This week’s episode features a conversation with Brian Butler, Vice President of Client Development at Flipt. PBMs use several tactics which drive up the overall costs of medical benefits. This expense is shouldered by members and employers, increasing pharmacy spend and pushing up plan costs. Innovating this model requires consumer empowerment to make intelligent health care decisions and advisors armed with specialty knowledge and data to impart to their clients.

What You’ll Learn From This Episode:

  • 03:33 The scope of the financial impact of PBMs
  • 06:52 PBM tactics that drive up cost unnecessarily
  • 11:24 Empowering consumers with intelligent decisions
  • 14:27 Advisors can deliver value with specialty knowledge and data
  • 19:34 Future forecast and ushering disruptive solutions to the PBM problem

Quotes:

03:45 “You have roughly, you know, 500 billion dollars in drug spend with approximately a hundred to a hundred and twenty-five billion of that retained by middlement. And there’s a variety of middlemen, it’s not just PBMs.”

05:05 “There’s definitely solutions to lower drug cost that can really be in almost a sponsored community effort to drive that revenue back into local communities.”

08:22 “While that zero dollar out of pocket cost you share as the member, your employer still picks up that remaining balance. And that remaining balance changes drastically.”

09:13 “It’s really important for me, as the consumer, to think about where am I going to fill this? It’s one of the highest cost, perhaps, medications or portions of spend in the health care benefit. And number two, are there any alternatives?”

12:30 “First and foremost is really leveraging technology to build a scalable solution and drive it directly to the member. Give them some incentives to participate in this consumerism model.”

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This week’s episode features a conversation with Steve Overton, Co-founder, and CEO at Plansight. RFPs are difficult on advisors and extra hard of carriers who may or may not know how they are being represented to clients. Additionally, RFPs are time-consuming, difficult to decipher, and sometimes written with a particular carrier or plan in mind. Technology is being used to smooth out that process and make the RFP experience simpler and more equitable for all constituencies.

What You’ll Learn From This Episode:

  • 03:31 Introducing consistency into the Really Frustrating Process
  • 06:05 The RFP process fosters biases and can leave carriers misrepresented
  • 09:14 Innovating RFPs with real-time technology
  • 16:24 Advisor benefits with using Plansight

Quotes:

03:54 “The acronym obviously means request for proposal. A lot of people call it really frustrating process or really frantic process and you’re kind of putting everything together at the last minute.”

05:05 “We’re working to bring in some consistency into the process as well. Because you imagine, it’s tough for the broker but it’s also tough on the carrier.”

08:22 “Obviously there are some consistencies but the most consistent thing we found was none of these are all that great. You’re taking a lot of information and you’re distilling it down to a decision-making tool.”

10:34 “You can’t see who is who but you can see, you know, benefit features and you can see cost. And then you can make a judgment. Hey, can I get more competitive on this?”

17:18 “You might have 10 quotes or 2,000 quotes. You kind of narrow it down to what you want to present and you hit a little button and it builds all of the spreadsheet presentations for you.”

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This week’s episode features a conversation with Mary Talley Bowden, M.D., an ENT from Houston, Texas and mother of 4 boys. After experiencing first-hand how traditional, insurance-driven practice models work against patients, Mary decided that she would innovate the patient experience in her own practice. By blending wellness and ENT, she has created a service that has vastly improved her patient satisfaction and catapulted her business to greater heights.

What You’ll Learn From This Episode:

  • 02:20 Mary’s frustrations with the traditional practice model
  • 05:03 Starting a practice and improving patient experience
  • 08:41 Mary’s wellness innovations to create patient-centric service
  • 16:18 Surgery is not the first option, it is the last resort
  • 18:26 Experiencing pushback with going cash-only basis

Quotes:

03:36 “I loved my physician but I hated the process. So I decided, if I go back, I’m not going to be beholden to insurance companies. I’m going to approach patient care with a more customer-friendly approach.”

10:04 “I don’t have a EMR, an electronic medical records. I hate those things because all it is people checking a bunch of boxes so they can get reimbursed by insurance at a higher rate.I take my own history and then I write a little note in the computer afterwards.”

12:53 “One of the key things I do that no other ENTs do is something called sinus therapy and it’s based off of what they do for patients with cystic fibrosis for their lungs called chest percussion therapy.”

17:08 “For me, I want to make sure that patient, before they get an operation, everything has been explored because surgery will not cure inflammation. So I really make a point of surgery being the last resort.”

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This week’s episode features a conversation with Carl Schuessler, Jr., Managing Principal at Mitigate Partners. Acting as a fiduciary means acting as stewards that improve financial outcomes. There is an emphasis on trust that has become even more apparent with the creation of the Affordable Care Act. Fiduciaries also deliver active management as opposed to passive management, a beneficial role that provides massive savings.

What You’ll Learn From This Episode:

  • 02:08 Agent, advisor, and broker: A fiduciary role involves trust and stewardship role
  • 06:07 There are opportunities to act as fiduciaries in non-Erisa plans
  • 08:58 The Affordable Care Act made fiduciary roles even more relevant
  • 13:54 The differences between active and passive risk management
  • 17:54 Getting employers to partner with a fiduciary

Quotes:

03:48 “I think while there is an opportunity of the interpretation whether or not a consultant is a fiduciary of a health plan, I think there is no question that a properly aligned consultant is a steward of the employer’s plan.”

10:04 “When it (Affordable Care Act) came to existence in 2010, there has been an explosion of innovation. And you and I talked about this prior for an industry that was stagnant of 50 years. And so now, I think our role acting as a fiduciary and steward has never been more important.”

13:59 “Active management is an employer taking control of their healthplan spending with the right solutions built in and cost containment and risk mitigation to control their costs. And it’s also about improving member outcomes. And lastly, financial outcomes for both the members and the employers.”

18:38 “We go through what we call the 6 opportunities of health care: the cartel, lack of pricing transparency, medical billing errors, the traditional PPO discount game, the pharmaceutical shell game, and David you saw it because I gave that talk in Tampa, and the lack of information and data.”

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This week’s episode features a conversation with T.J. Morrison, President at Benefit Design Specialists. Direct contracting offers competitively priced bundles to patients and quick payments to providers. They carve out a niche away from networks while, at the same time, avoiding direct competition with them. Direct contracting uses data-based baseline pricing to set the most competitive rates for otherwise cost-inflated procedures.

What You’ll Learn From This Episode:

  • 01:51 What is direct contracting and what are its main benefits?
  • 08:55 Lowest cost healthcare provides the best quality
  • 10:26 Broker interest in direct contracting is driven by partially and self-funded plans
  • 14:30 Creating a database to set baseline rates
  • 18:22 Looking at metrics on the patient side

Quotes:

03:25 “Many times these providers, through health plans, are waiting a month to three months to get paid for services where the typical direct contracting contracts, they’re looking for seven to ten business day turnaround.”

04:31 “Direct contracting attacking a niche that a network can’t, but at the same time we’re not trying to be in competition with any type of network.”

08:55 “The highest quality providers are the lowest price because they know their metrics. They do so many knees, hips, spinal fusions, colonoscopies, what have you that they know how long that surgeon should be in the room.”

13:49 “Good direct contracting model, you’re looking for that 30 to 80 percent savings on any given procedure, but ultimately you’re really pulling on that regional healthcare approach and a new line of revenue for the centers. That’s what gets them to act.”

17:11 “In doing all that work behind the scenes, what that helped create from a direct contracting standpoint is now we have a baseline on where we want our procedures and we know where we’re creating that value.”

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This week’s episode features a conversation with Mike Vasquez, CEO and Founder at Opioid Clinical Management. The opioid crisis has been largely ignored for the past 15 months but this doesn’t mean it has gone away. Novel withdrawal symptom indicators help advisors and employers identify the differences in addiction and withdrawal patterns. This allows employers to intervene with the providers to reduce their spend while safeguarding the health of members.

What You’ll Learn From This Episode:

  • 02:08 Opioid deaths reached an all-time high in 2020
  • 07:49 The direct and indirect costs of opioid addiction
  • 10:37 How employers can identify withdrawal symptoms of opioid addiction
  • 13:53 Withdrawal symptom indicators are the primary cost drivers
  • 15:46 Educating advisors and employers on the scope of the problem
  • 18:10 Intervening the providers instead of the members who are suffering

Quotes:

09:32 “We found 4 key indicators as we looked at and those were indicators inside of orthopedics, indicators inside of general surgery, indicators inside of injury itself, and in chronic pain management.”

10:02 “We find that we can reduce about 75% of the health plan spend which can correlate to as much as 10% of the total medical spend tied to just directly to opioids.”

11:38 “This is not an abuse pattern, this is not an addiction pattern, this is an intentional overprescribing indicator of a provider. These are the unintentional indicators that are happening just in everyday opioid usage.”

14:06 “The cost drivers are these unseen, unidentified health care side effects. So some people are aware of drug side effects, some people are aware of drug interactions, and what the doctors aren’t aware of the withdrawal symptoms. We call these withdrawal symptom indicators.”

18:35 “We are able to identify the provider who’s creating these costs as opposed to the member who’s experiencing them.”

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This week’s episode features a conversation with Silvia Garcia, Founder and CEO of Feel Logic and Happiest Places to Work and Former Global Director of the Happiness Institute of Coca-Cola. The topic of happiness, what it is and how do we achieve it, has been magnified by the pandemic. In the workplace, there are 8 ways that employers can facilitate happiness including increasing employee recognition, building a social support system, and focusing on personal growth.

What You’ll Learn From This Episode:

  • 02:08 Defining happiness and being empowered to hope for a better future
  • 04:59 The science of happiness and positive leadership
  • 07:58 Happiness in the workplace for small companies
  • 12:18 Concrete steps employers can do to facilitate happiness
  • 18:24 Looking to the future: The positive and negative ways technology affects happiness

Quotes:

02:29 “There’s something common which is, despite anything that happens that sends a feeling that a possible future that is better than today’s possible and that each of us can do something to get there.”

05:21 “We are driven by our emotions. Then we control them, we reflect over them but many, we are not aware of them. And they are powerful drivers of our decisions.”

08:45 “This is for everybody because the ingredients are not different whether this is a big or small company. The ingredients of happiness and happiness at work are the same.”

16:06 “Create some kind surprises to bring pleasure and surprises from time to time. Isn’t it like any relationship? We like surprises, so sometimes do that.”

16:19 “Play a lot with recognition. Part of us need it to be in a group is because we need to feel valued. So play on the recognition and do not only recognize the outcome, when things go great.”

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This week’s episode features a conversation with Surya Singh, CEO and Co-founder at gWell. Muskoskeletal claims are growing monster that gobbles up claims spends. Cutting-edge tech in genomics, AI, and machine learning help create diagnostics for the best treatments since many chronic conditions have genetic markers associated with them. At the same time, this technology cuts costs by as much as a third of current spends, a significant percentage that’s of interest to employers and patients alike.

What You’ll Learn From This Episode:

  • 01:57 Surya’s professional background
  • 03:44 Musculoskeletal claims: Rising costs associated with longer lives
  • 06:14 Genomics and genetics help diagnose chronic conditions
  • 13:46 AI and machine learning accurately determine the recovery time of patients
  • 18:46 Genetic testing and genomics cut overall spend by a third

Quotes:

05:06 “People are surviving longer and so after you get that first knee surgery, arthroscopic knee procedure, even a knee replacement or hip replacement, you may outlive it. You may live long enough that you need another one now.”

08:41 “For almost every common chronic disease or condition that develops, there are multiple genes at play. And not only are there multiple genes at play, those genes are expressed, they are used, in different combinations and at different levels by the body.”

15:39 “We can understand which of those pathways are the ones that are leading to better form and function, leading to better phenotypic outcomes for people. Artificial intelligence and machine learning are a way to be able to do that.”

18:22 “Which genetic markers that dictate whether or not they respond well to e-centric exercise, the weight-bearing exercise, and how long their recovery periods are in between can really help dictate are they out from being functional again for 2 weeks or a month or 6 months.”

20:30 “One thing I worry about in terms of making sure that the impact is as broad as it can be in terms of economics and in terms of value, and also to use another little cliche that’s used a lot now, that no one is left behind so to speak.”

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This week’s episode features a conversation with Suzanne Delbanco, Executive Director at Catalyst for Payment Reform. Consolidation in the provider marketplace has detrimental effects on patients, such as provider unwillingness to change in favor of improved patient experience. In policy reform, the central issue is price transparency remains a battleground where Suzanne is very active. She also comments on the recent uptick in direct contracting solutions and the incoming changes ushered by the pandemic.

What You’ll Learn From This Episode:

  • 01:43 Suzanne’s background: Changing the healthcare system for 10 years
  • 05:34 Payment reform: The state of provider marketplace consolidation today
  • 13:34 Advising policy reform on price transparency
  • 17:46 Direct contracting is not a broadscale solution
  • 20:17 Near future changes triggered by COVID-19

Quotes:

03:40 “Employers, states, Medicaid agencies, unions, universities who have lots of staff who have to buy healthcare for big populations, I’m trying to help them create a shared agenda for pushing the marketplace to be more responsive to the needs of those who buy and use healthcare.”

08:02 “We might come up with a perfect method of payment but if the price is too high, it doesn’t exactly bring better value.”

09:45 “When you have an increasingly consolidated healthcare provider marketplace, which means that providers have the market power and they are essentially calling the shots, it’s not only price that suffers but it can even be willingness to experiment.”

16:25 “The health policy commission, the data analysis institute that they’ve established and their sort of partnership and work with the attorney general’s office, has given Massachusetts insight into the working of their market that’s unparalleled.”

18:22 “I don’t think it will ever be a broadscale solution and it’s for very simple reasons that most employer purchaser organizations do not have the sophistication and the bandwidth to do this on their own.”

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This week’s episode features a conversation with Robert Pfeiffer, Principal at Disruptive Strategies. Disruption has become inevitable in avoiding increasing annual premiums. From going self-funded to fully utilizing technologies like on-site clinics and telehealth, employers can now confidently choose lower-cost healthcare without any loss in quality. New agile healthcare community facilities also drive down costs while also helping increase compliance, resulting in more accessible healthcare to even more patients.

What You’ll Learn From This Episode:

  • 04:38 Going for self-funded to provide reliable healthcare
  • 07:42 Using telehealth to enhance the physician-patient relationship
  • 10:03 Lower cost does not mean inferior healthcare
  • 15:44 Micro-scaling: Agile healthcare community facilities and specialty clinics
  • 18:01 Entering communities and partnering with local facilities

Quotes:

03:56 “It used to be employers of 500 or more that would look at self-funding and I see employers today in the range of 40 or 50 employees trying to change the game for healthcare because they’re just sick and tired of 8 to 10% bumps in their premiums.”

08:12 “I think you need to have, first and foremost, that relationship with a physician or mid-level provider who has all of your medical records, knows your family history, and can really guide you down the healthcare continuum.”

11:42 “There is no correlation between cost and quality in healthcare. And you’re absolutely right, in most cases it’s quite the reverse. Some of the best physicians in the country are doing work for far less than you might even be able to get it locally.”

15:30 “If we’re saving them let’s say 10% a year, that’s 1.2 to 1.5 million each and every year that they’re going to be saving on the medical plan. The cost of the rent and the facility over time become a very small factor in making that decision.”

17:17 “In almost every primary care clinic we have, there is some sort of pharmaceutical arrangement for particularly the maintenance medications. As an example, I have a DPC doctor myself and I pay 8 bucks a year for my blood pressure medication.”

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