pay or a max out-of-pocket is. So it’s 2:00 in the morning, and I’m having some kind of a health event, do I just pull an app out of my pocket and call some kind of advocacy system? The reason is ask is, there have phone based advocacy systems now for a long time, and sometimes they’re more sophisticated than others, and sometimes they’re just interactive voice response systems. How do I handle that at point of pain?

Justin:        Yeah, no. That’s kind of the big thing that we see, is that the advocacy services today, many of them, are really focused on in-bound engagement. They’re really expecting you to remember once you have the … After that one enrollment you’ve had, they’re expecting to take their, that card, or maybe that phone number that they had in that benefits packet, and you’re supposed remember that you actually can go back there and actually use it. I think that what we see, to answer your question, I say, “Yes.” We see that ideally you are going back to this application, or an application or some other service where you’ve been constantly reminded to return to. So that when it is 2:00 a.m. you are top of mind, and the …

That’s really the challenge. The challenge in the space is really on the engagement side of, “How do we get people back into an experience consistently?” Whether that’s through a wellness narrative, whether that’s through HR or wellness communication, whatever that is. But the thought that if you’re gonna give someone a card or someone a phone number and expect them to be able to use that when they actually really need it, it’s kind of unreasonable.

David:        And now, a word from our sponsor.

Captivated Health is a single source solution for your clients and prospects in the education and engineering verticals. The founders of Captivated Health have 35 years’ experience working with healthcare and benefit clients, and over that time they’ve developed a keen understanding of the unique problems mid-market clients experience. Frustrated by a lack of control, the unpredictability of ever-increasing healthcare costs, and the pressures and regulations of the Affordable Care Act, these groups have been adrift in the fully insured commercial marketplace, until now.

Captivated Health has built a program that solves those problems, and does so with virtually no disruption to employees, while saving clients millions of dollars. We wanted you to be among the first to know that Captivated Health is building a national distribution partner network so you can bring this cutting-edge solution to your education and engineering clients that you advise. To learn more about Captivated Health’s solution, go to our website at, or click on our logo on the Shift Shapers website.

David:        A lot of the phone-based advocacy systems are getting some pick up from employees, but they’re not getting the kind of engagement that I think all of us would’ve wished. I know there are some new technologies that are being employed, some version or some form of artificial intelligence, chatbots. Would you talk about those two things in particular, and how those might increase employee engagement and employee comfort?

Justin:        Yes, and I think it goes back to my last comment on the idea of personalization to the user. There’s really no way to do that without a, really an AI, that can actually synthesize that data, understand the most applicable time to reach out to a consumer. We use a chatbot in order to make it a really comfortable interface for members. Where at this point, luckily Siri, Cortana, Google Now, have kind of made the concept, and Alexa, have made the concept of talking to your device something that’s very, very normal, where 50% of the country has actually talked to their phone. Which is kind of a funny concept, talking to the phone and expecting it to answer back to them with the correct answer.

So what we see is that really the only to scale a service in a way where you can have a multitude of outbound communication across the entire day and across the lifetime of the user, and understand the exact time to interact, artificial intelligence is really what has enabled us to be able to do that. In cases where the AI is not able to answer those questions, or able to actually satisfy the need, then it’s able to connect to advocates, or a concierge, or nurses, or even in case doctors, in order to address needs when those comes in. So your example of 2:00 a.m. at night, ideally you’re talking with the AI, and then the AI is able to triage you effectively somewhat similar to a healthcare professional, to appropriate level of care. Ideally, that’s just an advocate, but in some cases it could be a doctor.

David:        I know one of the other things that you’ve done an awful lot of research on is another tool that seems to have great promise, but isn’t really delivering on the level of employee engagement that one might think it is, and that’s telemedicine. Where’s that going and how is that going to improve so that we do get that kind of throughput that we need?

Justin:        Yeah, so there’s two really main things that affect the utilization of telemedicine. The first one’s regulations, so making it easier and more accessible to members and having a wider range of scope of services. Telemedicine started off with a very narrow set of services that it could handle. Now there’s the services started to include behavioral health, specialists, HIPPA is starting to get involved. There’s second opinion options, and that kind of scope of services has expanded.

So what we see is the main problem with telemedicine is that people don’t really understand what that scope of services is. When you’re talking, it’s 2:00 a.m. and your two-year-old has a fever and you’re freaking out, you’re first inclination is, “Well, telemedicine could never satisfy this need.” And it can, and so I think that’s where we see having a comprehensive solution up front where you’re saying, “Hey, come for anything. Any question you have, whether …” However, obviously if it’s an emergency situation you should go to the ER directly, but if it’s a level below that how can we educate you in that process to understand that telemedicine is something applicable?

I think that’s the main thing that we have seen is that people really don’t understand. If you think of the funnel of a lot of these carriers are putting out their own telemedicine programs, for someone to remember to go to the carrier site that they go to once a year, which is hard enough. Then finding it on their site, which is buried. Then understanding that, “Hey, I have specific need that this is actually gonna satisfy,” and then going through process is very, very low. So what we see is, and we get excited about is, “How can we steer you from a need that you might not understand that is working with telemedicine?” So if you come and you say, “Hey, I have this weird abrasion on my skin. I need to see a dermatologist.” We say, “Well, wait a second. This is something that’s applicable to telemedicine.”

I think that’s where we’ll see the industry moving, is that these services will be focused more on, “How can we direct you to these lower cost of care?” Sometimes telemedicine won’t be the answer, right? Sometimes it’ll be retail clinics. Sometimes it’ll be urgent care. In some rare cases it’ll be ER. But really the point is, is that people don’t understand really what the scope is today. It is only going to improve, and then as those regulations change and it’s wider and wider scope of service, then it’ll become more of a commonplace and every day care for people in the country.

David:        Justin, in the few minutes that we have left, I’d like to cover something that we haven’t talked about, because we’ve taken this all from the employee’s aspect, the employee’s standpoint. But at the end of the day, risk management is critically important, and mitigating costs trickles into the employer. What kind of an impact can more robust services like this, that help employees engage, have on an employer’s bottom line?

Justin:        Oh yeah, no absolutely. It’s all about cost containment.

David:        Yeah, the-

Justin:        I guess there’s … It’s more than just cost containment, it’s also benefit satisfaction, which it’s … That’s also a level for the understanding that HR has spent a lot of time, along with the benefit consultants, organizing these plans for their employees. You really want people to use everything that you have put together for these plans. So making sure that utilization, not just for telemedicine, or the nurse advocacy, or for your accidental, or your life insurance, or whatever it is, is being used, but really that that’s all understood. Then making sure that that program is focused on attacking the pillars across the landscape is important.

If you’re looking at a program and they’re not talking about, “Hey, this is going to cost you less in claims per year, and it’s going to cost you less in claims by the amount of cost of the program,” that has to be part of the conversation. If it’s not really a 30-day ROI, then it’s probably not a program that’s gonna work well. I mean, there’s plenty of different strategies across the … across prescriptions, across procedures, across the diagnostics, there’s a lot of great services and programs and things that exist that allow us to focus on, “How can we really mitigate cost? How can we get in front of these different pillars and really make an impact?”

We get excited when integrated with TPAs, and being able to understand at-risk populations. Being able to outbound against those populations and make sure that, “How can we be more involved in their chronic management of their diseases?” So it’s really about cost and satisfaction. I think that depending upon where certain companies are, it’s really a different need for the different companies in the life cycle that they’re looking at.

David:        In the minute that we have left, we always like to wrap up where we can by asking the question, “Where do you see the future?” Where do you see all of this technology and all of this interaction going? What’s your vision?

Justin:        Yeah. The way I see it is that healthcare should be just like Siri, right? With correct answers, which sometimes Siri today doesn’t do that well of a job, or Alexa.

David:        I’m glad you added that.

Justin:        Yeah. I think that in 10 years, I like to think that … I think what’s so difficult about health in general, is that there’s a lot people in the space that can look at individual aspects of cost, or individual aspects of care, and they say, “Hey, I have a solution that’s gonna work well with this.” But they don’t take in account plan design, and they don’t in account the broker relationship, and HR, and understanding, “How can fit this into wellness programs? How can I synthesize all this different data and make it applicable to this individual or employee?”

I see that’s where the power of machine learning and AI over the next 10 years is going to allow us to synthesize more and more of this data at point of care, or really at point of question, and get you something that’s incredibly compelling from a decision point of view. I see that that’s where we’ll be, and from a regulation perspective and how things move, we see more and more burden shifting to employees. We know HSAs will be big next year, so that’s just more indicative that, “Hey, there’s probably gonna be more and more focus on the employees to be more responsible for pay.”

So there’s gonna be further and further consumerism across the space. So we’re really excited about the future. We think that putting the decision to the consumers, right where it needs to be, because we’ll have to break down the walls of opacity. I think that we’re gonna have a very, very transparent healthcare world within 5 to 10 years, and I think we’re all really excited about that.

David:        That’s a great vision, and something that I think of us have been looking for for quite some time. Justin Holland, CEO and Founder of HealthJoy. Again Justin, thank you for sharing your expertise with the Shift Shapers audience.

Justin:        Yeah, great. David, thank you so much. Appreciate it.

The ShiftShapers Podcast is a production of Strategic Vision Publishing and David Saltzman. This podcast may not be reproduced in any form, in whole or in part, without the express written permission of the producers. All rights reserved.



Last week the Senate failed to bring their reconciliation bill to a vote. Nationwide, the individual market is in trouble and advisors need to know what to tell their clients.

In Jessica Waltman’s quarterly conversation with the ShiftShapers audience, she offers her unique perspective on what really happened on the Hill and where we go from here. We explore whether the 2015 clean repeal bill is still viable and whether single payer is inevitable.

What will get added to the CHIP reauthorization bill that comes up in the Fall and how much change can it actually make? What can we expect and how do we advise clients? Jessica shares those answers . . . and more.

What You’ll Learn From this Episode:

  • The actual state of PPACA, and which components are working or failing.
  • What happened to the Senate’s reconciliation bill and why they’re facing so many challenges.
  • Why repealing now with a 2-year grace period for replacement is proving difficult for Republicans.
  • What recommendations have been made to HHS Secretary Tom Price.
  • Jessica’s expectations for the coming months of healthcare policy debate.

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Listen to the Full Interview:

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Episode Transcript:

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David:        Repeal and Replace didn’t even come up for a vote in the Senate. So now what happens? And what do you need to know to advise your clients? We’ll find out on this episode of ShiftShapers.

Change either paralyzes, or energizes. The choice is yours. You’re listening to the ShiftShapers Podcast. You’re about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change that you want to see. Here’s your host and chief transformation strategist, David Saltzman.

David:        This episode of the ShiftShapers Podcast is brought to you by Captivated Health, a captive insurance arrangement that helps small and mid-market companies escape the fully-insured marketplace and deliver stability, control, and savings without watering down employees’ benefits or increasing their premium share. If you have clients in the educational institution or the engineering vertical, go to our website at, or click on the company logo on the ShiftShapers website.

David:        It is time for our quarterly visit with Jessica Waltman. Jessica, as listeners know, is the Principal at Forward Health Consulting, but she’s also our resident expert on all things legislative, political, and regulatory. By way of setting the stage, we are recording this on Tuesday, July 18, 2017. We never do that, but it’s important, especially today, because this morning, Senate Majority Leader Mitch McConnell pronounced healthcare reform dead in the Senate. We’ve got loads to talk to Jessica about, but first, let’s say welcome.

Jessica:     Hi, David. It’s great to be back on the podcast.

David:        Always great to have you share your wisdom with us. We can get into the legislative stuff before, but let’s level-set and talk about the predicate. What is the actual state of PPACA in whatever markets you want to talk about?

Jessica:     Well, I think that most of your listeners understand this very well, but perhaps their clients don’t, their mother might not, their neighbor that’s asking them about it. The ACA is a thousand-page law. It has about 40,000 pages of related regulations. It has huge sections related to Medicare, Medicaid, the employer market, other programs. But what they’re talking about when they talk about “the ACA in a state of collapse” on television is of course the individual market, which covers about 7% of the US population. The individual market in a number of states obviously is suffering from a lack of competition, particularly on the exchanges, because there’s also a difference between the individual market generally and individual market insurers that want to participate in the exchanges.

When they say Obamacare is failing or the ACA is failing, I think what they’re really referring to is the individual market. It’s I think very important to keep making that distinction, because agents and brokers that may be listening to this or other people in the industry, you may be working with employers, employees that are hearing, “Every health insurer’s leaving our market,” and that’s probably not really true for them.

David:        With that said, the question is, what the heck just happened?

Jessica:     The House and the Senate made a choice a while ago that they would not try and work with any Democrats at all and they would try and create this Repeal and Replace legislation using the constraints of the budget reconciliation, which really limited what they could actually tackle. As we talked about before, the legislation that the House passed and the Senate considered really did not address most aspects of the ACA, and it really only did things that had to do with dollars and cents. For example, the employer market. It said it repealed the employer mandate. It didn’t. It just zeroed out the penalty. It was a very constrained piece of legislation.

Since it was a setup for a comprehensive tax reform, they decided to include a whole big component of it that really had nothing to do with the ACA. It was a reformat of Medicaid spending in the future. We had a very limited bill that did not fully repeal the ACA and made massive changes to Medicaid, and it really exposed a big divide in the Republican Caucus. No one really liked it. It wasn’t doing what they had promised to do for the past seven years, and it really never could. It’s not really surprising that it blew up in their faces.

Now we are where we are. We have a House-passed legislation. They went out on a limb there. We have the Senate unable to bring a reconciliation bill that addresses the ACA even to the floor, even to consider it. They did not have the votes that they needed to bring it, after trying two times to revise the legislation. Then, today, Senator McConnell said, “Well, we’re going to bring a clean repeal bill to the floor. We’re going to just repeal the ACA flat out and give ourselves two years to come up with a replacement, because we cannot come up with replacement language now.” They weren’t talking about just making tweaks to it like the original bill did. They were talking about repealing the entire thing.

As of when we’re recording, at least three Senators have said that they will not play a game of chicken over the next two years and try and craft a new replacement bill, so they will not allow Senator McConnell to even bring that measure to the floor of the Senate. Right now, they’re at a stalemate. They cannot bring anything up, and they’re going to have to regroup.

David:        Was that in part a way to build a firewall for the midterms?

Jessica:     Yeah, probably. He needs to get people on the record. Then, also, obviously there’s a huge amount of public backlash. This situation has made the ACA more popular than ever, because one of the interesting things that I think the Republicans did was they really didn’t communicate why they were doing this or any of the advantages or where any of the problems lie. Any of the good improvements that were their bill, some of the changes to HSAs or …

Just for an example, the ACA raised the limit, the increase in tax on the amount a person can deduct from their individual taxes if they have catastrophic medical expenses. It used to be 7.5% of the AGI, and the ACA raised it up to 10%. This was going to put it back to 7.5%. Now, I have a child with a catastrophic medical condition, so we have really high medical expenses, so for me this was really good news. I really saw that 2.5% tax increase as a tax against children or families with super high-cost medical expenses.

Instead of making a big deal and saying, “Hey, the ACA raised taxes on all of these poor families with really ill children, and we’re going to roll it back,” the Republicans said nothing. They didn’t make any big deal about that at all. There were lots of provisions in both versions of the bill that could’ve helped people. They didn’t do any PR campaign about any of those at all. Now they’re really stuck.

They’ve got the ACA super popular, and they have to answer to their constituents that really do not understand why in the world they were considering this to begin with. But they also have to answer to some of the mega donors in the Republican Party. A lot of people know of the Koch brothers, but there are lots of other people like the Koch brothers but less famous that contribute millions and millions of dollars to super PACs that help Republicans up and down the ballot in the states, and they all pretty much came together about two weeks ago at a meeting and said, “We’re not going to give you any more money if you do not do a full repeal.”

By holding this vote where he tries to flat out repeal the ACA and then do the two-year delay, Mr. McConnell does a bunch of things. He lets people go on record saying that they do oppose that, if they’re in a district where that would help them. It lets him say to the mega donors, “I held a vote. I couldn’t get it done. It’s not my fault. You can blame the Democrats or these moderate Republicans or whoever you want.” It also gives him a stopping point so that he can move on to other things, because we have to raise the debt ceiling. They would like to do comprehensive tax reform. They have to do the appropriations bills. They have a very short legislative timeline left, so he needs to move on to something else.

David:        You’ve been around the Hill a lot and you know an awful lot of what goes on there, both the part the public sees and the stuff behind the scenes. They did a clean repeal back in 2015. Obviously, as you just said, they’ve already lost three votes, but a lot of the folks who voted for that in 2015, knowing full well that it was going to be vetoed if it got to the President’s desk, aren’t going to vote for it now. Is it a lack of political courage? Is it politics? Is it policy? What’s the driving factor there?

Jessica:     There’s a couple of things. First of all, several of the people … You have Susan Collins, who did not vote for that in 2015. I think Lisa Murkowski did. The three people so far that have said that they won’t for this are Shelley Moore Capito, Lisa Murkowski, and Susan Collins. Susan Collins didn’t vote for it in 2015. Shelley Moore Capito was not in the Senate then, so she doesn’t have a record. Lisa Murkowski maybe has flip-flopped, but she doesn’t really have to worry. She is in a very safe seat in Alaska, and Alaska stood to lose a lot.

One of the differences that I think other people that may come stand behind them, and people like Bob Corker, Tom Cotton, that were concerned about this idea, was this isn’t a straight repeal. This would be a repeal with a two-year delay, so there would be no replacement right away. When they voted in 2015, they voted to replace it with a bill that had been largely authored by now HHS Secretary Tom Price. Was that a great replacement? Who’s to say? But they had something to go right away. This would be repeal with a big question mark.

That would put not just the individual market, which is already in trouble, in peril. It would also put employer markets, people in Medicaid, people in CHIP, Medicare … The ACA is a thousand-page law. It made all kinds of changes to Medicare programs, other things that really are not problematic right now. To have that all turned back possibly in two years would really send providers, insurers, employers, insured individuals into chaos.

I think that their excuse is going to be, or their rationale is going to be, that we cannot just go for two years and have an unknown. The market … It would just be too destabilizing.

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But in the meantime, they need to reauthorize CHIP. What’s going on with that?

Jessica:     The CHIP program needs to be reauthorized by September 30th. They already talked just cleanly reauthorizing it, which is what they’ve done the last few times that they needed to do that, so just extending the same amount of money. But it is a healthcare bill that needs to go through the related committees, and so it is possible … Going back to what we talked about in the very beginning of this podcast, what is really in trouble here? It’s the individual market, and particularly the exchange individual market.

Senator Lamar Alexander, who chairs the Health, Education, Labor and Pensions Committee in the Senate, has a bill that he introduced this spring, kind of a fallback measure, that would allow individuals who live in a state where there are no carriers in the individual market exchange the ability to use their tax credit money off-exchange, and it would have provisions for those who only have one or two carriers available. He said today that as soon as Senator McConnell holds this vote to proceed on a motion to repeal and delay for two years and that fails, which they would like to do very quickly, his immediate plan is to hold a hearing and start regular order on some individual market fixes.

My guess is that they may use the CHIP reauthorization or another moving vehicle in the short term to make some immediate market fixes. They may also address the issue of the subsidies, the cost-sharing subsidies and whether or not they’ll be funded for the next year or two to give some certainty to the markets, and they may be able to tack something else on. The CHIP reauthorization, really, it could go through cleanly and they could do all this attached to another measure, but it’s a logical vehicle that they have to vote on pretty soon where they could at least slap some Band-Aids on this.

David:        Against all of this background of stuff that’s going on in Congress, HHS Secretary Dr. Tom Price has made a request for information. What do you know about that? What’s come in? What kinds of things are you hearing? What do you think might happen with any of that stuff?

Jessica:     When they started talking about this Repeal, Replace, Repair earlier this year, they talked about doing it in three phases: the reconciliation, then a bunch of regulatory fixes, and then some market reforms to come later. Phase one, the reconciliation, fail. Now it looks like they’re going to move onto phase two, which they always wanted to do anyway, but now it becomes even more imperative. Secretary Price issued a request for information from really anyone in the middle of June. There was 30 days to provide comments. The comments were due last Wednesday.

What he asked for was for insurers, agents and brokers, employers, hospitals, anybody that had an interest to provide information for him to hit on four key issues: How could he improve enrollment and getting consumer information out to people, particularly in the individual and small group market? How could he improve affordability, particularly in the individual and small group markets, but really anywhere? What could he do to reform markets and what adjustments could he make that way relative to ACA rules and other rules that might be hurting the marketplace? Then, also, what could he do to give additional power back to the states, who have always traditionally been the prime regulator of the business of insurance? This is really to carry out the President’s executive order that he signed on the first day in office trying to ease the regulatory burden on individuals and employer purchasers of health insurance.

He got a wide range of responses. I can probably give you the link. We could link to it in your show notes. You can read them. They’re publicly available on if you are a weirdo like me and you like to read those types of things. You could see what groups like the Chamber of Commerce and the American Cancer Society and NEHU and other groups recommended. I can tell you that there is a wide range of recommendations of things that they could do via regulation to make things easier or smoother.

For those in the industry listening in this podcast, this is the stuff where, nuts and bolts, things might change that could either impact costs slightly or impact compliance requirements slightly, make things possibly easier and more efficient in the years to come.

David:        We’ve got I guess four minutes or so, maybe a little bit longer left. Let me throw out the bomb that people are starting to talk about. You hear this in industry meetings. Nobody really says it out loud, but if you’ve got a cocktail in your hand, the discussion is, “Is single-payer inevitable?” What’s your take on that?

Jessica:     I have to say, one of the most disappointing things about everything that’s gone on over the last seven, eight months or so to me is what I mentioned before about the Republicans conceding a lot of points and not really communicating and explaining themselves. I am very concerned about the haste and disorganization in which they rolled out their efforts and really didn’t sell things to the American people correctly. They ceded a lot of ground. For example, the whole concept of high-risk pools. I think that they really sold that very badly. Or age rating, where even states like California before said, when the health reform age rules of three-to-one were implemented, “This is too much too fast.” You had the very liberal elected Democratic Insurance Commissioner of California saying, “Whoa, back. These age band rules are causing premiums to rise too steeply in my state.”

When they put them into the Better Care Reconciliation Act and the American Health Care Act, returning age bands to just five-to-one versus three-to-one — in many states they were eleven-to-one before the ACA — with no explanation, now it’s an age tax. High-risk pools, which, some states they functioned well, some states they didn’t, I would be happy to go into a super nerdy discussion about them that no one would want a listen to, so we won’t do that, but they weren’t the devil that they were made out to be on TV.

Unfortunately, a lot of ground was ceded. I am very concerned that a lot of people that maybe would’ve been more agreeable to some of these changes now can’t do that, or there’s going to be a lot of PR work that needs to be done. I don’t think single-payer is inevitable, but I do think this whole effort was very damaging to those that support a more free market return to health reform. Maybe we do need a little bit of a cooling-off period, and then hopefully start with some small changes to the individual market and work from there.

But the individual market does need to start functioning a lot better, or I am afraid that people that don’t want to get super nerdy about health reform are just going to think that single-payer is inevitable. That in and of itself would be a whole huge debate. We would need a complete power shift in Washington, which of course could come in the next two to four years, but it’s not a certainty.

It’s very, very expensive. States that have tried it independently have all been unable to come up the financing. I don’t know that it’s inevitable, but I am really disappointed. I think there’s a lot of PR work that needs to be done. It’s not just PR. It’s explaining that there is a method behind this madness, that some of these policies are not intended to be cruel to people. They’re just trying to manage risk. We’re trying to be more transparent about costs. Medicaid may need reforms to be sustainable moving forward. There’s going to be a lot of explaining that needs to be done that unfortunately was not done over the last few months.

David:        I will tell you, as a communications guy, I spend a lot of time screaming at the television set. It’s a good thing that I have thick walls and no neighbors who are really close to me, because it is frustrating to watch the amazing inability to message and to be up front with these issues. But that gives us a lot to talk about on our next quarterly visit. With that, I’ll say, Jessica, thank you very much. Jessica Waltman, Principal at Forward Health Consulting, we always love speaking with you and we learn so much, so thanks for sharing your expertise.

Jessica:     Thanks, and I look forward to talking to you again soon.

The ShiftShapers Podcast is a production of Strategic Vision Publishing and David Saltzman. This podcast may not be reproduced in any form, in whole or in part, without the express written permission of the producers. All rights reserved.


Group Medicare may sound paradoxical, but it can help expand your practice while freeing up significant benefit dollars for your group clients. Jason McClellan is the President & CEO of Insurance Advisors Direct-Agency, LLC, and knows exactly what you need to do to take advantage of this rapidly growing practice area.

In this episode, Jason explains what Group Medicare is and how different products work and how they can expand your practice while providing a cost-effective solution that often provides a better offering for retirees.

What You’ll Learn From this Episode:

  • What group Medicare coverage is and how it works.
  • What group sizes can take advantage of these products.
  • How an advisor can learn about this market, the products, and how to add it to their practice.
  • What the employer conversation looks like.
  • What markets are open to this type of arrangement.
  • The vocabulary and training required to understand and educate others about Group Medicare products.

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Al Lewis, our guest on this episode of The ShiftShapers Podcast, is a serial entrepreneur, author, renaissance man, and the CEO of Quizzify. Quizzify is a healthcare education app that uses fun and games to teach employees how to buy and use healthcare. The service makes for smarter consumers and saves their companies a lot of money in healthcare costs.

In this interview Al shares his interesting journey, beginning with his time at Harvard Law School and culminating in the creation of Quizzify. We discuss current healthcare literacy issues, how to get employees excited about learning, and Al’s unique approach to solving these problems. We also cover how Quizzify integrates with a company’s wellness program and what employer conversations about healthcare and education look like.

What You’ll Learn From this Episode:

  • How got Al credited with inventing Disease Management.
  • What it will take to increase health care literacy.
  • How to engage employees in learning more.
  • The crucial difference between wellness and wellbeing.
  • The risks of doing too many CAT scans.

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The story of our industry over the last decade has been one of mergers and acquisitions. The ACA has propelled new levels of activity as benefit advisors are leaving the industry and selling their practices. This episode’s guest is in the middle of the action, and here to share his expertise and opinions on the advantages some firms have found by becoming part of a larger organization.

Brett Rosen is the Executive Vice President of Mergers & Acquisitions at One Digital, formerly Digital Benefit Advisors. In this interview, we discuss the most important things driving the M&A wave and how advisors are finding opportunities to join forces with other practices to create new practice models that deliver incredible value to their clients.

Later, we lay out the steps that agencies and their owners can take to prepare for merging, and why being acquired might be a good future strategy. Equally important, we also consider the view of larger firms and what they consider when they are buying another business.

What You’ll Learn From this Episode:

  • What is driving the recent uptick in M&A activity.
  • How PPACA has impacted the process.
  • The advantages that come along with a merger.
  • What agencies can do right now to prepare for a future merger or acquisition.
  • What purchasers look for when buying a practice.

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On this episode of ShiftShapers, our guest and I discuss the new and diverse tools that advisors within the insurance industry are using to market their businesses. The fastest growing method happens to be video, and Bart Camarata is an expert on the topic.

Bart is the creator and host of BenefitAdvisor TV, where he leverages his Middle Tennessee State education to produce quality video content. Bart takes on some preconceptions about video – is it expensive to get started? and is it difficult to get started? We also discuss how advisors and agencies can begin to use video in a variety of ways to market their practices. 

Listen in as Bart shares his thoughts on why he believes the video is the “King of All Media,” and explains how simple it can be for advisors to get started with the medium. We wrap up by laying out how video builds businesses and constitutes social proof in today’s market.

What You’ll Learn From this Episode:

  • The immediate advantages of video, including its ability to hit emotional chords better than other media.
  • Why video marketing is not just a “carrier thing.”
  • How advisors can get started with video.
  • How modern technology allows you to avoid breaking the bank and produce great content.
  • The ways that videos achieve social proof.

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Mark Gaunya and Jennifer Borislow continue their discussion from last episode about why healthcare is so expensive and share their ideas to slow rising prices. With the release of the second edition of their book Bend the Healthcare Trend, Mark and Jennifer are advocating for consumer-driven healthcare as the solution to rising expenses.

In analyzing the healthcare system, inflation greatly outpaces the general economy. Our guests explain why the industry’s prices rise so much faster than those of other industries, largely due to a lack of transparency or tangible competition.

Opportunity will grow from greater industry transparency and responsibility, as consumers will save money and maintain better health. We need to look beyond physical health and appreciate mental, spiritual, and financial health as well.

What You’ll Learn From this Episode:

  • The three essential principles of healthcare’s oncoming trend: Transparency, Responsibility, and Opportunity.
  • Why healthcare is the only industry where consumers don’t shop around.
  • What opportunities flow from responsibility and transparency.
  • The difference between wellbeing and wellness.
  • Why there has been an uptick in interest around self-insured plans. 
  • How companies of all shapes and sizes can approach a self-funded health plan, and how an advisor can approach that conversation.

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Nine years ago, Mark Gaunya and Jennifer Borislow wrote “Bend The Healthcare Trend” to explore how healthcare consumers could counteract the damaging effect of a system with misaligned incentives, opaque pricing schemes, and unnecessary complexity. They are about to release the 2nd edition of their definitive book and ShiftShapers talks to them about how much has changed; and how little has changed!

The authors believe that what has not changed is that consumerism and transparency are still the answer to an industry that remains unnecessarily confusing, even for many folks within the industry. The average layman stands no chance in a system created by the rule makers, for the rule makers.

Our guests lay out how the government, Big Pharma, hospital systems, and health insurance companies are incentivized to stop price deflation and maintain complexity.

The second edition is peppered with actual examples of how they have used the principles in the book with their clients – and the success those clients have enjoyed in gaining control over their plans while delivering a climate of health and well-being for their employees.

Mark and Jennifer also outline what has changed since the first time they wrote about consumer-driven healthcare in 2009. The lack of transparency in the market is still an issue, but organizations are starting to deliver tools that aid consumers in making choices.

Be sure you tune in for Part 2 next week!

What You’ll Learn From this Episode:

  • What prompted Mark and Jennifer to write the first edition of their book in 2009.
  • What has changed since then and why they’ve felt the need to update amidst our unsettled healthcare environment.
  • Who are rule makers that construct our healthcare system.
  • What it will take to de-isolate consumers from the cost of care.
  • How employers can take advantage of new legislation to provide healthcare to employees.
  • What it will take for more consumers to demand transparency.

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