Reconstructing Healthcare: Innovative Solutions For Employers To Lower Their Healthcare Costs

Colin Quinn, President of Included Health Communities, joins Michael in this episode of the Reconstructing Healthcare podcast to discuss how Included Health offers tailored care navigation and advocacy solutions to employers and health plans to support their diverse employees and members. Included Health's aim is to create equity in healthcare, with their first solution creating ways to help support the LGBTQ+ community. As President, Colin strives to raise the standard of healthcare for everyone, no matter what group you belong to or what industry you work in.  Colin Quinn received an MBA from Stanford University's Graduate School of Business and went on to work in the finance and sales side of the pharmaceutical industry prior to launching Included Health. In 2021, Included Health was acquired by Grand Rounds and Doctor on Demand which has created a robust navigation and advocacy platform to support Employers in raising the bar in their recruitment and retention efforts.  Here's a glance at what you'll learn from Colin in this episode:  Why Included Health was launched How Included Health's broad service offering can improve equity in healthcare How Included Health reached an NPS score of 98% Timestamps: 0:00 – Introduction and welcoming Colin to the show 1:15 – Who is Colin Quinn and what is Included Health Communities? 2:30 – How Colin pivoted from working in finance & sales in the pharmaceuticals industry to launching Included Health 7:15 – How the acquisition of Included Health will allow the company to get to the next level and better serve employers and employees 9:30 – What differentiates Included Health from the marketplace when it comes to healthcare navigations? 12:20 – How will virtual care, digital solutions, and navigation increase the level of equity in healthcare & why is Included Health leading the way? 20:30 – Why Included Health's approach to equity can help multiple diverse groups 22:15 – How does Included Health drive organizations forward in recruiting and retaining employees? 27:10 – How do employers find out what their workforce wants/needs? 29:10 – What does Included Health's consumer satisfaction look like? 30:35 – The research & development Included Health does to make iterative improvements to its offering 32:45 – Who is Included in Health's target market? 34:00 – What exciting developments are coming for Colin? 36:00 – How you can learn more about Included Health Resources: Learn more about Included Health Communities here: https://includedhealth.com/communities/ (https://includedhealth.com/communities/) Included Health's Twitter: https://twitter.com/IncludedHealth (https://twitter.com/IncludedHealth) Colin's LinkedIn: https://www.linkedin.com/in/colin-quinn-he-him-04956119/ (https://www.linkedin.com/in/colin-quinn-he-him-04956119/) Podcast Links: Website: http://www.reconstructinghealthcare.com/ (http://www.reconstructinghealthcare.com/) Apple Podcasts: https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325 (https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325) Instagram: https://www.instagram.com/reconstructinghealthcare/ (https://www.instagram.com/reconstructinghealthcare/) Facebook: https://www.facebook.com/ReconstructingHealthcare/ (https://www.facebook.com/ReconstructingHealthcare/) LinkedIn: https://www.linkedin.com/in/michaelmenerey/ (https://www.linkedin.com/in/michaelmenerey/)

Denise Shiffman, Founder and CEO of GroupWell, joins Michael in this episode of the Reconstructing Healthcare podcast to discuss how their data-driven, online group therapy platform is providing employers with a ground-breaking way to approach mental health. Group Therapy combines the treatment of both mental health and social health to reduce clinical symptoms. GroupWell leverages technology to provide a platform where clinician-led group therapy can be accessed for specific groups of individuals dealing with similar issues and challenges. In addition, GroupWell provides wellness affinity groups led by certified behavioral coaches that can help people with sub-clinical levels of stress and anxiety as well as nutrition, weight loss, parenting, and other topics to support people's emotional well-being.  Denise Shiffman held multiple executive roles at tech start-ups and at multi-billion-dollar tech and healthcare companies prior to starting GroupWell. This previous experience has helped her build a dynamic platform that can increase access to a mode of therapy that can help people learn the skills and behaviors to build connections and quality relationships and aid in the recovery from mental health conditions.  Here's a glance at what you'll learn from Denise in this episode:  The personal experiences that led Denise to start GroupWell How Group Therapy works and is proven to be as or even more effective than individual therapy How GroupWell leverages technology to deliver evidence-based group therapy for Affinity Groups Why employers and care providers must pay more attention to mental health Timestamps: 0:00 – Introducing and welcoming Denise to the show 1:10 – Who is Denise Shiffman and what is GroupWell? 2:35 – How Denise's experience with chronic anxiety led her to create GroupWell 5:45 – Making it through the pandemic, the state of mental health, and what lessons should employers be taking from the last two years?  11:00 – The issues that people with mental health issues face with current healthcare providers 12:30 – Why is group therapy a relevant mode of treatment and why Denise decided to focus on it 16:45 – How GroupWell works for those seeking mental health support 23:40 – Why Denise works with certified coaches that lead affinity wellness groups and how mental health treatment is larger than just therapy 27:10 – The timeline that GroupWell provides for their care 29:10 – Exploring the data around how group therapy works for those seeking mental health care 31:00 – How GroupWell attracts coaches and therapists to their network  35:20 – The method of tracking and sharing results with employers and how GroupWell keeps members engaged 38:50 – The pricing model for GroupWell 40:55 – How Denise plans to scale GroupWell 44:00 – Why the industry needs to adopt a more holistic approach 45:30 – How you can learn more about GroupWell and connect with them Resources: Learn more about GroupWell here: https://www.groupwell.net/ (https://www.groupwell.net/) Podcast Links: Website: http://www.reconstructinghealthcare.com/ (http://www.reconstructinghealthcare.com/) Apple Podcasts: https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325 (https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325) Instagram: https://www.instagram.com/reconstructinghealthcare/ (https://www.instagram.com/reconstructinghealthcare/) Facebook: https://www.facebook.com/ReconstructingHealthcare/ (https://www.facebook.com/ReconstructingHealthcare/) LinkedIn: https://www.linkedin.com/in/michaelmenerey/ (https://www.linkedin.com/in/michaelmenerey/)

Veeneta Lakhani, the Chief Growth Officer for Vida Health joins Michael in this episode of the Reconstructing Healthcare podcast to discuss how Vida Health is providing care for over 2 Million people through their digital platform that aims to treat both physical and mental illnesses in a combined effort.  Vida Health is a modular platform that aims to prevent, manage and even reverse chronic conditions by bringing together mental and physical healthcare through a ground-breaking digital platform that connects patients to therapists and coaches. Vida Health's clinical outcomes have led them to receive some of the highest customer satisfaction scores that we've seen on this podcast.  Veeneta joined Vida Health to ensure her work in the healthcare industry leads to a future of care where people are looked after day to day through combining physical and mental health work to achieve sustainable outcomes. Veeneta previously held multiple senior executive positions at Anthem Blue Cross and began her career in the insurance sector with McKinsey and company. Here's a glance at what you'll learn from Veeneta in this episode:  How Veeneta is working to make an impact on people's lives every day instead of just when they go to the doctor, and why she couldn't achieve this at a major national carrier How & why Vida Health combine both physical & mental health treatments Why the healthcare industry made significant progress during COVID-19 as it pertains to mental health, diversity, equity & inclusion. How Vida Health provides instant care when their clients sign up to their service by leveraging their digital platform The secrets behind Vida Health's high customer satisfaction scores and why digital healthcare may be the way forward Timestamps: 0:00 – Introduction 1:10 – Who is Veeneta Lakhani and what is Vida Health? 2:20 – Why did Veeneta leave a national carrier (Anthem) to join a digital health start up? 4:40 – What are the positive outcomes that can be taken from COVID-19? 9:20 – What is Vida Health and what problems are they attempting to solve? 12:00 – How Vida Health approaches their mental health support & care, and why they are leading the way for measuring the severity of mental health 16:50 – Coaches: How Vida Health is implementing mental health coaches into their service 20:30 – How Vida Health manages their team of clinicians and why they can provide instant care 23:30 – What conditions do Vida Health manage and what resources do they use to provide care 27:25 – The methods Vida Health uses to track the results of their patients' chronic conditions and does Vida Health consider themselves a wellness product? 30:40 – What is Vida Health's engagement rate and why is it outperforming their competitors? 33:00 – How are Vida Health tracking their customer satisfaction and what are the results/outcomes for their customers? 37:10 – How many employers/members are currently enrolled in Vida Health's program? 38:15 – What is next for Vida Health and what is their cost structure? Resources: Veeneta's LinkedIn: https://www.linkedin.com/in/veeneta-lakhani/ (https://www.linkedin.com/in/veeneta-lakhani/) Vida Health's Website: https://www.vida.com/ (https://www.vida.com/) Podcast Links: Website: http://www.reconstructinghealthcare.com/ (http://www.reconstructinghealthcare.com/) Apple Podcasts: https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325 (https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325) Instagram: https://www.instagram.com/reconstructinghealthcare/ (https://www.instagram.com/reconstructinghealthcare/) Facebook: https://www.facebook.com/ReconstructingHealthcare/ (https://www.facebook.com/ReconstructingHealthcare/) LinkedIn: https://www.linkedin.com/in/michaelmenerey/ (https://www.linkedin.com/in/michaelmenerey/)

Wally Gomaa, CEO and Co-Founder of SimplePay Health, joins Michael in this episode of the Reconstructing Healthcare podcast to discuss how they're empowering employees with high-quality care through easy-to-understand benefit design structures. SimplePay Health aims to disrupt the healthcare industry by making the complicated elements of traditional health plans (deductible, coinsurance, confusing bills) a thing of the past while providing their members with the highest level of care. Based out of Dallas, Texas, SimplePay Health is taking on the status quo to reward employees for making choices that actually help lower overall costs. As a former President of a national insurance carrier, CFO of a healthcare provider and a benefits consultant, Wally has gained unique insight into the healthcare industry and leverages the SimplePay Health platform to address some of the problematic issues within our healthcare delivery and payment system.    Here's a glance at what you'll learn from Wally in this episode:  The payment system that SimplePay uses to make healthcare a breeze Why Wally wants price transparency to become price CERTAINTY How virtual care providers can provide higher quality care Why simplifying complexities could bring the largest change to the healthcare industry Timestamps: 0:00 – Introduction & welcoming Wally to the show 1:05 – Who is Wally Gomaa and what is SimplePay Health? 2:35 – The Bike Accident: How being hit by a car changed Wally's perspective on the healthcare industry 4:10 – Why haven't price transparency tools & high-deductible health plans driven meaningful results?  7:10 – What is SimplePay Health doing to simplify health insurance? 11:20 – How to show patients the disconnect between quality and price for commodity healthcare services 13:35 – Using data to drive down costs whilst providing a higher quality service 17:45 – SimplePay Health's approach to using networks 19:30 – Pharmacies & Aligning Incentives: How to reduce the formulary waste and price variations found at pharmacies & align incentives with employees 22:50 – Digital Health Providers vs Brick & Mortar Providers: How virtual care providers can provide higher quality care 25:20 – How SimplePay Health is implementing digital mental health services 27:00 – Member Experience: How do employees navigate their healthcare service when using SimplePay Health? 31:50 – Outcomes & Results: What results can employers expect when signing up to SimplePay Health? 35:10 – How payments are managed by SimplePay Health 38:50 – What is the satisfaction level of employers and employees who use SimplePay Health? 42:40 – The evolution, growth, and future of SimplePay Health 49:25 – How can people get connected with Wally and SimplePay Health? Resources: SimplePay Health Website: https://www.simplepayhealth.com/ (https://www.simplepayhealth.com/) Call SimplePay Health: 800-606-3564 SimplePay Health Facebook: https://www.facebook.com/simplepayhealth/ (https://www.facebook.com/simplepayhealth/) Wally Gomaa's LinkedIn: https://www.linkedin.com/in/wallygomaa (https://www.linkedin.com/in/wallygomaa) Podcast Links: Website: http://www.reconstructinghealthcare.com/ (http://www.reconstructinghealthcare.com/) Apple Podcasts: https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325 (https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325) Instagram: https://www.instagram.com/reconstructinghealthcare/ (https://www.instagram.com/reconstructinghealthcare/) Facebook: https://www.facebook.com/ReconstructingHealthcare/ (https://www.facebook.com/ReconstructingHealthcare/) LinkedIn: https://www.linkedin.com/in/michaelmenerey/ (https://www.linkedin.com/in/michaelmenerey/)

Harris Rosen and Ashley Bacot of Rosen Hotels & Resorts join Michael in this episode of the Reconstructing Healthcare podcast to discuss how they've saved over $450 million in healthcare costs by implementing their own self-insured healthcare model. Rosen Hotels and Resorts has over 4,500 employees and turns over $350 million in revenue per year through their multiple hotels and resorts throughout Orlando, Florida. Harris and Ashley have created a healthcare model that not only saves the company in healthcare costs, but also provides healthier lifestyles for their employees, as they can choose their health over their wallet via the cost savings. Harris Rosen is the President and COO of Rosen Hotels & Resorts and has not only seen the growth of his hotel business, but through the success of his healthcare program, has created ProvInsure to implement their healthcare model into other companies. Ashley Bacot is the President of ProvInsure and Risk Manager for Rosen Hotels & Resorts. Ashley was integral in creating the self-insured healthcare model for Rosen that has helped save nearly half a billion dollars in healthcare costs since inception. Here's a glance at what you'll learn from Harris and Ashley in this episode: How Rosen Hotels & Resorts implemented their own self-insured healthcare model to save over $450 million since inception. The lessons taken from the Great Depression to survive COVID-19. How to remove the barriers within your healthcare plan to have healthier employees and reduce costs. The steps you can implement to allow your employees to choose their health over their wallet. Timestamps: 0:00 – Introduction 0:20 – Welcoming Harris and Ashley to the show 1:12 – Who is Harris Rosen? 1:50 – Who is Ashley Bacot? 3:00 – The history of Rosen Hotels & Resorts and how they grew into a $361 million per year company. 7:30 – How Rosen's grandparents lessons on debt helped Rosen Hotels & Resorts survive through COVID-19. 10:30 – Trying an alternate path: How an increase in healthcare costs led Harris to explore ways to provide primary care to his own employees. 15:00 – “Rosen Care”: The initial success that led to over $450 million in healthcare savings. 17:30 – Primary Care: Increasing access to quality primary care to employees via clinic access, benefit design & removing barriers. 23:10 – How having an onsite clinic has impacted the health of employees and has lowered healthcare costs 24:20 – Living by K.I.S.S and P.P.P.P.P.P – Keep It Simple Stupid and Prior Planning Prevents Piss Poor Performance 25:50 – Encouraging Compliance: How to allow your employees to choose health over saving money 29:10 – Why hospitals aren't interested in competition and why the government and employers should get tough 31:45 – Steering the employee towards high quality health care to create lower costs 33:30 – Saving nearly half a billion dollars and Harris Rosen's philanthropy 39:00 – Managing a hospitality business and enticing people to work for Rosen Hotels and Resorts 43:00 – If there was one question I should have asked: Fighting back against the insurance companies 44:40 – How you can learn from Rosen's model and implement it inside your business. Resources: Rosen Hotels & Resorts, Inc.: https://www.rosenhotels.com/ (https://www.rosenhotels.com/) ProvInsure: https://www.provinsure.com/ (https://www.provinsure.com/) Podcast Links: Website: http://www.reconstructinghealthcare.com/ (http://www.reconstructinghealthcare.com/) Apple Podcasts: https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325 (https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325) Instagram: https://www.instagram.com/reconstructinghealthcare/ (https://www.instagram.com/reconstructinghealthcare/) Facebook: https://www.facebook.com/ReconstructingHealthcare/ (https://www.facebook.com/ReconstructingHealthcare/)

Marshall Allen is an investigative journalist that has spent more than fifteen years exposing the ways that the health care industry preys on vulnerable Americans. Marshall currently writes for ProPublica and was part of the team to be a Pulitzer finalist for their work in covering COVID-19. In this episode, Marshall discusses how his time investigating the American healthcare system has led to writing his new book, titled “Never Pay the First Bill: and Other Ways to Fight the Health Care System and Win.” Marshall's career has seen him honoured with multiple journalism awards, such as the Harvard Kennedy School's 2011 Goldsmith Prize for Investigative Reporting and coming in as a finalist for the Pulitzer for his work at the Las Vegas Sun, where he worked before writing at ProPublica in 2011. In this episode, you'll hear about real-life victories as employers and employees fight the healthcare industry. From dealing with price gouging, errors in billing, fraud and unnecessary treatments, Marshall has seen it all. Tune in to hear how employers and employees can fight back and protect themselves from being taken advantage of by the healthcare delivery and payment system. Here's a glance at what you'll hear from Marshall in this episode: Why Americans pay so much for healthcare whilst getting so little in return How Marshall's career in investigative journalism led to him writing ‘Never Pay the First Bill' Why the business side of healthcare was designed to exploit both clinicians and patients How hospitals and insurance companies look after each other rather than the employee/employer. The inefficiencies and errors presented in the majority of medical bills and how to fight back Timestamps: 0:20 – Introduction to Marshall Allen 2:20 – Why did Marshall write: ‘Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win' 7:08 – “The business side of healthcare was designed to exploit both clinicians and patients” – How the healthcare system takes advantage of Americans 9:00 – The price variation patients deal with when going to hospital 11:35 – Why aren't hospitals showing transparent pricing and why aren't insurance companies loyal to the employer/employee? 15:15 – Employers are passing costs onto their employees 16:30 – Increasing health literacy for employees and employers 17:20 – How common are errors in medical bills? 19:20 – The medical debt collecting industry 21:30 – How to deal with medical debt 22:18 – Why would you sue a medical provider for an unfair bill 24:20 – The open price contract rule: Don't pay more than Medicare would 26:04 – How a hospital would react to a lawsuit in Small Claims Court 28:00 – Using a referenced based pricing plan and why hospitals don't like it 30:20 – Share your medical finance victories with Marshall 31:10 – Everybody's Guide to Small Claims Court 31:58 – Being aware of medical finance risks and how to avoid them 33:45 – Avoiding unnecessary care 34:10 – Avoiding immediate care 35:20 – Mammograms: An unnecessary care example? 38:05 – Stories of fraud in medical care and finance 40:40 – The David Williams case 44:00 – Who investigates fraud? 46:30 – Standing up to a bully: How to push back 49:45 – How to connect with Marshall Allen Resources: Follow Marshall Allen on ProPublica: https://www.propublica.org/people/marshall-allen (https://www.propublica.org/people/marshall-allen) Follow Marshall Allen on Twitter: https://twitter.com/marshall_allen?lang=en (https://twitter.com/marshall_allen?lang=en) Connect with Marshall Allen via LinkedIn: https://www.linkedin.com/in/marshallallen/ (https://www.linkedin.com/in/marshallallen/) Never Pay the First Bill on Amazon: https://amzn.to/3tS01ZQ (https://amzn.to/3tS01ZQ) Marshall Allen's website: https://www.marshallallen.com/about-marshall (https://www.marshallallen.com/about-marshall) Fair Health Consumer: https://www.fairhealthconsumer.org/ (https://www.fairhealthconsumer.org/)...

Dave Jacobs and David Greenberg join the podcast to discuss how Homethrive is providing their customers access to their own master’s level social worker and a digital platform to help provide care for their aging loved ones at home. Prior to Homethrive, Dave and David both served at Medline. Dave Jacobs as President of the Durable Medical Equipment division and Medline’s Post-Acute business that encompassed nursing homes, home health, assisted living and managed care insurance. David Greenberg served as Executive Vice President of Strategy and Group President, defining and supporting strategic priorities, leading business development initiatives to strengthen the Medline portfolio, and M&A. In this episode, you’ll hear why Dave and David decided to leave their high paying Senior-Executive roles at well-respected companies to create Homethrive. You’ll hear how Homethrive is helping people look after their aging parents while allowing them to stay in their own homes, instead of an aged care facility.  Here’s a glance at what you’ll learn from Dave Jacobs and David Greenberg in this episode:  The foundation story of Homethrive: Why the co-founders left their Senior-Executive roles to create their own company. How Homethrive is helping people look after their aging parents while allowing them to stay at home instead of an Aged Care Home. Why Traditional Benefit Offerings often aren’t enough for employees burdened with care-related responsibilities for their aging parents. How Homethrive is able to provide each customer with their own unique Care Guide and the types of services they offer. The positive impact this can have on employees knowing they have an advocate to address elder care issues for loved ones. Timestamps: 0:22 – Welcoming David and Dave to the show 1:00 – Who is Dave Jacobs? 2:00 – Who is David Greenberg? 3:42 – Why David and Dave left their Senior-Executive roles to create Homethrive 8:20 – The state of traditional benefit offerings in the age of COVID-19 10:50 – How organizations can transition their benefit offerings as employees and their parent's age 12:20 – Diversity, Equity, and Inclusion: Is their inequity in benefits and healthcare? 14:15 – The Homethrive Product: What problems are Homethrive trying to solve? 16:40 – Homethrive’s Unique Product Offering: Your own Care Guide and access to technology 20:55 – A concierge resource for eldercare issues and unique needs 24:20 – The Employee Experience: How do the children of aging parents use Homethrive? 27:00 – The Scope of the Problem: Do companies know that their employees need to have access to aged care? 28:10 – Suffering in Silence: Why aren’t employees bringing aged care up with CHRO’s? 30:10 – How does Homethrive recruit their Care Guides? 33:50 – The outcomes of Homethrive so far: Increasing productivity, reducing stress, increasing quality time 36:30 – How COVID-19 has impacted the Homethrive service 37:10 – Targeted Segments: The fee structure for the employer segment 39:50 – How many employees are managed under Homethrive and the incentives being offered 42:08 – Why Geography isn’t an issue 43:35 – If there was one question that I didn’t ask: How much of a need aged care is in the US? 45:55 – Being a high touch service company whilst utilizing technology 48:00 – How you can find more about Homethrive Resources: Homethrive: https://homethrive.com/ (https://homethrive.com/) Dave Jacobs LinkedIn: https://www.linkedin.com/in/dave-jacobs-215b702/ (https://www.linkedin.com/in/dave-jacobs-215b702/) David Greenberg LinkedIn: https://www.linkedin.com/in/david-c-greenberg/ (https://www.linkedin.com/in/david-c-greenberg/) Podcast Links: Website: http://www.reconstructinghealthcare.com/ (http://www.reconstructinghealthcare.com/) Apple Podcasts: https://podcasts.apple.com/us/podcast/reconstructing-healthcare-innovative-solutions-for/id1240066325...

In this episode, Michael interviews Nate Murray, the Chief Business Development Officer at Crossover Health. Crossover Health is a national primary care medical group that connects employees with remarkable care options while helping employers take control of their healthcare spend.  In this episode, you’ll hear about some of the deficiencies in primary care today and why many large employers have started to engage in direct contracts with providers to offer improved primary care to their employees. Tune in to hear about the evolution of the Crossover Health primary care model and how they are using a team based approach to deliver extraordinary care for their members. Here’s a glance at what you’ll learn from Nate in this episode:  What the Health 2.0 movement is and where it’s going. Why rushed doctor visits equate to poor healthcare and how this impacts costs How deals with Apple, Facebook and Amazon helped Crossover Health design a primary health model. How Crossover Health creates a relationship between patients and doctors How integrating behavioral health and physical therapy into the Crossover model impacts patient care How effective primary care can help companies reduce their downstream costs. Timestamps: 0:22 – Introducing Nate and Crossover Health 2:55 – How Nate got into healthcare 4:38 – Nate’s wife having rheumatoid arthritis exposed the inability between what insurance companies were capable of compared to doctors. 7:16 – It’s less about the health insurance, and it’s more about the quality of healthcare that’s having an impact on costs. 8:12 – The Primary Care Crisis: Primary Care is the speedbump to the expensive healthcare industry. 11:20 – The system is lowering the quality of care. Doctors can’t provide quality if they’re seeing 30 patients a day. 14:48 – Crossover Health: How they transitioned into focusing on primary care by securing a deal with Apple. 18:00 – The Foundation of Primary Health: How Crossover is able to provide virtual primary care in all 50 states. 19:00 – The Triple Aim: Quality Experience Outcome 22:20 – Integrated Care Teams: How to analyze what a patient needs and then deploy a team to create the outcomes needed. 26:00 – Creating “Touch Points” with a patient: “Regular” is about having a relationship with a patient, rather than infrequent check-ups.  30:00 – Sherpaa Acquisition: How Crossover is acquiring companies to help deliver their triple aim.  32:00 – Creating a new offering with virtual primary care 34:12 – How did COVID-19 impact the utilization of virtual primary care?: “We could still operate and serve patients remotely.”  35:40 – Reaching out to 100,000 members to ensure they had care during COVID-19. 37:50 – Primary Care Doctors went above and beyond during COVID: “They were in it for the right reasons and didn’t turn away patients.” 38:34 – Crossover Pricing Studies: How the economics of primary care help companies reduce their downstream costs. 44:08 – The goal is to allow our patients to create trust with our recommended doctors.  45:24 – How Crossover bills for its services 46:35 – ‘Fee for Service’ creates an environment to rush patient visits. Crossover is strongly against fee for service.  47:39 – Implementing a value-based cap to dissuade overbilling. 51:40 – Patient Experience: How Crossover got a Net Promoter Score north of 90. 54:04 – Employers need to take a step back and consider “how can my employees trust our healthcare service?” 55:08 – Conclusion Resources: Crossover Health Website: https://crossoverhealth.com/ (https://crossoverhealth.com/) Nate Murray’s LinkedIn: https://www.linkedin.com/in/nathanlmurray/ (https://www.linkedin.com/in/nathanlmurray/)

In this episode, Michael moderates a webinar that highlights an employer who took action to help their employees find higher quality, more cost-effective care. The episode highlights two panelists, one with Christin Deacon, the Assistant Director of the New Jersey State Health Plans, and the second with David Vivero, the Co-Founder and CEO of Amino.  Christin is a healthcare leader and public sector entrepreneur. She is a former deputy attorney general and private sector restructuring attorney, and her unique background allows her to have a different perspective on the status quo in the realm of healthcare. She engaged with Amino to get ahold of out-of-network spend and make an impact on the trajectory of cost in New Jersey, which is $2B on pharmacy and $5B on medical and growing.  When David Vivero spoke with Christin and learned the needs of the state and its members, he learned that staying within the network and better hospital selection were primary concerns. Employers and employees were having trouble finding cost-effective care, and he knew Amino’s platform could solve for that.  The state was able to move fast and implement Amino in just eight months, and their first push was the digital experience and matching people with the right provider and tools. David explains that the goal was to solve the three fundamental problems of healthcare guidance: providing the data to inform a good decision, creating an experience that delivers results, and distributing it effectively.  The Amino Smart Match label finds the high-performance network by stratifying the network by cost, quality, experience, and appropriateness, and their Integrated Benefits Tool connects the dots in the healthcare system so members cut through the noise and find exactly what they need.  Amino is all about “Getting back to it.” They understand that people don’t want to be experts in healthcare and just want to be healthy with the support of quality, cost-effective care. And with an NPS score of over 80, it’s working. On the horizon, Christian sees more engagement in digital health, a spike in telemedicine, new models of delivery, and more opportunities for education. As for Amino, they have an exciting road ahead. They’re following trends in the market, working towards ER avoidance, and getting into retail clinics.  Here’s a glance at what we discuss in this episode:  00:30 - Introducing the panelists and discussion. 03:00 – Christin’s unique background, burnout, and draw to public service.  04:15 – The division of pensions and benefits and the health benefits climate in 2018. 05:10 – Status quo, out-of-network spending, and getting ahold of cost and spend.  05:50 – The trajectory of cost: $2B of pharmacy, $5B on medical and growing. 6:35 – One or two large claimants can make or break a year; you can’t assume someone is watching every dollar with such a large plan.  07:00 – Her interest in Amino; she listens to podcasts, including the Reconstructing Health podcast, and heard the interview with David Vivero. 07:45 – David’s first conversation with Christin and how the Amino solution can benefit the state.  08:15 – The first few conversations were about learning the needs of the state and its members, specifically, staying in-network vs. out and hospital selection.  10:05 – They learned the challenges, stakeholders, and experience and the ways Amino could help.  10:50 – Employers and employees have trouble finding cost-effective care; Amino solves for that.  11:30 – They implement Amino in 8 months; Christin’s first step in moving it forward was the digital experience and matching people with the right providers and tools.  13:25 – They integrated Amino through their carrier to be wherever members go to get their information. 14:05 – The obstacles Christin faced when replacing Horizon’s tool with Amino’s. 14:25 – There’s general reluctance and lack of trust...

In this episode, Michael interviews Omar Dawood, the Chief Medical Officer and Head of Sales at Calm, the #1 app for sleep, meditation and relaxation. The app has over 100 million downloads and over 1.5M 5-star reviews. Omar is a clinician and stage IV cancer survivor with over 25 years of senior management, medical research and clinical experience, innovating medical devices and digital health products as a senior executive. At Calm, he leads B2B employer and health plan sales and is passionate about helping people around the globe lead healthier, happier lives by building resilience through better sleep and improved mindfulness. While 20% of Americans are dealing with a mental health illness of some sort, Omar believes that we shouldn’t forget about the other 80% of people who experience stress and anxiety without a mental health diagnosis. That’s where Calm comes in to act as a preventative measure to improve behavioral and mental health as well as resilience through mindfulness practices, meditation, and strategies for better sleep.  Calm started as a B2C app but is making strides in the B2B sector to support employers, employees, and organizations. And it’s working. The sign-up rate on employer accounts is 30% with 80% engagement, and the experiences it offers – like the “Daily Calm” and “Sleep Story” – are helping employees reduce stress, sleep better, respond better to life, communicate more effectively, and boost immunity around the world.  The benefits Calm offers to organizations and employees is clear. For organizations, they provide actionable insights and aggregate trends. For employees, they offer pathways to increased resilience and wellbeing and a “Calm Effect” that touches every area of their life. Calm’s NPS is just over 70 and they do qualitative ratings and satisfaction measurements in a number of ways. The team at Calm is excited for more innovation in behavioral and mental health and encourage collaboration in the field in order to spread health and happiness to billions.   Here’s a glance at what we discuss in this episode:  00:50 - Introducing Omar and Calm.  02:30 – His cancer diagnosis changed his view on medicine and the industry’s lack of data; he didn’t appreciate the value of mental and behavioral health until 10 years ago.  04:45 – He saw a need to bring an engaging experience to behavioral health; this is how he came upon Calm and loves his role in bringing that to employers/employees.  06:30 – The 1 in 5 statistic: Omar believes we should consider the preventative health of the other 80% who also experience stress and anxiety but aren’t diagnosed. 08:50 – The pandemic opened up the dialogue that we’re all coping and should do something about it because we’re human, not because we’ve been diagnosed.  10:00 – Most employees experience stress and anxiety; digital health made help easier and more accessible, but still sat downstream in terms of treatment. 12:50 – What was missing was something more upstream and preventative. 13:00 – EAP services 0-3% engagement, Calm’s sign-up rate is 30% on employer accounts and average engagement of 80%; it’s not seen as behavioral health at all.  14:40 – Calm is an experience, not a product, and becomes a part of the user’s life to support better resilience through meditation, mindfulness, and better sleep.  16:30 – They started with B2C and are now working with employers and organizations to broaden their impact.  18:15 – The benefits of meditation: The “Daily Calm” content through the app helps people respond (not react) to life and communicate better.  21:30 – It impacts your immune system, your ability to support yourself through challenges, and shift your perspective.  23:20 – Narrated mindfulness topics: Gratitude, visualization, positive frameworks, communication. 27:00 – Using Calm for better sleep: The “Sleep Story” is a bedtime story told by a narrator of your...

In this episode, Michael introduces Justin Leader, the CMO of Highlight Health and a self-funded benefits and risk advisor. Early in his career, Justin learned about the major shortcomings of the healthcare and health insurance industry and how it is built for profitability, not value. When he met Josh Spivak, the CEO of Highlight Health, they saw an opportunity to build a better solution for an underserved segment of the population.  Highlight Health’s mission is to deliver affordable and accessible healthcare to the nation’s underinsured populations. Their product is not a health insurance product, but rather a healthcare product where in exchange for a fee, an employer’s underinsured employees get access to healthcare, education, and an advocate. The populations they serve typically don’t work enough hours to qualify for full time benefits, can’t afford their traditional benefits, or may be offered limited MEC or Minimum Value plans that really don’t offer access to comprehensive healthcare.    Highlight Health’s goal is to systemically help people access 80-90% of their basic healthcare needs through their platform and mitigate risk for catastrophic events. Highlight Health differs from other vendors in the market by providing an advocacy service for members and negotiating with Hospitals to provide inpatient and outpatient care at zero or reduced cost through federally-funded programs. Highlight Health is busy collecting feedback and success stories from members and they look forward to a future full of collaborations and philosophically-aligned partnerships to better serve their members.  Here’s a glance at what we discuss in this episode:  01:00 - Introducing Justin and Highlight Health.  02:40 - How he got into benefits consulting. 05:45 - How he became a part of Highlight Health.  07:50 - The political approach to healthcare and the point that’s missed.  09:00 - There’s tremendous pain when trying to navigate the healthcare system. 11:45 - The collective problem in healthcare and the responsibility all must take. 12:40 - The working poor and healthcare illiteracy.  14:00 - The difference between health insurance and healthcare.  14:15 - The Highlight Health product; your friend in healthcare.  15:10 - They focus on accessibility and care; advocacy is a cornerstone. 16:45 - They provide education and value to empower people to make better decisions.  18:22 - They take regulations and laws and leverage them to access care across the country.  19:30 - This is not a health insurance product, it's a healthcare, capitated product. 21:10 - Thoughts on GAP funding.  21:40 - How the drug component of Highlight Health works. 24:30 - Highlight Health’s vision for the future.  25:20 - How community-based programs work and how Highlight Health would help a member get care in a selected hospital system.  28:40 - Their goal is to systemically help people access 80-90% of their basic needs through their platform and mitigate risk for catastrophic events. 29:25 - They can provide compliance components and supplemental products.  32:00 - The employer’s get a simple, consolidated bill from Highlight Health. 33:05 - Employee outreach: They communicate the programs appropriately and offer virtual support.  36:30 - They’re collecting feedback and success stories and are holding big institutions accountable for the community care they’re required to provide.  39:00 - He’s looking forward to getting people excited for something new, collaborations, philosophically-aligned partnerships, and to leave a legacy. Resources https://highlight.health/ (Highlight Health) https://www.linkedin.com/in/justindonaldleader/ (LinkedIn)

In this episode, Michael introduces Doug Aldeen, a healthcare and ERISA attorney. He has represented reference-based pricing organizations, PPO networks, medium to small self-funded plans, TPA’s and provider sponsored HMO’s in various capacities.  Doug started his career at an insurance defense firm, then worked at a local HMO for years. It was there that he learned the ins-and-outs of the healthcare industry and realized that “discounts” aren’t real, but the prevalence and unsustainability of cost-shifting very much are. He found that in many cases there’s no correlation between what hospitals charge and their cost, and “turbo-charging”—where hospitals raise billed charges at unreasonable rates—is common in commercial insurance yet illegal in the Medicare world. Doug has seen “turbo-charging” of 12-24x, and 30x pricing on prescriptions and implants.  Surprisingly, employers are often completely unaware of what’s going on under the hood of their healthcare plan. They’re left in the dark because of limited access to data, billing statements without itemized, line-item costs, and “Revenue Neutrality Agreements” that sometimes allow providers to be paid more than they bill. Doug believes commercial insurance plans serve as an ATM for hospitals at the employers and patients expense, all because no one is monitoring, auditing, and demanding to see what’s getting billed, what’s getting paid, and why. And with the employer fiduciary duty under ERISA, this could be a costly oversight for employers that may lead to lawsuits in the future.  Doug works primarily with employers who have self-funded plans and reference-based pricing plans. He develops direct contracts with Hospitals and Providers on behalf of employers and their employees. For Doug, a successful agreement with a provider should be simple; only clean claims are paid, all claims are auditable, price is reasonable and there is a benefit incentive for employees to receive care at the facility.  More importantly, a safe harbor has been created where the employee can receive care without having to worry about balance bills which are not allowed under the contract. With his day to day work and advisory position at RIP Medical Debt, Doug is making a positive impact in the healthcare industry and we’re excited to see him keep up the good work.  Here’s a glance at what we discuss in this episode:  00:30 - Introducing Doug, a healthcare and ERISA attorney who helps employers and payers offer affordable healthcare to employees and dependents.  02:12 - He’s been a lawyer for 28 years; he worked in an insurance defense firm doing dram shop cases in 1997 and ended up at a local HMO for 7 years. 03:30 - The most fundamental flaw in the industry: discounts aren’t real, overpaying, and cost shifting in the commercial market are unsustainable.  05:45 - There’s no relation between what they are charging and their cost; we need honest conversations and common middle ground.  06:30 - Hospital “turbo-charging”: Hospitals charge X and insurance companies match it with the premium; it’s “chumminess” between providers and insurance carriers.  08:35 - Turbo-charging is expressly illegal in the Medicare-world but not the same in the commercial world; you can see this anywhere from 12-24x. 09:30 - He’s seen 30x pricing on Rx and implants; CFOs need preservation of P&L and need to get motivated to understand how this all works.  11:00 - Turbo-charging is illegal with Medicare; we can’t vilify healthcare providers, it’s not them. 12:40 - Data ownership: Cigna owns the data and allows you to access it on a limited basis; the data should be a part of the plan; you should be able to see bill charges. 14:10 - Anthem has a “Revenue Neutrality Agreement” executed on the side with the hospital system - they found 30% of claims were paid more than the billed charges.  16:05 - Employers don’t know if they’re getting what they’re...

In this episode, Michael introduces Mike Poelman, the founder and president of Apta Health. Although Mike started his career as an accountant and controller, he quickly realized that he was a salesman at heart so he shifted into the TPA world working on self-funded health plans. This is where he realized that things needed to be done differently. Mike saw that lack of transparency and collusion were the biggest problems in the industry, and legacy solutions simply weren’t designed to provide employers what they needed, which is what inspired him to create a number of companies, including Apta Health. Apta Health aggregates middle market employer groups under one umbrella so they can benefit from care coordination and cost containment solutions that are typically only available to Fortune 500 size companies. This member centric approach allows more effective customer service, higher member engagement by a team of experts/advocates to reduce provider gaps, contain costs, and improve the member journey. In fact, 88% of employees engage with a care coordinator even before a claim enters the system, which is unheard of in the industry.  The team at Apta Health has an NPS rating of over 70 for their members, employers, and providers because of their attention to the customer experience first and the TPA second. Apta Health has an exciting future ahead. They’ve recently won the 2020 Health Value Award from the Validation Institute and look forward to continuing their use of analytics and data to empower brokers and employer groups to make easy, cost-effective decisions.  Here’s a glance at what we discuss in this episode:  00:45 - Introducing Mike, the founder and president of Apta Health, who is passionate about providing self-insured solutions.  01:05 - Apta Health is a provider of care coordination and cost-containment solutions to optimize self-funded healthcare programs. 02:30 - He started as an accountant and controller but is a salesman at heart; when he first started in the industry, all he had was a phone book and phone.  04:05 - He didn’t intend to be a part of a TPA but he knew he wanted to change things by looking from an employer standpoint first.  04:40 - He started Novo Benefits, a platform where employers are empowered to get direct contacts and unbundle their programs.  05:30 - They’ve evolved into an aggregator with Apta Health; they are changing the industry and empowering employer groups.  06:50 - The key issues in the healthcare industry: transparency and collusion. 09:00 - What Apta Health does: They aggregate employer groups under one umbrella so they can benefit from large group level pricing, solutions, and engagement.  10:36 - They offer Fortune 500-level engagement to the underserved middle-market.  11:00 - The Quantum care coordination model and how it’s different: more effective disease management, better execution, and functionalities done by one pod. 12:30 - Apta is a conglomerate of solutions; they’re getting 200% better engagement  13:50 - The member journey, reduce provider gaps, drive the member experience, and get results and better engagement.  15:47 - A team of experts/nurses help guide and navigate patients through disease management to get them what they need, not just verify coverage.  17:25 - The pod team helps members find more cost-effective solutions they may not know about and create a trusting relationship with members.  21:15 - Stories of above-and-beyond service from the team that is fighting for the member.  22:35 - Deep analytics helps decide what’s best for groups, they use quality metrics, point solutions drive what needs to happen, and an easy number to reach support.  25:15 - Their PCP-centric model helped them avoid wasteful spending; the real-time intercept helps direct members and helps them avoid unnecessary tests.  28:00 - Mike shares his experience with his

In this episode, Michael introduces Dr. Simon Mathews, a distinguished researcher, clinician, author, and Chief Medical Officer at Vivante Health. He is also a practicing gastroenterologist at the John Hopkins School of Medicine and the Head of Clinical Innovation at John Hopkin’s Armstrong Institute of Patient Safety and Quality.  Simon’s research centers around understanding and improving the quality of digital health for patients. Unfortunately, he finds that the key issues in healthcare revolve around inefficiency, fragmentation, and a lack of a team-based approach that is centered around the patient’s best interest. This inspired him to work with Vivante Health, so patients with digestive issues could get the personalized, tech-forward support they need to heal. And with digestive disorders—everything from reflux to IBS to autoimmune disorders—making up a burden of $136 billion dollars on an annual basis, it’s clear that there’s a serious need.  Vivante Health serves the large, underappreciated, and sometimes stigmatized realm of digestive disorders with a comprehensive and personalized digital platform. Patients are provided with a care team, including a licensed dietician and health coach, and their progress is supported with app reminders, appointment support, check-ins, and progress reports. Although tech is leveraged to best support the patient and their results, it’s the care team outreach and their personal touch that bridges the gap for truly positive user experience and improved outcomes.  The care team at Vivante Health has an NPS rating of nearly 80. They work primarily with employers and are flexible in the way they integrate with new and existing systems. Although excited for everything currently underway, Simon looks forward to more clinical pathways and screenings in the future to continue to help patients quietly or outwardly suffering from digestive disorders.  Here’s a glance at what we discuss in this episode:  01:00 - Introducing Simon, his accolades, and how he came to work with Vivante Health.  03:00 - He studies the space of digital health, it’s gaps, and it’s solutions, which was a perfect fit for Vivante Health.  04:20 - Key issues in healthcare: Inefficiency, fragmentation, and a lack of a team-based approach. 06:45 - On digestive disorders: Nobody has digestive disease in general, they have something specific like reflux, IBS, a type of liver disease, pancreatitis, etc.  08:25 - Digestive disorders make up a burden of $136 billion annually; they come with a stigma and people don’t always feel comfortable with it.  09:38 - How digestive disorders are being treated today and the cost implications vary widely, as the types of disorders vary. 12:30 - The link between gut health and overall health, including immune and emotional health; there’s a connection. 15:05 - The Vivante Health product and service; the space they serve is large and underappreciated. 15:40 - It’s a comprehensive digital platform that addresses the management of the digestive disease and is integrated with common tech and a care team. 16:15 - With a health coach and licensed dietician, patients get a personalized program based on their history, gaps in care, best practices, and evidence.  19:05 - How they improve the customer experience: App reminders, appointment navigation, health coach support, check-ins, assessment tools, and progress reports.  21:30 - The microbiome assessment: Certain diets/lifestyles have certain bacterial compositions and we can manipulate that bacteria, our microbiome.  25:00 - The clinical rigor and evidence are of utmost importance for Simon and Vivante. 27:30 - How progress is tracked with Vivante Health: Assessments, trend anticipation, self-management improvement, and care team outreach. 30:45 - Their care team NPS rating is almost 80 and people appreciate a personal touch.  31:45 - On cost: Over 2x...

In this episode, Michael introduces Dawn Cornelis, the co-founder and Chief Transparency Officer of ClaimInformatics. ClaimInformatics is a payment integrity solution that helps its clients identify improper healthcare claim payments and recoup the money for the employer.  When Dawn entered the world of claim processing 30 years ago, it didn’t take long for her to see that money was being wasted on a massive scale via unnecessary procedures, upcoding, bad systems, and egregious contracts. Unfortunately, there’s more abuse now than ever. With 3-7% of healthcare claims being inaccurately paid, it’s grown to be a problem that is worth over a trillion dollars. This inspired her to co-found ClaimInformatics to catch errors, fraud and contain costs for members. She emphasizes that these costs aren’t savings, it’s money that shouldn't have been paid in the first place.  ClaimInformatics has a process where they are able to identify six levels of errors that lead to overpayments, including upcoding, miscoding and outright fraud. They review ASO/TPA network agreements, acquire and review all data, re-adjudicate claims, then share the results with clients to illustrate the level of overpayment in their plan. From there, they initiate the recovery process where they typically recover 80% of improper payments on behalf of the employer. In addition to recouping money for the employer, they put providers on notice who are engaging in egregious billing practices that they are now being watched and will be reported to the Network and Medical Board if behavior continues.  ClaimInformatics works primarily with clients who are self-funded and under ERISA guidelines. They have flexible fee structures with aligned incentives to generate results for their clients. Dawn recommends everyone take a hard look at their reports, review their ASO agreement, and become acquainted with their performance audit terms. ClaimInformatics stands for integrity and member-centric service, and we’re excited to see how they continue on this trajectory into the future.  Here’s a glance at what we discuss in this episode:  00:30 - Introducing Dawn, the co-founder and Chief Transparency Officer of ClaimInformatics. 02:30 - 30 years ago, she got into the claim processing and became a System Configuration Specialist; she then became a plan administrator for a Fortune500 commercial group.  05:35 - They read the story in the data, and the data isn’t good in terms of waste via unnecessary procedures, expensive services, bad systems, and egregious contracts.  07:45 - ClaimInformatics is all about integrity; they ensure payments are accurate and in accordance with agreements made.  08:30 - They catch errors and fraud to contain cost; it’s not savings, it’s money that shouldn't have been paid in the first place.  10:55 - Why are we still seeing 2-3% leakage when that waste is 100% preventable? 11:15 - Most of their clients are self-funded and under ERISA guidelines.  11:30 - The ClaimInformatics process: They review ASO, ascertain and review all data, re-adjudicate claims, then take the results to show clients what they’ve captured. 12:50 - They follow the same guidelines as a claim’s office, make deposits on behalf of clients, and are member-centric in terms of protecting their overpayments, too.  14:05 - They ensure member liability is made whole; they go back three years and see lots of coding and billing errors that are non-compliant of the rule sets.  17:15 - Historical claims review results: Incorrect codes and upcoding make groups and members pay more.  19:30 - Medical records either support or don’t support the coding choice; they have seen upcoding happen frequently across the board with outside billing companies.  21:10 - There’s more abuse today than ever; there are six levels of errors that they’ve identified.  25:22 - Providers are paid...

In this episode, Michael introduces Jim Wachtel, the Executive Vice President of Sales and Marketing for Renalogic. Renalogic is dedicated to helping employers manage kidney disease in their employee population and reducing dialysis costs with preventive programs and pricing solutions.  Jim was inspired to enter the healthcare industry because he recognized the cultural issues around healthcare. He wanted to support a company that not only helps make treatment accessible to those who need it but also takes measures to prevent chronic illness in the first place.  With this mission in mind, Jim found Renalogic. Renalogic works to reduce the costs associated with dialysis — a treatment for End-Stage Renal Disease (ESRD) — and offers a Kidney Dialysis Avoidance Program for at-risk members. Kidney disease is known as “the silent killer” for a reason: It is estimated that 40% of people with kidney disease don’t know it. And if it progresses from Stage 5 to ESRD and dialysis begins, treatment is expensive — up to $1.3 million per year, per member.  Renalogic started with cost-containment solutions, but their goal is to actually put their cost containment business out of business and focus on prevention instead. They have had a 99.3% success rate of keeping people off dialysis and have, in many cases, helped members reverse their kidney disease. They do this with personalized coaching that empowers participating at-risk members to take charge of their health. This, in turn, creates a ripple effect in their families that inspires cultural change one household at a time.  As far as payment goes, Renalogic imposes payment on the dialysis provider and works to ensure Medicare is maximized for those who qualify, even before the age of 65. They have a proprietary way to re-price claims in a way that is fair and defensible. For their Kidney Disease preventive program, they have a pay-for-performance structure and only bill for employees that have signed up to work with their nurse practitioners/coaches.  Renalogic has an exciting future ahead that includes a data service that will allow better service for those at-risk for kidney disease. And with a big vision that includes a healthier culture through education, empowerment, and preventative support, we are excited to see how the trickle-down effects of Renalogic’s efforts play a role in the health of future generations.  Here’s a glance at what we discuss in this episode:  00:30 - Introducing Jim, Renalogic, and Jim’s background and education. 02:00 - He knew we had cultural issues around healthcare and that “the American lifestyle is wreaking havoc on chronic disease”. 03:30 - Jim became interested in working with companies that help combat chronic illness and disease.  04:45 - The problem is that the expertise required for solutions is hard to find; for employers, it’s hard to keep costs down while still providing quality care.  06:00 - A small percent of the population is a majority of the costs; this 5% needs to be addressed in a reactive and proactive way. 07:05 - They empower members to take charge of their health and don’t see people as a line item cost. 09:20 - A large percent of the population has some stage of chronic kidney disease and up to 40% of people who have it don’t know it.  10:35 - After Stage 5 of chronic kidney disease, you go into ESRD which is when dialysis is started; it costs up to $1.3M/ year per member, the 3rd highest flagged stop-loss claim. 11:45 - The dialysis marketplace is concentrated and the duopoly in the market doesn’t have an incentive to lower costs.  13:15 - They started with cost-containment solutions and have a system to re-price claims in a way that is reasonable and fair. 16:06 - ESRD makes you eligible for Medicare before age 65 so that becomes a second payer and becomes primary after the waiting period. 17:30 - They “impose the payment on the provider”; why...

In this episode, Michael introduces Dr. Cristin Dickerson, a founding partner at Green Imaging, a full-service virtual medical imaging network owned and operated by board-certified radiologists. Dr. Dickerson founded Green Imaging to provide affordable, high-quality medical imaging for uninsured and high-deductible patients across the U.S. While she was working for a radiology group in Houston, she realized that she didn’t have control over many aspects of quality or her hours, and everything in Houston was extremely overpriced for patients. Instead of opening a brick-and-mortar center, she instead found imaging centers that were at 50% capacity and bought their unused time at a discount. These were savings that she could then pass on to the patient.  Green Imaging also reverses the traditional billing model so they’re in control of the finances and eliminate the issues that come from split billing. Although pricing can fluctuate in different geographic markets, they’ve still been able to achieve up to 60% savings relative to insurance carrier network discounts. Green Imaging is seen as a great referral source for many imaging centers, driving utilization by helping employers communicate the benefit of their service. They are appreciated by patients, employers, and centers alike, and have a 4.9 average star rating to prove it.  Green Imaging has partnered with 1,400 imaging centers and counting, and they are currently serving 250,000 lives across the country. With more employers looking for affordable and creative solutions for their employees, we’re excited to see Green Imaging grow through aligned incentivization, affordable costs, and quality service.  Here’s a glance at what we discuss in this episode:  01:00 - Introducing Dr. Cristin Dickerson, her background, education, and inspiration for founding Green Imaging.  02:20 - Cristin’s journey from being a physician to being a healthcare entrepreneur, her mission, and how the Radiology Group of Houston evolved.  04:00 - The issues in the imaging industry that Cristin saw and wanted to be solved; quality control, price, and an ability to control her hours.  05:15 - The difference between Green Imaging and traditional imaging and radiologist processes.  07:30 - The biggest issue in our healthcare system: 70% of doctors are employed by or subsidized by hospitals; hospitals are more expensive than independent physicians.  08:50 - COVID-19 is challenging employers to look for more creative and affordable solutions for employee healthcare.  09:15 - Why diagnostic imaging is so expensive: Physicians owned by hospitals are incentivized to keep care in the hospital system. 11:20 - Radiology groups and the issue with split billing; the “surprise bill”, the scan, and the interpretation.  13:30 - Price variations in the market: The game between hospitals and insurance companies often leaves the patient paying way more for imaging than they should.  17:00 - Michael shares a story of when he was quoted $2,500 for an MRI that he found elsewhere for $500. 17:30 - The Green Imaging product and service: She lets the imaging center set their pricing and they’re all very interested in contracting right now.  18:45 - Pricing is variable because the market is variable, but they have been able to achieve 60% savings. 21:30 - Green Imaging is the best referral source for some of the imaging centers because they wouldn’t otherwise be at capacity or be able to find new patients easily.  22:40 - They can pay within 2 weeks of receiving a claim; sometimes it takes longer to receive the claim. 23:45 - They have partnered with 1,400 imaging centers and will be in all states except New York and will shop for care if there isn’t a center near a patient. 24:50 - How billing works: Everything goes through them and is made easy through their app and their claims and reference-based pricing.  26:35 - They work...

In this episode, Michael introduces A.J. Loiacono, the CEO at Capital Rx, a pharmacy benefit manager seeking to create the first efficient and transparent marketplace for prescription prices and ultimately reduce prescription costs for employer groups.  A.J. has over 20 years of experience in pharmacy benefits, finance, and software development. Although he never thought he’d end up in the same industry as his father, he loved the nature of pharmaceuticals and recognized the inefficiencies within the system. He realized that, although every other industry has changed massively over time, pharmacy benefits have gone largely unchanged for over 20 years.  The problem with the pharmaceutical industry is that buyers (employers) and sellers (pharmacy stores) haven’t been able to communicate freely about pricing. Instead, they communicate through a PBM that inflates and distorts the true cost of the drugs. Capital Rx’s mission is to redefine the way prescriptions are priced and administered in the U.S. so there is more transparency and directness between buyer and seller. They do this through their proprietary Clearinghouse Model℠ that uses NADAC or National Average Drug Acquisition Cost to eliminate prescription drug price variance that is standard when using the AWP (Average Wholesale Price) + discount model. Capital Rx prides itself on its focus on administration and care, not price manipulation and setting. They have a high-touch process that both employers and patients appreciate and an NPS score of 92 to prove it.  The Capital Rx platform is designed to create maximum value for the employer and employee and includes low net cost formularies, simplified/transparent contracts, and rebate guarantees, and high touch service and reporting for both the employer and consultant. With success stories abound and a transparency-based model, we’re excited to see how Capital Rx continues to redefine the pharmacy benefits space long into the future. Here’s a glance at what we discuss in this episode:  01:00 - Introducing AJ Loiacono, his background, mission, and work in the industry.  04:10 - He read about software conversions for pharma in Forbes and was intrigued.  06:30 - He’s studied the pharmacy supply chain and understands the drug pricing. 07:30 - The shift from volume to value; We give incorrect value to pharmaceuticals.  08:55 - Drugs are inflated and pharmaceuticals have an inelastic demand curve.  10:30 - The haziness around drug pricing controls the supply chain. 11:10 - PBMs and carriers adopted one formulary for the best rebate.  12:40 - Buyers (employers) and sellers (retail pharmacies) should freely communicate on price, but the PBMs prevent it, which is problematic. 15:10 - AWP Data says in the second line that it shouldn’t be used as a price point.  16:30 - They use NADAC pricing; they find it more transparent and contrasting with AWP. 18:40 - Price only changes if CMS sees a +/- 2% shift; many states use NADAC. 19:06 - Capital Rx is the only PBM that built a network around NADAC. 21:00 - NADAC is a closer approximation to what the pharmacy actually pays.  22:05 - Pharmacies are hesitant to reduce the price because the savings never make it to the payer; the artificial variability doesn’t come from the pharmacies.  23:30 - There’s no crazy price fluctuation in the Capital Rx model because they use the same benchmark across the board.  26:50 - Inflation in the NADAC model in relation to the AWP; NADAC deflates 10%/year for generics, it was deflating in AWP as well, but the consumer sees an increase.  29:50 - It all goes back to a lack of communication between the buyer and seller because of that middleman that pads profits.  32:45 - They have value-driven formularies and are focused on value, precision, and removing waste.  38:10 - They quote their

In this episode, Michael introduces Jason Hellickson, the CEO of Regenexx, a global provider specializing in interventional orthopedics. Regenexx partners with self-funded employers to significantly reduce their orthopedic spending while providing employees a choice in care. Regenexx orthopedic procedures leverage the body's natural healing ability to repair damage to bones, muscles, cartilage, tendons, and ligaments non-surgically and with great outcomes. Jason is a long-time athlete who underwent shoulder surgery in 2008. Although the surgery was deemed “successful”, the fact that it took him 12 months to recover, 12 months to swim again, and lasting pain caused him to question whether there were better alternatives. Years later, when he received the same prognosis on his other shoulder, he insisted on an alternative. With Regenexx he was able to swim again just 6-8 weeks after the procedure. He learned that Regenexx could be offered through a self-funded health plan, so he partnered with them as an affiliate and then later became the CEO. Jason believes that our orthopedic care continuum needs a reinvention because surgery is no longer the only option. With almost 6% of GDP spent on elective orthopedic surgeries a year and about 50% deemed ineffective, the reinvention includes new and advanced “interventional orthopedics” that cut costs, are less invasive, and frequently allow patients to avoid surgery altogether.  Regenexx is backed by clinical research, saves employers up to 70% on elective surgeries, and saves patients the pain, recovery time, and uncertainty of surgery. And with a research-based and outcomes-monitored model, they are transparent, ensure a high standard of care and have a comprehensive accreditation process to be part of their provider network. They work with employers as a direct contractor and help educate members on the benefits of interventional orthopedics so members are informed and know it’s an option to consider in lieu of invasive surgery.  With a Net Promoter Score of 74, their education and service are clearly working. In addition to high member satisfaction, Regenexx has also recently been awarded the Traction Award at the Employer Health Innovation Roundtable. Just from the event, 12 large employers agreed to move forward with Regenexx - a big win that seems to be just the beginning of an exciting road ahead. Here’s a glance at what we discuss in this episode:  01:00 - Introducing Jason, Regenexx, his background, and his unique journey.  03:00 - He got one surgery and began looking into alternatives for his other injuries. 04:00 - He found Regenexx, entered into an affiliate partnership, and became the CEO. 06:30 - Issues from a care and cost standpoint in orthopedics: almost 6% of GDP is spent on elective orthopedic surgeries a year, yet 50% are deemed ineffective procedures. 08:20 - Many people put off surgery for an average of 5 years; this “gap in care” leaves them in pain which is where “interventional orthopedics” comes in.  09:30 - Interventional orthopedics is a less invasive and needle-based procedure using orthobiologics (your natural healing cells).  12:30 - The healing happens at a cellular level and allows the body to unleash its natural healing powers. 13:30 - Efficacy rates: Orthopedics used to be the only option, so efficacy was not considered; Regenexx clinical research and studies prove its efficacy.  16:15 - Regenexx is research-based and outcomes-monitored; proper diagnosis, a well-executed procedure by a skilled physician, and orthobiologics. 18:00 - They vet and constantly educate their physicians and lab techs to ensure a standard of care that is monitored within a transparent outcomes database. 19:20 - They have 75 locations and over 100 physicians across the country, and growing. 19:50 - The average cost of orthopedic surgery is around $25,000-30,000; the average

Topics Revenue Cycle Management Rising healthcare costs Bundled Pricing Cost Savings Centers of Excellence Improving Employee Experience In this episode, Michael introduces you to Sachin ‘Sach’ Jain, CEO of Carrum Health. Join us as we discuss how Carrum Health has created an alternative marketplace for lower-cost surgical procedures with a focus on creating an exceptional employee experience. Here’s a glance at what you’ll learn in this episode: Who Sachin Jain is, and how he found his way into the healthcare field. The Healthcare Marketplace – Why supply and demand play such a vital role in costs, and why the healthcare marketplace doesn’t interact or operate like any other marketplace for service and goods in the country. How Carrum Health is working to solve two systemic issues in Healthcare payments today How Carrum Health created a marketplace for select surgical procedures that sits outside of traditional HMO/PPO network to allow providers to compete directly for the employer’s business. Why the bundled platform that Carrum offers runs 40-50% cheaper than pricing through traditional insurance carrier networks. The screening process – What Carrum does to ensure their Centers of Excellence providers meet the highest level of quality. What geographical regions Carrum is available for employers How Carrum is geared towards the patient experience, and how they strive to remove the stress of surgery and hospital stays so that patients can focus on healing. Costs to participate in the Carrum platform www.carrumhealth.com (http://www.carrumhealth.com/)    

In this episode, Michael introduces Marek Ciolko, the CEO of Gravie, a unique health plan that offers employers a shared savings model and employees the opportunity to personalize their insurance to meet their needs. Gravie does this by helping employers control costs while still providing employee-selected coverage and a better experience throughout the process. Marek has a long history of operations management for Deloitte and companies within the healthcare industry. It was on this journey that he realized that there are only so many ways to bend the curve and reduce healthcare costs for everyone with incentives alone. He realized that the core of health insurance needed to be tackled, which is why now, through Gravie, he strives to level the playing field between the group and individual marketplace of health insurance within their platform.  The current state of the world with the COVID-19 outbreak makes it painfully obvious that the consumer is underserved in our current system. Gravie’s mission is to improve the way people purchase and access healthcare. They focus on an underserved area of the market, which is group sizes with between 100 and 1,000 lives. Gravie works with employers to establish a defined contribution and then provides a platform of plan design options for employees to select from that meets their individual needs. In essence, Gravie is a marketplace and a decision support system for employees. In addition to offering a marketplace to employers, the Gravie product is a level-funded offering that helps small employers self-fund, manage risk and share in excess surplus when claims are less than expected; to date, 30% of customers are receiving refunds at the end of the year. As a startup with 3 years of experience, Gravie is already taking massive strides to control healthcare costs for middle-market employers and employees and we look forward to seeing them grow and expand their offering.  Here’s a glance at what we discuss in this episode:  01:00 - Introducing Marek, his background, and his motivation for launching Gravie.  02:30 - He worked for Deloitte and RedBrick Health and learned the challenges with healthcare costs.  04:00 - With Bloom Health, they worked to make insurance customizable so employees could shop and the market could provide what they need.  05:05 - Gravie levels the playing field between group and individual insurance marketplace by granting true consumer involvement in the selection process.  06:55 - Health insurance is very expensive - our current global climate is highlighting that issue.  09:00 - Sometimes companies don’t have enough choices for their employee’s diverse needs; people end up getting more than they need or not having enough. 09:50 - Consultants and brokers oftentimes see the employer as their client, not the employee.  10:30 - Customization and tailoring allow the consumer to pay for what they need and leave out what they don’t. 12:00 - Employees have to go through their employers for health insurance, which makes it expensive for employers to attract and retain employees year over year.   15:20 - Employers need a way to cap (fix) their healthcare liability while keeping their employees happy - that’s where Gravie comes in.  17:11 - Gravie offers cost predictability and management of the entire system, including insurance, the administrative process, savings benefits, and employee customer service.  20:00 - It leverages stop-loss and helps small employers self-fund easily; Gravie gets a share of savings when claims are less than expected, so they’re incentivized to keep costs below the employer’s cap. 24:00 - They’ve been in business for 2-3 years and have seen 95% retention and 30% of customers receiving refunds at the end of the year.  25:30 - The resources and programs they offer are medical management,...

In this episode, Michael introduces Steve Watson, a CFO/CHRO and founder of Trendbreakers, a community of finance, human resources, and benefit advisor professionals that are on a mission to break the trend of rising employee healthcare costs. Trendbreakers helps CFOs, CHRO’s and business owners make the best employee benefit decisions by offering support, education, and consulting.  Steve is a unique guest because he’s on the payor side of business...i.e., he is working for an employer who ultimately pays for healthcare via their insurance. He recognizes that the current healthcare system is lucrative for organizations and certain people, but also sees the problem with employers and families paying heavily for benefits they may not even use. A few years ago, his employer had a million-dollar claim that was going to increase premiums by 30% - and his broker’s commission by 30%, too. Through deeper investigation and learning, he recognized the incentive imbalance and that the system was rigged against employers.   He was able to slash his company’s benefits costs, save thousands, and allow employees to enjoy no increases and better benefits - all while drastically reducing the administrative burden of enrollments and changing plans. After doing it for his own company, Steve realized that others in his position needed the network, strategies, and best practices to do the same. So he built Trendbreakers, the educational platform that helps inform business owners, CFOs and CHROs make the best healthcare decisions for their company and its people.  Steve believes that a lack of accountability across the board has been a detriment to the system as a whole. He believes brokers must be transparent, accountable and have a high level of expertise in the exact areas their clients need so they can offer the best solutions. He also recommends brokers be conscious of the way they communicate with employers and use words and comparisons they can understand.  Brokers have an excellent opportunity to educate and be a fiduciary for the employers they serve. And it’s important that employers have a plan in place that they’re confident in and has room for continued growth and savings down the road. Trendbreakers has a promising road ahead bridging the gap between peers and colleagues to create a system where everyone benefits. Here’s a glance at what we discuss in this episode:  01:00 - Introducing Steve, the CFO, CHRO, and founder of Trendbreakers.  05:30 - What Steve thinks about our healthcare system and when the reality sunk in.  09:30 - He transitioned into a self-funded plan to address the issues.  12:00 - Now, he can impact the results, get data, and benefit from no claims. 13:05 - Employees have benefited from no increases, better benefits, and they lifted the administrative burden of having to have an enrollment. 13:30 - Trendbreakers provides education to company leaders, executives, and HR leaders so they understand the industry and speak the same language.  14:50 - Broker/Consultant must-haves: Transparency, accountability, expertise. 17:05 - Brokers don’t always share new solutions with their clients that could save them significant dollars.  20:00 - Brokers must communicate concepts in a way that the CFO/CHRO/owner understands because in many cases, they’ll need someone else to sign off on it, too. 22:20 - CFOs want to know the internal risk and meet other people who are self-funding to feel confident about their decision.  24:10 - It takes peers, stories, and a group for people to feel confident about making a decision - just listening to a broker isn’t enough. 25:05 - If an HR leader needs to get the rest of the leadership on board, they must first do things on the back-end that won’t change anything for the employees.  26:30 - Have a 3-5 year plan and make incremental changes - each step will

In this episode, Michael introduces two partners of ScoutRx, Robert LeCureaux, the VP of Client Development and Amy Bandy, the VP of Operations. ScoutRx helps employer groups and members maintain affordable prescription drug costs through the use of their three core cost containment strategies.  When previously working in the pharmacy and PBM industry in very different roles, Rob and Amy both recognized that it was very profit-driven and not much thought was given to the consumer and the burden of cost. They didn’t like this status quo - and how members had no voice and too many roadblocks - which is what inspired them to team up with other partners to create Scout Rx.   With a lack of marketplace options to address the rising price and utilization of specialty medications, ScoutRx has made it their mission to bring overall costs down and create a better member experience. To date, they have been able to drive an average savings of about 43% for their clients, a sign that they are succeeding in their mission thus far. To be clear, ScoutRx is not a pharmacy benefit manager or administrator. They’ve partnered with a PBM to administer their program while they use their own core strategies autonomously.  ScoutRx operates using three core strategies: Their Specialty Pharmacy Program, Copay Optimization Program, and International Pharmacy Program. Through their Specialty Pharmacy Program, they help members pay little to no money out-of-pocket for specialty drugs by finding drug manufacturer foundations and financial programs that patients can qualify for to offset the entire cost of the drug. The Copay Optimization Program takes advantage of drug manufacturer coupon cards to reduce the cost of the drug and potentially eliminate the patient’s copay altogether. The International Pharmacy Program allows members in the U.S. to get their high-cost or specialty medications from Canada at a substantially lower cost with eliminated copays and reduced cost to the group. The amazing part about all of this is that most of the logistics are done behind-the-scenes at ScoutRx with little effort needed from the patient.  And as far as savings go? Some groups that they’ve worked with had a 96% generic utilization rate and were still able to save over $100,000 in their first year. The savings range in the first year is vast - from 16% all the way up to over 70% - and these savings continue into future years which will lead to lower inflation than employers would see with typical PBM’s and insurance carriers in the industry. ScoutRx is paid a percentage of savings which they outline in regularly distributed, fully-transparent, line-by-line reports. ScoutRx is a good fit for small-to-midsized self-funded companies with 2,000 employees or less. While ScoutRx is a new company, its leadership team is experienced and its methodologies are proven. ScoutRx has a bright future ahead disrupting our healthcare system by making high-cost prescriptions more easily accessible to patients.  Here’s a glance at what we discuss in this episode:  00:30 - Introducing Rob and Amy, two partners for ScoutRx. 03:00 - The inspiration for ScoutRx: Rob saw that the industry was profit-driven and that not much thought was given to the consumer.  04:30 - Amy saw all the roadblocks between members and their prescriptions in the traditional setting and wanted members to have a better option.  06:00 - The key issue with the drug delivery and payment system of today is that specialty medications are often inaccessible to groups and patients.  10:30 - Their specialty pharmacy program addresses accessibility so that patients can get pharmaceuticals for little or no cost.  11:50 - The Patient Assistance Program - It’s a financially-based program where the manufacturer offers its medication free of charge for those who qualify.  13:30 - ScoutRx helps its members through...

In this episode, Michael introduces Matt McCambridge, the co-founder, and CEO of Eden Health, a virtual primary care and navigation platform centered around care teams. Eden Health helps employees navigate today’s complicated healthcare landscape across insurance, primary care, and mental healthcare so they can make smart, well-informed and cost-conscious decisions.  Matt had a personal situation that influenced his decision to move out of the venture capital space to launching a start-up in healthcare. When Matt’s sister was sick as a kid, Matt and his family personally witnessed the broken components of the healthcare system. Now, Matt is seeing how the “coordinated care” offered by Eden Health has made a difference in the lives of patients like his sister.    Eden Health is a certified Primary Care Medical Home - the top-of-the-line quality certification in the country for primary care; this model emphasizes team-based care, communication, and coordination, which has been shown to lead to better care and why Eden has integrated specialties like behavioral health and physical therapy. The reason for including behavioral health, Matt explains, is that many other health issues are rooted in mental health conditions and these must be addressed to make meaningful progress with the patient’s health conditions.  Matt’s company is different than other in-person or virtual primary care solutions in that it is highly integrated with a core focus on eliminating the employee’s hassle as a patient. Typically, it’s very confusing for employees to figure out where to go and for what, which is why Matt believes you simply cannot separate navigation from primary care and delivery. For this reason, they have an app with the accessibility to virtually chat with a doctor 7/365, and this connection enhances the solutions offered. By leveraging technology, they’ve been able to provide their users with the appropriate instant and personalized care.  Eden Health also offers physical locations across the country for those who need it, and will even send a provider from their pool on-site to the workplace. Matt understands that the key to helping patients is engagement - and that engagement is more likely to occur if patients are receiving high-quality care through an integrated platform that they can easily use. Eden Health tracks their patients’ satisfaction with star ratings, and they proudly report an average of 4.95 out of 5 stars with a 75% response rate.  Employers can engage with Eden Health in two ways: They can either fully-cover Eden Health for unlimited access or fully-insured with a fee that is reduced when insurance is taken into account since they would be considered an in-network provider. Eden Health has an exciting road ahead as they expand into new geographies and continue to grow and serve.  Here’s a glance at what we discuss in this episode:  00:30 - Introducing Matt, the co-founder and CEO of Eden Health.  03:00 - The insights Matt received about healthcare from doing venture capital. 04:50 - The problems with the current primary care model.  10:00 - How Eden health is different from other primary care solutions.  13:20 - The importance of engagement that’s backed up by quality.  14:30 - Why behavioral health is integrated into the program. 17:00 - On their certification as a primary care medical home. 18:50 - Why it’s important that Eden Health makes 66% fewer referrals to specialists. 21:20 - The process behind their specialist “closed-loop referrals” and how they short-cut the patient journey.  24:45 - Pop-up on-site visits, permanent brick and mortar clinics, and the experience they create in the workplace.  27:30 - On the trusted patient-provider relationship, how it keeps patients healthy over time, and a case study.  32:00 - On the integration of navigation at the...

In this episode, Michael introduces Gabriel Mecklenburg, the co-founder and COO of Hinge Health, a musculoskeletal solution for employers and health plans. Hinge Health is pioneering the world's most patient-centered digital hospital, starting with musculoskeletal health. Gabriel brings a unique perspective to the company because of his background in clinical research and because he, too, has been a patient needing this type of care.  When Gabriel sustained a ligament tear practicing Judo while in college, he became exposed to many musculoskeletal treatments. He realized that the whole field was very much “behind the times” - and decided to switch his area of study to pursue a better solution in the industry. Because he felt distant from the patient when doing clinical research, he and his partner decided to do something that could positively impact patients at scale. When they realized there was nothing out there for musculoskeletal health from a digital health perspective, they created Hinge Health.  Musculoskeletal injuries may be minor (a twisted ankle), acute (an ACL tear) or chronic (persistent lower back pain). Gabriel explains that chronic injuries are the biggest driver of avoidable cost. At Hinge Health, they focus on chronic injuries because they are the ones that, with the right care, can be lessened and eliminated without medications or surgery - which is what our current healthcare system resorts to all too often.  The solution to chronic pain is multi-faceted. It requires physical therapy, ongoing education, and strategic behavioral change - and our current healthcare system simply can’t deliver on these needs despite the supporting research. Not only that, but the frequency at which a patient would need in-person care to get real results is totally unrealistic.  The Hinge Health model takes established best-practices and turns them into their three-pillar approach that addresses exercise therapy, behavioral health, and education. Their educational component dispels myths and educates clients on scientifically-proven best practices, the behavioral health pillar helps patients create behavioral change that lasts, and the exercise therapy consists of sensor-guided movements with live feedback. They can do the exercises whenever and wherever - not just at a therapist’s office - and their adherence is tracked digitally.  In a recent 10,000-patient study, 3 in 4 of their patients completed the entire 3-month core program. This level of treatment adherence is unheard of with traditional physical therapy, and a testament to the effectiveness of their program and the accountability provided through digital monitoring. More importantly, they’ve helped people reduce pain by over 60% - which is twice the reduction of pain you see when you put someone on opioids. Hinge Health will soon be releasing their digital musculoskeletal treatment study, which is perhaps the largest ever conducted in the industry. They’ve got a bright future ahead eliminating chronic pain and improving lives through their mission.  Here’s a glance at what we discuss in this episode:  00:30 - Introducing Gabriel, his background, and his inspiration for founding Hinge Health. 05:45 - What falls within musculoskeletal disorders and injuries and which Hinge Health focuses on. 07:45 - The problems with how the system is currently dealing with chronic musculoskeletal pain. 09:50 - The Hinge Health model, their three-pronged approach, and how they engage patients with each approach.  15:25 - The patient journey: What to expect and how they’ve dramatically improved their adherence rate. 21:45 - The quality of Hinge Health coaches and exercise therapists. 24:00 - Meaningful results, why Hinge Health patients are engaged and see results, and how Hinge Health helps patients avoid surgery and drugs.  26:45 - The “sister conditions” that are often present with...

In this episode, Michael introduces John Powers, the Executive Vice President of Sales and Marketing for Advanced Medical Pricing Solutions (AMPS). AMPS provides market-leading healthcare cost containment services for self-funded employers, public entities, municipalities, labor unions, brokers, consultants, TPAs, payers, reinsurers, and HMOs. John is widely known as one of the most successful fraud investigators in the industry having conducted investigations in all 50 states and over 120 countries internationally.  John dove into the healthcare industry about 12 years ago when he saw problems arising within the system. He found that many people held a misconception about their healthcare plans by thinking their plan covers everything when, in fact, it likely doesn’t. John believes consumerism is the missing link in our healthcare model, and he predicts a future where more employers move to a model of defined benefits. This, he believes, will make the system more equitable and transparent.  Among other services, AMPS conducts medical bill reviews. They focus on hospital and facility claims, both inpatient and outpatient, that are in or out of the network. This line-by-line itemized review by coding specialists ensures that the correct treatment was done at the right time and for the right price - and their turnaround is only an average of 3.3 days.  The problem is that most claim payers (TPA’s, Insurance Carriers) don’t get itemized facility bills, so they never get the chance to review them for errors and see where they’re being incorrectly charged. To complicate matters further, some health plans aren’t even requiring itemized Hospital bills prior to paying them. John speculates that this is because healthcare companies see hospitals as their most valuable asset.  Shockingly, errors on hospital bills are extremely common, and 95% of the time they go unnoticed. AMPS uncovers errors in virtually 100% of bills ranging from $2 to $200,000, and most of their clients see an average of 10% in savings. And since AMPS only gets paid from the savings they find, there’s no upfront cost to using their service. The errors are corrected before the client pays the bill, as it’s notoriously difficult to request a refund after payment has already been rendered.  John insists that if employers want to get control of their medical spend, they must unbundle the health plan components and get away from the limitations imposed by traditional insurance carriers. That way, they can review and audit their claims just as they would any other facet of their company’s budget.  To prove why medical bill review is so important, John suggests asking your carrier account manager these three fundamental questions:  Are you conducting a prepayment facility medical bill review for us, and if so, at what threshold and what are the results? How many errors have you found?   Are you a fiduciary to my plan?  Please confirm what network discount I am getting and what does that equate to as a percentage of Medicare? John is confident their response will surprise and disappoint you, as they likely aren’t conducting a prepayment medical bill review, aren’t a fiduciary, and aren’t giving you the savings you thought.  AMPS provides other services, like a reference-based pricing program that they’ve offered for the past 8 years. There are two models: Prospective, which negotiates on the front end but costs more, and retrospective, where negotiation is after the service and there are greater savings. They also do direct contracting. This is where consumerism and competition come into play to benefit both the hospital and employer.  AMPS is excited to offer more direct contracts so patients can save money, know their options, get great care, and make informed decisions. The medical bill review process - and the other services that AMPS has to offer - are...

In this episode, Michael introduces Shane Foss, the founder and CEO of Hooray Health. Hooray Health leverages an Urgent Care and Retail Clinic National Provider Network built for Individual and Group limited medical insurance plans. Shane has over twenty years of tenure as an executive in the medical industry and it was through this work that he became frustrated with the healthcare options in America.  When Shane injured his back and needed medical care, he experienced the shortcomings of the healthcare delivery system first-hand when he received a balance bill from an urgent care center. He was able to negotiate down his bill, but the experience left him wondering what other Americans do in similar scenarios. This led to his discovery that many Americans are “functionally uninsured” and there’s no standardization of cost or transparency in the healthcare system.  Shane was thus inspired to create a new platform that filled a gap in the market: affordable basic healthcare. Through this inspiration, Hooray Heath was born. Hooray Heath offers a low-cost, practical healthcare plan that is supported by technology and a robust provider network of Urgent Care and Retail Clinics. It is unconventional - which is exactly what Shane wanted. In a country where 75% of the population makes less than $50,000 a year (and many work part-time), Hooray Health offers peace of mind, basic healthcare, no surprise bills, and a fixed price that starts at only $99. The member experience through Hooray Health is simple and centralized through their mobile app, where they offer “telemedicine”, a 24/7 bilingual medical concierge, pharmacy discounts, and more. It’s a fixed indemnity plan but feels like a regular PPO for basic coverage - and is 30% less than other similar plans on average.  They offer two plans: a basic plan and a “plus” plan. The basic plan covers a wellness visit, five annual visits to the retail clinic or urgent care, and a $5,000 accident policy. The “plus” option includes everything in the basic plan plus a hospital indemnity buy-up for an additional $60. Hooray Health is easy to deploy and makes joining a seamless experience for both individuals and large corporations.  Hooray Health has an exciting road ahead. Next year’s version of the mobile app will be even more integrated and supportive, and they’re working on formulating supplemental alternatives for high-deductible health plans. Hooray Health focuses on a segment of the population that is often overlooked when it comes to healthcare - part-time employees and low-income earners - and makes it so basic coverage is accessible, affordable, and easy for employers and employees alike.  Here’s a glance at what we discuss in this episode:  00:30 - Introducing Shane and Hooray Health 02:00 - Shane’s previous work in the industry and what inspired Hooray Health 05:45 - Why Shane believes we’re “functionally uninsured” as a country 08:00 - Employers need to manage their healthcare expenses like any other expense 09:30 - How Hooray Health works and who they serve 14:30 - The difference between Hooray Health indemnity plans and regular benefit plans  16:00 - The difference between the basic and “plus” plan 18:00 - How the Hooray Health concierge service works  20:20 - Information about their medical bill negotiation platform 21:30 - Pricing, how they track consumer satisfaction, and their growth since launching  24:45 - Who Hooray Health is for, how it can help reduce turnover, and where they provide coverage 29:30 - How Hooray Health connects and communicates with its members  31:00 - What to expect next year and why Hooray Health beats out the competition Resources Hooray Health Phone Number: 1-866-7HOORAY

In this episode, Michael introduces Dr. Neil Leibowitz, a psychiatrist, attorney, and the chief medical officer at Talkspace Online Therapy. Talkspace is a technology company whose aim is to expand access to mental healthcare. Dr. Leibowitz has an impressive educational and professional background and spent a good deal of time working with larger healthcare organizations. Through his experience, Dr. Leibowitz ultimately concluded that the smaller companies doing interesting things were the ones that would truly change the game, which is why he was drawn to Talkspace. When it comes to access to care, Dr. Leibowitz made the surprising discovery that even those with insurance struggle to get care when they need it. With high co-pays, deductibles, and luck-of-the-draw when it comes to doctors, inaccessibility does extend even to those with good coverage. What’s more, when it comes to effective therapy, it’s critical to find a therapist who “fits,” as opposed to one randomly selected in the provider network.   Talkspace was created with accessibility and affordability at the forefront and makes it possible for users to be matched with licensed professionals based on their personal needs and preferences. Best of all, if the “bond” isn’t there, users can switch therapists – no hassle. A key feature of Talkspace is messaging therapy: where the user messages their therapist and receives timely responses without needing to travel or schedule an appointment. People get access to their provider on their terms and can even record symptoms – like an anxiety attack – to send to their therapist for feedback. The Talkspace intake is quick and painless, and treatment is measured with the use of tracking tools. Over time, progress is tracked so the therapist and patient can measure improvement. Talkspace then ranks the therapist’s work based on these results so that therapists who rank higher can help more people.   The research shows that messaging therapy works, and the Talkspace platform provides access to therapy for those who otherwise wouldn’t have gone to an office due to the fear of stigma, budget, or even plain hassle. They’ve created a great work environment for therapists and have worked hard to create a fluid, positive consumer experience. They get rich, granular feedback from clients and use that input and NPS (Net Promoter Score) data to constantly improve. Talkspace drives engagement through education and awareness, and they market therapy in a destigmatized way. They often work through employers to reach their employees and provide an easy, effective and affordable solution for all.    With more frequent communication, therapy can be much more effective. Talkspace has created a new modality for therapy that provides the possibility for speedier results in the most comfortable setting – home. Talkspace is reconstructing mental healthcare and making it more possible and accessible than ever before.    Here’s a glance at what we discuss in this episode:  00:45 – Introducing Dr. Neil Leibowitz, his background, and his current work [02:50] – Why he was drawn to Talkspace [04:00] – Prevention, stigma, access and the reasons people don’t get care [07:45] – Identifying who is a “fit” in healthcare and finding a “match” [08:50] – The Talkspace product and model [11:15] – Messaging therapy and why it’s the therapy of the future [13:30] – The process to begin with Talkspace [16:00] – How therapists are selected and ranked based on data-driven results  [18:00] – How patients are assessed now and improvements in the future [21:10] – Why therapists are attracted to Talkspace [23:40] – Dr. Leibowitz’s response to skepticism of the efficacy of tech-spaced therapy [25:00] – The studies they have conducted to prove the effectiveness of Talkspace...

Topics: Specialty Drugs Specialty Pharmacy vs. Retail Pharmacy Pharmacy Benefits Misaligned Incentives Price Transparency  Medication adherence versus compliance Quality of care  Cost Savings In this episode, Michael introduces you to Andy Reeves, the Co-owner and CEO of OptiMed Specialty Pharmacy. Join us as we discuss how OptiMed Specialty Pharmacy is bringing transparency to the market and helping employers circumvent traditional specialty pharmacy distribution channels to lower costs. Here’s a glance at what we discuss in this episode: Andy’s experience as a clinical pharmacist and what motivated him to become an entrepreneur  Key issues that are impacting our health care delivery system and how misaligned incentives are increasing costs   How siloed health care impacts employer and employee costs OptiMed seeks to harmonize health care for the consumer through integrated services to reduce overall costs  How a specialty pharmacy differs from a retail pharmacy  The difference between medication adherence and compliance  How OptiMed addresses medication adherence  How OptiMed engages employees as an alternative specialty pharmacy option OptiMed offers an alternative distribution source to employers providing a more cost-effective option by charging a flat fee for their services  Typical savings an employer might see when using OptiMed Specialty Pharmacy How the acquisition cost + admin fee model that OptiMed uses differs from the traditional AWP Discount model + Rebate Model used by Traditional PBM’s and carriers How to leverage an incentive copay structure to steer employees to utilizing OptiMed  How OptiMed takes a proactive versus a reactive approach in redirecting employees at the point of care  An example of egregious pricing for infusion drugs in a facility vs. the pricing that could have been achieved with OptiMed Why stop loss and third party vendors are interested in programs like OptiMed  How OptiMed functions as a liaison between the patient and providers to help patients with continuity of care and manage costs OptiMed provides clients with detailed reporting that includes quality metrics, performance, and member reporting  OptiMeds ability to import quality pharmaceuticals into the United States that provide savings between 40-70% What encouraged Andy to launch Ascend PBM in 2017 Why leadership should encourage disruption and view their health care benefits as a risk mitigation strategy  To learn more about OptiMed Health Partners visit: (https://www.optimedspecialtyrx.com/about)

Topics: Misaligned incentives Fraud, Waste, and Abuse Health Insurance Consumer spend Medicare National Provider Identifier In this episode, Michael introduces you to Marshall Allen, an Investigative Journalist at ProPublica. Join us as we discuss how Marshall pierces the healthcare facade by investigating and reporting on stories that highlight the dysfunctional elements of the healthcare system that negatively impact consumers and patients, including his most recent article, “Health Insurers Make It Easy for Scammers to Steal Millions. Who Pays? You”.  Here’s a glance at what we discuss in this episode: ProPublica focuses on investigative journalism that is in the public’s interest related to the abuse of power across industries  What inspired Marshall to become an investigative healthcare journalist and the types of stories he focuses on How fraud, waste, and abuse impacts all consumers of healthcare  How a personal trainer without a medical license was able to obtain multiple National Provider Identifier numbers under the same name Why Medicare doesn’t regulate who they assign the National Provider Identifier number to  How both Medicare and health insurance companies allowed a convicted felon to bill for fraudulent medical services  How the employee out-of-pocket cost in the benefit design was circumvented and how self-funded employers were the biggest losers in this fraudulent activity How the fraudulent billing scheme was discovered and reported to major insurance carriers and why very little was done to take action to curb the fraud How misaligned incentives impact the initiative to address fraud in the health care system  Approximately 10% of the 1.2 trillion dollars spent in the American healthcare system is fraudulent and stealing  How the lack of resources at the Texas state department of insurance impacted their ability to investigate and address the fraudulent billing activity Different approaches the insurance companies and the government could have taken to combat this fraudulent activity  A facade has been created to generate high spend within the healthcare system that has led to unnecessary complexities and passivity How Marshall seeks to expose that all the players in the healthcare system are colluding against the payors in a system designed to extract as much money as possible from payors and consumers How the shift in insurance cost share directly impacts employee’s financial wellness and how 1 in 5 Americans have medical claims in collections  The role employer leadership must play in order to address lowering healthcare costs Contact Marshall at (mailto:marshal.allen@propublica.org)   Visit (https://www.propublica.org/topics/healthcare) Visit (https://www.propublica.org/series/the-health-insurance-hustle)

Topics: Pharmacy Benefit Manager (PBM) Misaligned Incentives Price Transparency  Efficacy versus Effectiveness Consumerism Specialty Drugs Drug Waste Drug Manufacturer Rebate Steerage   In this episode, Michael introduces you to Mort Jorgensen, the Co-founder, and CEO of Rx’n Go, Paul Ford, the Founder of OrchestraRx and Pramod John, the CEO of VIVIO Health. Join our round table as we dive into the current state of the Pharmacy Marketplace and ideas to challenge the inefficiencies and problems in traditional Rx purchasing.  Here’s a glance at what we discuss in this episode: The table’s opinion about the current mergers of the largest PBMs with insurance companies and how this could impact the marketplace The complexities and challenges with the current pharmacy purchasing structure  How payors have zero visibility into the pricing for Generics, Brand and Specialty Drugs How current benefit design is a part of the transparency problem  The Pareto Principle, how it relates to drug spend and why employers need to take a more proactive stance on what drugs are allowed to be used if they want to save money How the presence of multiple middlemen in the drug distribution system creates additional cost and inefficiency Why our biggest problem may not be a lack of transparency, but rather an unwillingness for payors to stop doing business with the vendors who profit off of higher drug costs Misconceptions about drug manufacturer rebates and why the impact of rebate driven drug steerage should be a greater concern than how much the drugs cost Understanding which stakeholders benefit from drug manufacturer rebates  Understanding that consumerism doesn’t really work when it comes to drug choice given it is usually a provider who is the one selecting the drug for the patient The differences between efficacy versus effectiveness and why we continue to pay for drugs that do not work How employers can reduce waste within their benefit design How employers can protect themselves from Big Pharma and Specialty Drug costs Why FDA approval of a drug doesn’t necessarily warrant covering it on an employer’s formulary Why paying for bad drugs that don’t work creates a disincentive for Pharma to create drugs that actually work Why employers need to start taking a more proactive role in selecting what drugs they are willing to cover and pay for Questions that an employer should be asking to ensure their pharmacy vendors have aligned incentives  The government’s role in creating policies that address data sharing, drug pricing, and transparency To learn more about Rx’n Go visit: (https://www.rxngo.com/) To learn more about OrchestraRx visit: (https://www.orchestrarx.com/) To learn more about VIVIO Health visit: (https://viviohealth.com/)

Topics: Healthcare Financial Wellness Navigation Quality Transparency Steerage  Narrow Network Smart Match Health Savings Account   In this episode, Michael introduces you to David Vivero, the Co-founder and CEO of Amino Health. Join us as we learn about Amino Health, a health care financial wellness platform that integrates with an employer’s existing health care benefits to enable employees to find, book and pay for high-quality care.  Here’s a glance at what we discuss in this episode: How David Vivero’s diverse experience in real estate, venture capitalism and working with disruptive startups led him to launch Amino Health How David’s own health care experience inspired him to change the status quo by providing transparency, empathy, and convenience in health care Why price transparency alone isn’t enough to fix our broken health care system  The definition of health care financial wellness and why it is important  One of the biggest financial strains on individuals is their health insurance and unexpected out of pocket costs The booking and navigation components of Amino Health and the strategies they deploy to engage consumers to utilize their tool How Amino Health is helping consumers succeed in searching for providers, booking appointments and paying for health care How Amino Health’s centralized data allows individuals to identify high quality and low-cost providers and facilities  Amino Health encourages users to choose the Smart Match designation to steer individuals to high-quality low-cost providers and facilitates The sources of Amino’s data for cost and quality information  How Amino Health has the ability to connect employees with point solutions and other benefit programs offered by their employer How an employer can use incentives to drive utilization of smart match providers How employers should think of health savings account and how they can leverage Amino Health’s HSA offering within their financial wellness platform Why it’s important to ask what the ROI of your health savings account is How Amino’s tool is connected in real-time to their Health Savings Account and can show the financial impact of selecting one provider vs. another provider The average engagement and utilization of Amino’s clients  Amino’s NPS Score  Consumers do not want to receive data they want to receive an experience To learn more, visit (https://partners.amino.com/home)

Topics: Healthcare Literacy  Wellness Gamification Content Tool Employee Engagement Behavior Change   In this episode, Michael introduces you to Al Lewis, the CEO of Quizzify. Join us as we learn about Quizzify, a health literacy content tool that leverages gamification and comedy to educate individuals and drive savings and well being through increased awareness. Here’s a glance at what we discuss in this episode: How Al Lewis’s diverse experience in consulting, leadership and authorship lead him to launch Quizzify  The employer’s key role in the quality of care and cost containment of healthcare expenses  How Quizzify works and is different from every other wellness program out there The definition of health literacy and the economic impact of low health literacy  The differences between health literacy and traditional wellness How Quizzify aligns incentives with clients by offering an engagement guarantee  Quizzify is the only vendor that partners with Harvard Health and Medical School which provides integrity in the content published by Quizzify How Quizzify partners with clients to strategize on participant engagement, communication, and incentive structure 10% of an employee population will engage each month with no incentive, however, implementing a small incentive will increase participation to approx. 50% a month Quizzify’s robust standardization of reporting allows employers to drill down into their data How the employer has the ability to customize their own questions based on their benefits information and Quizzify will write them on their behalf How Quizzify provides guaranteed savings for employers with access to their claims experience What wellness vendors mean when they provide messaging about return on investment versus the value of an investment The difference of efficacy between a mandatory wellness program compared to a “nice” wellness program  Who Quizzify is a good fit for and their fee structure  Obstacles that Quizzify has faced implementing their program with employers  How Quizzify has reconfigured its program into a health risk assessment that exceeds the traditional health risk assessment standards To learn more, contact Al Lewis at Quizzify.com (http://www.quizzify.com)

Topics: Healthcare Finance Healthcare Literacy Misaligned Incentives Corruption Supplier Induced Demand Forced Competition Consumer Education Change Management Steerage   In this episode, Michael introduces you to Dr. Eric Bricker, an internal medicine physician, and former Co-Founder and Chief Medical Officer of Compass Professional Health Services. Join us as we learn more about Dr. Bricker’s new venture, AHealthcareZ, a healthcare finance video blog designed to educate on all things healthcare and create a more educated payor community.   Here’s a glance at what we discuss in this episode: Dr. Bricker’s clinical, business and leadership experience and why he founded AHealthcareZ How Dr. Bricker identified an opportunity to educate healthcare stakeholders and consumers about healthcare fundamentals   Why Dr. Bricker chose video as the medium to provide education on an array of topics to create a healthcare knowledge foundation for his audience The types of topics that Dr. Bricker covers in his video blog How AHealthcareZ enables individuals to build their knowledge base by providing videos in chronological order Examples of how the video blog topics are valuable to the provider community How the video blog uncovers many of the dysfunctional elements in our healthcare system The importance of aligned incentives to provide quality and cost efficiency to the end consumer The challenge in getting business leaders to embrace change in approaches to healthcare purchasing Dr. Bricker’s opinion on our ability to solve our healthcare crisis Why strategies and solutions must be customized for each employer to challenge the status quo What Dr. Bricker would do if he was designing a healthcare solution from scratch Challenges and opportunities that Haven Healthcare may face as they seek to transform healthcare The ideal role technology can play in disrupting healthcare and what the metric for success looks like Potential challenges with a single-payer health system What is next for Dr. Eric Bricker? To learn more, visit the video blog at (https://www.ahealthcarez.com)

Topics: Opioid Crisis Pain Killers Mental Health Addiction Chronic Pain Treatment Facilities In this episode, Michael introduces you to Tim Ryan, the Founder of a Man in Recovery Foundation. Join us as we learn more about how opioid addiction impacted Tim’s personal life and how he is striving to help others’ suffering from addiction and bring awareness of the opioid epidemic. Here’s a glance at what we discuss in this episode: Tim’s story as a successful consultant, entrepreneur and his journey from heroin addict to convict to becoming the founder of A Man in Recovery Foundation The types of drugs that fall under the umbrella of opioids Why 90% of individuals who are addicted to opioids will either succumb to an overdose or will be incarcerated   How 75% of addiction begins with prescriptions and overprescribing from providers How insurance coverage plays in role in inadequate options for treatment of addiction How a lack of treatment facilities and short duration of treatment via insurance coverage impacts the ability for recovery While there are over 30,000 treatment centers in the U.S., there is huge variation in quality of care and limited resources to guide people to higher quality facilities Examples of how opioids don’t discriminate against different socio-economic classes Dope Man, an A&E documentary on Tim’s work helping addicts get into quality long term treatment centers to aid in recovery The challenges of raising money for Tim’s foundation and why people may be more likely to donate more money to other sources than to help people with drug addiction How drug and alcohol abuse costs the taxpayers over a trillion dollars a year The cost of incarceration vs. addiction treatment Why employers should care about the opioid crisis and tactics to help employees struggling with addiction Why employers should quantify the prevalence of opioid utilization within the medical carrier, pharmacy benefit managers and workers compensation Three key steps that employers should be taking to combat the opioid crisis How an employer can identify quality treatment facilities for directing employees How we can shift the conversation from opioid crisis as a moral failure to a chronic condition To learn more, contact Tim Ryan at (http://www.timryanspeaks.com) , 312-502-8671 or maninrecovery@gmail.com

Topics: Medical Captives Stop loss Risk Taking, Risk Sharing, Risk Shifting Data Analytics Transparency Cost Control Direct Provider Network Funding Strategies Cost Containment Strategies   In this episode, Michael introduces you to Michael Schroeder, the President of Roundstone Insurance. Join us as we discuss how Roundstone Insurance provides employers with expertise in the captive marketplace coupled with turnkey insurance management services. Here’s a glance at what we discuss in this episode: Michael’s experience as a practicing attorney, a property and casualty insurance expert and his path to joining Roundstone Insurance and applying the property and casualty captive insurance model to employer health insurance How small employers are impacted the most from healthcare cost inflation How the lack of price and quality transparency in healthcare is one of the key issues in the payment system Why some states such as Montana, North Carolina, and Oregon have stepped away from the traditional provider networks and have adopted reference-based pricing to control health care cost The misconception around the relationship between cost and quality The basics of captives and how they compare to traditional insurance companies How common captives are in the marketplace How Roundstone Insurance’s medical captive provides self-funding strategies with pooled risk to the middle market who may not have access to it otherwise How employers that participate in the medical captive have the ability to obtain claims data, utilization and implement cost containment strategies that would not be available in fully insured products Stop-loss basics and why it is more advantageous through the medical captive How Roundstone Insurance combines risk-taking, risk sharing and risk shifting to create an ideal funding strategy that works best for the employer Stop loss efficiencies within the medical captive compared to traditional stop loss Roundstone’s average renewals are 1/3 to 1/2 of traditional stop loss renewal The reporting an employer can expect to receive and the average captive dividend that employers have historically received The one statistic that an employer should be tracking How many employers are currently participating in Roundstone Captives and the types of employers that are a good fit for the captive Why focusing on employee experience is crucial with self-funding approach (https://roundstoneinsurance.com/roundstone-university/about/) is a free learning management system for employers and consultants The impact of state regulations on medical captives Fee structure to join the medical captive and exit provisions How Roundstone’s Cost Savings Investigators (CSI) team provide employers with analytical tools and resources to identify and learn about cost containment solutions Roundstone’s website and contact information (https://roundstoneinsurance.com/)

Topics: Opioid Crisis Advocacy Pain Management Mental Health Addiction Chronic Pain Stress Management In this episode, Michael introduces you to Harry Nelson, a leading health law expert, and the author of The United States of Opioids: A Prescription for Liberating A Nation in Pain. Join us as we discuss the history of the opioid crisis, the implications of the current epidemic and what role employers can play in being part of the solution. Here’s a glance at what we discuss in this episode: Why Harry was inspired to write The United States of Opioids: A Prescription for Liberating A Nation in Pain The evolution of America’s first opioid crisis in the late 1800s and early 1900s and how the reverberations from the first crisis are evident in the current crisis How the second leg of the Opioid crisis began in the late 70’s and early 80’s How it was only in the early 2000s is when we first began identifying data on overdose, death rates and addiction related to opioids In 2017, there were over 49k opioid overdose deaths from both legal and illegal opioid drugs and 12 million Americans with an opioid specific addiction and 50 million of americans report having chronic pain Addressing the question of who is to blame for this crisis and the many contributors to the current epidemic The importance of challenging the status quo to obtain alternative ways to access care for addiction and chronic pain The government’s primary response to the opioid crisis includes providing access to Naloxone, the overdose reversal drug, alternative pharmacy pill solutions, early intervention, medical devices and providing access to rehabilitation Why we need to look beyond healthcare and government solutions to move the needle on the opioid crisis How Employers can enable employees to utilize employer sponsored services that are available for stress reduction and mental health How Employers have an enormous opportunity to create a workplace that encompasses the four sources of human happiness including connection, control, context and competency Why Harry encourages employers to take an active role in addressing the opioid crisis through awareness, intervention and prevention How all proceeds of the book go to a number of nonprofit organizations To learn more about Harry visit (https://harrynelson.com/) To stay up to date on the Opioid crisis visit (https://notanotherstat.com/) To learn more about Harry’s law firm visit (http://nelsonhardiman.com/) To purchase the book on Amazon (https://www.amazon.com/United-States-Opioids-Prescription-Liberating/dp/1946633321)

Topics: Telemedicine Virtual Clinic Primary Care Direct Primary Care On-Demand Primary Care Pediatric Care Subscription Impact Entrepreneur Pharmacy Utilization   In this episode, Michael introduces you to Robbie Cape, CEO, and Co-Founder of 98point6. Join us as we discuss how 98point6 is seeking to tackle the primary care crisis by removing barriers and offering a people friendly and cost-effective platform to increase access to primary care. Here’s a glance at what we discuss in this episode: Robbie’s extensive experience in consumer technology businesses and products and what led him to co-found 98point6 The current state of primary care and the challenges providers experience within the traditional environment By 2020 there will be a shortage of 20,000 primary care physicians in the United States How a genuine relationship with a primary care provider can lower the incidence of premature death and provide a lifetime savings of 33% per individual healthcare cost Why some healthcare innovation is going in the wrong direction and are leading to a more transactional healthcare experience without a relationship with primary care Factors that lead to primary care providers’ low job satisfaction and/or consider leaving their practice How 98point6 seeks to remove barriers so that everyone can have access to quality primary care through their virtual clinic platform The differences between 98point6 virtual primary care compared to a traditional telemedicine and other “sickness services” The way 98point6 designs an experience that ensures the highest levels of quality with regard to the care they deliver and why having full-time, W-2 providers is an important quality component of 98point6 How 98point6 utilizes artificial intelligence to enable their provider’s efficiency by allowing them to focus 100% of their time with the patient during the clinical encounter 98point6 is determined to build the connective tissue between service and patient relationships through technology Consumers engage with 98point6 through a mobile application, secure text messaging, phone conversations and videos The medical encounter begins immediately with an automated assistant and within 2 minutes, a physician joins the chat Consumer feedback on 98point6 and their NPS scores   The 98point6 pricing model and who they are a good fit for Robbie is most excited about the recent launch of their pediatric services, making all services available 24/7 365 days a year https://www.98point6.com/ (https://www.98point6.com/)

Topics: Onboarding Platform Comprehensive Digital Platform Benefits Administration Care Navigation Innovative Marketing Self-funded Plans Medical Loss Ratio Third Party Administrator   Reference Based Pricing   In this episode, Michael introduces you to Nancy Reardon, Chief Product and Strategy Officer of Maestro Health. Join us as we discuss Maestro Health’s comprehensive platform to make employee health and benefits people friendly and cost effective. Here’s a glance at what we discuss in this episode: Nancy’s extensive leadership experience in health insurance and what led her to join Maestro Health How a lack of transparency and misaligned incentives in healthcare has led to skyrocketing employer costs and HR administrative burdens, year after year Why the medical loss ratio (MLR) has created misaligned incentives and why insurance companies are not motivated to reduce costs How Maestro Health provides a single comprehensive platform designed to simplify health benefits and includes TPA services, benefits administration and consumer account services (Health Savings Accounts, etc.) Maestro Health provides a consultative approach with employers to help them understand the multiple approaches available for provider reimbursement Maestro Health’s approach to “people friendly reference based pricing” compared to traditional reference based pricing strategy How Maestro Health integrates technology and care navigation to lower costs and increase quality outcomes Pharmacy Administration options with Maestro Health and their approaches to addressing specialty drug spend Maestro’s data driven approach to care management and how they use motivational interviewing as a holistic approach to encourage members to utilize their clinical management programs Maestro Health’s unique resources and strategies to simplify the healthcare experience for consumers Maestro Health’s unique marketing approach to engage and educate consumers Maestro Health’s pricing model and who they are a good fit for Why we need to educate and equip employees with tools before they become a consumer of healthcare Maestro Health’s website and contact information (https://www.maestrohealth.com/)

Topics: Women’s Health Pediatric Health Digital Clinic Platform Family Planning Fertility Maternity Return To Work Telehealth Consumer Experience Point Solutions   In this episode, Michael introduces you to Katherine Ryder, Founder and CEO of Maven Clinic. Join us as we discuss how Maven Clinic simplifies and modernizes the maternity and family planning healthcare experience for women and families. Here’s a glance at what we discuss in this episode: Kate’s unique background in business and financial journalism and what lead her to found Maven Clinic Why there is need to empower women’s health and recognize their consumer spend Reasons why 43% of new mothers are dropping out of the workforce even though 75% did not intend to leave How Maven simplifies and modernizes the maternity and family planning healthcare experience for women and families Maven is a digital clinic that provides a holistic experience with high touch and on demand information via mobile app with access to physicians, specialists and care concierge services The types of providers that consumers have access to via Maven’s Network including OBGYN’s, Nutritionists, Physical Therapists, Mid-wife’s, Lactation Consultants, Pediatric Occupational Therapists, Behavioral Health providers, Sleep Coaches, Adoption Coaches, etc. Maven’s process for recruiting providers and measuring quality of care How Maven’s return to work curriculum helps employers improve their return to work process for new parents coming back from leave and provides a support system for the employee How Maven engages employees and delivers a personalized consumer experience Maven’s NPS score and how they measure their success with Maven users Maven’s reporting and benchmarking capabilities The efficiencies and cost savings of remote women’s and pediatric care compared to a traditional clinical setting Maven can be used across industries to attract and retain talent How Maven compares to traditional carrier care management programs Maven’s pricing model for their core service as well as buy-up services that are available to employers The challenge of standing out among the many different point solutions that an employer may have to pick from and their various priorities Exciting goals for Maven as they publish longitudinal studies about women and family health Maven Clinic’s website and contact information (https://www.mavenclinic.com/)

Topics: Sleep Health Management Outcomes Based Treatment Population Sleep Health Solutions Performance Improvement Neuroscience of Sleep Sleep Medicine Insomnia Sleep Apnea In this episode, Michael introduces you to Dr. Jeffrey Durmer, Co-Founder and Chief Medical Officer for FusionHealth. Join us as we discuss how FusionHealth’s practical sleep applications improve the health and well-being of employees and ultimately help employers manage their healthcare costs. Here’s a glance at what we discuss in this episode: Dr. Drumer’s healthcare experience and what lead him to co-found FusionHealth How Dr. Durmer integrated the clinical and science aspects of sleep The most common sleep conditions and how they impact individuals Sleep as a process and why it is fundamental to our overall health How sleep conditions compare to disease and the differences between sleep disorders and sleep problems For every 1,000 individuals in an employer population about 40% have a sleep disorder or issue but only 5% may actually be getting treated How sleep duration, quality and time impact individual performance and ability to function How sleep problems impact individuals who are already diagnosed with chronic conditions How Fusion Health provides the employer with data on their population that identifies sleep conditions, chronic disease associated with sleep conditions and the current cost PEPM How FusionHealth applies neuroscience onto a mobile application platform that provides individuals with tools that lead to personalized sleep profiles and care plans What the Fusion Health program includes for the consumer How the ability to monitor real time data leads to better care and an improved consumer experience The efficiencies and cost savings of remote sleep care compared to a clinical setting FusionHealth’s value based pricing model Qualitative outcomes of the individuals that engage with FusionHealth FusionHealth’s website and contact information (https://www.fusionhealth.com/)

Topics: Type 2 Diabetes Medication Reduction Diabetes Reversal Nutritional Ketosis Clinical Trials Performance-Based Reimbursement Increased access to care Cost Savings In this episode, Michael introduces you to Bill Snyder, Vice President for Enterprise Partnership Health Plans at Virta Health. Join us as we discuss Virta Health’s mission to reverse type 2 diabetes in 100 Million people by 2025 and how they are accomplishing this. Here’s a glance at what we discuss in this episode: Bill’s healthcare leadership experience and what inspired him to become a part of Virta Health The issues our healthcare delivery system faces as it pertains to misaligned incentives and a lack of price and quality transparency How Virta Health is using food as medicine instead of the traditional approach of additional medications Virta’s definition of diabetes reversal is maintaining a sub-diabetic HbA1c below 6.5%, with the elimination of all diabetic medications, except for metformin What nutritional ketosis is and how a low carb lifestyle impacts a person with diabetes 60% of individuals in the clinical trial reversed their diabetes, 94% of participants either fully eliminated or reduced their insulin levels and 12% lowered BMI and sustained their progress How long it takes to get most patients to sub-diabetic levels and off medication How Individuals receive a specific care team for the duration of their participation in the program including a Virta employed physician and health coach Frequency and type of patient interactions with their care team How individuals receive durable medical equipment and use a mobile app to interact with the care team and track their data Why Virta Health’s speed of impact and aligned incentives have resulted in 90% engagement and retention in the first year How Virta Health uses a performance-based fee structure, guaranteeing results for actual patient results How Virta interacts with primary care providers Type of savings the Virta Health program can achieve for an employer Types of employers that Virta is currently working with Virta Health’s website and contact information (https://www.virtahealth.com/)

Topics: Chronic Conditions Consumerism Clinical and Financial Outcomes Data Science Behavior Enablement Smart Coaching Medication Affordability and Optimization In this episode, Michael introduces you to Glen Tullman, Executive Chairman of Livongo. Join us as we discuss how Livongo empowers people with chronic conditions to live better and healthier lives. Here’s a glance at what we discuss in this episode: Glen’s healthcare entrepreneurial experience and what inspired him to launch Livongo Why our healthcare delivery system is broken and how our system makes it harder for people to live and function with chronic disease and illness How the lack of consumer incentives and price and quality information drives inefficient consumer behavior How Livongo empowers people with chronic conditions to live better and healthier lives How Livongo aggregates data, personalizes it and equips the consumer with the best applicable solutions Livongo focuses on the following chronic conditions – diabetes, hypertension, weight management and behavioral health Livongo uses cellular connected devices to collect the consumer’s information and monitor health patterns How Livongo uses personalized data and insights into how to stay healthy to motivate consumers to make behavioral changes to better manage their chronic conditions What makes Livongo unique as an Applied Health Signals company and how the leverage end user feedback and iteration to drive better results By implementing Livongo, employers save on average $83 per month per diabetic   Why the Net Promoter Score (NPS) is impactful and how Livongo leverages it’s NPS scores to make changes and improvements in its service model Why employers should be taking a proactive approach in leveraging innovative partners to provide quality services at lower costs Livongo’s website and contact information (https://www.livongo.com/)

Topics: On-Demand Health Insurance Consumerism Clinical Care Paths Aligned Incentives Cost Savings Dynamic Copays Price Transparency In this episode, Michael introduces you to Tony Miller, Co-founder and CEO of Bind On Demand Health Insurance. Join us as we discuss how Bind provides an innovative platform to address some of the deficiencies in traditional insurance products and makes health insurance easy, affordable and flexible for consumers.   Here’s a glance at what we discuss in this episode: Tony’s serial health care entrepreneurial experience and what inspired him to launch Bind Why our healthcare delivery system is broken and value-based reimbursement may not be the solution How Bind arms consumers with the tools they need to make appropriate cost and quality decisions regarding their healthcare. Bind’s unique Core and Buy-Up plan structure How the “smart” copay structure within Bind compares to traditional insurance copay structures and deductibles/co-insurance How Bind incorporates a quality metric into a treatment care path with a dollar incentive through the dynamic copay structure for consumers to access How Bind aligns incentives for consumers and physicians while redefining reimbursement models Why  condition management programs should originate with the physician How Bind provides consumers with tools to empower them with price certainty for medical & pharmacy services How Bind has created a shared savings model with all stakeholders, including plan sponsors and consumers, to target and eliminate waste in the system How the additional premium for buy-up services is financed in a tax efficient way Bind’s unique dynamic member experience through their concierge team and mobile application Examples of member engagement and why on average 55% of enrollees have utilized the app Why Bind encourages their on-demand health insurance as an option paired with an employer’s legacy insurance plan Exciting new horizons for Bind and interest in expanding to Medicare, Medicaid, and individual market Who Bind is a good fit for Bind’s website and contact information (https://www.yourbind.com/)

Topics: Concierge Support Cost Management Price Transparency Network Optimization Medical Bill Review Reference Based Pricing Level Funding Third Party Administrator (TPA) In this episode, Michael introduces you to Keith Lemer, CEO of WellNet Healthcare. Join us as we discuss how WellNet Healthcare provides employers with an entrepreneurial approach to reducing health care costs and a platform to proactively manage their healthcare expense just like any other expense in their business. Here’s a glance at what we discuss in this episode: Keith’s entrepreneurial/healthcare experience and his career evolution that led to WellNet Keith’s take on what is wrong with our healthcare delivery system and why cost continues to rise How WellNet’s provides employers with a “crawl, walk & run” approach to drive the level of cost savings that an employer wants to achieve WellNet’s ability to educate, incentivize and reward employees for accessing lower-cost health care services that provide network optimization How WellNet drives 66% of employees to engage with their concierge team to shop for lower cost options in the network WellNet’s method to determine quality of physician and facilities and how this compares to traditional TPA/carrier tools to measure cost and quality How WellNet incorporates medical bill review to identify unreasonable charges and recover savings for employers WellNet’s process for implementing reference-based pricing programs and how their concierge team plays a key role in minimizing disruption and balance billing Why level funding products are advantageous for smaller employers or employers preparing to transition to a self-funded platform What questions employers should be asking of their Broker/Consultant at renewal WellNet is vendor agnostic and an open source platform with the ability to integrate with various point solutions How WellNet simplifies the consumer experience and provides touch points throughout the patient journey WellNet uniquely offers a stand-alone pharmacy benefit carve-outs and disease management plans direct to employers WellNet’s fee structure and performance guarantees An example where WellNet delivered over $4 million in savings for one employer Who WellNet is a good fit for and who they are not a good fit for New developments on the horizon for WellNet WellNet’s website and contact information (https://wellnet.com/)

Topics: Misaligned Incentives Engaged Healthcare Consumer Price Transparency Center of Excellence Local Healthcare Tourism Integrative Medicine Cost Savings In this episode, Michael introduces you to Dr. Josh Luke, a veteran hospital CEO and award-winning healthcare futurist, public speaker, and author. Join us as we discuss Dr. Luke’s newest book, Health – Wealth 9 Steps to Financial Recovery where he outlines specific steps employers can take to proactively control their healthcare costs. Here’s a glance at what we discuss in this episode:   Dr. Luke’s unique professional experience and what lead him to a career in healthcare Why Dr. Luke was motivated to author Health – Wealth 9 Steps to Financial Recovery Why the healthcare delivery system is broken and as a result costs continue to rise A high-level overview of the content in Health – Wealth 9 Steps to Financial Recovery Dr. Luke provides examples of how capitalism plays a key role in the bankrupting of our healthcare delivery system How the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), has impacted utilization in hospitals Examples of how the healthcare delivery system is designed to provide care that may not be necessary or beneficial to the patient How the saying “don’t worry your insurance will pay for it” has lead to employee lack of ownership of healthcare decisions and spending The disconnect between consumers and understanding how healthcare is purchased and why employers and employees need to become engaged healthcare consumers Dr. Luke’s 9 Steps to Financial Recovery for an employer Why American businesses are complacent with the status quo How innovative strategies such as Centers of Excellence align incentives to drive employees to a higher quality of care while lowering healthcare costs Examples of corporate health-wealth approaches ranging from rewarding long-term employees with full genome testing to promoting integrative medicine Additional resources on Linkedin at Health – Wealth: Employer Forum on Reducing Healthcare Spending, or visit: https://www.health-wealth.com/, or Text JOSH to 72000 to receive updates via text

Topics: Hospital Billing Errors Medical Bill Review Reference-based pricing Price Transparency Network Discount Model Chargemaster Balance Billing Cost Savings In this episode, Michael introduces you to Dr. Merrit Quarum,  Founder and CEO of WellRithms Inc. Join us as we discuss how WellRithms endeavors to transform healthcare through Hospital medical bill review and transparent and economically sustainable reimbursement practices. Here’s a glance at what we discuss in this episode: Dr. Quarum’s diverse health care experience and why he founded WellRithms What is wrong with our healthcare delivery system as it pertains to affordability, reimbursement, and lack of price transparency How WellRithms provides an integrated facility medical bill review and establishes a reasonable reimbursement amount for medical services Why detailed facility medical bill reviews may not be happening with traditional TPA’s and networks and they may not be protecting an employer from unreasonable charges Examples of Hospital medical bill errors and why auditing is so valuable The prevalence of Hospital medical bill errors The average amount of cost savings WellRithms medical bill review yields clients The difference between reference-based pricing compared to traditional network reimbursement pricing Why reference-based pricing based on Medicare multiples may pose a problem if the facility or hospital challenges the reimbursement   WellRithms reference-based pricing methodology compared to traditional reference-based pricing and why WellRithms methodology is legally defensible, backed by case-law How the WellRithms methodology of pricing is fully indemnifiable and the employer and employee is protected when a Facility challenges the reimbursement level The types of savings an employer can achieve relative to the Network Discount Model Myths about balance billing with reference-based pricing and how egregious balance billing scenarios frequently happen in a network discount model How a self-insured program with WellRithms reimbursement structure compares to capitation models WellRithms unique cost structure and who they are a good fit for WellRithms website and contact information: (http://wellrithms.com/)

Topics: Mental Health Behavioral Health Access to Care Quality of Care Evidence Based Care Consumer Experience In this episode, Michael introduces you to Sean McBride, Head of Partnerships at Lyra Health. Join us as we discuss how Lyra Health is transforming mental health care by creating a frictionless experience for patients, providers and employers using technology and data to connect companies and employees to high quality mental health providers, coaching and evidence based therapies.   Here’s a glance at what we discuss in this episode: Sean McBride’s digital health background and why he joined Lyra Health as one of their first employees   What is wrong with our healthcare delivery system as it pertains to mental and behavioral health The misconceptions about effective mental health therapy and what evidence based therapy is How credentialing of providers doesn’t necessarily have a relation to quality of care/therapy delivered How Lyra Health is trying to address mental health access to care and quality of care How Lyra helps patients with access by ensuring provider availability within their network and decreasing typical wait times to see a therapist by approx. 3 weeks Why many therapists have stopped accepting insurance, were unwilling to be a part of a network How Lyra has endeavored to remove obstacles to providers being part of a network, streamlining direct deposit payment and matching the therapist’s specialty with the appropriate patient panel How Lyra Health has grown their network to include 3,000 therapists nationwide – of that number 25% of the therapists were referred by current participating therapists The three main reasons evidence based treatment and therapies are important How Lyra Health identifies therapists that are practicing evidence based care and ensures quality control once a provider is part of their network Why Lyra Health will reimburse providers at a higher rate than traditional networks How Lyra is integrating digital self care experiences with in-person therapy sessions How evidence based coaching and digital self therapies are available to employees who do not have a clinical diagnosis Lyra Health’s unique cost structure and who they are a good fit for Lyra Health’s website and contact information: (https://www.lyrahealth.com/) or email at partnersatlyrahealth.com

Topics: Specialty Drugs Data Analytics Net Acquisition Cost vs. Discount Pricing Improving Health Outcomes Specialty Drug Waste Prior Authorization Cost Savings Misaligned Incentives In this episode, Michael introduces you to Pramod John, CEO of VIVIO Health. Join us as we discuss how VIVIO Health, a specialty drug platform, utilizes data analytics and outcomes based models to help employers control their specialty drug spend. Here’s a glance at what we discuss in this episode: Pramod John’s software engineering and supply chain background and why he founded VIVIO Health How drugs may be prescribed off-label and physicians prescribing patterns may be influenced by payments from drug manufacturers How misaligned incentives have propelled our healthcare system into a cycle of complacency and how VIVIO Health seeks to break the cycle Why its critical to focus on specialty drugs to contain costs in Rx spending Why the current discount pricing model doesn’t work and leads to higher medical inflation year after year Why a focus on specialty drug discount guarantees in PBM contracts may not be in the best interest of employers and lead to the purchase of higher cost drugs when lower cost drugs are available Why the assumption that smaller companies like VIVIO Health can’t negotiate pricing competitive with Big PBM’s is false Why a stamp of approval from the FDA may not mean a drug is safe or effective The difference between effectiveness of a drug and efficacy and how many drugs on formularies are not impactful for improving clinical conditions they are designed to treat The problems with the traditional prior authorization process and how VIVIO Health has  changed the process to be a data driven approach to determining the optimal therapy for the specific patient How VIVIO Health’s data collection process helps an employer to monitor if the drugs that are being prescribed are actually working and effective The resistance from PBM’s to allow a vendor like VIVIO Health to carve out the administration, procurement and management of the specialty drug component VIVIO Health’s platform and how they are improving the employee experience and helping reduce waste in prescribing practices and employer spend on specialty drugs by 30% to 50% VIVIO Health’s transparent cost structure and typical ROI with current clients Obstacles that VIVIO Health has overcome to implementing their program with employers VIVIO Health’s website and contact information: (http://www.viviohealth.com/) , pramod@viviohealth.com

Topics: Pharmacy Benefit Manager Self-Funded Health Plan Misaligned Incentives Rebates Formulary Waste Formulary Design Specialty Drugs Clinical Programs Performance Guarantees In this episode, Michael introduces you to Mindi Fynke, President and CEO of Employee Health Insurance Management (EHiM). Join us as we discuss EHiM’s unique service-oriented PBM model and how they can effectively lower an employer-sponsored health plan’s drug spend. Here’s a glance at what we discuss in this episode: Mindi Fynke’s clinical experience and why she founded EHiM   How rebates from drug manufacturers are intended to move market share and the act of taking rebates from drug manufacturers can be a misaligned incentive and contribute to increased healthcare costs How EHiM seek to address pharmacy waste in an employer’s sponsored health plan’s drug spend with custom formulary design and clinical programs for each client’s unique demographics and claims The conflict of interest that may exist when PBM’s own their own specialty pharmacies EHIM’s book of business Specialty Trend is 6% relative to National Specialty Trend of 18% How EHiM implements a unique solution of clinical interventions and negotiations with drug manufacturers to help employers manage their specialty pharmacy trend well below the national average The difference between a traditional PBM’s customer service and EHiM’s patient advocacy model How EHiM competes in the market without receiving or offering drug manufacturer rebates, driving savings of 20% -30% in overall drug spend Examples of misaligned incentives in formulary design that can be costly to the employer and how EHiM can customize many components in Pharmacy Benefit Administration (Network, Formulary, Plan Design, Clinical Programs) to “move market share” towards lower cost alternatives EHiM’s transparent fee structure options EHiM’s ability to provide performance guarantees based on actual employer net spend vs “discount guarantees” EHiM’s new and exciting technology capabilities with state of the art adjudication system The difference between partnering with a smaller pharmacy benefit manager compared to a larger PBM EHiM’s website and contact information: ehimrx.com, mindi@ehimrx.com

Topics: Fraud, Waste and abuse ERISA Fiduciary Liability Third Party Administrator (TPA) Self-Insured Employers Payment Integrity Misaligned Incentives   In this episode, Michael introduces you to Rick Anthony, Executive Vice President for 4C Health Solutions. Join us as we discuss how 4C Health Solutions, a payment integrity solution, seeks to tackle the epidemic of healthcare fraud and waste for self-insured employers and government programs.   Here’s a glance at what we discuss in this episode: Rick’s extensive experience as a benefit consultant and why he joined 4C Health Solutions The problem with the Network Discount Model The definition of fraud, waste and abuse in healthcare and how it accumulates to $300 Billion annually How fraud can consistently go undetected within a health plan How employer Fiduciary Liability is also applicable to employer health plans and the current risks employers may not be aware of How 4C Health Solutions enables employers to uphold their ERISA fiduciary responsibility to take the steps necessary to protect the assets of employee health benefit plans What 4C Health Solutions provides compared to a traditional auditing firm 4C Health Solutions’ process for reviewing an employer’s claims history and how they identify on average 7-20% of illegitimate claims How 4C Health Solutions’ adjudication system prevents improper payments before they are paid without delaying the claims payment process The category where most of the fraud, waste and abuse claims have been identified The willingness of TPAs vs. other insurance carriers to work with 4C Health Solutions The concept of an employer owning their data and why some carriers are resistant to contract language that specifies this ownership of data 4C Health Solutions breaks down barriers to provide employers with independent visibility into their health benefit programs How 4C Health Solutions will leverage their data to help employers identify the most efficient providers who offer the highest quality care 4C Health Solutions’ fee structure options and typical return on investment for employers Barriers that 4C Health Solutions has encountered resulting in employers not implementing their service 4C Health Solutions’ website and contact information: (http://4chealthsolutions.com/)