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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This week’s episode features a conversation with Mike Case Haub, CEO at CHC Health. Optimized medication can reveal drug therapy problems that patients were not even aware of, as well as determine if lower-tier medications can work just as well or better than current prescriptions. This translates to cost savings to employees and employers. These conversations also reveal to patients what drugs they have to take and why, therefore increasing adherence and patient buy-in.

What You’ll Learn From This Episode:

  • 01:39 How optimized medication therapy can benefit patients
  • 06:55 Pharmacogenetic testing becomes more accessible
  • 08:22 Tailor-fitting optimized medications in plans
  • 11:09 Cost savings for employers and increasing user engagement
  • 14:39 Increasing adherence with customized and emphatic plans

Quotes:

02:28 “Also, we can look at it from a cost perspective too. Oftentimes, we’re finding patients that might be on a higher-tier, so maybe they’re on a third-tier medication, and there may be some more cost alternatives for that patient.”

03:05 “We actually have a negative return on investment on medications in the US, so for every $1 we spend on a medication, we spend another $1.17 to reverse the effects of that medication.”

12:04 “Hey, if I can make sure our employees that maybe are having depression issues, if we can make sure they’re on the right medications and they feel supported, they’re more likely to show up to work and be productive.”

14:54 “My focus, well what we try to focus on, is yes we want to make sure patients are adherent but we want to make sure they’re adherent to the right drug therapy.”

15:41 “Adherence is driven primarily by the likelihood that [patients] feel like this is an important medication for them to be taking and that there’s a reason for them to be taking it.”

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This week’s episode features a conversation with Doug Geinzer, Founder and President at High Performance Providers. Bundled plans provide cost benefits to providers while also connecting patients to quality healthcare. Direct contracting gives patients lower costs which are transparent upfront and provides options for destination medicine too. For an even more attractive offer, patients also get safety guarantees in high performance networks with proven reliability.

What You’ll Learn From This Episode:

  • 01:51 Direct contracting: Benefits for both purchasers and providers
  • 09:06 Bundled plans for destination medicine
  • 12:04 Tailored bundles, hospital transfer agreement, and superior service
  • 16:04 Connecting patients to quality healthcare

Quotes:

04:32 “In a bundled arrangement, the terms are negotiated before the surgery even occurs. So there is a flat amount. It’s transparent and that purchaser writes one check rather than multiple checks.”

05:52 “The purchasers want it to be easy. The providers want to earn more money. And this satisfies both of their needs.”

07:43 “From the provider side, you’re eliminating your administrative department that is doing the billing, the coding, the appeals, the collections, everything that comes with it. They’re spending about 27% of what they’re billing collecting what they charged.”

08:52 “Patient doesn’t have any patient obligations, so the plan will waive the co-pay and the deductibles for the patient because they’re saving so much money and they know they’re going to be able to get that patient back to work sooner.”

19:23 “With all of the providers that I work with personally, they have to publish their outcomes every year. So now their outcomes are out there because we need to guarantee that we are in the upper 5 percentile of the practitioners in the United States.”

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This week’s episode features a conversation with Matt Scovil, CEO at Medefy. Apps and AI are essential pieces in modern healthcare but having real people communicate with members, using technology to assist, has produced significantly higher engagement. Also, a multi-channel approach that involves the entire household empowers individual members to make much more informed healthcare decisions.

What You’ll Learn From This Episode:

  • 01:58 Outdated methods cause a lack of member engagement
  • 05:05 Using AI and apps to support rather than be the face of healthcare products
  • 11:34 Opening up communication channels that members want to engage with
  • 17:05 Reaching out to demographics with a multi-channel approach

Quotes:

03:32 “In the 2000s, people are different. They want to consume things differently. They want to interact with things differently. And so the scope of the problem really fell on how do we get down to the user level, the patient level, the member level, and do things the way they want to do.”

06:24 “We have found the best fit for those types of machine learning AI pieces is to support a real person rather than try to make it the face of the product, which is still very much lacking in terms of complexity for the average healthcare experience.”

13:37 “We’re able to reach out to the population live and because it’s real people, we’re starting these communications or these conversations and people reach back. They want to talk. They don’t turn off these notifications. They want to be engaged.”

17:51 “Getting the spouse engaged if it’s a heavy blue-collar male-dominated group, you know, the female of the household makes 85% of the healthcare decisions on average for her family. So getting her engaged is very, very important.”

19:08 “People have the best health outcomes when they can talk to somebody that already knew what to do.”

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