Talking politics and benefits is like walking a tightrope in heavy winds, but our guests say it can be done without falling off.

With healthcare so tied to politics these days, many advisors feel they have no way to avoid the subject when speaking with prospects and clients. Can you maximize your impact as an advisor and remain politically neutral? Jess Waltman and Dave Mordo say, “yes”.

In fact, they believe that if you do it the right way, that conversation helps to position you as an expert. They provide some real-life examples that show how having those discussions can provide a real business advantage. Jess and Dave caution that you have to know your audience and offer techniques (such as turning the conversation to compliance) to offer a safety net for those “other” parts of the conversation.

What You’ll Learn From this Episode:

  • Can you actually talk politics with your clients?
  • The importance of differentiating between politics and policy.
  • Why talking politics in the right way can demonstrate your expertise on the subject matter.
  • How to talk about political topics in the right way.
  • Different strategies to use when politics are involved.

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Eric Silverman is one of the most disruptive forces in the area of “enhanced benefits”. You may have been calling them “voluntary” or “ancillary”, but Eric is passionate in his belief that neither of those words make the case for a benefit offering that is more important to clients and employees than ever before.

In this fast-paced interview, Eric explains how advisors interested in enhanced benefits fall into four distinct classes and delves into which group you want to be in for maximum productivity and client satisfaction. If you are currently active in this space or if you have been on the sidelines thinking about how to incorporate these solutions into your practice’s offerings, make sure to listen to this episode.

What You’ll Learn From this Episode:

  • Why language is important and the specific messages it sends when it comes to benefits.
  • What the four classes of advisors are as it pertains to enhanced benefits.
  • What two keys are for success.
  • If and when using professional enrollers is practical and advisable.
  • Why the current marketplace and today’s plan designs are driving enhanced benefits.

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ShiftShapersCoverArtEvery time talk turns to single payer, folks use the Canadian healthcare system as a reference. How does that system really work and does it provide better care for our northern neighbors?

For answers, we went to our Canadian friend Ron Hansell, President of Cross Border Benefits. We start by asking Ron for an overview of their system – just to level-set the discussion. He explains how their system is paid for, what it costs and how their citizens interact with it.

We discuss some of the results of a recent Fraser Institute study about how their costs are rising and how and why so many Canadians seek care abroad – most in the United States. We also look at the effect of ever-lengthening waiting times for treatment that seems to be inherent in their health care arrangement.

An ever-growing number of U.S. companies have a presence in Canada, and Ron explains what those companies and their advisors need to know to advise them properly.

What You’ll Learn from This Episode:

  • What the Canadian Healthcare System is like.
  • What the Canadian system costs.
  • How Canadians interact with the system.
  • How lengthy wait times drive Canadians to the U.S. for healthcare.
  • What U.S. companies need to know about benefits in Canada.

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Last week we explored buying leads. This week, in part 2 we will discuss how to maximize the potential of those purchased leads.

If you were surprised at how much has changed if you are buying leads, our guest this week, Don Runge, President of DMR and LeadGuru, believes that the established methodologies still work best for getting the most out of those leads.

Don contends that advisors need to make a “mind-shift” that challenges a lot of what they may believe about working leads. He also cautions that a lead is not a sale, but rather, a convenient excuse to begin a conversation with a prospect.

You will learn why CMA is more important than PMA and we will discuss the three things you need to work on before you call on those leads. For good measure, (and probably because we recorded the interview at lunchtime), we throw in a quick discussion of Chicago-style pizza!

What You’ll Learn from This Episode:

  • What the big issue is with acquiring and using leads.
  • What mind-shift advisors need to make.
  • What the most affective approaches are.
  • How to define a lead if it’s not a sale.
  • Why CMA is more important than PMA.
  • Three things advisors need to work on before they call.

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ShiftShapersCoverArtBuying leads has become more of a science than an art and the process is infused with new technology that helps you treat each lead like a $1000 bill.

We asked Richard Bufkin, President of Target Leads to update us on lead purchasing, a traditional process that has been brought very much up to date. Richard is the second generation of a business that is 32 years old and that has been in his family for 25 years, so he has seen that evolution up close and personal.

During our conversation, Richard also dispels some commonly held beliefs. For some products, fancy mailing pieces generally do not perform better than plain old black and white mailings. We learn how reply options have changed greatly – including “PURLS” (personalized URLs).

We learn about the critical importance of an integrated CRM and how your response time may dictate your success. Richard also talks about clustering, and resting zip codes.

What You’ll Learn from This Episode:

  • How Target Leads – a family business – has changed over time.
  • What’s new in lead purchasing.
  • Why CRM systems are critically important.
  • What “clustering” is and how it affects lead generation.
  • Why Richard will lock out leads for 90 days.
  • Which is more effective – fancy color mailings or plain old black and white.
  • What PURLs are, and why they’re so crucial to getting exposure.

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Drug costs are soaring and driving more of medical spend than ever before. The good news is that there are tools coming to market to help consumers and plans alike.

That is what our guest, Gary Becker, CEO of ScriptSourcing and I discuss on this episode. We begin with an exploration of why prescription drugs are so much more expensive in the United States than they are in other countries. We discuss the particular drugs that are driving the pharma cost component to all time highs.

Gary explains the three strategies being employed by many plans and discusses how advisors can have this conversation with their clients. We conclude our conversation with Gary’s view that advisors must start charging for their services on a quantifiable, performance-based structure.

What You’ll Learn From this Episode:

  • Why drugs are so expensive in the USA.
  • How pharma is driving medical spend consistently higher.
  • The expected increases in pharma costs in the coming years.
  • What constitutes international pharmacy management.
  • How specialty meds fit into the pharmacy market.
  • The landscape of international pharmacy tourism and its effects on the pharma market in the US.
  • Whether advisors should bring this model to their employers, and whether they should get compensated on a percentage-of-savings basis.

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ShiftShapersCoverArt“Consumer” and “shopping” go together everywhere in our lives – except in healthcare. What would happen if consumers could easily shop for non-emergency surgery and get bundled pricing, all with the help of a concierge to guide them through the process?

That is the question that Dr. Sanjay Prasad, Founder and CEO at SurgiPrice discusses on this episode. We begin by discussing how the current system has trapped patients and employers and forced unnatural consumer behavior. A surge on himself, Dr. Prasad has designed a system that helps to correct this anomaly – at least, for non-emergency surgical needs.

He acknowledges that it might be difficult for patients to understand and assess the price and quality metrics and believes that a concierge can help. We also explore what happens when a consulting surgeon indicates that they feel a surgery might not be medically necessary, and how a patient’s primary care physician deals with that second opinion.

Finally, we explore the notion of bundled pricing and how much plans can save versus the itemization that has become the standard – until now.

What You’ll Learn From this Episode:

  • Why bundling costs can have a lot of benefits.
  • Why consumers haven’t been able to shop for non-emergency care.
  • Why this is the perfect time to bring this pricing tool to consumers.
  • How benefit advisers can add this option  to their practice.
  • If fully insured carriers are interested in bundling costs and consumer-driven surgery selection, or will be dismissing the concepts.

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Episode Transcript:

David:     How would the market change if consumers could shop for nonemergency surgeries and pay bundled pricing, too? 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 delivers 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.

We talk an awful lot on the podcast about consumerism and more to the point, the lack of consumerism, the lack of individuals to be able to move markets in ways that they want that makes sense for them, and to discern pricing. We’re very excited this morning to be talking to Dr. Sanjay Prasad. Dr. Prasad is Founder and CEO of an organization called SurgiPrice. He studied this area and this problem. They’re working very diligently on trying to bring some tools to market that will impact that in a very significant way. With that, welcome Sanjay.

Sanjay:      Well, thank you, David. It’s an honor to be on your show. I think very highly of you and your show. Thank you.

David:        Well, we appreciate that. Thank you. A little bit about your background so that folks understand where these solutions … What part of your brain these solutions are coming from?

Sanjay:      Well, I’ve been a practicing surgeon for 25 years. I’ve seen patients come and go, and I’ve seen my colleagues, and how they operate, and how things work in a hospital setting, how things work in a surgical setting in an ambulatory surgery center, what the costing is, the finances, et cetera. I am absolutely flabbergasted by the system we currently have that has not evolved. We have a system now where patients are herded from primary care doctors to specialists without any regard to costs, without any regard to quality, the quality of care that’s delivered. This is absolutely unbelievable. We don’t shop for anything else in this way, but in healthcare, patients … and I can easily be a patient, and you can easily be a patient. We are herded from primary care doctors to specialists without any regard to our needs. So, it’s horrible what’s happening out there.

David:        To what do you attribute that? I mean, it doesn’t happen, or more to the point, I guess, we don’t allow it to happen in any of our other consumer encounters. Why has it been allowed to happen? What’s the ground in which those infertile seeds have been planted?

Sanjay:      Well, I think people inherently trust their primary care physician. There’s absolutely nothing wrong with that. When the condition is severe enough to warrant a surgical specialist getting involved, they have to ask themselves the proper questions: Why is my primary care physician referring me to this surgeon? What is the basis behind that referral? Is it based on quality of outcomes over a number of cases that he sent that person? Are there other possibilities, other alternatives to treating the condition that’s at hand? I think consumers have to be more intelligent. They have to be armed with tools that allow them to make more informed choices.

David:        So, you obviously feel that the time is right to start bringing those tools to market why? What’s the perfect storm that’s come together to make this the right time to move forward?

Sanjay:      Well, the exploding healthcare costs, obviously. Employers are dealing with double-digit annual increases in their premiums, and healthcare expense is becoming a bigger part of their expense sheet, month to month, year to year. Insurance carriers continue to raise the premiums on a yearly basis. On the patient end, what’s happened is there’s been a certain shift of financial responsibility from the employer to the employee. As you were well aware, the deductibles are getting higher. Patients often times are not even able to afford some of their surgical care. When you can’t afford surgical care, then it’s a question of access. Now, we don’t have access to surgical for some folks.

David:        So, it is indeed a perfect storm of a number of different things in confluence that are bringing us to this point. Where you’ve been focused is on helping folks get pricing, and pricing in a different way as well, for nonemergency surgical procedures. Talk a little bit about the process and how that works.

Sanjay:      Sure. The system is really simple. If you really look at it from the outside 30,000 feet up, it’s a very simple system. When patients are told they need surgery, we’re basically gathering the medical records. We’re helping the patient gather those records through a concierge service. Then we are uploading these records in a HIPAA compliant fashion to a server, cloud server, and then distributing those records to board-certified surgeons … it could be local, regional; it could be national … through an app called the Surgi Connect app. What we’re doing here is basically getting multiple opinions. We’re getting multiple opinions using the flow of electrons. What we’re doing is we’re validating the medical necessity of having the procedure, alternatives that there might be to the procedure.

If that procedure is indicated, and surgeons can review the MRI scan or the CAT scan that shows the conditions right on our app, they can enter their pricing: Surgeon’s fee, facility fee, anesthesia fee, and they can also add in there and report on what their experience has been with that procedure, in terms of how many cases they’ve performed, what’s been their success rate for that procedure, what’s been the complication rate, and they can also qualify their complications. They can have an area where they can actually discuss and explain why they may have had certain complications. So, we’re creating a platform for patients where we’re really creating a platform for marketplace competition, if you will.

David:        If I’m a consumer, does that information all come back to me? Does it come back to my primary care physician? Where does that go?

Sanjay:      So, the information that we gather back from the surgeons, that is pricing data, and quality metric data, we take that data and compare it against what’s nationally reported and against national norms, and letter grade their quality metrics. So, what the patients see are a list of surgeons. They see their qualifications, how many cases they may have performed over the last 12 months. They see their out-of-pocket costs related to going to surgeon A, B, or C. Then they see a list of quality metrics, so then up to five quality metrics graded on letter grading system: A, B, C, and D. So, this starts the conversation. Patients are free to contact their bidding surgeon through a telemedicine platform. What we’ve created is a system where you can sit at home and you can get multiple opinions from the universe of providers that are local to you, regional to you, national, and even international.

David:        Are you finding that consumers are comfortable once they’re armed with that information in going out and contacting the bidding surgeon? Because for a lot of folks, physicians are still on pedestals. It’s difficult, and it may be a generational shift for them. We’ve talked about that on the program, until they’re completely comfortable saying to their primary doc, “You know what? I’m going to go get some other prices and some other opinions.”

Sanjay:      Yeah, and this really deals with healthcare literacy. There will be some patients will listen to their primary care physician and only go to the surgeon that was referred to. Then, there will be mostly other surgeons, perhaps other younger patients that will embrace this whole idea. It’s very disruptive. There’s no question, but what we’re doing is we’re holding the healthcare system accountable, accountable both in terms of pricing and accountable both also in terms of quality. So, in the very beginning, it’s going to be a bit difficult for the consumers to understand. That’s why we have the concierge to help them understand what the differences are.

David:        So, they have somebody who’s qualified, who can kind of talk them through the data that you provide back to them?

Sanjay:      Yeah. We call ourselves a healthcare technology company, but we’re really service first. We’re really services and technology. The concierge is critical. It’s similar to going to a hotel and having a concierge desk and having basically everything taken care of for you. Any questions you have, you can communicate with the concierge at any time you want. So, we have someone, a compassionate soul that really handholds them from the moment that they’re told they need surgery until they’re back to work.

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. 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 ShiftShapers website. Two things from chatting with you off air that I thought were really interesting. I’d like to explore both of them. It’s entirely possible when the information is sent out to the network of surgeons that somebody may come back and say, “We don’t think this surgical procedure is medically necessary.” What happens then?

Sanjay:      Well, the multiple opinion service does create the system where you have some conservative opinions. Remember, surgeons are very different. Surgeons are different. They’ve trained at different institutions. Some institutions are conservative. Some are more radical thinking that surgical options are necessary earlier on. So, what we’re doing here is taking advantage of the varied opinions that are out there. Again, these are all board-certified surgeons. Yes, some will render opinions that the condition isn’t severe enough to warrant a procedure. Maybe physical therapy is warranted. Maybe acupuncture, maybe alternative forms of treatment would be recommended initially, and a surgical option would be recommended later. So, it starts that whole conservation.

On our platform, the customer, the patient can reach out to that bidding surgeon who says that a conservative option may be more prudent and determine the reasons why, what his reasoning is. It’s all about information, David. In today’s world, patients are just completely information-locked, and we want to unlock their ability to get the proper information.

David:        Well, that’s going to be the key. What’s interesting besides the medical information that you get back, and you’ve alluded it a couple of times, the pricing that’s being offered here is what you refer to is bundled pricing. What does that mean, and why is it important?

Sanjay:      Well, it’s important to bundle simply because it creates a system of accountability. If you have a knee replacement, and what we’re talking about is bundling the surgeon’s fee, the facility fee, and the anesthesia fee, and if you provide upfront pricing … you can do this procedure at this cost … then there’s some accountability in the operating room with opening disposables, et cetera, that’s already been taken to account. Then, there’s an effort within the healthcare system to control the cost, because there has to be some profit margin, obviously. So, I mean, those are the beauties of upfront bundled pricing. I’m not sure I made myself clear, but did you have another question on that?

David:        Well, no. So, basically, it’s a flat price … instead of playing the game that gets … we’ll talk about this in a moment, but at the moment you’re playing more in the partially self-funded space. So, a TPA … I’ve helped run a TPA for quite a long time during one portion of my career … a large surgical claim will come in, and it maybe gets negotiated down once, and maybe it gets negotiated down twice. In this case, what you’re seeking to accomplish is that the bundle pricing is one kind of flat fee that includes everything and is kind of equivalent or better than what that last reprice would be, isn’t it?

Sanjay:      Absolutely. The other thing our system does is, when you have surgery today, you get bills for six months a year later for radiology, for a laboratory test, for the pathology. What we’re trying to do is eliminate all those bills. We want to know what the bundled price is right from the beginning before the patient has the procedure, and hold the healthcare system accountable.

David:        There’s normative data on both … you mentioned on the quality, but is there also normative data on the pricing so that when a patient is looking at these various prices that come back to them, they understand where those prices are relative to the market or their geographic area?

Sanjay:      Well, yeah. There are companies that are doing this right now that have developed normative pricing across the country, but we think that price is very plastic. We think of price as being very plastic both on the surgical end, the facility end, and the anesthesia end. If they have underutilized time, an empty Friday or a Friday afternoon that’s free, what we’re finding is that these surgeons, these facilities are willing to drop their price to get that patient through the door, and just become more efficient. So, we think of price as being very plastic, week to week, month to month, case to case.

David:        Interesting. I alluded to the fact earlier, currently, and this makes sense. You’re working mostly or almost exclusively with partially self-funded plans. Are there any fully-insured plans that are interested in having this discussion about this kind of a service? Have you found those folks yet?

Sanjay:      We were certainly in conversations. No, we haven’t found great interest yet, but we certainly peaked their interest. When you have a large insurance carrier with a network of providers, it’s a beautiful system to adopt within their network of providers if they’re able to do it. So, we’ve had this discussion with Blue Cross a few years ago. They love the whole idea. They just said that the infrastructure changes and the amount of capital needed to make those changes is prohibitive. So, there is definitely interest. I think this is the way for the future.

David:        What kind of reaction are you getting from the initial physician from the primary care physician or from the initially referred specialist or surgeon? How are they reacting to this? Because as you mentioned, it’s disruptive, and I guess, depending on what chair you’re sitting in, disruptive can also mean intrusive.

Sanjay:      The primary care physicians are loving, because now they’ve got a way of determining quality where they didn’t have it before. Before, they were referring patients to surgeons, they were on the basis of playing golf, or their kids go to the same school. Now, there’s accountability. So, the primary care doctors actually will embrace it and do embrace it. The surgeons, initially, any time you disrupt the system, everybody takes a step backward. The older surgeons may not find this what they want to do, but the younger surgeons have certainly embraced the platform in a very big way. They see an opportunity to get access to surgical patients right through their smartphone as opposed to going through 100 patients in the waiting room. So, they see this as a very efficient system, a way of getting access to surgical patients that they never had.

David:        Well, because we’ve talked about effectiveness, but we haven’t talked a lot in the medical community about efficiency and so that’s an interesting wrinkle. Question for you, and we’ve got a few minutes left. What kind of an impact does this kind of pricing does this have on cost? Because at the end of the day for a plan, it’s all about throughput and cost, and unit cost, and et cetera. What are the deltas that you’re seeing?

Sanjay:      We did a pilot study with a large employer nationwide. We bid out a bunch of cases, probably about 70 cases or so, and we’ve found savings of $3900 per procedure on average. That is unbelievable. It’s an unbelievable number. That’s even taking out couple of the outliers they had from a surgery center … I won’t tell you where, but was getting paid $140,000 and $170,000 for a sinus surgery outpatient. So, we took those cases out. Despite even taking those cases out of that pilot, we found a savings of about $3900 on average, which is unbelievable.

David:        That certainly is attention-getting. There’s no question. So, in the minute or so that we have left, I always like to kind of wrap up with our guest and ask what they see the future looking like. If you were to place where you’re being disruptive and intrusive, if you prefer that word, where do you see the future of this going? How do you see it growing, and the take-up, and engagement, and all of those pieces that you want and that you need?

Sanjay:      The engagement on the provider has been actually quite rapid. The engagement on the consumer end is going to require some education. Once people get used to the idea of bidding out their surgery, it’s just like they look for a hotel online, for a vacation spot. Now there’s services where you can do that, but they will embrace it, and they’re going to like it very much, because now they’ve got in a way of validating a surgical opinion. They’ve got a way of lowering their out-of-pocket costs, and in many cases, getting their deductible to vanish, which is really what our end goal is. So, we think the future of healthcare is in marketplace competition. There’s no question. We can only speak to the surgical aspects of healthcare, but I see marketplace competition entering into the MRI, into radiology, diagnostic radiology the with physical therapy. I mean, I think it’s just going to explode. It’s just a matter of time.

David:        A great place to leave our interview on a hopeful note. Dr. Sanjay Prasad, Founder and CEO at SurgiPrice. Sanjay, again, thank you for sharing your expertise with the ShiftShapers audience.

Sanjay:      Thank you again, David, and I wish you the best with your endeavors. I’m really honored to be on the show. Thank you.

David:        Our pleasure, thank you.

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.


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.

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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:

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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.

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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.