Speaker 1: 0:00

Did you know that there were HRAs before there were HRAs? Yeah, that's what I said. What did I mean? We'll find out on this episode of Shift Shapers.

Speaker 2: 0:12

Change either energizes or paralyzes. The choice is yours. This is the Shift Shapers podcast, bringing the employee benefits industry interviews with individuals and companies who are shaping the industry's shifts. And now here's your host, david Saltzman.

Speaker 1: 0:33

And to help us answer that question, we've invited David Slove, ceo at Nonstop Health. David, welcome to the podcast. Thank you, david. Pleasure to be here. Thank you so much and it's all our pleasure. But give us a little bit of your background. How'd you get to be doing what you're doing today?

Speaker 3: 0:51

I am a lifelong entrepreneur, startup guy and fell into the healthcare business a little over 20 years ago when I had an investor in a prior business who I owed a favor to, who called me on it and said I have this business where I administer benefits for a union and the software I'm using is 15, 20 years old help and I found out later he had just sold his business and was on an earn out, so my help was very instrumental to him, was very instrumental to him and through that I got a quick look into the healthcare system and decided that what I had done in tech and what I wanted to do in healthcare lined up very nicely and have been in the healthcare world ever since.

Speaker 1: 1:36

When I mentioned early on that we were talking about HRAs before HRAs were invented. What we're talking about is something called a MERP M-E-R-P Broad terms, david. What's a MERP?

Speaker 3: 1:48

Well, a simple term. The initials MERP Medical Expense Reimbursement Plan kind of says something and nothing all at once. But essentially what a MERP does is it allows you to use the IRS tax preference model for employers funding health care, and it has been around since the 1950s. And what it does essentially is it allows an employer to put funds in for the expenses of a high deductible health plan in our usage and those expenses then get covered by our administration of the expenses. And then we throw in a few extras on top of it to make it a very interesting outcome for both employers and employees.

Speaker 1: 2:29

So for practitioners, how does it differ from an HRA and how is it the same as an HRA?

Speaker 3: 2:35

Or is it An HRA is no, no, it's actually fundamentally different. Hra, much like an HSA or an FSA, is a per-participant plan in which a block of money is contributed and then utilized for expenses. In the case of an HRA, the employer puts it in 100%. In the case of an HSA, both the employer and the employee can contribute and in an FSA the same holds true. The difference is that FSAs are very limited in how much money can be put in per year per enrollment. Hsas are limited, but substantially larger than FSAs, and HRAs are unlimited. And what we've done with the MERP is we've taken advantage of that capability to allow a highly customizable financial outcome with a very predictable algorithmically outcome for the employer and the employee and effectively we've de-risked the self-insurance component of healthcare.

Speaker 1: 3:34

That's fascinating, so let's talk in real terms. What's the problem that we're solving by using a MERP?

Speaker 3: 3:41

So the MERP addresses one of the most fundamental problems in American healthcare, which is costs are skyrocketing at three, four times the annual inflation rate, going on 40 years, and even though the employer is using tax preference money, the expenditure has reached the point of pain for the employer. So employers have shifted more of the burden of cost onto employees, both through the contributory model to the healthcare programs they offer ie how much you pay, how much I pay and also through the way the plans themselves are designed, so that more and more of the expense of direct consumption of retail healthcare the day-to-day stuff doctor's visits, testing prescriptions is borne by the employee, despite the fact that a substantial portion of their income is represented through that employer funding of a healthcare program. So we really take aim at that. The secondary problem, beyond the cost problem, is that over the last two generations the American healthcare system has slid in efficacy to.

Speaker 3: 4:47

People will unkindly call it a third world health plan, and that's really not true. Having been in India and other places in the third world, that's just not what we are. But against the benchmarks of the top OECD countries we are at the very bottom now and people will say well, that's because you're insured versus there being state plans, and that's not true either. The two of the five best health plans in the world, part of the World Health Organization, are the French and the Japanese, who have very little in common other than they have insured plans that work well, and so it's not necessarily the underlying capitalist architecture of American healthcare, it's frankly the way in which it's operated, which has become less and less wholesome financially and, frankly, ethically, and we really look at that as another area where we can take aim and deliver superior outcome.

Speaker 1: 5:43

So we've talked about this on the podcast frequently. We've essentially created a group of people that we call functionally uninsured. They have a medical plan.

Speaker 1: 5:54

they have an ID card in their wallet but they can't really afford to use it. How does this? How exactly? Let's talk about how this works in practical terms. We've got Joe, and Joe makes $40,000 a year and has two kids and a spouse and has a huge deductible and a lot of out-of-pocket. How does this come in and play with his existing core medical plan to help him not be functionally uninsured? Sure?

Speaker 3: 6:23

Well, it's worse than functionally uninsured. Sure, well, it's worse than functionally uninsured. He's really at this point. If he's using the health system, he's bankrupt, and whether he knows it or not.

Speaker 3: 6:33

When we routinely, when we come into new client situations, we meet with the staff in private meetings, one-on-one, we're often told well, I have these three credit cards maxed out, are you going to make that go away? And the short answer to that is we can't change history. But what we do is very fundamentally different. We have a 100% first dollar coverage approach. We will not offer our program if employers will not honor that requirement, and what that means simply is there is no deductible and the first dollars that they have whether it's office visits or emergency rooms or prescription drugs or whatever it might be they're provided with a funding mechanism. And in addition to that, the funding mechanism is a visa card, so that they don't ever have to write checks up front and then wait for reimbursement, because your example a 40K worker with a wife and two kids, even if there's a two-income household, they're at or below the poverty line. And so the reality is they're making choices of $1,500 payments for various deductibles or other expenditures that are competing not with going to the Bahamas on a trip, but paying their rent, paying their electric bill, paying their water bill, and so it's not shocking that, in addition to being under or walking uninsured, they're also getting worse.

Speaker 3: 7:55

Their health is getting worse, and it's become a very fundamental problem, because with healthcare, the basic truth is that it's not a linear function, and so if you don't do the earlier low-cost elements, like most complex systems, you pay later.

Speaker 3: 8:10

I use the example of the car industry, where a defect in design can be fixed on the design system for pennies, maybe dollars worst case, and at the very far end of the spectrum, you do a factory recall of Ford F-150s and it costs $50 million for a problem that could have been solved for 25 to 50 cents, and the healthcare system has a similar exponential curve to it.

Speaker 3: 8:34

And so the first dollar notion we have has been a game changer for people. We are routinely besieged with thank yous for anything from a child who they couldn't afford to put tubes in there and the child was deaf as a result to cataract surgeries deferred that they can now get done to. Oh, I didn't know, I had this chronic problem, I just was tired all the time, and once we got on your plan and I went in. I had a simple, chemically fixable problem for $500 after 15 years of poor quality of life, and so this isn't just a financial issue, it's an ethical issue, and we believe that the first dollar coverage model is so much the reason for our end user experience being superior.

Speaker 1: 9:22

So if I go to a provider, do I just give them the visa card and say, hey, whatever, the insurance doesn't cover charge to this, don't send me a balance bill, correct?

Speaker 3: 9:32

Literally. So what happens is let's take the two or three most common transactions. I go to the doctor Okay, it's not a preventive cover, I'm on an insured plan PPO, hmo, pos, it makes no difference and a traditional plan might've had a $25 or $50 deductible that might've prevented me from going. It might not have. But now I go and I've got this HSA $6,500 deductible plan. And so the provider checks your card, they look at your insurance with XYZ insurance company and say, okay, you owe us $114 because they know that's what the charge is going to be adjudicated at. And the employee hands them the credit card, they swipe it and they're done.

Speaker 3: 10:14

And then the back-end process of the four or five billing steps all occur invisible to the employee but highly visible to us in managing their employer's funds. And so that's the most common transaction at the service side. And then in the pharmacy, obviously it's even easier, because then it is adjudicated to the penny and again they give them their carrier card or it's on file. They look it up, they see that HSA plan as an example and they go okay, well, you're buying this generic at $6.22, swipe. Or you're buying this non-preferred branded product, and it's $1,120, swipe, done. And so you don't have people splitting pills, you don't have them missing cycles and you don't have them going through all of the known decay and chronic conditions problems that you get when people can't afford the copayments and the deductibles.

Speaker 1: 11:12

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Speaker 1: 11:48

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Speaker 3: 12:38

You do. I mean the thing that we did early on it was zero, zero, zero. No deductible, no copayments, no out-of-pocket as long as you stayed in network. But there were two problems. We ran into that. Some of the carriers objected to that model. The employees didn't have enough skin in the game a point of conversation for another time, but ridiculous given how much of their wages go into healthcare. But the other issue is the employer couldn't customize to fit a price point and what happened is that in many times we were in overwhelming savings for them and typically at the low end we'll save an employer 10%, 15% on premium the first year and it compounds another 2% or 3% each year.

Speaker 3: 13:21

So we have clients who've been with us 7, 8, 3% each year. So we have clients who've been with us seven, eight, even 10 years who are saving 40% over a traditional plan now with the same carrier in the same network. But we also have clients particularly in states where the spread high to low is smaller, because obviously in the American market you have states that are super expensive for healthcare Alaska, new York, california. You have states that are a lot less expensive traditionally Texas, florida, some of the other states in the Southeast. Well, first of all, inflation's caught up with everybody to some degree and has made the problem for us lesser because everybody's way up there now. But also, if I've got a budget to meet and I've been giving people a low plan, that was we'll call it in metal tiers a silver plan, and then a buy-up option to a gold plan.

Speaker 3: 14:15

With our model we can give you the first dollar coverage and we can give you a low plan that has $2,000 or $3,000 of back-end exposure the last $2,000 or $3,000, and a buy-up to a full no-exposure option. And what it does, frankly, is it allows people who know they're heavy users to do the buy-up in a very small increment and have nothing out of pocket. It allows the lower users to buy the lower-cost plan, but everybody gets the first-dollar coverage. And so let's assume it's again a $6,500 out-of-pocket exposure and the employer provides a $2,500 option in exposure for an employee-only plan, they get $4,000 in first dollar funding before they hit it. 90% of people will not get to that $4,000. And if it's a family coverage, any kind of dependent, they get double that. So then, even if one person is maxing it out to $6,500, they still have another $1,500 for the other folks on the plan, and so what happens is people who know they're not chronic users and are comfortable taking a little risk can buy the lower-cost plan through their employer, and it gives the employer tremendous flexibility.

Speaker 3: 15:33

You know I hate using other people's market risk, but it's a name-your-price health plan where you can pick where you want to be on that curve and we let people dial it up or down Year to year. They can change it and they can offer multiple options and people go. Well, isn't that going to lead to an adverse pool? Well, the answer is no, it doesn't. It's the same overall group of people, the same fractional number of people, hit the out-of-pocket maximum and so, because that's a small fraction of population, the overwhelming number of transactions and, frankly, even the dollars live in that first $3,000 or $4,000 of spending. In our model, because we don't get the shock claims Effectively, if you think about it in self-insured terms, we use the carrier out-of-pocket maximum as our specific limit for any given employee and instead of it being $100,000 or $200,000 or $25,000, it's typically $6,000 to $9,000. So it makes each of those heavy users one unit, but a small unit against the overall average versus that massive gap in a full self-insured product.

Speaker 1: 16:44

Do you have any data, anecdotal or real, about what the impact of employees having this first dollar coverage is on claims from deferred care?

Speaker 3: 16:56

We do. So. The most telling information we've gotten is our largest groups over the years get much more detailed access to information and some of our mid-tier groups, where we have Springbok or other analytics chassis that see the full claims run. The first thing that happens is literally in the first year, and then compounding thereafter. The number of inpatient days per thousand member months drops steeply. So again, that whole notion of any complex system basic rule of Deming quality assurance models is solve it early, solve it cheap works here brilliantly. And so what happens is office visits go up. They use the card, fills on generics go through the roof to almost 100%, and what happens is you get less serious conditions.

Speaker 3: 17:46

And I use a simple illustration for people.

Speaker 3: 17:48

If 100 people all have a bad upper respiratory infection and none of them go to the doctor, a fair number of them are going to end up in an ER and a fair number of those are going to end up in a hospital and possibly with chronic conditions.

Speaker 3: 18:01

If 100 of them go to a doctor, the 90 who need simple generics and they're done great. We probably could have used over-the-counters and those 90 people would have been fine either way and we just spent $9,000 in doctor visits and another 10,000, I'm sorry, another thousand in generic drugs. Okay, so we spent 10 grand, but the 10 people who we spent the next thousand dollars on, if one of them hit an ER, they were cracking past a thousand. So the break-even fistula is one of those 10 people and if one of them would have had an inpatient day, starting at $20,000, at the hotel hospital. We're so far ahead and people have less sick days, they have less contagion in their own household and thus on the broader marketplace in which their families function, and so you get a community wellness outcome, whether it's workplace or more broad, based on that notion of fix it early, fix it cheap.

Speaker 1: 19:02

Yeah, when I was a TPA we used to use the example of little Johnny, who got a cold and parents said well, we can't really afford to take him to the doctor, so we'll wait, we'll treat him with over-the-counter stuff. Fast forward 10 days little Johnny is in pediatric intensive care with pneumonia Damn near kills him. And that's a $90,000, $130,000 bill.

Speaker 3: 19:21

Yep, and that's the curve. And the reality is again that people go. Well, you're being an alarmist. What fraction of people? Well, it doesn't matter, because at any percentage that is an efficacy-based analysis it's a huge win to get people to the doctors. Every insurer in the country would argue to that point. Every physician in the country would argue to that point. Nobody really questions that logic and, honestly, there's no reason to question it. It's just an obvious systemic truth.

Speaker 1: 19:54

So if I'm an advisor A, how do I integrate this into what I'm already doing? And, B, what's the conversation like with an employer who is maybe skeptical and hasn't heard of a MERP since 1970?

Speaker 3: 20:07

Or ever right? I mean because they're relatively recent phenomena. Honestly, people didn't test the tax code on this for a long time. It was just done on per account basis and, to be honest, our number one competitor in almost every situation is it's too good to be true. And when we were starting out, we sold directly, we went directly to the employer. We had very sophisticated materials and supporting processors. We partnered with medical associations, the community health center movement notably, and we were able to overcome that inch by inch. It was slow, rolling, but you get to the first 10 or 20 groups in a community and it's referenceable and too good to be true goes from an overwhelming problem to a problem. And now we're at 500 employers later. Basically, and now too good to be true is okay. Well, would you like 10 or 20 references? You want them in your state, your industry, your carrier, which combination would you like? And so we rather quickly get that.

Speaker 3: 21:10

But the more fundamental problem for anybody selling any program into the medical system is the inherent problem of friction, of inertia, of well. We've been doing it this way and we have now almost 1,400 brokers around the country, brokers and consultants who work with us at over 100 agencies probably at this point close to 300 agencies and we give them a number of supporting materials. We've got a training program we offer them, not just on what a MERP is but how to deal with change and how to position change effectively. And we've brought in real expertise from the academic community to support those programs. And we make all this available on a no-charge basis to the community because, again, we believe the change is fundamentally critical, not only for our fiscal outcomes and of course we want to be successful but also for this whole notion of community. We started as a mission-based company and we retain that approach. We believe it's a basic human right to have access to healthcare and it's not to me a political argument about, well, there's a government or a non-government, because at the end of the day, that's not the point you want to make. I'm indifferent to that problem. To me, the problem is how do you actually make good on that commitment? And that's really what we've approached and what we've done really. I mean, if you ask our clients, they'll tell you we save them anywhere from $1,000 to $3,500 a year per enrolled employee in premium. It goes up over time. The renewals are better than they've ever had before. And if they want to move from a partial self-insured the MERT model, to a fully self-insured, we can tell them their risk profile, we can help them, with our consultant partners, make that transition and maybe 5% 10% of that marketplace is interested in doing it, because the people who are in that program are people who are in the insured system 90-plus percent of the time. We work with carrier ASO plans and TPA ASO plans but at the end of the day, the bulk of the clients we serve prefer to be in the safety net of the traditional carrier model, net of the traditional carrier model, and so we give them that migratory path.

Speaker 3: 23:30

But, more importantly, we reduce the employees and the employer's inflation dramatically and dramatically. Really, the context and this isn't a few percentage points, we're talking about compounding it gets up to 15% to 20% almost automatically, and it's not a speculative thing. Up to 15% to 20% almost automatically. And it's not a speculative thing, it's math, because we pass through the reserves algorithmically with simply the underlying inflation, not the administrative inflation. In 12 years of doing this, we have changed our rates upward zero times, zero inflation in 12 years. The reserves that we're collecting for these transactions, which are not the hospital and not specialty drug, because those people hit out of pocket and we're done with them. So that doesn't inflate. And so our inflation rate is 2%, 3% on an annualized basis over the last 12 years and even in the higher inflation in society over the last couple of, at 9% compounded.

Speaker 3: 24:33

And you can see what's going on. Because they're only buying 60% of the carrier inflation rate with these high deductible plans. The other 40%, a quarter of it, has zero in inflation. The rest has a two or 3% inflation rate and without setting up the fancy equation, which isn't that tough, you get another 2% to 3% automatically every year, systemically, in the way our product is designed.

Speaker 3: 25:10

So the number two skepticism for employers is well, what's going to happen? You're just buying the business like a carrier, would we go? No, we renew algorithmically and our average renewal is under 3%, including your carrier inflation rate. And they don't believe that. So we show it to, we give them references and the reality is almost a third of our clients get a rate pass the first year, and by that I mean our reserves, our fees, plus the carrier inflation on their underlying plan means they pay the same thing all in for that nonstop health bundle that they paid in year one, and if you ask consultants how many rate passes a year they get per hundred groups, you would find that the number is somewhere between two and zero, and so the fact that a third of our clients experience that and it's referenceable has become a very viral effect for our consulting community.

Speaker 1: 26:05

We've talked a lot about hard dollar costs. I'd like to end with two other questions. The first is how much do you find employee satisfaction going up, and how does an employer measure that? Is it just lack of gripes going to HR?

Speaker 3: 26:20

Well, I think the squeaky wheel is always the one that gets the most attention in the executive suite, because we don't want this aggravation. That's why we have HR. It's kind of their first reaction, guilty. Okay, I'm with them. And we measure it every year twice for all of our members. We do surveying. We have done surveying as a practice for seven or eight years.

Speaker 3: 26:44

We measure our satisfaction on any number of metrics with each of our service teams, and that includes everything from how the experience was in getting on the plan how was your renewal? How is your usage of the card when you have manual claims, how is that going? When you call us and ask for help, how well do we do there? And so we have very detailed serving. We get a very high response rate. I think our low response rate is in the 20% level, and sometimes it's higher than that. So we're very actively managing to that, and so when we see changes where our growth is impacting people, good or bad we're pretty able to pinpoint where in the service delivery system we either have done something really well or not done well, and it's a continuous improvement model.

Speaker 3: 27:31

I mentioned Dr Deming's work earlier and I'm a huge believer in the notion of continuous improvement in statistical quality. I came out of the 80s working with manufacturers in that world and it's always been important to me to understand that when you're growing as aggressively as we have we've been growing at 30, 40% a year for years now you have to really be measuring your understanding of the user experience. But one of the things we did early on is we revolutionized the way credit cards were used for Merck's. Historically, you could only use them basically at a pharmacy because that was auto-adjudicated at the point of sale and we said you know that's silly, we know it's an in-network transaction most of the time, and why don't we let them use it for everything and algorithmically determine when we need to ask for paperwork? So we ended up sampling about 3% of our transactions by number and by dollars to make sure that they are following the rules of our plan design and, as you might imagine, the compliance rate is extremely high. Somewhere in the neighborhood of 94% to 96% of the transactions are observably correct out of the box and don't need us to touch them, and of the three or 4% that do even those, 85, 90% are legitimate transactions. And so the historic model of make 100% of the people pay the price for the 2% of bad actors. We just flip the script on it and, at the end of the day, we've been able to do that while bringing our service costs down over time, and that's why our prices have held constant on the service over more than 10 years. It's not that we're not inflating wages we are, of course and offering more services, but I kind of look at the Apple model of how they've priced devices over the years as a really powerful consumer loyalty builder. Hold the price constant and keep giving people more and more value for their money. Then people can budget, they can get used to that and they get a better and better experience over time. And this is an industry where, whether you use the net scores or the net promoter scores or any other metric, has relationships.

Speaker 3: 29:42

Somewhere in between congressional representatives and lawyers is where the healthcare folks fall in.

Speaker 3: 29:48

And we're sitting here running at a whole nother level and we look at our satisfaction levels and we're typically in the high 80s to low 90s of people grade us a four or a five and we consider it a real problem if we're not at 90 plus in that for any client and we go back to the team and go okay, what are we not doing right here?

Speaker 3: 30:08

And you know, some of the things that we've learned is bilingual requirements. So now our entire organization runs bilingual english and spanish and whether it's printed materials, web content, emails or human beings live on the phone, it's available very easily in either language. That all by itself had a huge impact, unless people think that's purely a California Florida issue or Texas Florida California issue, no, no, no. We have clients, particularly in the nonprofit world of community health centers, who are serving farmworker populations and other migrant populations all over the country. One of our biggest centers that's bilingual is in North Carolina, another one's in Illinois, and so for us, this has been a huge improvement in how we come to market and something that seems obvious after the fact, but before the fact. But before the fact, you know employers, oh, we don't need that. And then we find out well, actually you do need that.

Speaker 1: 31:10

Yeah, lots of things seem obvious after the fact because we all have 20-20 hindsight. One last question Do you get comments from employers after a year or two of implementation that this helps them attract and retain employees as well?

Speaker 3: 31:23

a year or two of implementation, that this helps them attract and retain employees as well. Honestly, that was one of the postulates we had at the outset, that people just kind of went, yeah, no, and then about. I think it was about 2017, I think we were about four years into it. The National Association of Community Health Centers was a big partner of ours and we were at one of their national conferences and one of our clients was in a room filled with CFOs and said look, because it was about recruitment and retention, it was a particularly difficult period for them to recruit people. So, look, I can tell you, the magic's off for us. It's nonstop. And people went. Huh, and the CFO went. Our retention rate has gone up massively. We used to turn over 38% or something like that of our non-professional workers every year and now we turn over 9% and people went.

Speaker 3: 32:16

No, that's BS. That part of the messaging as much, maybe more than even the financial messaging has really carried the day, and particularly as we went from direct to working through brokers entirely. We went from almost entirely a nonprofit and educational book of business to a massively diverse book, and one of the things that I knew was going to happen is manufacturers were going to eat this up, and of course they have Semi-skilled, non-union labor in this country is in a huge, huge shortage, and health plans like ours, I mean it blows people away. And so that is perhaps the real secret sauce. From the employer's perspective they have to get the costs under control. That's literally table stakes, but they could do that through crappy benefits just as easily as us, but the consequences are so fundamentally different that the equation turns out to be super easy, and so our retention rate through everything through COVID, through growth, through changing to brokers has been climbing. I mean we were at over 100% on an enrollment-weighted basis last 2022 and in the high 90s last year. I mean these are numbers that in the medical industry are probably unprecedented.

Speaker 3: 33:35

And look, we have our problems, just like everybody else the growth business, the complexity of what we do.

Speaker 3: 33:41

I mean we didn't sell through the channel for a long time because it was a complicated product, but by the late 19 timeframe, we felt good that the product was complete and that we had created a unique product against which we can compete with HSA, ppo, hmo, et cetera, and it stood on its own, and our partners have validated that in absolutely stunning terms and so it's been a really spectacularly interesting experience. But that retention and recruitment story boy, that's the pocket. On this People say, well, that's a marketing thing. But again, going back to that whole mission of the human rights side of this and the whole issue of equity, it has really resonated across the country and people are saying, oh, probably all your clients are in blue states. Well, no, our fastest growing states in the last two years have been Louisiana and Texas, and last time I checked I don't think people would have called those the blue zone. And there's a reason for it Everybody's the employer relationships and it's allowed the change to be much more comfortable for our community to bring forward.

Speaker 1: 35:09

And that's a great place to end our conversation for today. David Slove, CEO at Nonstop Health. David, thanks for sharing your expertise with our audience.

Speaker 3: 35:17

I'm delighted and, david, I love your program and I look forward to having another conversation down the road, perhaps. So thank you, it would be our pleasure, thanks.

Speaker 1: 35:25

David.

Speaker 2: 35:27

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