Podcasts about insurance carriers

Lowenstein Sandler's Insurance Recovery Podcast: Don’t Take No For An Answer

Play Episode Listen Later Dec 5, 2024 34:15

I'm putting a meme in the show notes. It's my second meme ever, so I'm clearly on a roll. As you can see, it's a picture of two kids taking a test; and the one kid is cheating off the other kid. It's a How to Do Spread Pricing test, and the kid with carrier has his eyes all over the PBM kid's test. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Look, this is a thing now, medical spread. And similar to how PBM spreads adds up to millions, billions of dollars, medical spread is not change in the couch cushions. Did you see the lawsuit against Cigna? Cynthia Fisher mentions it in the conversation that follows. Spoiler alert, here's the numbers: Self-insured employer paid $4 million for a claim. In this case, there's a slide on this Cynthia Fisher gave me, by the way, if you want to see all this written out. So, the employer pays $4 million. The provider was paid—drumroll, please—$876,000. I'm pausing so that sinks in: $4 million paid by the employer; $876,000 of that makes it across the trench to the provider. What happened, you may be wondering, to the $3.2 million in the middle there that the self-insured employer wrote a check to their carrier for? If I'm the employer, I think I would sort of want to know where the $3.2 million went, because … yeah. I think anyone would be hard-pressed to explain how a prudent fiduciary is managing to pay millions of dollars of its plan members' money for services that actually cost a fraction of that. And this is just one claim. But you came here for a show about transparency. Why, you may be wondering, am I talking about medical spread pricing? It's not a super far leap, so many of you are probably there already; but let me quote Chris Deacon. She wrote, “As these conglomerates expand control over healthcare delivery and administration, radical transparency is our only bulwark. Patients and employers deserve to know exactly what they're paying for, without hidden fees disguised as care costs.” I don't think anyone would say that transparency alone is sufficient to transform healthcare, but it's definitely a start for sure. So, yeah … transparency. The reason why lawsuits about overpayments, big ones—and there's a bunch of them afoot right now, not just that Cigna one—but the reason that these are going down in the first place is because hospital prices and carrier prices are now somewhat available. And we have some plan sponsors—the ones who are worried about fiduciary duty, at least—these plan sponsors are able to cobble together the math to catch a glimpse of how much money is vanishing. Dollars they and their members are paying for medical claims that never make it to the care team providing the care. And who is shocked? Are you shocked? I'm not shocked. Let me read a sentence from a carrier contract that Justin Leader sent me the other day. Section 6.3: “Claim administrator's compensation for its services under the agreement shall include the difference between the net claim payments reimbursed to the claim administrator by the employer and the net amounts paid to providers by the claim administrator.” Translation: We are allowed to add spread pricing. We are able to arbitrage. We are able to mark up (or whatever you want to call it) by any amount we want, and you, plan sponsor, just signed up to pay for it. So, that happened. Listen to episode 433 with Justin Leader, by the way. The show is called “The Mystery of the Weekly Claims Wire,” otherwise known as the Not Transparent Weekly Claims Wire. So, look … transparency: We can talk about it in terms of medical prices. We can talk about transparency in terms of contracts. And actually also in terms of quality, but we don't get into that today. Bottom line, plan sponsors need enough access to billing data and hospital prices to calculate how much the middle folks are taking in spread, which is, as aforementioned, quite a thing. For more actual data on the magnitude of spread pricing goings-on, ask Dan Ross. That's my suggestion. He's got spreadsheets he can show you of how much plan sponsors are paying and how much providers are charging and how much is going missing in the middle. For even more on this, read the recent Owens & Minor lawsuit that just got filed, which is just a case study in how hard some of these middlemen/carrier entities are working to obscure and hide what they are doing. Because, yeah, sunshine is a great disinfectant, and that's what transparency is. Sunshine. Here's another interesting link from Chris Deacon. I say all this to say, this is the kind of transparency that Cynthia Fisher and I talk about in the show today: contract transparency, bill charges transparency, and hospital or medical price transparency for plan sponsors. We do not get into today consumers or patients using price information to shop, just FYI. We also do not get into, really, price convergence, which is what happens when hospital and carrier prices become available in a market and is often brought up on or about conversations about transparency. Okay, I will say just one thing about price convergence. There was some chatter in anti-transparency press releases from parties mostly that didn't want to be transparent at all, no way no how. But there was some talk a couple of years ago that if contracted prices became transparent, the healthcare industry would raise their prices to match the highest in the market and the result would be rising healthcare prices and greater total costs. That turns out, it seems, to be false. There's a study that shows that the bottom of the market (those with the cheapest prices) do, in fact, raise their prices but not as much as the top of the market lowers theirs. So, there is actually net savings. Read about the Turquoise Health study and an article that Forrest Xiao and team posted that shows this, and it's the first study of its kind, at least that I have seen. Okay, so contract transparency, data transparency, that's what's on deck to discuss today with Cynthia Fisher, as I have mentioned several times already, who has a long history as an entrepreneur in the healthcare space. So, Cynthia Fisher gets U.S. healthcare, and she gets being a plan sponsor and a fiduciary. She is founder and chairman of PatientRightsAdvocate.org, as well as Power to the Patients. Her focus is on ensuring that all healthcare shows prices up front so that we can have accountability and integrity in billing and at any point of care. Cynthia has said early and often that transparency protects the ultimate purchasers of healthcare—meaning plan sponsors, plan members, and patients—from overcharges, spread pricing, or otherwise. Where there's mystery, there is margin, as Anthony Ciaccia has said often. Cynthia's call to action is as follows, but listen to the show to hear her say it more eloquently. C-suites, CFOs, in-house counsel use purchasing discipline that your company probably uses elsewhere in the procurement of health benefits. Cynthia Fisher also says as part of the call to action, refuse to sign blank checks to the healthcare industry and refuse anti-audit provisions. She also has a call to action for the accounting industry to stop ignoring auditing the health plans. And this matters just given the bald-faced fact right now that overcharges are party sized. Let me wrap up with this: There's a lot of brute force tactics out there being deployed by some plan sponsors that effectively keep plan members from getting the care they need because they are functionally uninsured. I've done multiple shows on this, and I link to some of them below. I just can't help to think, some of this brute force, you know, high-deductible health plans and some pretty savage cost containment strategies, might be unnecessary if middleman excess profits were eliminated. Well, I say this with some evidence, actually. Andreas Mang (EP419) was on the pod. He talked about saving 15% or more by being smart about contracts and plan assets at the financial and purchasing level. Brian Uhlig … was talking to him the other day. He was telling me he saved $80 million just doing contracts right. Also Claire Brockbank (EP453) talks about this; Cora Opsahl (EP452), too, from 32BJ. Those are two recent shows, again, about how much money can be saved by only signing contracts that ensure transparency. Also mentioned in this episode are Patient Rights Advocate, Chris Deacon, Justin Leader, Dan Ross, Forrest Xiao, Anthony Ciaccia, Andreas Mang, Brian Uhlig, Claire Brockbank, Cora Opsahl, Mark Cuban, and Mark Cuban Cost Plus Drug Company. You can learn more at PatientRightsAdvocate.org. Cynthia A. Fisher is founder and chairman of PatientRightsAdvocate.org, a nonprofit organization seeking healthcare price transparency, giving power to American consumers—patients, employers, and unions—to lower their costs of care and coverage through a functional marketplace and choice. Cynthia is best known for her pioneering work as founder and CEO of ViaCord, Inc., a leading price-transparent umbilical cord blood stem cell banking company which she started in 1993. In 2000, she co-founded and was president of the cellular medicines company ViaCell, Inc., of which ViaCord became a division. ViaCell went public in 2005, was acquired by PerkinElmer, and exists today under the ViaCord brand. Cynthia also serves on the public company boards of the Boston Beer Company, Inc. and Easterly Government Properties, Inc. She serves on the Florida Council of 100 and the board of the National Park Foundation, and she previously served on the board of directors of Water.org. Cynthia holds an MBA from Harvard Business School and a bachelor's and honorary Doctorate of Science degree from Ursinus College. 09:03 What is the goal of PatientRightsAdvocate.org? 10:28 Is American competitiveness being affected by healthcare spend? 13:47 Why is transparency a root cause to healthcare costs? 15:11 What's going on across the country to empower transparency in healthcare? 19:31 “I think people are fed up.” 21:22 The Cigna lawsuit in California. 26:36 How do employers navigate contracts against anti-steering? 28:54 EP419 with Andreas Mang. 29:33 EP452 with Cora Opsahl and EP453 with Claire Brockbank. 29:45 EP433 with Justin Leader. You can learn more at PatientRightsAdvocate.org. Cynthia A. Fisher of @PtRightsAdvoc discusses #medicalspreadpricing and #contracttransparency on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW40), Mark Cuban and Ferrin Williams (Encore! EP418), Rob Andrews (Encore! EP415), Brian Reid, Dr Beau Raymond, Brendan Keeler, Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451)

2025 Outlook: What to Expect from Your Insurance Carriers

Play Episode Listen Later Dec 5, 2024 20:00

Lynda A. Bennett, Heather Weaver, and Josh Weisberg of SterlingRisk continue their year-end conversation about what changed in the insurance recovery space in 2024 and what to expect in 2025. Lynda, Heather, and Josh anticipate rate relief and broader coverage in cyber insurance, provided that companies can show that they have good risk control measures in place. They also expect this year's Crowdstrike event to affect the availability of contingent business income coverage, high jury verdicts in personal injury cases to result in continued rate pressures and potentially more restrictive coverage in the excess casualty insurance market, and the new administration in Washington, DC, to have an impact on the insurance space generally. Speakers: Lynda A. Bennett, Partner and Chair, Insurance RecoveryHeather Weaver, Counsel, Insurance RecoveryJosh Weisberg, Chief Risk Officer, SterlingRisk

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Ep 190 | Jim Andrews | Precedent is Streamlining Information Exchange Between Law Firms & Insurance Carriers

The Lawyer Stories Podcast

Play Episode Listen Later Jul 31, 2024 43:35

The Lawyer Stories Podcast Episode 190 features Jim Andrews, President & Cofounder of Precedent, a platform streamlining information exchange and negotiation between law firms and insurance carriers, located in Santa Barbara, California. Jim shares with us about his vast insurance background and how he made his way with Grant Little to launch Precedent. We discuss how Precedent is a plaintiff's law firm connectivity into insurance carriers and how Precedent assists at all points that a plaintiff firm and insurance carriers would interact. Precedent's goal is to reduce administrative tasks, eliminate endless back and forth, and minimize stalemates. This saves insurance carriers and law firms' money while reducing errors and helps both parties work more efficiently, ensuring fair and reasonable settlement outcomes.

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"Whatley" - Fostering a Collaborative Environment between Restoration Contractors and Insurance Carriers

IAQ Radio

Play Episode Listen Later Jul 19, 2024 65:55

Mark Whatley is an influential voice in the property restoration and insurance technology sectors. He co-founded Sureti, a company that provides third-party fund control services aimed at accelerating property claims payments, ensuring faster and more efficient resolution for restoration contractors and insurance carriers. Whatley is also the founder and board president for Actionable Insights (AI), a non-profit organization dedicated to enhancing the property restoration industry by clarifying billing standards and training on modern claims settlement tools. AI focuses on fostering a collaborative environment between restoration contractors and insurance carriers, ensuring industry wide best practices are maintained. In addition to his entrepreneurial adventures, Whatley has served in various leadership roles, including Senior Vice-President of Claims Operations for CORE Group, where he contributed to the development of advanced claims settlement processes using 3D technology. With over a decade of experience in the restoration industry, Whatley is recognized as a thought leader and innovator. He holds certifications as an Xactimate and Matterport trainer and is a licensed general contractor, bringing practical experience to his leadership roles.

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Spartanburg Mobile Urgent Care Provider Accepts All Major Insurance Carriers

UBC News World

Play Episode Listen Later Jul 2, 2024 2:21

Get the urgent medical care you need right where you're - no need for emergency room visits or to inconvenience yourself. Call GoMed Mobile Urgent Care at (844) 994-6633 to book your appointment. Learn more at https://gomedhealth.com/locations/urgent-care-spartanburg-south-carolina/ GoMed Mobile Urgent Care Spartanburg City: Spartanburg Address: 1230 John B White Sr Boulevard Website: https://www.gomedhealth.com Phone: 18449946633 Email: info@gomed.net

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Episode 282: Watch out for the Tornados! (talking to you, insurance carriers)

The Insurance Dream Podcast

Play Episode Listen Later May 30, 2024 4:20

This has been a record setting tornado season. What does that mean for insurance? Today's episode sponsored by: Digital Marketing (theinsurancedream.com)

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Strategies for Insurance Carriers

iTunes - Insurance Journal TV

Play Episode Listen Later May 21, 2024 4:12

In this clip from Weathering the Storm: Cyber Insurance Risk in 2024, insurance carriers must adopt comprehensive approaches to manage cyber risk portfolios, leveraging both internal and external resources … Read More » The post Strategies for Insurance Carriers appeared first on Insurance Journal TV.

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Encore! EP363: How to Cut Healthcare Admin Burden in Half, With David Scheinker, PhD

The Maximum Lawyer Podcast

Play Episode Listen Later May 9, 2024 33:59 Transcription Available

For a full transcript of this episode, click here. I'm gonna encore this episode with David Scheinker, PhD, for several reasons; but here's a big one: Why are we as an industry not doing what David Scheinker suggests in this episode? Why are we not doing, I don't know, kinds of logical things to reduce admin burden in this country when everyone agrees admin burden is a problem? But let me back up for a moment for context. Two things happened since this show originally aired. One is that I was invited to a fireside chat by the Advisory Board to talk with Abby Burns, one of the amazing hosts over at Radio Advisory; and we talked about value in the healthcare industry. And if you define value as benefit divided by costs, and you can cut costs—like cut admin burden costs in half—then you have created some really nice communal value, which we talked about at length during that aforementioned fireside chat. Here's the other thing that happened since this show originally aired. I read the book by Mike Leavitt, mainly because Steve Schutzer, MD, kept talking about it. The title of the book is Finding Allies, Building Alliances. Maybe I will do a book report about this at some point, but let me share a couple of key quotes just to get the party started here. Mike Leavitt wrote, “A diverse alliance, well led and well managed, can bring resources to bear on a problem that no organization can match—even the largest of organizations. The synergy of resources—from financial to intellectual—can deal effectively with a wide range of issues confounding organizations today.” I found that very interesting. Here's the second quote, which deals with what the top reason is that such diverse alliances may wish to hook up. “[It's] a common pain: A shared problem that motivates people and groups to work together in ways that could otherwise seem counterintuitive.” Hmm … so, back to administrative burden. Let's review the facts that David Scheinker, PhD, shares in the interview that follows. He says any given transaction will cost provider organizations 14% of the total transaction costs to manage to get paid. Yes, it costs 14% of a transaction merely to get paid for the transaction. This is a big reason why both Peter Hayes, in the episode with him (EP424), and also Marshall Allen (EP425) talk about for why cash prices can be a whole lot less than going through insurance prices because you can skip a lot of insurance burden. Now, on the payer side, add to that 14% an additional 5% to 15% to pay said transaction. That 30% of healthcare is waste stat that keeps getting tossed around. Listen to the show with Will Shrank, MD (EP413) for more on that. But, yeah … here's 20% to 30% of every transaction that is waste. And we haven't even gotten into redundant care or inappropriate back surgery yet. Our industry spends up to 30% of our money just trying to get paid and pay. Here's a case study for you. You know who has already solved for this whole “it's really hard to get paid and pay” dilemma? Derivative traders. It used to cost derivative traders $100,000 to do a contract, any given contract. And they worked together and got this down to $5000 by doing some of the stuff that David Scheinker talks about in the show. And, I don't know, I feel like the healthcare industry could also do this, too, if they wanted to. But there are a whole bunch of reasons why our industry cannot seem to get together and be as ruthlessly practical as derivative traders—or banks, who have figured out how to work together to process credit cards to reduce their own common pain. Here are but a few of the reasons, potentially, why the healthcare industry doesn't get together to reduce administrative burden in some of the ways that Dr. Scheinker talks about. 1. Some organizations actually make a lot of money off of that transactional waste. As but one example—and not to just pick on one, but we don't have all day—how about some RCM (revenue cycle management) companies who may or may not be owned by the same vertically integrated stacks as the payers themselves? As I have said any number of times, one person's—or potentially an entire country's, as the case may be—one party's waste, is somebody else's honeypot; and I am not sure if this is any exception. 2. Legacy technology and data systems and all the sunk costs therein 3. As Kaye Davis and Katrina Hubbard reminded me about the other day, there are some serious regulations in healthcare due to everybody being a vendor of CMS that adds a layer of regulatory complication to many collaborations. Also, state laws sometimes have an unintended side effect of making it tough to collaborate. Now, are there any precedents for this type of collaboration in the healthcare industry? Yeah, actually Surescripts, which, don't forget, was created by an alliance of PBMs (pharmacy benefit managers) who worked together because they all wanted to enable e-prescribing and needed a joint platform to do it. Look, I could say a lot about this one, but nonetheless, so much of what gets talked about in the show today with Dr. David Scheinker is very, very actionable. Just want to note that since David Scheinker was on the show, he and his team have done some major research over the past few years into ways that contracts can be standardized. If enough of you reach out and say that you're interested, we, for sure, can have David come back on the show and discuss. David Scheinker, PhD, is a clinical professor of pediatrics. He's the executive director of systems design and collaborative research at Stanford Children's Health. He also founded and directs SURF Stanford Medicine. And with that, here is your original episode. Administrative costs in the United States have a bad rap. You don't have to look too far to find an article about how there's now, like, 10 administrators for every 1 physician in this country. Or 3 to 4 billing people for every physician. Or consider what Dan O'Neill was talking about in episode 359. He was talking about IPAs (independent physician associations) and other managed care entities. As Dan mentions, contracting with some of these IPAs is like an “I love 1990” flashback. The contracting process transpires via mail. Not email, mind you. Mail. Like, stick-a-stamp-on-the-envelope mail. So, in sum, there's a lot of pretty well-founded complaining about administrative costs in this country. A lot of this administrative stuff is truly inefficient and a fantastical waste of time. So, here we are freaking out about staffing shortages, overlooking that doctors at the heights of their careers are spending some percentage of their time not counseling, treating, or diagnosing patients but twiddling their thumbs on hold with one insurance company or another slowly burning out by the inefficiency of it all. Or doing pajama time, and we all know that too much pajama time means also burnout on a silver platter. So then, let's get granular here. If we're trying to quantify admin costs, how you do that is to quantify how much each transaction costs. How much does it cost to send a bill and get paid for it? How much does it cost to file an appeal and a denial of a prior auth? Add all those transactions together and you get the full cost of the administrative burden. In this healthcare podcast, we're digging into a paper about admin costs written by David Scheinker, PhD (my guest today); Barak Richman, PhD, JD; Arnold Milstein, MD, MPH; and Kevin Schulman, MD, MBA. I have the pleasure of speaking with David Scheinker, PhD (as I mentioned), who is the lead author on this paper. Just to underline a major takeaway from this conversation with Dr. David Scheinker, he reiterates a recommendation to eliminate a big proportion of administrative costs. I guess I should say spoiler alert here, but the major takeaway/recommendation is this: Standardize healthcare contracts between payers and providers. Every payer and every provider finds one contract template and uses it. I don't mean one template per payer or per provider, although that probably would be a revelation in and of itself. But I mean that all payers use one basic provider contract. A couple of specifics here: The template that I'm referring to (and that Dr. David Scheinker is referring to) consists of parameters. What do I mean when I say parameters? Consider what Airbnb does when you're looking for a place to stay, as an example. How many bedrooms (that's a parameter)? How many bathrooms (that's a parameter)? How many amenities (that's a parameter)? After everybody picks their standard set of parameters, at that point, all parties can negotiate and come up with whatever they want for what is the price of an extra bedroom or whatever value you're gonna assign to that parameter. Go nuts there, but from a data collection and analytic perspective and a getting paid perspective, it is way easier to do it that way—meaning it's way easier to execute and report when all of the contracts use the same parameters. Also, you can build tech to do a lot of that because you don't have to write algorithms with exponential variables. Also mentioned in this episode are Abby Burns; Michael Leavitt; Steve Schutzer, MD; Peter Hayes; Marshall Allen; William Shrank, MD; Kaye Davis, MPH; Katrina Hubbard; Dan O'Neill; Barak Richman, PhD, JD; Arnold Milstein, MD, MPH; and Kevin Schulman, MD, MBA. You can learn more by connecting with David on LinkedIn and following him on X (Twitter). David Scheinker, PhD, started his career as a research mathematician and switched to healthcare operations to work on an interdisciplinary team and have a more immediate impact. He is a clinical professor of pediatrics, the executive director of systems design and collaborative research at Stanford Children's Health, and a member of the Clinical Excellence Research Center (CERC) at Stanford University. He founded and directs SURF Stanford Medicine, which brings together students and faculty from the university with physicians, nurses, and administrators from the hospitals. He studies clinical care delivery, hospital operations, sensor-based and algorithm-enabled telemedicine, the socioeconomic factors that shape healthcare, and healthcare policy. 10:39 What's the quantitative administrative cost in an average transaction? 11:05 What's the quantitative administrative cost in a healthcare transaction? 11:58 What does the healthcare billing and administration cost add to the US's overall healthcare spend? 12:53 Is it possible to cut billing and administrative costs in healthcare? 14:17 “In some ways, the problem for healthcare should be simpler.” 15:30 What does the complexity of the current system look like in a doctor's office? 18:42 How did David go about studying healthcare administrative costs? 21:34 “It doesn't have to be simple; it should be standardized.” 24:50 What would be the pushback on standardizing contracts in healthcare? 25:43 Why is it possible to gain more value by losing customization in contracts? 27:20 “Never let a good crisis go to waste.” 27:41 “It's much easier in healthcare to build something new than to change something that exists.” 30:47 What benefits does telemedicine have to cutting administrative costs? 32:17 What is another significant benefit of using standardized contracts? 33:26 Why haven't standardized contracts become a common thing in the current healthcare system? You can learn more by connecting with David on LinkedIn and following him on X (Twitter). @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Dan Mendelson, Dr Benjamin Schwartz, Justin Leader, Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick

Precedent: Rethinking How Claims are Settled Between Law Firms and Insurance Carriers with Jim Andrews

Play Episode Listen Later May 7, 2024 36:15

Watch the YouTube version of this episode HEREAre you looking for a way to streamline your law firm's efficiency with claims? In this episode of the Maximum Lawyer podcast, Becca Eberhart chats with Jim Andrews about his innovative platform, Precedent, which aims to improve the efficiency of attorney-handled claims. Jim shares what Precedent is trying to achieve within the legal space. Precedent tries to bridge the communication gap that exists between plaintiff firms and insurance carriers, which can be a complicated relationship. Since both areas work with each other frequently and still use outdated methods to share information, Precedent uses AI to streamline and standardize administrative tasks and communication.Jim shares how AI is being used to reduce timelines for claims making their way between both industries. One of the features of the AI technology being used is extracting all the necessary information insurance carriers need from documents the legal firm provides. When it comes to this important information, the system can identify missing or incorrect information on the spot. Since it can be spotted quickly, it provides legal firms the ability to adjust and change what is needed. This ultimately limits the need for unnecessary and lengthy communication between both sides.Take a listen to learn more about Precedent!00:23 The mission of Precedent1:29 The communication problem between firms and insurance carriers13:04 The implementation of AI in streamlining injury cases17:43 Addressing the communication problemTune in to today's episode and checkout the full show notes here. Connect with Jim:WebsiteLinkedin

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Earning Respect from Insurance Carriers: Tips and Strategies

Listen To This Bull LIVE!

Play Episode Listen Later Apr 22, 2024 73:37

In this episode, we will discuss effective tips and strategies on how to earn respect from insurance carriers. Whether you are a seasoned professional or new to the industry, these insights will help you build strong relationships and gain the trust of insurance providers. Watch till the end to learn key tactics for establishing credibility and standing out in the competitive insurance market.Support the show

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Encore! EP391: A Case Study for Anyone Trying to Level Up Primary Care That I'm Gonna Call “How Margin Shoves Mission Off the Bus,” With Scott Conard, MD

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Play Episode Listen Later Apr 11, 2024 36:53

For a full transcript of this episode, click here. Here's a great musing that I read on LinkedIn: How will alternative primary care models fare when growth mode gets balanced with profitability and VC-supported burn rate is transformed to Big Retail bottom-line expectations? Mission v. margin. I'm gonna add to this: How will alternative primary care models, or even just doing good primary care, fare when it encounters the current system rife with perverse incentives of all kinds, including, yeah, for sure, Big Retail bottom-line expectations but also Big Health System and Big Payer bottom-line expectations and current business models? This show from last year was wildly popular—maybe one of our most popular shows—and relisten to it in the current context of what's going on right now in the primary care and MSO (Managed Services Only) space. Coming up, I'm gonna probably do a whole show on this if I can get my act together; but this encore is really relevant right now. One piece of podcast business before we get into the episode: Please sign up for our weekly email if you haven't already, especially if you consider yourself part of the Relentless Health Tribe. I am mentioning this not only because it's a great way to keep track of our shows because you can do an email search to remember where you heard something, since a good deal of the show intros are in the emails, but also, there's a plan afoot to hold some Zoom meetings to talk about different topics etc—and you won't be notified of such goings-on unless you're subscribed. You can unsubscribe whenever you want, by the way; and I am way too busy to send more than one email a week or spam if that was a concern. On Relentless Health Value, I don't often get into our guests' personal histories. There are a bunch of reasons for this, which, if you buy me beer, we can talk podcast philosophy and I will tell you all about my personal, very arguable opinion here. Nevertheless, in this healthcare podcast, we are going rogue; and I am talking with Scott Conard, MD, who shares his personal story. You may ask why I decided to go this route for this particular episode, and I will tell you point-blank that Dr. Conard's experience, his narrative, is like the perfect analogue (Is analogue the right word [allegory, composite example]?). His story just sums up in a nutshell what happens when a PCP (primary care provider) does the right thing, manages to improve patient care for real, and then at some point gets sucked into the intrigue and gambits and maneuvering that is, sadly, the business of healthcare in the United States today. Before we kick in, I just want to highlight a statement that Scott Conard makes toward the end of the show. He says: So, this isn't about punishing or blaming aspects of care that are being overrewarded today. It's really about what's the path forward for corporations, for middle-class Americans, and for primary care doctors who don't choose to be part of a big system. We have to figure out how to solve this problem. I hope people don't hear this and think that there are horrible people at some not-for-profit hospital systems, for example. There are some great people at not-for-profit health systems, but they have some really screwed-up incentives. A few notable notes from Dr. Scott Conard's journey and words of wisdom that I will just highlight up front here: He says that as a PCP, you actually can produce high-value care in a fee-for-service model … if you think differently and you change practice patterns. I have heard this from others as well, including most recently David Muhlestein, PhD, JD, who says this in an episode (EP393). As Dr. Scott Conard says later in this episode, healthcare organizations must embrace the art of medical leadership. So, I guess that's a spoiler alert there. Another point that Dr. Conard makes very crisply toward the end of the show is that doctors can kinda get pushed and pulled around in this mix. You have docs just trying to provide good care, and they work for one entity that gets bought and now it's some other entity … and what's happening upstairs and the prices being charged or somebody somewhere deciding not to make prices transparent, or deciding to sue low-income patients for unpaid medical bills or what charity care to offer or not to offer. These are not doctors in clinics making these calls, and we need to be careful here not to homogenize what some of these health systems are choosing to do like some kind of democratic vote was taken by everybody who works there. Health systems, hospitals, are many-celled complex entities. And a third takeaway—there are a bunch of takeaways in this show, but a third one I'll highlight here from Dr. Conard's story—is the old fiduciary responsibility code word being used by health system administrators as a euphemism for strategies that might need a euphemistic code word because the strategy has questionable community benefit. In the case study that we talk about today, the local health system managed to raise healthcare spend in North Texas by $100 million year over year. Employers and employees in North Texas communities wound up paying $100 million more year over year in healthcare one particular year. This was prices going up. It also was removing a big systemic initiative to keep heads out of hospital beds. Reiterating here, we are not talking about doctors here particularly because, of course, the vast majority of doctors are trying to prevent avoidable hospitalizations. But suddenly in North Texas, physicians did not have the population health efforts and the team really standing behind them helping to prevent avoidable hospitalizations. That sucks for everybody trying to do the right thing, and, as has been said, burnout is moral injury in a cheap Halloween costume. Moral injury happens when you have good people, clinicians, doctors, and others who realize that what is going on, at best, is not helping the patient. Also mentioned in this episode are Benjamin Schwartz, MD, MBA; David Muhlestein, PhD, JD; Brian Klepper, PhD; Al Lewis; Robert Pearl, MD; Karen Root, MBA, CCXP; and Wendell Potter. You can learn more by emailing Dr. Conard at scott.conard@converginghealth.com. Scott Conard, MD, DABFP, FAAFM, is board certified in family and integrative medicine and has been seeing patients for more than 35 years. He was an associate clinical professor at the University of Texas Health Science Center at Dallas for 21 years. He has been the principal investigator in more than 60 clinical trials, written many articles, and published five books on health, well-being, leadership, and empowerment. Starting as a solo practitioner, he grew his medical practice to more than 510 clinicians over the next 20 years. In its final form, the practice was a value-based integrated delivery network that reduced the cost of care dramatically through prevention and proactive engagement. When this was acquired by a hospital system, he became the chief medical officer for a brokerage/consulting firm and an innovation lab for effective health risk–reducing interventions. Today, he is co-founder of Converging Health, LLC, a technology-empowered consulting and services company working with at-risk entities like self-insured corporations, medical groups and accountable care organizations taking financial risk, and insurance captives to improve well-being, reduce costs, and improve the members' experience. Through Dr. Conard's work with a variety of organizations and companies, he understands that every organization has a unique culture and needs. It is his ability to find opportunities and customize solutions that delivers success through improved health and lower costs for his clients. 06:54 What triggered Scott's career journey? 07:31 What caused Scott to rethink what is good primary care? 08:11 Why did Scott realize that he is actually a risk-management expert as a primary care doctor rather than someone who treats symptoms? 09:25 EP335 with Brian Klepper, PhD. 09:53 How did Scott's practice change after this realization? 10:04 What is a “Whole-Person Risk Score”? 11:08 Scott's book, The Seven Numbers (That Will Save Your Life). 13:05 “You start to move from a transactional model to a relationship model.” 15:31 Did Scott have any risk-based contracts? 16:08 Why is it so important to look at total cost of care and not just primary care cost? 21:08 Scott's book, The Art of Medical Leadership. 22:13 EP381 with Karen Root. 30:43 Why did Scott move over to help corporations? 33:10 EP364 with David Muhlestein, PhD, JD. 33:51 “Everybody thought they were honoring their fiduciary responsibility, and the incentives are completely misaligned.” 34:31 EP384 with Wendell Potter. 34:43 “It's the system that's broken; it's not bad people.” You can learn more by emailing Dr. Conard at scott.conard@converginghealth.com. @ScottConardMD discusses #primarycare #marginvsmission on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Jerry Durham, Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen

Diplomacy: Building, Strengthening, and Repairing Carrier Relationships

IA Forward

Play Episode Listen Later Apr 8, 2024 26:41 Transcription Available

Shane and Tonya discuss building, strengthening, and repairing relationships with insurance carriers.IA Forward to can help you take your agency from good to great. Learn more at iaforward.com, and follow IA Forward on LinkedIn, Facebook, and Instagram.

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229. The Fascinating Impact of a Hard Market on Insurance Carriers w/ Curtis Goldsborough

The Ryan Hanley Show

Play Episode Listen Later Feb 15, 2024 56:51

Our latest episode takes a whimsical turn with the LinkedIn meme master, Curtis Goldsborough, who's cracking the serious facade of the insurance industry. ✅ Join the Insurance Growth Masterclass: https://masterclass.insure ✅ For daily insights and ideas on peak performance: https://www.instagram.com/ryan_hanley/ ✅ Hire me to speak at your next event: https://ryanhanley.com/speaking

229. The Fascinating Impact of a Hard Market on Insurance Carriers w/ Curtis Goldsborough

The Ryan Hanley Show

Play Episode Listen Later Feb 15, 2024 58:10

Our latest episode takes a whimsical turn with the LinkedIn meme master, Curtis Goldsborough, who's cracking the serious facade of the insurance industry. ✅ Join the Insurance Growth Masterclass: https://masterclass.insure✅ For daily insights and ideas on peak performance: https://www.instagram.com/ryan_hanley/✅ Hire me to speak at your next event: https://ryanhanley.com/speaking

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Advanced Medical Strategies - Stacy Borans - Founder of AMS

Self-Funded With Spencer

Play Episode Listen Later Dec 19, 2023 62:29

Advanced Medical Strategies - Stacy Borans - Founder of AMS Stacy Borans is a seasoned expert in healthcare technology and data analysis, with a robust background in medical cost management. As a key player at Advanced Medical Strategies (AMS), she has been instrumental in developing software solutions for payment accuracy, risk assessment, and business intelligence in the healthcare industry. Her perspective on healthcare technology and data analysis in medical cost management is shaped by her experiences at AMS, where she noticed excessively high bills during medical reviews and saw an opportunity to work on the financial aspect of cost management. Stacy advocates for transparency in chargemaster pricing and cash pricing, and emphasizes the importance of reference-based pricing. She believes that these strategies can help determine the relevant charge for medical services, although she acknowledges that it may not always result in the lowest price. Join Spencer Smith and Stacy Borans as they delve deeper into this topic on the next episode of the Self Funded podcast. Chapters: 00:01:08 Creative cocktail concoctions 00:06:46 AMS: Innovating Healthcare Management Solutions 00:10:43 Understanding the Financial Impact of Self Funding 00:16:21 Shaping the Future of Healthcare Cost Containment 00:21:13 Healthcare Solutions for Complex Medical Cases 00:27:24 Catastrophic Diagnoses Cost Projections Software 00:33:09 Comprehensive Risk Assessment and Pricing Tool 00:40:38 Achieving Transparency in Healthcare Decision-Making 00:46:32 Analyzing Group Risk Profiles Using Census Data 00:56:26 The Impact of AI on Healthcare Diagnoses Key Links for Social Self-Funded's Channel - https://www.youtube.com/ @SelfFunded Listen on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Listen on Spotify for Podcasters - https://podcasters.spotify.com/pod/show/spencer-harlan-smith Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/ Key Words: Medical Strategies, Claims Strategies, Data Analytics, Business Intelligence, Business Intelligence Software, BI Software, Claims Analytics, Insurtech Software, Software for Underwriters, Systems for Carriers, Software for Insurance Carriers, Technology for Insurance, Technology for Insurance Brokers, Tech for Insurance Consultants, Tech for Healthcare, Software for Doctors, Software for Third Party Administrators --- Support this podcast: https://podcasters.spotify.com/pod/show/spencer-harlan-smith/support

Advanced Medical Strategies - Stacy Borans - Founder of AMS

Self-Funded With Spencer

Play Episode Listen Later Dec 19, 2023 62:29

Unfiltered Stories | P&C Insurance Carriers: Have you revisited your target operating model in the era of prompt engineering?

HFS PODCASTS

Play Episode Listen Later Nov 28, 2023 23:06

In this HFS Videocast, HFS' Reetika Fleming has a candid conversation with Xceedence CEO Arun Balakrishnan on the market dynamics in P&C insurance, how to reframe target operating model considerations in light of GenAI and technology advancements, and the changing nature of service providers to support the journey.

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EP417: 5 Kinds of Payer and Provider Collaborations and 5 Must-Haves for Said Collaborations to Work, With Josh Berlin, JD

The GloucesterCast Podcast – Good Morning Gloucester

Play Episode Listen Later Nov 2, 2023 33:43

Yeah, it's a fact that the vast majority of past and present provider and payer relationships are not exactly collaborative. They may better be described as fairly adversarial, actually—especially when viewed through the lens of provider organizations trying really hard to find a payment model that will enable them to do better by their patients and deliver better outcomes. We've had Justina Lehman (EP414), Ali Ucar (EP362), Dan O'Neill (EP359) talking about this from the provider organization standpoint. We also had Dan Serrano (EP410) and Will Shrank, MD (EP413) corroborating here. But after each of these earlier episodes, many comments and conversations ensued about said potential (or not) payer/provider collaborations. And there was a theme of many of these online exchanges. The theme was wondering if we'd all get laughed at for even talking about these rare and elusive Shangri-la scenarios. Like expending words and energy thinking about payers and providers working together was as crazy as being seen earnestly discussing, I don't know, whether mermaids know about pants or something. And that's why I wanted to get Josh Berlin on the podcast today: to talk about the why, the what, and the how of collaboration. I wanted to know if there really is a solid why here for the why collaborate, especially from a payer point of view. And when I say payer, I mean a payer kind of payer like a Blue Cross, United, Cigna, Aetna plan kind of payer. And I'm calling that out because payers are intermediaries in all cases except for their fully insured members. Except for that one book of business, entities actually taking the risk are taxpayers or self-insured employers. So, saving money on its face is not a super compelling value proposition. Listen to the show with David Contorno (EP339) for the why there. As we talk about in the interview that follows, though, what might be compelling is predictable spend, possibly—or even more compelling could be a competitive differentiation for that payer that leads to higher market share. Payer/provider collaborations can also lead to a more resilient market foothold that can stand up to threats from upstart competitors or big tech and big retail swooping in looking for a tasty slice of this $3 trillion industry. There's also the potential for a higher profit margin. And, oh, one additional reason to collaborate if you're a payer that we don't get into super heavily but I'd be remiss to not mention is the whole Star Ratings thing for Medicare Advantage plans, because stars equal big money. But a payer is not gonna get that Star Rating shekel if providers aren't delivering high enough quality care. Also, of course, we have HEDIS (Healthcare Effectiveness Data and Information Set) and other quality measures that have financial value ascribed to them. In the conversation that follows, Josh talks about different types of collaborations. Collaboration is a really very vague term, so what exactly is this collaboration, what does it entail, and how do you do it? Josh told me that there are five kinds of collaboration, and here they are in order of their depth of entanglement, I guess you could call it. 1. Sharing data back and forth 2. Use that data to identify areas of need and then do something programmatic together, like create clinical pathways or work on one very specific type of quality program. 3. A joint venture (JV)—you JV and work together on some sort of narrow network kind of product 4. Become capital partners in some way. 5. Having a risk-bearing kind of relationship—the provider gets a piece of the premium dollar So, that's the five types of collaboration. But here's the things you've got to tick through, that you have to really go through and make sure you've got all these things before you start. Otherwise, it'll be a monumental waste of time. 1. Complementary capabilities that enable scalability 2. A desire for sustainability in a market, and both have common goals and objectives and an agreed-upon time horizon 3. Both parties need to be pretty flexible. Rigid products have a shelf life. You've got to be willing to advance with market dynamics flexibly—know how to iterate around whatever it is you're doing. 4. Excel at collaboration. If you're going to collaborate, you have to know how to collaborate. And that's a cultural thing. 5. Compatible risk profiles—this means not just “taking risk” but knowing how to do it in a way that will work and navigating around things that could cause trouble when moving from fee for service to a more capitated way of going about things. Josh talks about some of them. Just to loop back around on #4 there, because … yeah, to collaborate, you need to collaborate. I call Josh out on this one, and he reiterates that … yeah, nothing to take for granted here. It might seem obvious, but it's so frequently an internal unknown unknown—at a lot of payers especially. I mean, if I'm a provider organization and you force me to only communicate with you through snail mail (ie, postage stamp, letter box, the whole nine), I don't know, I'd kind of get the vibe that I'm being enthusiastically ignored, which I just cannot square with a collaborative spirit of any kind. Josh Berlin is a founding partner of Rule of Three, which is a consulting firm. Rule of Three has clients that are physician practices, hospitals, health systems on the traditional side; and they also work with nontraditional organizations like Walmart Health and Wellness. They also work with payers, like regional blues and employer plans. You can learn more at Rule of Three and by connecting with them on LinkedIn. Josh M. Berlin, JD, is CEO of Rule of Three, LLC, with more than 25 years of experience, most of which has been in healthcare advisory in service to his clients. Most recently, he has served as principal and co-practice leader of Citrin Cooperman's Healthcare Practice and managing partner for IBM Watson Health's Strategic Advisory Practice, leading a unique group of consultants in each instance to serve clients across the full healthcare ecosystem (providers, payers, employers, governments, advocacy, etc). Prior to those roles, Josh served as a principal in the healthcare consulting practice at Dixon Hughes Goodman (now FORVIS), helping to lead their strategy consulting business, and served as a leader in all versions of KPMG (KPMG Consulting/BearingPoint and KPMG). Currently, he serves on the Boards of the Validation Institute, Population Health Management journal, and HealthTrackRx. Josh's expertise spans both the consulting and healthcare industries. Some of his clients have included the Hospital Corporation of America, the Department of Health and Human Services (including the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services), various pediatric health systems, the National Association for Healthcare Quality, Nebraska Medicine, Penn Medicine, the Ochsner Health System/Network, the BJC Collaborative, and The Leapfrog Group, as well as a variety of other healthcare organizations. Josh has developed long-standing client relationships at all levels of organizations, notably including some of the most prestigious C-suite executives in healthcare today. 06:06 Why should payers want to collaborate with providers? 09:46 “Collaboration … is bilateral. … Both sides, plan and provider, should be equally as interactive with the individual populations they work with.” 12:37 What are the must-haves for collaboration between providers and payers? 13:10 What are the five different types of collaboration? 16:03 What are the five characteristics you want to be focused on in partnership? 21:35 EP359 with Dan O'Neill. 22:16 In order to collaborate, do you have to be collaborative? 26:11 Ochsner as a great example of collaboration. 27:46 Episodes with David Carmouche, MD, and Eric Gallagher. 28:51 A collaboration failure in Haven. You can learn more at Rule of Three and by connecting with them on LinkedIn. Josh M. Berlin of Rule of Three, LLC, discusses #payer and #provider #collaboration on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #healthcare Recent past interviews: Click a guest's name for their latest RHV episode! Dr Adam Brown, Rob Andrews, Justina Lehman, Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6)

Gloucester Homeowners Insurance Solutions With Brandon Pratt 9/30/23 Some insurance Carriers are pulling out of Gloucester- Here are your options:

Play Episode Listen Later Sep 30, 2023

Gloucester Homeowners Insurance Solutions With Brandon Pratt 9/30/23 Contact Brandon at brandonpratt@worldinsurance.com Link to join here- www.facebook.com/goodmorninggloucester Press play to listen (audio)- Press play to watch and listen (video)- When you subscribe you need to verify your email address so they know we're not sending you spam and that you want to receive the podcast … Continue reading Gloucester Homeowners Insurance Solutions With Brandon Pratt 9/30/23 Some insurance Carriers are pulling out of Gloucester- Here are your options: →

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Why do hospitals charge private insurance carriers 250% more than Medicare for the same procedures?

America's Healthcare Advocate

Play Episode Listen Later Sep 9, 2023 39:11

This week our guest Terri Raimondi joins host Cary Hall for a revealing look into the high cost of health insurance and why its so high. Our experts tell all and you're going to learn where is the money going (and guess who pays for it)? Cary Hall: "You know, they always say, follow the money. We're going to help you follow the money. And we're going to have that discussion about national health care and how it works. And why is it the Europeans spend less on health care and than we do. We're going to talk about all those things today with this national expert Terri Raimondi here in the AHA studio with me". We will explain Self-Funded Health Insurance Programs, Employer Self-Funded Health Insurance Plans and tell you what BUCA plans are and what a Third Party Administrator does. Episode 1928 Lean more, contact Terri Raimondi: terriraimondi@me.com Got a show idea? Contact Cary Hall: https://www.americashealthcareadvocate.com/contact-us

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Should You Not Give Employees the Benefit Design They Think They Want? With Lauren Vela—Summer Shorts 6

Listen To This Bull LIVE!

Play Episode Listen Later Aug 24, 2023 9:03

Lauren Vela is back on the pod today with a summer short that originally was a section of episode 406 that, unfortunately, I had to cut. It was a little bit tangential to the “why with the employer inertia” theme that the original episode was about. But tangential does not mean unimportant. This clip has some really critical insights on a different topic that may or may not to a greater or lesser degree contribute to inertia. And I'm gonna call this other topic the benefit design that most employees might ultimately be the most satisfied with might not be the one that they are explicitly asking for. Let's start with three kinds of market research insights that Lauren Vela, my guest in this healthcare podcast, uncovered when interviewing friends and neighbors not in the healthcare industry about their benefits: 1. Nobody reads their benefit information. 2. They are unhappy with their benefits. 3. The most important thing for them is to have choice. They want to avoid the notion of “managed care.” In thinking about this, I was reminded of a Henry Ford quote: “If I asked my customers what they wanted, they would have told me a faster horse.” Or Steve Jobs famously said, “Some people say, ‘Give the customers what they want.' But that's not my approach. Our job is to figure out what they're going to want before they do.” Jobs's whole thing, after all, was that true innovation often comes from anticipating customer needs and desires before they can articulate them themselves. So, let me reconcile Lauren's findings when she interviewed people about what they want in their benefits and what Henry Ford and Steve Jobs have to say about the matter. First of all, patients/plan members—most people have never experienced a comprehensive primary care situation where they are assisted in finding the highest-quality specialists or sub-specialists and have their care coordinated. They have never had someone worrying about them in their “in-between spaces,” as Amy Scanlan, MD (EP402), put it, between appointments. This is all just a fantasy. It is a reputed Shangri-la that almost no one has ever seen with their own two eyes. But what many have seen—I have; you have—are narrow networks in which cost containment is wielded like a brute-force weapon, where, for example, the NCI-designated cancer centers are out of network as a way to make sure that people with cancer don't sign up for your plan … or don't last long on your plan if they do. (Did I say that out loud?) Do I sound like I suffer from a brutal lack of trust? Yes, I do—and I was just role-playing there an employee probably pretty accurately. Most of us remember the HMO a-go-go years when your PCP was an administrative gatekeeper and you had to see them to get a specialist appointment—except you never could see them. Wait times were weeks or months, obviously by design, right? But this way-too-expensive PPO model is the devil I know because, even if it totally sucks, it's better than the conspiracy theories and/or accurate or exaggerated recollections of other options. Here are my recommended next steps. Listen to the shows with Vivek Garg, MD, MBA (EP407), and Scott Conard, MD (EP391), and Douglas Eby, MD (EP312), as a start. All three make it really clear that advanced primary care—maybe even direct primary care—can not only save money, but it also can produce better health and patients are super happy and usually clinicians, too. It's like a quadruple aim home run. But none of this can happen if we say “integrated care or advanced primary care and you have to go there to get a referral” and then leave whatever that means up to employees' or plan members' imaginations. Communication is really required here, as it is when rolling out most new things—not just cars or cellular telephones. You can learn more about Lauren's work by connecting with her on LinkedIn. Lauren Vela is a passionate advocate for a more rational and sustainable healthcare system and recognizes the influence had by employers and other commercial purchasers through their oversight of employer-sponsored insurance plans. As an independent consultant, she partners with entities that are committed to changing the ineffective status quo. Previously, Lauren was the director of health care transformation with Walmart, where she partnered with the Walmart Benefits team to identify solutions concerning low-value care, site of care, and vendor evaluation. Prior to her tenure at Walmart, Lauren led market strategy and member initiatives for the Purchaser Business Group on Health, where she cumulatively spent two decades working within various healthcare sectors, including health information technology, provider organizations, and pharmacy benefit management. Lauren also served, for seven years, as the executive director of the Silicon Valley Employers Forum, a trade association of high-tech employers collaborating on innovative delivery of both domestic and international benefits. The cartoon. The decisions commercially insured employees across the country are truly facing … ©Dan Piraro 05:15 Do employees really understand what it means to have integrated care? 06:57 Why employees want choice and avoid the notion of managed care. 07:15 “I'm not sure that Americans really know what would be better.” 07:19 What would be a better way to do integrated primary care in America? 08:04 How do you fix it without disrupting what everyone thinks would be better? You can learn more about Lauren's work by connecting with her on LinkedIn. @laurenvela1 discusses #employeebenefitdesign on our #healthcarepodcast. #healthcare #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance Recent past interviews: Click a guest's name for their latest RHV episode! Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon

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BreakingBull: ASTM Definitions Manipulated to Suit Insurance Carriers?

Play Episode Listen Later Aug 15, 2023 18:20

Are the ASTM Definitions being manipulated to suit insurance carriers? A concerted effort to change some definitions for use in the ICC building codes has been happening for a number of years. We have copies of those definitions. Is it innocuous, or is this an effort to reduce coverage in insurance policies without reducing premiums? We'll let you decide.Support the show

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EP410: The Imperative and a 201-Level Financial How-To for Payers and Provider Organizations to Collaborate to Help CKD Patients and Others With Chronic Conditions, With Dan Serrano

Construction + Small Business Marketing: It's a Code World:

Play Episode Listen Later Aug 3, 2023 34:13

In this healthcare podcast, I am talking with Dan Serrano; and we're talking about payer/provider collaboration—blocking and tackling, I'm gonna say—from primarily a financial and revenue point of view. I'd classify this as, say, a 201-level discussion (ie, not entry level, but it's also not super deep in the weeds). We mainly cover the ins and outs of why a provider organization should probably be looking to get paid to better take care of patients with chronic disease and drive better patient outcomes at lower downstream costs and, to some degree, also why payers should be helping provider organizations in their local communities to do so by providing some help and shelter on the journey from here to a capitated payment. The focus today is really, I'd have to say, on the messy middle, where a provider organization does not have capitated contracts nor access to any premium dollars, which, by all accounts, is the holy grail here. The premium is where it's at, and provider organizations might want to be aiming to get a piece of that action. The why for this “get the premium dollar” prime directive is pretty self-evident when you look at the big bucks rolling around in the coffers of those who are collecting said premium dollars. So, this “get the premium” endgame is, for sure, a big piece of the why—why, if I am a provider organization, I might want to take the time and energy and spend the money to embark on a path that might lead me to be able to get compensated for the stuff that patients really want and need to do better, which includes all of the things that I spoke about with Eric Gallagher in episode 405. Also, Vivek Garg, MD, MBA, in episode 407 and Amy Scanlan, MD, in episode 402. Spoiler alert: It's not easy. Now, I asked Dan Serrano, as aforementioned my guest today, to offer up his advice here in the context of CKD (chronic kidney disease) patients. Why did I ask Dan to use the CKD case study, as a touchstone? Well, first of all, talking about this topic in totally theoretical terms is not ideal. We need an actual example for a lot of this to kind of make sense, combined with the first step for most outcomes improvement programs, which is to study your data and pick a patient population to focus on where the data suggests that you can have a big impact. And speaking of impact, did you know that an underlying reason why heart failure patients get hospitalized and rehospitalized is because of underlying CKD? So, impact in the short term and longer term, which I'll get to in a sec. Another reason is—and I'm quoting John Rodis, MD, MBA, here, who is the independent medical director of QC-Health®—Dr. Rodis said the other day, “I sure as heck hope I don't get CKD, because if I do, chances are I'm not going to be diagnosed. And even if I am diagnosed, I won't be treated properly.” So, there's that. And I can see why he's saying that. Two out of five patients with ESRD (end-stage renal disease) don't even know they have kidney disease at all. And the number of patients with progressing CKD on any kind of evidence-based treatment plan is stunningly low. But also, here's another reason I asked Dan Serrano to talk about CKD patient populations specifically as his example: I and Dr. Rodis and the team at QC-Health are not the only ones who have figured out that CKD patients are notoriously expensive and way underdiagnosed. You know who else has figured this out? Payers. Also, private equity. In fact, I was in a meeting with a payer recently, and they stated they had to get CKD patients into point solutions. This payer—and I've heard of others, too—none of these entities are waiting around. And I guess, fair enough, if you look at some of the population health data, that I'm sure these payers and others are looking at. But if you work for a payer and you're listening right now, what I would say, “Okay, with the point solutions, one that you have carefully vetted, of course, because we have patients suffering right now and dollars being frittered away right now.” But I also would submit that those point solutions will perform a whole lot better if we are all gunning for synergies. PCPs (primary care physicians) and traditional FFS (fee-for-service) models in this country need your help. The payment models and admin burden are decimating. Payers certainly are a group with some culpability here. (Sorry to be saying the quiet part out loud.) Instead of forgoing them, please help PCPs. Am I saying be altruistic? Actually, no. Listen to episode 409 with Larry Bauer or episode 391 with Scott Conard, MD, or an upcoming show with Jodilyn Owen and what you will hear is the amazing ability for clinicians rooted in the community to actually drive change in their local markets. In fact, I'd hypothesize that these community-rooted organizations probably have a better track record for actually moving the needle on patient outcomes than any snazzy tech that I have seen, although I am sure that there are one or two very effective snazzy techs out there—the exception proves the rule and all that. Bottom line: As I do so often, I am advocating for payers and provider organizations within communities to collaborate, regardless of whether there's a third party also in the mix. I am reporting all of this in the spirit of being helpful but also with some degree of urgency for any care delivery organization because, I mean, really, forget about the holy grail of trying to capture a percentage of the premium if the money is already going elsewhere to too many point solutions who are already capturing a portion of the premium. IRL, this is what's already going on out there. But where there's a challenge, there is also opportunity. As I have said pretty repeatedly for the past four minutes, because the bar is so low and because CKD patient outcomes are bad news, in general, from a lot of angles, CKD is actually a great place for providers to work hard to improve care and quality. From a financial standpoint, I think there's also a great business case for payers to help provider organizations do so. Doing better than the local standard of care is not hard, sadly. And what that means is that there's so much money that's possible to save due to the expense of this condition. And if you're a payer, even a payer with a third-party CKD solution, if you can help local PCPs and others level up their care, then either you don't have to pay for the third-party point solution for patients who can be managed successfully locally and/or there's a more frictionless path for those patients to be identified and get into the point solutions that are available to them. Let's all keep in mind that patients at rising risk are falling through a lot of cracks. You can have the best point solution in the world, but if patients aren't making it there, then, yeah, no outcomes will improve. No costs will be reduced. Everything I just went through are also all of the reasons why we picked CKD as our focus for a national Groundswell Movement™ that the benefit corp I am co-president of is kicking off to improve CKD patient outcomes. If you are also thinking about improving CKD patient outcomes, for sure, hit me up. On to a few thank yous. Thank you so much to Carl Hansen, MD, a direct primary care physician, for a really generous tip in our tip jar. Also, thanks so much to Keith Passwater, who is CEO of Havarti Risk Services and Pasco Advisers, for a really nice donation to the cause over here. It was such an honor and a pleasure to moderate a panel at the Society of Actuaries' latest meeting at Keith's invitation also. Additionally, may I extend thanks to Dffdgg, RKC2023, and Healthy economist for super nice iTunes reviews. The shout-outs are amazing, especially when public like this. Also much appreciated how you have shared Relentless Health Value with your colleagues. Back on track, let's hear from Dan Serrano, who is a consultant with COPE Health Solutions, where he works to help clients figure out the best way to make investments that drive better outcomes in a more cost-efficient way. You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com. Dan Serrano joined COPE Health Solutions in September 2022 as principal and senior vice president. He supports Analytics for Risk Contracting (ARC) finance build and cost models in terms of drive and delivery with Great Lakes Integrated Network (GLIN). He is a seasoned healthcare/finance professional with 20+ years' experience and has held a number of roles across the industry and has primarily served as a senior finance leader with proven ability to drive strategy development and execution across multiple business lines for complex organizations in various stages of maturity. Prior to COPE Health Solutions, Dan served as senior vice president of finance at CareAbout, a private equity–backed start-up focused on driving performance for primary care physicians. He also was the vice president of value- and risk-based contracting at Mount Sinai Health System, where he worked to align contracting, operational performance, and network strategy for employed and voluntary physician groups. Prior to his role at Mount Sinai, Dan served as vice president of commercial products at Healthfirst, market chief financial officer at ChenMed, and Mid-Atlantic Region chief financial officer at Aetna, where he focused on driving strategic financial decisions by analyzing the value drivers for each of the stakeholders across the industry. Dan holds a bachelor's degree in finance from the Peter J. Tobin College of Business at St. John's University. 09:08 What is the importance of payer/provider partnerships in reducing costs with chronic condition care? 10:52 Josh Berlin, JD, of rule of three; look out for his episode in a few weeks. 11:19 What's the endgame here with this payer/provider collaboration? 11:43 What advice does Dan have for providers who want to do better by patients with chronic conditions? 15:11 Who's driving costs in the system? 15:50 Why is lowering the average cost of chronic condition care important? 17:03 Why is there a meaningful delta between well-controlled CKD patients and those who aren't well managed or identified? 21:57 What does a realistic time horizon look like for addressing chronic condition care? 22:38 Why is it important to start in a shared savings place? 25:25 William Shrank, MD, of Andreessen Horowitz; look out for his episode in the fall. 26:35 Financially, what is the goal and how are we achieving a sustainable goal? 29:06 What is the balance between progress and risk here? You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com. Dan Serrano of @COPEHS discusses #chronicconditions and #payer #provider #collaboration on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249)

Why Insurance Carriers Do What They Do w/ Reggie Brock

Play Episode Listen Later Jul 30, 2023 35:12

Reggie Brock joined the Hook Better Leads Podcast to discuss hostility in the roofing industry, roofing claims fights, the history of insurance and more! He also spoke to the Hook team about personal development which we are grateful for!Find more about Reggie at https://www.reggiebrock.com/ See more from us at: https://hookagency.com/ & @HookAgency on all socials.

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Hitting the Hard Market Panic Button

IA Forward

Play Episode Listen Later Jul 13, 2023 25:50

Are you starting to hit the panic button in this hard market? Shane and Tonya discuss options to keep your agency afloat as the changes keep happening.Learn more at iaforward.com and follow IA Forward on LinkedIn, Facebook, and Instagram.

market insurance panic hitting life insurance health insurance integra panic button insurance carriers independent insurance agency independent insurance agent

Encore! EP365: The Real Deal With PBM Contracts and Drug Rebates, With Scott Haas

Play Episode Listen Later Jun 22, 2023 33:05

I hope you enjoy this encore episode of one of the most popular shows in the last 12 months. One of my mentors often said price is irrelevant. He said he would sell anything for any price as long as he could define the terms of the deal. During this conversation today with Scott Haas about PBMs (pharmacy benefit managers), that quote was playing in my head like an earworm. I'm henceforth gonna struggle with the term rebate to define dollars that the PBM gets back from Pharma, because, according to my guest in this healthcare podcast Scott Haas, it turns out “rebates” comprise only about 40% of those back-end dollars that some PBMs manage to score from pharma manufacturers. I don't have any insight really into this, but Scott Haas certainly does—and this is the average that he has seen in his work and that we're going to dig into today. But in sum … wow! Let me just repeat that a mere 40 cents on the dollar of the gross amount that PBMs take in “rebates” from Pharma these days winds up going back to plan sponsors, even plan sponsors who are getting “100% of the rebates.” If you didn't understand what I just said, no worries. I'm gonna explain it right now. If you did and you know the why behind all of this also, you could probably skip ahead about five minutes. Here's the backstory on this whole rebate fandango. Let's start with part one of what is a two-part transaction. So, part one: the deal between pharma manufacturers and PBMs. In general, a pharma manufacturer signs a deal with a PBM to give back whatever percentage of their gross sales revenue to the PBM at the end of the year, say. It's along the same lines as a cash-back coupon for the PBM. Why would a pharma company be up for giving cash back like this? Well, to get on a PBM's formulary, giving cash back is like the price of admission. PBMs have a lot of leverage, after all—at least the big ones. They control access to millions and millions of patient lives. So, if Pharma wants their drug to be accessible to those millions and millions of lives, they have to play the cash-back game, otherwise known as the rebate game. They have to agree to give back to the PBM a certain amount of cash on the back end. So, PBM pays Pharma's list price up front—that's the gross amount paid, based on the list price of the drug—and then after all the cash back gets toted up at the end of the year, there'll be a net price. List price or gross price minus the cash back equals net price. It's this net price that's the true kind of final price which the pharma company gets paid per script by said PBM at the end of the day. These days, most everybody pretty much knows that PBMs are getting these so-called rebates—this cash back from pharma companies that I just explained. And it's pretty common knowledge the so-called gross-to-net bubble (the gross-to-net dollar amount) is pretty huge, meaning the rebate or cash-back amount is pretty huge. And many have also noticed that the gross-to-net dollar amounts seem to be growing bigger and bigger every year. I mean, for one insulin manufacturer, consider this: Their list price, their gross price, is $350 per script. And their net price after cash back/rebates was $52 this past year. Wait ... what? After all the cash back to the PBM, the insulin manufacturer got paid 86% less than their list price—$350 went down to $52 per prescription. The PBM vacuumed up 86% of the dough for every script written for this particular brand of insulin. Okay … so, say Pharma gives $100 back to the PBM based on the terms of their deal. Call that part one of this example transaction. Here's part two: the deal between PBMs and health plans or self-insured employers. Health plans and self-insured employers are customers of the PBM. They hire PBMs to manage the pharmacy benefits for their members or employees. So, because everybody knows this whole rebate thing is going on, as part of the contracts that the PBMs put in place with their customers (meaning the health plans or employers), the PBMs tell their customers that they're going to give 100% of the rebates back to the plan/employer. So, you'd think that if the pharma manufacturer paid $100 to the PBM, that the customers of the PBM (the plan sponsors) would get the $100 back then, right? The PBM would pass on 100% of the savings, as it were, if they're saying that they're gonna give 100% of the rebates. I mean, if this is actually true, that $100 in and $100 out, then the PBM is potentially performing a useful service, right? They're lowering drug costs for their customer, the plan sponsors for their members and employees. Except … turns out, not so much. Because what is a rebate, really? A rebate can be anything the PBM defines as a rebate. And it turns out that, on average, as I said before, according to those in the know, something like $60 of that $100 is not a rebate. It's an administration fee. Or a data fee. Or an education fee. A clinical program fee. Some other name that is not rebate. As my guest Scott Haas says, the term rebate is meaningless because it can mean whatever the PBM wants it to mean. It's like inconceivable from The Princess Bride. I do not think that word rebate means what you think it means. Now it is a tangled web we weave here, and for more on why I say that, listen to the episode with Chris Sloan (Encore! EP216) entitled “How Medicare Part D Plans Became Addicted to Drug Rebates.” There's also a show with Pramod John, PhD (EP353) where we dig into, specifically, specialty drugs and rebating and so-called rebate walls. But net net, all of this probably myopic focus on rebates means that you have to keep an eagle eye out for so-called exclusions in contracts if you are a plan sponsor. So, what are exclusions? This is that whole thing where some cheap generic is excluded from a PBM formulary while some expensive brand for the same condition is on formulary. Why would a cheap generic be excluded from a PBM formulary? Simple. Cheap generics don't have rebates. PBMs lose a lot of money when some high-priced specialty drug, for example, goes generic. They might have made thousands of dollars per script on that high-priced brand by collecting its rebate. Think about that insulin example. The rebate is 86% of the cost of the drug. And everybody wonders why some cheap generic insulin or biosimilar or whatever isn't on formulary. It is not a mystery when you're dealing with for-profit enterprises built around a model of revenue maximization. So, given all this, what's my guest Scott Haas's bottom-line advice in this whole thing? If you're a health plan or employer and you're trying to negotiate a PBM contract where your spend is predictable and your contracted price promises have any meaning whatsoever, Scott Haas's advice is, you have to ensure that the contract defines the actual prices for the drugs in the contract. With absolute numbers. Not percentages off or weird formulas or the empty promise of getting an AWP or a WAC (which means average wholesale price or wholesale acquisition cost) or any of the other various acronyms for some drug pricing schema. All of these are basically shorthand for “this price could change at any moment.” There's a reason in-the-know people say AWP stands for “Ain't what's paid,” meaning ain't what's ultimately going to be paid by plan sponsors. What is necessary in PBM contracts is the final price—that number. Some digits with a dollar sign in front of them and a “per unit” after them. No acronyms and no percentage signs. Whoever gets to define the terms ultimately controls the price. So, get the price up front. As mentioned several times already, I am talking to Scott Haas, who is a senior VP over at USI Insurance Services. He's speaking today from the perspective of a plan sponsor, meaning from the point of view of a health plan, including those health plans managed by and paid for by a self-insured employer and their employees. For more information on PBMs and how drugs get adjudicated, listen to the show with AJ Loiacono (Encore! EP231), which was one of the most popular episodes over here at Relentless Health Value. Somebody on a LinkedIn post the other day commented on how much she appreciated AJ Loiacono's frank assessment of things and how she would love to go to a meeting with more people similarly telling it like it is. That's pretty much what we aim to do at every episode over here at Relentless Health Value, and AJ nails it on that objective for sure in this episode. One last thing, also on the show: Scott Haas brings up GPOs that the Big Three PBMs have been spinning up to aggregate and maximize all of those rebates that we just talked about. I discuss this exact topic at some length in another incredibly popular episode with Mike Schneider (Encore! EP288). You can learn more at usi.com or by emailing Scott at scott.haas@usi.com. Scott Haas has over 38 years of employee benefits experience. His background includes the development and validation of care management programs; prescription benefit management solutions; provider network evaluation, valuation, and negotiation; and underwriting. Scott started and operationalized a third-party administrator (TPA) and a pharmacy benefit manager platform from scratch. He has worked in the arena of alternative funding for most of his career. Scott's primary focus is in the area of alternative delivery and financing of healthcare other than fee for service, along with prescription benefit and healthcare risk management consulting. Scott has held officer-level positions within Blues plans and TPAs as vice president of sales and marketing, vice president of underwriting, and president. Scott has also served as a trustee for both union and non-union health and welfare and pension plans. Scott frequently shares his consulting expertise speaking at national events hosted by organizations such as Health Rosetta, the International Foundation of Employee Benefits, the Health and Welfare Plan Management Conference, the Western Pension and Benefits Conference, and the Self-Insurance Institute of America (SIIA). Scott has authored and coauthored articles on various topics over his career. Scott earned his bachelor's degree in business administration and economics from the University of Nebraska at Kearney. Scott also holds Chartered Life Underwriter (CLU) and Registered Health Underwriter (RHU) designations. 10:34 What's the major flaw with the buyer-seller relationship between plan sponsors and PBMs? 12:08 What are the five things that need to be considered in order to get a fair price from a PBM? 13:21 Why does using average wholesale price cause problems for plan sponsors? 15:10 What does it mean to put the network risk on the PBM? 17:15 What's happening with drugs moving from specialty brand to specialty generic? 19:19 “A generic is a generic; in our world, it's binary.” 23:36 “The term 100% of rebates is really irrelevant.” 23:59 What does it mean to have a minimum guarantee in drug rebates? 26:43 “When you do a line-item assessment … is it producing an optimal result in comparison to competitively achieved … pricing for generics … and for specialty?” 27:57 “Plan sponsors need to grow a backbone.” 28:40 EP342 with Christin Deacon. 29:10 Why do you need to understand your consultant's process as a plan sponsor? 29:36 Why do you need to understand formulary exclusions as a plan sponsor? 29:46 Why is it important to create a more equal PBM contract? 30:57 “Rebates inure to the benefit of the plan sponsor; they don't necessarily benefit the consumer.” 31:50 What does Scott do at USI? You can learn more at usi.com or by emailing Scott at scott.haas@usi.com. Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400)

EP408: Who's Suing Who? An Overview of Healthcare Legal Goings-on, With Chris Deacon

Talk Money, Presented by Shoemaker Financial

Play Episode Listen Later Jun 15, 2023 39:43

I couldn't resist the “who's suing who” because, yeah, you can't go wrong with Aretha Franklin references. Back on the pod we have Chris Deacon, who is going to give us a rundown of the legal goings-on going on right now that impact self-insured employers, carriers, hospitals, and taxing authorities like cities. Chris breaks down the legal activity into three main categories, and then we discuss some examples of lawsuits in each category. So, here's the outline of our upcoming conversation: 1. Breach of Fiduciary Line of Cases Against Carriers a. Bricklayers vs Anthem Class Action b. Mass Laborers vs Blue Cross Blue Shield c. Member vs Cigna 2. Carrier vs Hospital (upcoding) and Hospital vs Carrier (underpayment) a. United vs TeamHealth b. TeamHealth vs United 3. Taxing Authority vs Nonprofit Hospitals a. Tower Health line of cases in Pennsylvania b. Pittsburgh vs UPMC This episode itself is a little on the longer side—and I didn't want to edit too many of Chris's words of wisdom—so I'm gonna make this a little bit shorter, this intro. But just one point that I'll make, and this is about the first category of legal activity wherein self-insured employers mostly try to pass the “who is actually the fiduciary” hot potato to carriers, ASOs (administrative services only), and TPAs (third-party administrators). And the carriers, ASOs, and TPAs are like, “It ain't us.” Moving forward here, I'm just gonna say carriers as a catchall for carriers, ASOs, and TPAs to save myself a mouthful. But bottom line on this topic, I just want to underscore something that Chris makes clear later on in the show: Plan sponsors (ie, self-insured employers) are the fiduciary, the sole fiduciary, at least according to the carriers who are getting sued right now. This is the position that you can see them taking in every lawsuit that I have seen. What the carriers say also, as a follow-on, is that if there is any contractual language between the carrier and the employer that violates the CAA (Consolidated Appropriations Act) or any other regulations, it is or was the employer's responsibility to not sign the contract. It's not the carrier's responsibility to point out that there's stuff in their own contract that's in violation for the employer to sign. And this includes contracts that don't give self-insured employers the right to their own data, which is pretty much a rate critical for any and all CAA compliance. As Justin Leader wrote the other day in reference to the bricklayer case, “To get to the point of filing the suit, there was a solid 2 years of failed negotiations [for the bricklayers to get their own claims] data.” Two years trying to get claims data that is necessary for a fiduciary to have from a carrier who is saying essentially, “Good luck with that. You're the ones that signed our contract.” Here's one of Chris Deacon's latest LinkedIn posts about this topic. And here's another one from Jeff Hogan that was interesting. Also, here's the link to the earlier episode with Chris (EP342), where we dive into the deep end on the topic of the CAA, which was signed into law at the beginning of 2022 and states that self-insured employers have certain rights and responsibilities based on their role as the fiduciary of their health plan. For more on the Member vs Cigna case, check out the encore episode with Dawn Cornelis (Encore! EP285). The show with Vikas Saini, MD, and Judith Garber, MPP (EP394) comes up where we talked about hospitals and their charitable giving. And lastly, I mention the show with Suhas Gondi, MD, MBA (EP404) about who is on the board of directors of hospitals, big nonprofit hospitals in particular. My guest in this healthcare podcast, Chris Deacon, is a lawyer by training. She ran the state health plan for the state of New Jersey, which covered about 820,000 public-sector lives. She now has an independent consulting firm, VerSan Consulting. You can learn more at versanconsulting.com and connect with Chris on LinkedIn. You can also email her at cdeacon@versanconsulting.com. Chris Deacon has a deep understanding of the fiduciary role health plan administrators hold and should be leveraging in order to drive value for their plan sponsors and members. An attorney by training, Deacon formed VerSan Consulting, LLC, in order to educate and engage employers to be more prudent purchasers of healthcare. From creative procurement methodologies and demanding contracts to population health initiatives and primary care investment, Deacon believes that large employer-sponsored health plans have not only an opportunity but an obligation to drive healthcare transformation that delivers value for the market. Prior to founding VerSan Consulting, Deacon ran one of the largest health plans in the country for the New Jersey Department of Treasury, which covered over 820,000 public-sector lives, including state employees, teachers, and uniformed professionals. During her tenure, Deacon was credited with helping the state save over $3 billion through a number of initiatives, including enhanced oversight, payment integrity programs, procurement strategy, and strict accountability for the vendors with which the state engaged. Deacon has also served as a deputy attorney general and then special counsel to Governor Christie where she oversaw the Department of Banking and Insurance, Economic Development Authority, and Treasury. She holds a JD from Rutgers Law School and bachelor's degree in international affairs from The George Washington University. 04:47 What does the current legal landscape look like, and how does it bode for the future? 07:24 “We need to catch the legal framework up with the current reality.” 19:53 How is this first circuit decision affecting who might be found liable in future cases? 21:38 What happened in the Member vs Cigna case? 24:49 Are we heading in the direction of the employer having fiduciary responsibility? 25:47 What's happening in the Carrier vs Hospital cases? 28:49 Who's really paying the price for the current business practices being examined in court? 30:00 What's happened in the Tower cases? You can learn more at versanconsulting.com and connect with Chris on LinkedIn. You can also email her at cdeacon@versanconsulting.com. @VerSan_cdeacon discusses current legal affairs in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance Recent past interviews: Click a guest's name for their latest RHV episode! Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285)

”Tips on Money Management”, ”Issues Insurance Carriers Face”, and ”Scam School - Summer Tips”

Play Episode Listen Later Jun 14, 2023 45:36

Talk Money with Jim Shoemaker Join Jim Shoemaker and Scott Jordan as they share the "Fundamentals of Money Management". Dane Williams helps us to understand the "Issues and Concerns Insurance Carriers Face Today". Daniel Irwin takes us back to "Scam School" and "How to Avoid Summertime and Vacation Scams"! "Helping You Make the Most of Your Money"

scams fundamentals money management your money talk money summer tips scott jordan management issues scam school insurance carriers dane williams

EP407: Considering Comprehensive Primary Care at Humana, With Vivek Garg, MD, MBA

Play Episode Listen Later Jun 8, 2023 35:28

Okay … let me get real here for a sec. For a few reasons, I wanted to chat with Vivek Garg, MD, MBA. Dr. Garg is CMO (chief medical officer) of primary care at Humana. Dr. Garg is an inspiring and incredibly articulate individual, and I like to both learn from and also be kept on my toes by the likes of such folks. But also, yeah, I'm suspicious of vertically consolidated payers. I mean, you listen to this podcast. I don't need to recap what the financialization of the healthcare industry has done to patient care. But you heard my manifesto in episode 400. It's about trying to find the right path forward and being open to exploring options here. It's considering what doing well by doing good actually means. It's contemplating whether to celebrate some good stuff going on in the industry even if there's some not-so-good stuff going on in that same sector or even in that same company. Bottom line: We're living in the real world here, and utopia is not on the table, at least anytime soon. So, that means there is always going to be one thing that we are always going to have to have to weigh in our consideration set, in our assessment equation that I talked about in my manifesto in episode 400. What's this one thing? It's self-interested, shareholder-centric goal setting. In other words, just because I spot a self-interested, shareholder-centric goal doesn't mean I'm automatically gonna get out my red Sharpie and cross off the whatever with a sour expression on my face because … yeah, if I did that, a whole lot of Americans are not gonna get, even incrementally, better healthcare. The right equation to determine if something is net-net good is always going to be nuanced. The equation should weigh the impact of the self-interest, which is always going to be there, against the impact on patient care and patient financials and how the whole thing impacts clinicians at a local level or maybe a national level, depending on what's going on. I'd also suggest that there's no real broad strokes here, because the equation for any given initiative or pilot or approach is really singular. I think it'd be a big mistake to lump together, for example, all payviders across the country and assume that their impact is all the same. Or all Medicare Advantage plans. Or anybody doing advanced primary care. All of these words/groups I just referenced are relevant to the conversation today. You have some payviders, for example, doing all kinds of crap with dummy codes and/or anticompetitive contracts and/or steering only to their own medical groups which they staff inadequately and/or blanket denials of anything that will throw off their medical trend calculations and/or prescribing and care pathways coinciding with their own highly financialized PBM (pharmacy benefit manager) formularies. But then, on the flip side, you also have some interesting things going on that help patients and their communities. A key ingredient of these interesting things is taking into account longer time horizons. Longer time horizons are actually pretty key here for anybody trying to do anything preventative or anything involving forming patient relationships. Also, of course, you have those who are doing some combination of the good stuff and the not-so-good stuff; and one of the reasons why the not-so-good stuff becomes so ingrained is that risk adjustment (especially if you're a payvider) across the board has anything but a longer time horizon. So, let's dig into what Dr. Vivek Garg has going on at Humana Primary Care, which includes CenterWell Senior Primary Care and also Conviva Care Center. I ask Dr. Garg some pretty hard questions about balancing the tension between being a payer with a PBM with an incentive to deny care and a provider organization seeing patients that is also beholden to those same shareholders. Dr. Garg taught me a new term, and that's the “dyad model,” where you have doctors and admins working together or clinicians and admins working together. You get the clinical team to shadow the administrative team, and you get administrative team to shadow the clinical team. You teach doctors and others the business of medicine, and you teach admins what it's like to be a clinician or a patient on the other end of some of those policies. Now, if you have a good memory, you are probably also recalling that Eric Gallagher from Ochsner (EP405) talked about this exact same concept (ie, working together, ie, the scrubs and the suits coming together into this dyad leadership model). There's a quote from Denver Sallee, MD, in episode 402 with Amy Scanlan, MD, talking about pretty much this exact same thing. And furthermore, this whole getting doctors up to speed on the business of medicine is gonna be the topic of an upcoming episode with Adam Brown, MD, MBA. So, yeah … this is becoming a thing—the idea of teaching clinicians the business of medicine. But the opposite should also get some focus—teaching admins the medicine of medicine. Dr. Garg cites three pillars to improving an organization's ability to sustainably deliver better healthcare, and these three pillars are (1) to focus on the patient experience, (2) to focus on outcomes, and then (3) to engage the clinical teams and really protect them, to protect this precious resource that doctors and other clinicians actually are. Taken together, these three pillars coincide with the pivotal question here. And that pivotal question is: How much is any given entity actually investing in clinical leadership? Because in combination, great clinical leadership plus the three pillars (ie, a focus on experience, outcomes, and clinical engagement), you put all those things together and it adds up to each individual who works in the place to harness their own intrinsic motivation—to be able to explore and double down on and actually achieve the reasons why they went into healthcare to begin with and spent years of their lives in school in order to do so. Dr. Garg mentions the latest Humana report in the show. And then I mention how I interviewed Steve Blumberg from Guidewell (AEE12) about the 2020 Humana report. Also mentioned on this show is episode 312 with Doug Eby, MD, MPH, CPE, from the Nuka System, and episode 405 with Eric Gallagher from Ochsner. You can learn more at humana.com, centerwellprimarycare.com, and the Humana report. Vivek Garg, MD, MBA, is a physician and executive dedicated to building the models and cultures of care we need for loved ones and healthcare professionals to thrive. He leads national clinical strategy and excellence, care model development and innovation, and the clinical teams for Humana's Primary Care Organization, CenterWell and Conviva, as chief medical officer (CMO), where they serve approximately 250,000 seniors across the country as their community-based primary care home, with a physician-led team of practitioners, including advanced practice clinicians, nurses, social workers, pharmacists, and therapists. Dr. Garg is the former chief medical officer of CareMore and Aspire Health, innovative integrated healthcare delivery organizations with over 180,000 patients in over 30 states. He also previously led CareMore's growth and product functions as chief product officer, including expansion into Medicaid primary care and home-based complex care. Earlier in his career, Dr. Garg joined Oscar Health during its first year of operations as medical director and led care management, utilization management, pharmacy, and quality, leading to Oscar's initial NCQA accreditation. He was medical director at One Medical Group, focusing on primary care quality and virtual care, and worked at the Medicare Payment Advisory Commission, a Congressional advisory body on payment innovation in Medicare. Dr. Garg graduated summa cum laude from Yale University with a bachelor's degree in biology and earned his MD from Harvard Medical School and MBA from Harvard Business School. He trained in internal medicine at Brigham and Women's Hospital, received board certification, and resides in New Jersey. 07:27 What does comprehensive primary care look like, and what can we expect from it? 07:39 Is the comprehensive primary care model the single biggest tool to help improve health? 10:41 How does a competitive ecosystem affect a comprehensive primary care model? 15:44 What is the impact of physicians and clinicians on the delivery of comprehensive care? 19:25 EP312 with Doug Eby, MD, MPH, CPE, of the Nuka System. 20:22 “What we need to do with the technology is actually support and enable the team.” 21:42 Why it's important to create “space” in your comprehensive care model. 24:56 What three areas does every organization need to pay attention to? 31:03 Why the opportunity for alignment is greater than the potential for conflict. 32:48 Why long-term orientation is a key to success, even in an ecosystem that's more short-sighted. 34:30 AEE12 with Steve Blumberg. You can learn more at humana.com, centerwellprimarycare.com, and the Humana report. @vgargMD of @Humana discusses comprehensive #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance Recent past interviews: Click a guest's name for their latest RHV episode! Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399)

Encore! EP249: The War on Financial Toxicity in North Carolina as a Case Study Everybody Should Be Keeping Their Eye On, With Dale Folwell, North Carolina State Treasurer

Play Episode Listen Later May 25, 2023 32:29

So, let's talk about North Carolina. What a weird outlier of the direction of other states getting active on their healthcare spend. I'm talking about Texas, Indiana, Wisconsin ... I'm naming so-called red states because the legislature in North Carolina is a Republican majority. Gotta say, normally I'm down for a little weird. I find it mostly charming. But with the information I have at present about what's going on in North Carolina, I don't love this for you. And when I say “you,” I pretty much mean any family who happens to live in North Carolina or any businesses in North Carolina trying to afford their employee health benefits right now. This whole shebang and the reason I'm covering this on Relentless Health Value is that it is also extremely relevant to anybody else in this country as a case study or a cautionary tale, depending on your point of view. So look, there's two pieces of legislation running through North Carolina's Senate and House right now, but both of these pieces of legislation—one that Blue Cross Blue Shield (BCBS) is angling for and the other one that UNC, a big hospital chain in North Carolina is all hachi machi to get passed—both of these have precedents. Both of these things were done elsewhere, and the results were not great, to put it mildly. BCBS wants to be able to open up a holding company that is able to take BCBS policyholder payments and invest them in for-profit ventures—BCBS being a nonprofit and all. Here's a quote Chris Deacon mentioned on LinkedIn from an article on this topic: “A 2019 examination of the aftermath of 11 conversions of BCBS affiliates showed that fully insured premiums increased roughly 13 percent … suggesting a post-conversion exercise of market power. Significantly, rivals of these large converting insurers also raised their prices following the conversions.” And here's a link to a Health Solutions podcast with Cristy Gupton, Chris Deacon, and North Carolina Commissioner Mike Causey. So, that's one of the pieces of legislation on the docket. Then, on the hospital side of the equation, we also have a proposed bill that could give UNC Health Care a green light to expand and buy more physician practices and hospitals without as much oversight. Proponents of the bill say that this will better enable UNC to take over struggling rural hospitals in danger of closing. Considering that UNC has already taken over rural hospitals in danger of closing, not exactly sure how or why basically removing federal and state antitrust scrutiny is helpful here. I went around looking for evidence that if you reduce antitrust scrutiny and enable more unfettered consolidation and expansion that population health outcomes improve. I could not find any. I did find lots of great talking points, but all of them seemed a little light on the evidence. There is, however, an insane amount of evidence at this point that shows unfettered hospital chain consolidation harms local communities from a financial standpoint without improving the quality or outcomes of patient populations, especially when hospital chains, in conjunction with third-party payers, are not willing to share their pricing, even with their largest customer. But I'm getting ahead of myself, because this is exactly what I'm talking about in this 2019 interview with Dale Folwell, the state treasurer of North Carolina. And it is a doozie of a frustrating story, just to cut to the chase. Look, you might be able to hear I definitely have an opinion formed on this topic, and I don't want to sway yours until you look into all of this yourself. But I loved what Jeff Leston wrote the other day. He wrote, “The North Carolina Legislature proves that they report to the healthcare industry in the State, not the people who actually elected them.” Okay … teeing up the interview today, this whole thing started when the North Carolina State Employees Health Plan (SEHP) crafted a proposal to pay network hospitals based on a transparent pricing schedule. Considering that SEHP purchases benefits for 720,000 people in North Carolina at a cost to taxpayers of billions of dollars, this seems reasonable. When you're the fiduciary of thousands of dollars, let alone add six more zeros, it would seem to be nonnegotiable to actually see the numbers and not write a check to a black box. Nonetheless, a few of North Carolina's largest hospital chains disagreed. They wanted to bill whatever they wanted to bill shrouded in a cloak of secrecy. In this healthcare podcast, as I mentioned earlier, I am speaking with North Carolina State Treasurer Dale Folwell. This is a rebroadcast from an interview in 2019 but still, somewhat sadly, completely relevant. You can learn more at nctreasurer.com. You can also connect with Treasurer Folwell on Twitter at @DaleFolwell or on Facebook at Dale Folwell. Dale R. Folwell, CPA, was sworn in as State Treasurer of North Carolina in January 2017. As the keeper of the public purse, Treasurer Folwell is responsible for a $100 billion state pension fund that provides retirement benefits for more than 900,000 teachers, law enforcement officers, and other public workers. Under Treasurer Folwell's leadership, the pension plan was rated among the top five highest funded in the country and won accolades for proactive management and funding discipline. In 2018, the state's coveted AAA bond rating was reaffirmed by every major rating agency, making North Carolina one of only 13 states in the country to hold that distinction. Treasurer Folwell also oversees the State Health Plan, which provides medical and pharmaceutical benefits to more than 720,000 current and retired public employees and is the largest purchaser of healthcare in North Carolina. Folwell was first elected to public office as a member of the Winston-Salem/Forsyth County Board of Education. He brought his problem-solving skills to the North Carolina General Assembly in 2004, where he served four terms in the House of Representatives, including one term as Speaker Pro Tempore. Treasurer Folwell began his career as a blue-collar worker and became a Certified Public Accountant and investment advisor after earning bachelor's and master's degrees in accounting from UNC-Greensboro. 05:59 The North Carolina state spend on healthcare. 07:21 “In medical terms, why has this become acute?” 08:00 One week of work for starting North Carolina troopers and teachers out of every four is going to family healthcare costs. 09:14 The problem of health insurance vs healthcare. 09:59 “If they can do this to the largest customers in this state … imagine what they can do to them.” 10:20 “This is about the industry whose whole business model is based on secrecy.” 11:47 “We've already focused on the why, and now we're [focusing] on the how.” 12:46 “We're trying to attack a problem.” 15:46 What the Clear Pricing Project aims to do. 18:08 “We're not trying to be disruptive; we're trying to fix a problem.” 19:55 Why the Clear Pricing Project went the self-insured route and how that's worked for them. 24:14 Who's behind the institutions fighting transparent pricing in North Carolina. 25:15 Instances where the Clear Pricing Project could actually stand to help rural hospitals make more money. 27:29 Dale's advice for other states trying to do this. 28:49 Dale's message to healthcare providers out there who want to see this change to price transparency. You can learn more at nctreasurer.com. You can also connect with Treasurer Folwell on Twitter at @DaleFolwell or on Facebook at Dale Folwell. @DaleFolwell discusses #financialtoxicity in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance Recent past interviews: Click a guest's name for their latest RHV episode! Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes

texas education house state north carolina financial wisconsin indiana republicans senate gotta cpa case study aaa toxicity unc treasurers providers certified public accountants proponents north carolina state instances health solutions state treasurer unc greensboro bcbs north carolina general assembly paul holmes insurance carriers speaker pro tempore rachel reid dale folwell north carolina legislature state health plan unc health care chris deacon

The 3 Ingredients Every Recruitment Agency Needs for Long Term Success, with Kevin Burch, Ep #174

The Resilient Recruiter

Play Episode Listen Later May 18, 2023 69:10

What are the factors that drive short-term results while ensuring the long term success of your recruitment business? If you have ambitions to grow your recruitment agency, you'll enjoy my conversation with Kevin Burch the CEO and co-founder of Questpro Consultants. Since they opened in 1996, Questpro has grown to a team of 35 people providing four service offerings: temp, retained/contingency, executive search, and college graduate placement. In this episode, Kevin shares three of the secrets that have contributed to sustainable growth for the long run: Fostering a culture of achievement and empathy Diversifying revenue streams The mindset of embracing technology and staying relevant QuestPro, a staffing and recruiting firm based in Dallas, Texas specializing in the insurance and risk management industry nationwide. Episode Outline and Highlights [03:02] Kevin shares his perspective on collaborating, sharing ideas, and being in a community with competitors. [08:20] How Kevin got into recruiting. [12:42] Staff retention - How QuestPro's staff tenure is way above average. [21:28] Getting rid of toxic people to protect your business culture. [27:09] The role that caring and empathy play in your business. [34:37] How Questpro diversifies its revenue streams. [42:16] Giving back to the insurance industry with their QGrad Division [50:56] Embracing technology to evolve and stay at the forefront. Protecting Your Business Culture From Toxic People Over the last 25 years, Kevin has built a team of 35 people which is already an achievement on its own. But the thing that stood out to me is how he is able to retain these talents. He has 3 or 4 people with a tenure of 20 years, several more in the 10-15 range, and some between 5-10 years. Out of his 35 team members, only 11 are under the 2-year tenure. If there is a key factor contributing to this phenomenal achievement, it is Questpro's working culture. Kevin shared how they celebrate little things and big things, initiate fun contests, and reward and recognize performers. These engagement activities in Questpro are actually initiatives from the top management. For Kevin, the culture that they have is a culture not only of achievement but also of caring and empathy. Kevin also discussed the importance of protecting their culture by letting go of toxic members that can disrupt team dynamics. He shared their story where they had to let go of large producers for the greater good of the group. Despite being a small company at the time, he was willing to let go of a big revenue contributor for the well-being of others. You will hear how making this move led to their company hitting their best revenues the following year that they made that decision. Diversify Your Revenue Streams Kevin has a tremendous experience with permanent, retained, contingency, and contract staffing. He shared a very interesting mix in his business that includes 50-50 on temp and permanent (direct hire). They have four service offerings, namely: Questpro – Contingency and Retained Search QTemps – Temporary and Temp-to-Hire Contract Staffing as well as Payroll Services QGrads – Internships, Entry-Level, and College Graduate Placement QExecs – Executive Placement through Seasoned Contract Executives As Kevin said, “The theory that if you are a temp company you surely can't be a permanent staffing partner, or you can't be a retained partner is not true.” They even offer a “Grad Division” which helps keep the industry they serve full of fresh talent. For recruitment business owners, the idea of diversifying your revenue stream is critical for success. If you are currently doing only direct hire or perm placements, for example, consider adding recurring revenue streams such as temporary, contract, or interim. Keep on Learning and Embracing Technology Another takeaway from this episode is how Kevin and his team embrace technology. Being a recruiter for more than two decades, Kevin finds the last few years have been interesting and they have seen a big flip in how business is done. We discussed how they are staying at the forefront of their market, such as: Using videos when interacting with clients and candidates Best practices for using text messaging effectively in their search process Discussion of available tech tools and platforms that they use in their business For Kevin, re-learning and embracing technology is an advantage that contributes to his longevity in the industry. Our Sponsors This podcast is proudly sponsored by i-intro and Recruitment Entrepreneur. i-intro® is an end-to-end retained recruitment platform. Their technology and methodology allow recruiters to differentiate themselves from the competition, win more retained business, bigger fees, and increase their billings. Their software combined with world-class training enables you to transition from transactional, contingency recruiter to consultative, retained recruiter. Instead of being perceived as a “me too” vendor, you'll be positioned as a “me only” solutions provider. Be sure to mention Mark Whitby or The Resilient Recruiter. Book your free, no-obligation consultation here: https://recruitmentcoach.com/retained Recruitment Entrepreneur is the world's leading Private Equity firm specializing in the international recruitment industry. If you've dreamed of starting, scaling, and selling your recruitment business, this is your chance. James Caan and his team at Recruitment Entrepreneur are actively seeking ambitious recruiters in who they can invest. They provide everything you need to grow a successful recruitment business including funding, financial expertise, coaching and mentoring, operational strategy, back-office support, marketing, and talent attraction solutions. Be sure to mention Mark Whitby or The Resilient Recruiter. Start a conversation here: https://recruitmentcoach.com/vc Kevin Burch Bio and Contact Info Kevin co-founded Questpro Consultants in August 1996. Kevin went from the next great sportscaster and play-by-play man to sitting behind a desk and dialing for dollars! Now 25 Years later, he can safely say that it is the best decision he ever made. From coast to coast, Kevin and his team match top-notch insurance talent with the absolute best Insurance Carriers, Brokers, TPA, and more. When he's not playing KOAR (King of All Recruiters), Kevin is at home with his lovely wife, Lauren, and three sons, that continue to challenge and keep him young: Parker, Owen, and Taylor. Kevin is also addicted and frustrated all at once by golf but loves the game. Kevin on LinkedIn Questpro website link Questpro on Facebook Questpro on YouTube Questpro on Twitter @Questpro_ People and Resources Mentioned Gail Audibert on LinkedIn Simon Lafosse on LinkedIn Bullhorn TextUs Hinterview Connect with Mark Whitby Get your FREE 30-minute strategy call Mark on LinkedIn Mark on Twitter: @MarkWhitby Mark on Facebook Mark on Instagram: @RecruitmentCoach Related Podcast You Might Enjoy TRR#116 How Treating People Well Delivers 30% Annual Revenue Growth for 15 Years, with Simon La Fosse TRR#153 Meet The Recruiter Who Survived And Thrived Through Four Recessions, with Gail Audibert TRR #171 4 Essential Skills that All Recruitment Business Owners Need to Be Successful, with Chris DiNaso Subscribe to The Resilient Recruiter

EP400: My Manifesto, Part 2: Where the Rubber Hits the Road

Play Episode Listen Later Apr 13, 2023 21:51

I hope you listened to episode 399, which was Part 1 of this two-part exploration of my manifesto, meaning my aims and my path or framework to achieve those aims. Regarding the first part of my manifesto, episode 399 from two weeks ago, here's the tl;dl (too long, didn't listen) version; but please go back and listen to that show (Part 1) because it's about you—and it's a compliment and a thank you, and you deserve both. Just to quickly recap, Part 1 of my manifesto is that I started this show because I want to, and wanted to, provide information to those in the healthcare industry trying to do the right thing by patients, to get you the insights that you might need to pull that off, to create a Coalition of the Willing, as I've heard it called. When we get reviews like the one from Megan Aldridge, a self-proclaimed Relentless Health Value binge listener, I feel very gratified because it makes me feel like I'm chipping away at this mission and in a non-boring way. Thank you, Megan. Along these lines, there was also a recent review from Mallory Sonagere, who says she listens to learn new things and to be a little sharper at how she approaches her day job. And just one more I'll mention: I loved the review from Mark Nixon calling Relentless Health Value the best healthcare podcast out there. Every review like this I take as validation that maybe I can count some measure of success toward achieving the mission to empower others on their journeys to make it better for patients or to transform the healthcare industry. But this whole endeavor to create a manifesto is also borne out of me struggling personally to figure out what “having personal integrity” in this business actually means when it comes to deciding what to do and what not to do, when it comes to deciding who or what to try to help or support or who or what to step away from either passively or actively. I mean, how this podcast gets funded is my business partner and I pay for it with money from our consulting business and from some tech products that we have on offer. Who do we choose to take on as clients, and what are we willing to do for them or help them with? These are questions that literally keep me up at night. And this is what this episode, Part 2, is all about. It's about my struggle and how I attempt to navigate my own path forward. And holy shnikeys, it's tough to find a path, especially when you have the sort of perspective that I've wound up with over these past however many years. It can feel like no matter what I do, there's negatives as it relates to the Quadruple Aim. You raise one of the quadrants, and something else for somebody else certainly has the potential to be negatively impacted. We cannot forget here in the short term, but, for sure, often in the longer term as well, it's a zero-sum game. Every dollar someone takes in profit under the banner of improving health or even saving money is a dollar that someone else paid for. Is the amount of profit fair? Where'd that money come from? Is there COI (conflict of interest), and if so, what's the impact? I think hard about things like this. An inescapable fact is that there has been a financialization of the healthcare industry, and that includes everybody who also gets sucked into the healthcare industry whether they want to be or not (ie, patients/members and plan sponsors and, oftentimes, physicians and other clinicians, too). But the financialization of healthcare means that most everybody at the healthcare industry party has a self-interest to either make money or save money. And sometimes the saving money means saving money for themselves, not necessarily anything that is ever gonna accrue to patients or members. Now let's say I'm trying to determine if I want to take on a new client or decide if I personally want to promote or do something or other. This self-interest that abounds all around matters here because it means it is often very tough to find some kind of “pure” initiative to hitch your wagon to. The crushing reality that we all face is you gotta earn a living. The other reality is that often the person that benefits from the thing you want to do (ie, the patient) is not gonna pay for it. And frequently, physician organizations won't either. If everybody was lining up to pay to get something fixed, the problem would not be a problem, after all. But the only way your moral compass is the only moral compass in play is if you're doing whatever you're doing for free, really, or by yourself—and thus you are not encumbered by anybody else or any self-interest beyond your own … and your own motives are the only motives that you can control. I hear all the time initiatives and coalitions and advocacy organizations and even research funded by grants … these things also get bashed as suspect because who'd that money come from and whose “side” are the funders on. Nikhil Krishnan wrote on LinkedIn the other day (and I'm gonna do a little bit of editing, but yeah). He wrote: “Patients have low trust in healthcare because they think every stakeholder is incentivized not in their best interest. Many patients think the hospitals want to keep them sick, the [carriers and plan sponsors] don't want to pay their claims, the drug companies want to keep them on their meds, etc. And we can't pretend like that … isn't true.” Every party, every stakeholder has some measure of self-interest. They have to; otherwise, they'd be out of business. It's all a matter of degrees. No big group, no entire category gets to stand on the high ground here when you think like a patient. There's great hospitals and great people who work at hospitals, and then there's people doing things that cause a strikingly large percentage of patients to fear going to the hospital for clinical and/or financial reasons. Pick any other stakeholder and I'd tell you the same thing. Any other stakeholder. It's basically up to us as individuals to do the right thing. In every sector of the healthcare industry, there's good eggs and there's bad eggs and there's eggs in the middle just doing their day jobs as instructed. Personally, I want to be a good egg, and that's what my manifesto is all about. Let me dig into this a bit further for just a sec and then I'll continue with my personal manifesto for how I find my own path of integrity through all of this confusion. Here's another anecdote. Stuff like this I make myself crazy thinking about: I was listening to a podcast, and one of the guests said, “I wanted to get my MPH [Master of Public Health] because I felt a personal calling to be altruistic.” Then, 120 seconds later, he says something like, “So then, when it came time to pick my internship, I hunted around to find the one that paid the most money—and that's how I wound up working for an HMO in the '90s.” Consider how that strikes you. How do you feel about that guy right now, who, by the way, has gone on to support some very interesting and probably impactful initiatives? There's this commonly used phrase, “Let's do well by doing good.” So, back to that HMO intern. Let's just say we all agree that these HMOs were not unconflicted organizations. We all know they had a reputation for putting profits over members, and a reason they went out of business was because they denied care. They refused to pay claims for patients who had AIDS. And it turns out that the friends and families of people with AIDS are incredibly well organized and sued the crap out of the HMOs, which may have expedited their demise. You know what the intern was doing at the HMO? He was helping them with data analytics, and his personal goal was to use that data to improve patient outcomes. So, okay … here's the thought experiment: Do we want this HMO taking money that they're gonna take anyway and then not adding the value that they potentially could add with their data because they don't have any smart, dedicated, highly compensated interns working there to keep the ship pointed in a decent direction? I mean, I guess if I know I'm gonna spend a dollar as a member of that plan, I'd prefer to get as much as possible for my dollar that is already being spent. Maybe from that perspective, this guy is doing well by doing good. You see how this gets messy when you take a theoretical statement and then apply everyone's real-world prejudices and predilections to it. Here's a last point to ponder, and this is another thought experiment … so, just heads up and then I'll get to the point here: Say you are asked to help with a program run by a Medicare Advantage (MA) plan to provide those in need of transportation a ride to their annual wellness exam. Do you help? Those who listen to this show will fully understand there's a lot of self-interest involved in getting patients to the annual wellness exam because … risk adjustment. Also, star ratings. Listen to the show with Betsy Seals (EP375 and EP387) if you need the full story here. Short version is, MA plans can't upcode, either fairly or aggressively (if they are so inclined), if the patients don't show up for their annual physical. So, there's a lot of money for them at stake. But, then again, are physicals important for patients? Do they improve patient care and health? If we think yes, then again, is this doing well by doing good to help patients get to their appointments? After literally years of asking myself questions like this—and most of them were not thought experiments—I came up with my manifesto. And there are three parts to it, and I will go through each of them. But here's my manifesto in full: If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients. Here's how I think about the first part of my manifesto: If the thing results in a net positive for patients, then I'll do it. And keep in mind, I could talk about this for seven hours; so everything I'm saying is oversimplified to some degree and has as many nuances as there are stars in the sky. So, to calculate the net-positive impact, I think through what good the thing could do and weigh that against the negatives. And there are always negatives because, most of the time, the work that I do anyway has to get paid for by somebody and that somebody has some self-interest. Self-interest means that they are attaining something that furthers their business goals. Let me list two major upside/downside contemplations: 1. How much good does the thing actually do for patients? I think about this. What's the value here? Is it a little? Is it a lot? Will this thing be a distraction for clinicians, because time is often the most precious currency? If we're talking about some kind of navigation or utilization management, what's the reason someone wants to do this? Is the reason clinically and, for reals, evidence driven? Or are we predominantly doing this to enrich shareholders or save plan sponsors money in ways that are not a win-win for patients in the clinic right now trying to get cancer treatments for their kid? I try to think like a patient and be as impartial as possible. 2. Money. Where's the money for this thing coming from, and who wins in this particular initiative (ie, is it a win-win and patients win something worthwhile)? Now, the company doing the funding has got to win, too; otherwise, they wouldn't fund the thing. That's where it gets subjective, and, as aforementioned, do I care if the company in question wins if the patient wins, too? Or is this company so damn evil at its core that I am willing to sacrifice the opportunity to do a good thing for patients in order to not have anything to do with said possible funding entity. Or am I cutting off my nose to spite my face because this is a really important thing for patients and this particular company is the only one that's gonna fund it? Because tragedy of the commons or whatever else. Again, this gets dicey really fast. Let me poorly paraphrase a little exchange I saw on LinkedIn the other day that had me completely preoccupied during my work-from-home midday walk around the block for at least three days. Somebody wrote (maybe that Master of Public Health intern), “Given how intractable it feels to me to try to reduce healthcare spend, I think I'm going to try to help patients get more value out of the dollars that are currently being spent by them or on their behalf.” Do you think that's a worthy goal? Well, not everyone does. Somebody in T-minus 8 seconds responded, “That's a toxic way of thinking. Everyone who is not actively working to reduce healthcare spend by putting patients in cash-pay models is part of the problem.” This is a good segue into the second part of my manifesto. The first part is: If the thing results in a net positive for patients, then I'll do it. Here's the second part: The timeframe is short-term or medium-term. And here's what I mean by that. My main focus is helping patients right now. This is what this has to do with the aforementioned exchange on LinkedIn wherein someone was trying to figure out how to get more out of the dollars we're currently spending and someone else said that's toxic, because we should rip it all down and build a better model. There's incremental change, and then there's disruptive change. These two things are not mutually exclusive. Apparently, Mr. This Is Toxic doesn't agree with me, but as I said in the last episode, there's that Buckminster Fuller quote: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” And sure, I like to aspire to that as much as the next person. But does aspiring to a big hairy goal mean completely forgoing any incremental ways that patients can be helped immediately, like right now? If you ask me—and you're listening to this, so you de facto asked me—incremental change will probably actually support and beget disruptive change. So, incremental versus disruption is not a battle royale. These things are not diametrically opposed. They're probably actually aligned. I could go on a tangent here to explain why, but I'm not going to … except to say tipping points. But forget about that for a sec. Here's the more basic question: If all parties are interested in transforming healthcare, legit, how does someone trying to do it incrementally, or improve value for patients right now, in any way negatively impact someone trying to be disruptive and/or trying to change financial models? Keep all this in mind and now let me get back to my manifesto. I'm worried about patients, and I'm worried about them largely right now, short term to medium term. So, if I have the opportunity to help a patient—and I think about my two grandmothers (God rest their souls) here, but both of them would have died in the healthcare system multiple times in avoidable ways had my family not been there advocating for them—if I have the opportunity to help a patient, I will do so as long as I believe that the impact is a net positive in the shorter term. Disruption is a longer-term operation. Some have said it's a generational change. When I see stuff like Toxicity Guy wrote on LinkedIn, I really try to understand what his point is, as I always try to understand what people's points are. Could he be arguing that no one should work to improve care right now or try to maximize what we get for the bucks that we've already been shelling out? And, if so, for what reason … so that what happens? So that resentment about poor-quality care builds up to a boiling point such that everybody shuns the status quo and moves to a new care model and financial models faster? Is that the aim of Toxicity Guy? To force a let-them-eat-cake moment for the purposes of triggering a faster revolution? I've probably thought about this guy's motives and his potential impact harder than he has. In my manifesto, in my worldview, I don't let grandmas suffer right now so that someone else has a better narrative, even if I am in full support of what that person is trying to do and the mission that they are on, which, by the way, is a longer-term one. This gets me to the third part of my manifesto: The assumption is that transforming the healthcare industry will take a village and I am not alone. When I state this outright, it's gonna seem self-evident; but sometimes it's hard to not push blame here like Toxicity Guy, so I say this sort of in his defense. Here's the point of contemplation: There's maybe four big parts of the healthcare industry at a minimum. We have those trying to fix SDoH (social determinants [or drivers] of health). We have those trying to fix medical morbidity (ie, are patients on evidence-based pathways and taking meds appropriately, limiting polypharmacy side effects/cascades). Once a patient is in the healthcare system, what happens then? Then we have those working hard to improve behavioral/mental health. And lastly, everything going on with what I'm gonna call FDoH (financial determinants of health)—patients making decisions or having decisions made for them due to financial implications for them or for somebody else. Lots of stuff rolls up under these categories, but even just listing out these four things, we got a hell of a lot of work to do to improve the lot of patients and taxpayers and make it easier to do business in this country. I always try to keep in mind that it will take a village. Just because someone is working on getting patients housing or eating better does not imply that they don't care about employers struggling to curb claims billing waste, fraud, and abuse—and vice versa. It's just not everybody can do everything. For me personally, I tend to focus my attention on helping as many patients as possible get on what would be for them the optimal treatment plan or best care pathway. That does not mean I'm anti-someone working on getting more competition in the payer space. Nor does it mean I'm against trying to curb the price of overpriced (as per ICER [Institute for Clinical and Economic Review]) pharmaceutical products or legislate to rein in hospitals doing stuff that, in my book, they should not be doing. I am all for getting all of these things done. I just do not have the bandwidth or the depth of expertise to do everything myself. I would suspect that no one does. As my grandma used to say (and anyone who attended a slumber party seance in eighth grade might know), many hands make light work. You get 15 girls each holding out but two fingers, and you can lift up your friend, no problem. When I keep in mind that it takes a village, it helps me curtail the tendency to become paralyzed in my quest to help patients because I can see a potential problem it might create somewhere else in the industry or somewhere else down the line. I have to trust that one of my fellow villagers is holding down that end of the fort. Here's a quote from J. Michael Connors, MD, that he wrote in his newsletter: “When you point one finger, three are pointing back at you … It's like everything you learned in kindergarten seems to be so applicable to our approach to healthcare. Sadly, the game of finger pointing and pushing blame on others is killing real innovation in healthcare.” This is so real, which is why inherent in my manifesto here is my efforts to remember we are all on the same team (all the good eggs, anyway). That it takes a village, that there will be some things that some people are doing that I maybe don't fully agree with. There might be groups who don't accomplish much. There are certain people doing well (ie, doing self-interested things) but, at the same time, creating a better place for patients. As long as, in general, we are all following the same North Star, we'll achieve much more spending our time focused on our own missions and not worrying about what other people are doing. And when I say “not worrying about what other people are doing,” I mean people in the “good egg” village. I do not mean I intend to stop calling out conflicted and net-negative self-interested behavior, because this is what some people in the village should hopefully have their eyes on and get busy working against. The village here, it's a Venn diagram. At the point where other people's circles intersect with my mission or what I think would be better for patients, these are the people I can work with and collaborate with. These are the people that I'd take their business or I'd try to help them if I can. My manifesto is to determine when something is a positive for patients and then to find others who will win as a result of that thing happening. Then I can study why this is a win for those others, which is always going to be some self-interested why. And then I can think through what the negatives are if their self-interest comes to fruition. Is it still a net positive? If yes, proceed. Look, this making it better for patients, this transforming healthcare, it is hard, dispiriting work. It's a long slog. I'd like to suggest we encourage each other. Can we be the wind beneath each other's wings when we find a kindred spirit? Can we focus on the points of intersection and spend our energy deepening what's going on there? So again, here's my manifesto: If the thing results in a net positive for patients, then I'll do it. The timeframe I'm concerned about … short-term, medium-term. The assumption is that it will take a village to transform healthcare and I am not alone. I feel kind of exhausted having finished that. But let me ask you this: What is your manifesto? If you have one or if you have thoughts on this, go to our Web site and click on the orange button to leave a voice message. My hope is to do an upcoming show sharing what you think. For more information, go to aventriahealth.com. Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups. 03:16 “It's a zero-sum game.” 03:26 Is the amount of profit fair? 03:37 What is an inescapable fact of the healthcare industry? 03:54 What does the financialization of healthcare mean? 04:19 Why does the self-interest in healthcare matter? 06:18 “It's basically up to us as individuals to do the right thing.” 10:03 What is the first part of Stacey's manifesto? 10:18 How does Stacey calculate the net positive of an impact? 10:41 What are two major upsides/downsides that Stacey contemplates? 13:31 Why are incremental change and disruptive change not mutually exclusive? 17:40 “I always try to keep in mind that it will take a village.” 19:19 Why finger pointing is killing innovation in healthcare. For more information, go to aventriahealth.com. Our host, Stacey Richter, discusses our #healthcarepodcast and where she sees the path moving forward. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355)

Encore! EP285: Who Is Auditing These Healthcare Bills? Also, That Cigna Lawsuit, With Dawn Cornelis, Cofounder and Director of Transparency at ClaimInformatics

Play Episode Listen Later Apr 6, 2023 30:14

Well, this episode became extremely relevant again after that Cigna case bubbled up in the news. Here's the “too long, didn't read” version: Attorneys filed a class action lawsuit against Cigna, alleging that the carrier is overcharging for lab services or did overcharge for lab services. The plaintiff is an individual member of a Cigna plan. The complaint tells a pretty wild story. On the Explanation of Benefits (EOB) that this member received for lab services, the amount billed was over $17,000. My understanding is, this member went to Labcorp to get those lab services. Cigna claimed it had negotiated a discount of over $14,000 for those lab services, meaning the remaining balance was something like $2700. OK … good news, I guess. Instead of the lab services costing $17,000, they cost $2700 to the plan and member. Except Cigna said to this member that they were only gonna pay $471 on the member's behalf. This left the member with the responsibility to fork out over $2000 in deductible and coinsurance payments. I'm rounding the numbers here for brevity. So, in sum, member's told she owes $2000+ out of pocket for charges that were allegedly originally over $17,000. Now, a couple things: The cash price for an uninsured customer at Labcorp for the same services was $449, according to the complaint. Also, weirdly, on the Explanation of Benefits, Cigna allegedly said that the lab services provider was not Labcorp. It was “Health Diagnostic Lab” (or everything I just said in all caps with some letters missing) instead of the actual provider Labcorp. Then the plot thickens … The lawsuit alleges that this “HLTH DIAG LAB” is a pseudonym for Cigna Healthcare of Arizona and that this Cigna affiliate used their pseudonym to create a fake invoice. This is also a quote from the complaint. Bottom line, and this is the real point I wanna make here, the actual out of pocket to the payer was something less than $500, $600, you would think. But it appears that the plan was hoping to get almost 5x that out of the plan member. And had this plan member met her deductible that year, I would speculate that this 5x would have come out of the pocket of the plan sponsor. Either way, 5x margin? That's some pretty sweet returns. Look, the point I'm making here isn't about this particular case. It's about the totality of the thing. This case just got a whole bunch of attention because, as Julie Selesnick put it on LinkedIn recently, “This case … hits all the high notes—overcharging, keeping the spread, fraudulent billing.” But think about this for a second. You think this was an isolated incident? That someone in Arizona had a brainstorm to juice their quarterly earnings and set up a whole company to jack up one person's lab payments? I don't know. What do you think? As Lee Lewis mentioned on LinkedIn, while this case has a lot going on, a member getting charged $2500 for what should cost $450 or whatever … he wrote, “I've seen worse.” I say all this to say: Plan sponsors? Hi there. Are you getting your claims data, and are you having it audited for stuff like this? And by whom are you having your claims data audited for stuff like this? And that's not a rhetorical question. I mean, here we have a well-respected payer opening up (allegedly) a reseller of lab services sending allegedly fake invoices. That's one way to vertically integrate, I guess. Here's another way you can vertically integrate that maybe we all should be aware of: companies that provide audit services that many plan sponsors use to check if claims have been paid properly. Those same auditing companies, these same companies oftentimes have another book of business besides their auditing claims for plan sponsors work. They also work with provider organizations doing revenue optimization. Right. They help providers maximize their revenue, revenue that is coming from … claims they send plan sponsors. Sometimes when I talk about this stuff, I feel like I'm in a cartoon—like that meme with all the Spider-Men pointing at each other and nobody knows who is actually Spider-Man because everybody is dressed up in the same costume pointing and saying the other guy is the one causing the problems here. As Dawn Cornelis says in this episode today, approximately 30% of healthcare spending (ie, healthcare payments) are some combination of fraud, waste, and/or abuse. It's a $1-billion-a-day problem. In this episode, we dig into the three main issues that Dawn tends to find when looking at the claims that were going to hit the checkbook of a plan sponsor as per their payer or TPA (third-party administrator): 1. Claims that were not paid correctly: Turns out, 5% to 10% of claims just aren't paid right. There's a whole motley crew of errors that can transpire, but bottom line, the bill was for $10 and somehow the plan sponsor was gonna pay $15. Or they double paid. 2. Things that, if we knew about them, we could do better in the interest of the member: Jeff Hogan put this really well on LinkedIn the other day. He wrote, “Today's purchaser fiduciary needs great analytics to prioritize the needs of their members … including wasteful and abusive vendors, site of care, cost/quality variation in health systems.” Do labs that the plan is being charged $2500 instead of $450 go here or in the next problematic category? I'm not sure. 3. Claims that are just wrong: They should never have been sent in the first place. We also talk about kind of a different issue entirely: the hidden fees that are buried in some of these payer contracts, which felt like a reprise, frankly, of the conversation I had with Paul Holmes a few weeks ago in episode 397 talking about PBM (pharmacy benefit manager) contracts and all the hidden fees and, ultimately, probably costly provisions buried in them that plan sponsors are on the hook for—a lot of times very unknowingly. You can learn more at claiminformatics.com or by emailing Dawn at d.cornelis@claiminformatics.com. Dawn Cornelis is a professional in healthcare cost containment with 30+ years of dedication to combatting improper payments, fraud, waste, and abuse. She has led the industry in developing healthcare transparency technology platforms and services. As a result of her efforts, hundreds of millions of dollars of improper payments were delivered through pre- and post-payment technology programs. She is an expert in the field of healthcare claims data, with an emphasis in audit and recovery, and has navigated the payment systems of all of the national healthcare carriers. Furthermore, she approaches each project with integrity and attention to detail while cultivating long-term client relationships. In 1993, Dawn cofounded the first audit and recovery firm and served for 17 years as the chief operating officer of Claim Recovery Services while representing some of the best Fortune 100 companies. In 2017, Dawn cofounded ClaimInformatics, a healthcare technology company that offers a SaaS-based solution product to support health plans in the marketplace that addresses the new transparency regulations. She developed and trademarked multiple technologies and has a United States Patent Pending named CONTINUITY OF CARE (Publication #20150127370). Dawn currently serves as a member of the Self-Insurance Institute of America's price transparency committee, which focuses on legislation and education for self-funded entities. Over the course of her career, Dawn's efforts have supported national and local organizations spanning financial, healthcare, union, and government sectors. With her years of healthcare knowledge, Dawn is a proven expert, consistently delivering excellence. 06:57 The story in the data. 07:33 Who's submitting these claims? 08:04 The three problems with the data. 10:54 The varying factor between carrier systems to stop fraud, waste, and abuse. 11:32 Why carriers don't push for better systems to stop inappropriate dollars. 13:28 The difference between fraud, waste, and abuse. 14:46 “When it becomes the norm, that's what's very bothering.” 15:10 The barriers or hurdles in the marketplace. 17:38 What we don't know about but could do better at when looking at the data. 19:10 “It's not so much the health system and what they are charging. It's about … what the contracted rate is agreed to. That's what drives our costs.” 20:04 “Data's fixed for itself.” 22:49 Identifying and eliminating fraud. 22:54 The lack of enforcement behind preventing illegal billing. 26:01 How providers ensure they aren't inadvertently harming employers and patients through billing. You can learn more at claiminformatics.com or by emailing Dawn at d.cornelis@claiminformatics.com. Check out our encore #healthcarepodcast with Dawn Cornelis of @claiminformati1 as she discusses saving billions through healthcare billing. #healthcare #podcast #digitalhealth #healthtech #healthcarebilling Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard

EP399: My Manifesto, Part 1: The Relentless Health Value Tribe, I Salute You.

Play Episode Listen Later Mar 30, 2023 11:38

This week and in episode 400 of Relentless Health Value, at the encouragement of the Relentless Health Value team, I'm gonna do two shows entitled “My Manifesto,” Part 1 and Part 2. In other words, why did I start Relentless Health Value and what's the goal around here? I started contemplating this mission to define the mission thinking about how healthcare will ultimately be transformed and my role (if any) in all of this—or, more accurately, your role as a listener of this show and, often enough, someone who has the ability to take action. You there, listening right now, you are the alchemist who will transform the words that you hear here into something tangible. And that is how this show makes a difference. It is through the Relentless Health Value Tribe, and you, whether you realize it or not, are a very special person. But before I continue along this complimentary vein, let me back up for just one sec and talk about how I realized how special you are to begin with. It's a funny thing because I get asked all the time who listens to this show, sometimes with a “Who listens to this show?” vibe. I mean, we talk about complicated topics; and when I say we talk about complicated topics, I mean we hurl ourselves right in the middle of them. Acronyms and 400-level perplexities abound. I used to say who listens to this show when asked—and this is absolutely true—I used to say that more than 40% of you are senior-level executives with decision-making authority, which might mean you are a doctor or a nurse or other clinician and a leader of some kind, either formally or informally. You could work at a provider organization, a payer, a digital health company (big or small). Maybe you make policy, you're a researcher, private equity … You're an EBC (employee benefit consultant) or work in benefits at an employer. Maybe you do something in the population health space. You could be a legislator looking for insight. A journalist. Right? We get around. But while the audience of this programme is big (very big by some standards), I run across healthcare industry peeps often enough in decision-making roles who listened to half a show one time and decided it wasn't for them. It took me a long time to put my finger on who listens and who does not, and this was also the moment that I started thinking about our listeners as a tribe. The people who listen 99% of the time are listening to figure out how to do the right thing for patients or members. They want to know how what they do fits into the larger picture, this larger healthcare ecosystem. And they want to know this for actionable reasons. I mean, frankly, this is a lot of the reason why I started this show to begin with: because I found myself in a similar situation (still am, truth be told). I started to understand that doing something in healthcare is like a game of pachinko. The action, which might feel like it logically should result in X good thing for patients, bounces around in this black box that is the healthcare ecosystem and may pop out the other side in ways that are the opposite of what was originally intended. I want to have positive impact, right? All of us do, or you wouldn't be listening right now. And that is the common thread that holds us all together—besides, of course, being smart, capable, curious, and incredibly charming individuals. And I say all this with evidence: Every single person I have met who listens to this show on the regular meets all of these criteria. You are great people, and it is a distinct honor and a privilege to spend time with you every week. I am proud, really proud of what this group of individuals has accomplished. We have moved needles, and we have pushed agendas. Now, I know you people. You are going to be doing one of two things right now. Twenty percent of you are gonna be smiling and thinking about the program you started or the work that you did and the accolades that followed. Or maybe you're just simply aware of what you've done because you have data, or patients or members or family members thanked you and you saw that look in their eyes and you knew how much what you did meant for them. Or you work for a company that is laser focused on some kind of disruption, and it's small enough that you can clearly see your impact. But there's a lot of you (the majority of you, frankly) I get on the phone with, and you're less sure if you've actually had any impact. You are frustrated—and a little depressed maybe—because you see all this madness and ways patients are harmed all around you. You see maybe decisions that you realize have a deleterious (ie, bad) impact on patients or members. You are now eyes on, and now you feel largely powerless. I will tell you the same thing that I tell every member of the Relentless Health Value Tribe who says this. I don't doubt it might be more difficult to see the impact you are having if you work for a larger company or if you work for one of these incumbents, especially when you have a recognition that there might be other departments or other individuals doing things that you may not be fully aligned with. But do not doubt that you have impact and that that impact is meaningful. I was talking to Larry Bauer, and he told me with a lot of conviction (and he's one that would know) that you, Relentless Health Value listeners, you are the innovators. You are the ones who spot problems, and you tinker around with available resources and you figure out how to make it just even a little bit better for patients or members. Think about it this way and just hang with me through this: CEOs do not actually drive what happens in their organizations. The big bosses set up the incentive structures and are the tip of the spear (or whatever that metaphor is) for sure. But an organization's behavior is decided by 10,000 probably tiny little decisions each and every day … 100,000 decisions by the employees of that organization. It's the sum of all those micro choices, those micro moments, that determine the impact that that organization has on those it serves. I saw a meme the other day: “When people travel to the past, they worry about radically changing the present by doing something small. Few people think that they can radically change the future by doing something small in the present.” Who your boss is doesn't matter is my point. If you are touching things in the middle of that pachinko game, you have power. Right? We are all decision makers here, and we are not synonymous with the companies that we work for. We are not the Borg. Would it be nicer and faster if there wasn't an ongoing financialization of the healthcare industry? If boards of hospitals and private equity and C-suites all would put their “mission before margin” hats on for a change? Yeah, that would be ideal. Would it be nice if the disrupters among us had more market penetration? Sure … the good ones, absolutely. And probably the best path forward is to get ourselves over to a company that's building a new model to make the current one obsolete, to quote Buckminster Fuller. But it's not like it's an either/or. In addition to having a long-term vision, maybe we can do something in the meantime here. I'd rather that some patients and members get treated some amount of better right now as well as envisioning a new model to make the current one obsolete. We each might be pressing forward, I don't know, 0.01% at a time; but let's just consider that 0.01% in this country is 35,000 people plus their families and ~$300 million when it comes to healthcare in the US. Multiply that impact by everybody listening right now—there are thousands of you. So please do not dismiss the impact that you have, no matter who you work for: thinking critically, considering the larger picture, recognizing the impact that your organization has in big ways and in small ways and then making big and small choices and decisions that are aligned with your values and your integrity. Sometimes people will talk to me about what they want their legacy to be, and this is kinda it. So, how to deepen that possible impact that any of us might have? It is always the highlight of my day when I hear that one of you has found somebody else in the RHV Tribe and the two of you (or three of you or four of you) have struck a deal to do something. You've collaborated in some way. The larger organizations everybody might work for … maybe they're on board or half on board, but again, we are not our companies. I love it when I hear that a physician organization hooked up with somebody at a payer and figured out how to do a pilot or collaborate on something, not going through the official Contact Us forms or whatever but by finding somebody on the same mission in that other organization and then everybody working up the chain in their own organizations from the inside. So many different individuals who work for so many different parts of the healthcare ecosystem listen, and there are lots of synergies to explore, especially if we stop thinking at the organizational level and start thinking about what we individually want to achieve. It's possible to help each other, to find the overlapping bit of the Venn diagram where interests align and something can get done. And I'll talk about that more in Part 2. Here's from Malcolm Gladwell's The Tipping Point. He wrote: “If you want to bring a fundamental change … you need to create a community … where … new beliefs can be practiced and expressed and nurtured.” This, maybe in sum, is the ultimate goal of Relentless Health Value: to provide that loose-knit community so that those in the Relentless Health Value Tribe who want to can find like-minded people across the industry to work with, the ones who are also just as well informed and understand how this ecosystem knits together—meaning you can more easily work with them to find points of mutual interest that are net positive for patients. There was a point in my podcast career where I thought having a really broad audience of listeners from all across the industry was kind of a problem because it makes it really hard to answer the question, “Who listens to your show?” But now I realize it's a huge accelerant to our potential impact. As I was recording this, I realized I probably should do one thing here; and that is at some juncture, I will probably make an RHV Tribe directory or something. So, go over to our Web site and sign up for the weekly email, which you can do on the Web site, because whenever I get around to doing that, I will start with everybody on the mailing list (because I have your email address). I'll send out a notice or something and ask if you'd like to be part of that directory. This is Part 1 of my manifesto. Next week (hopefully, if I can get my act together) or, if not, the week after that, I will bring you Part 2. In the meantime, thank you from the bottom of my heart for being who you are and doing what you do. It is going to be Relentless Health Value listeners who turn this oil tanker of a healthcare industry around. I guarantee it. For more information, go to aventriahealth.com. Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups. 00:47 What is your role as the listener of this show? 01:27 How did Stacey realize how special our listeners are? 01:56 Who are our listeners? 03:15 Why did Stacey start the Relentless Health Value podcast? 04:10 What have the listeners of the Relentless Health Value podcast and its guests accomplished? 05:13 What is Stacey's advice to listeners that feel powerless? 06:22 “It's the sum of all those micro choices … that determine the impact that that organization has on those it serves.” 09:22 “There are lots of synergies to explore.” 10:51 Sign up for our weekly email here. For more information, go to aventriahealth.com. Our host, Stacey Richter, discusses why she started our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard

EP398: Why Is the Commercial Payer Marketplace in California Completely Boring? With Jacob Asher, MD

Play Episode Listen Later Mar 23, 2023 34:07

Yeah, so while the commercial payer marketplace is completely boring, the reasons it's boring are not. Let me walk you through this conversation I have in this healthcare podcast with Jacob Asher, MD. First, we establish that the relative number of each carrier's commercial members in California don't seem to change year over year … and this has been true for years. When you rank order carriers by member count, the song remains the same. It's Groundhog Day. Here's a link to the 2022 CHCF (California Health Care Foundation) enrollment almanac, which shows for the large group market, Kaiser has captured and retained just over half of enrollees. Anthem comes in next with 14%, Blue Shield gets 9%, and then bringing up the rear we have UHC, Aetna, Cigna, Centene, and all others in descending order splitting the remaining 21%. Hmmm … intriguing, the whole idea that these relative member counts remain so consistent. Then Dr. Asher and I dissect what is anybody actually doing to cut into the Kaiser market share or try to grab share from the two blues plans, if anything. Dr. Jacob Asher was a great guy to have this conversation with. He was a practicing head and neck surgeon with Kaiser Permanente, and then he also served on the Permanente Medical Group Board of Directors. Then he changed careers and became a full-time health plan chief medical officer for, first, Anthem, then Blue Cross, then Cigna, then UHC (UnitedHealthcare). Now he's “retired” and reflecting back on unsolved and unaddressed issues within healthcare. And we've covered one here: Why is the commercial payer market as boring as it appears to be in California? Now, after I had this conversation with Dr. Asher, I called up Wendell Potter, who everybody already knows (EP384), and Lauren Vela, who everybody also probably already knows, but she has spent her career at various employer coalitions and now works at a big employer transforming their health benefits (and she lives in California). I learned a few things that really helped me frame my thoughts on some of the issues that surfaced in the conversation that I had with Dr. Asher and that you'll hear today. So, let's get to it. Why doesn't the relative market share of the big payers change year over year in California in the commercial space. May I present six reasons: 1. Everybody I talked to—Dr. Asher, Wendell Potter, Lauren Vela—first thing right out of the gate that practically everybody mentioned is employer inertia. Trying to get an employer to switch carriers is like trying to pull Excalibur from its stone. And right, not so surprising, it's disruptive and obnoxious for employees and also benefit teams if carriers are switching all the time. 2. EBCs (employee benefit consultants). They have deals with carriers and others, and they also have a lot of power over employers. Listen to the show with AJ Loiacono (EP379) and Paul Holmes (EP397) for more on this. 3. As Wendell Potter put it, “The commercial market is [as a whole] stagnant. No real growth nationally. And in many states, the real money for carriers is not in the self-funded market; so they don't care much about aggressively competing for market share.” Given that chart that just came out the other day showing the insane relative gross margins that carriers are making on Medicare Advantage patients, which is over double other lines of business … yeah, totally. 4. Just keep this in mind before we barrel into reason #4 here for a stagnant and maybe not exactly competitive market. Kaiser excluded, all of the rest of the California payers have what amounts to largely the same provider network. I'm exaggerating slightly here, but largely the same hospitals, the same consolidated integrated delivery networks. And one thing that's pretty clear (not just in California but across the country): Plans who bring the most members get the best prices from these hospitals and other provider organizations. Also, as Dr. Asher mentions in the show today, he never saw an employer buy on quality. Most were far more concerned about discounts. So, right … we have some circular reasoning here or circular logic. The big plans get the best prices, and then, because they have the best prices, they maintain their market share. But wait … there's more to this one, and it's not just big gets you lower prices. Remember from episode 395 with Brennan Bilberry? He talked about the concept of the Most Favored Nation (MFN) anticompetitive clauses in hospital contracts. This concept is also super relevant here for payers as well if you think about it. This MFN Most Favored Nation anticompetitive clause, this is where a big hospital and “big carrier” have a chat … in a back room. The hospital agrees to not give any other carrier a lower price than the “big carrier.” These MFN clauses are, of course, terrible for competition and plan sponsors and any patient with cost sharing. A lot of states have started to ban, restrict, and limit these clauses. The DOJ brought a case in Michigan about this, and here's a great federal government summary of the problem: “The department and the state of Michigan alleged … that the MFN clauses in [Blue Cross Blue Shield of Michigan's (BCBSM's)] contracts with Michigan hospitals decreased competition among health plans. Some … clauses required hospitals to charge competitors more than the hospitals charged BCBSM, often by a specified percentage. Moreover, BCBSM often agreed to raise the prices that it paid hospitals, in part to obtain [the] MFN clauses.” Oh, hey … I'll let you raise your price so I can have a Most Favored Nation clause, just as long as I get a lower price, which is higher than it was originally. And this was actually back in 2013. I have no insight at all or knowledge, or I am not suggesting in any way that what was going on in Michigan is going on in California. However, this anticompetitive practice is common enough. If you're interested in how common, count the lawsuits. 5. Employers are unaware a lot of times of how they are being charged more than what might be appropriate. And they are largely unaware of options other than Blue Cross, United, Cigna, Aetna … the big payers. 6. As Dr. Asher talks about and which I never really thought about, Kaiser doesn't have Medicaid patients. [Correction: Kaiser does have some Medicaid members—just less than others.] And because their network and hospitals to a large extent are closed, they also don't have uninsured patients to a large extent. So, no charity care to speak of and, therefore (at least as it is posited), they can be cheaper because they don't have to cost offset. So, their price advantage has a structure element here that could make it even more untouchable. So, there's your six reasons. You can start to see basically all of these things solidify into the same thing. It's less about trying to get new business and more about locking in the existing business. It's not really a secret that this market is rock hard. Plans realize that. They realize that the cost of keeping an enrollee is cheaper than acquiring a new enrollee. So, carriers focus sales and marketing efforts on holding on to their existing customers, especially the coveted jumbo accounts. Interestingly (and I was talking about this with Lauren Vela), the more clinical programs a carrier has deployed for an employer, the more the carrier is locked in there. So, the more the clinical value proposition resonates, the more clinical stuff that gets integrated. Changing plans becomes even more disruptive, and employers are even more likely to remain where they are. So, there's more to clinical programs than payers catching themselves a little PMPM (per member per month) something something upcharge recurring revenue or trying to get new business. It's also locking in customer retention. Is any of this specific to California? Some of it is—like a lot of the Kaiser stuff—but most, not. Meaning a lot of the country doesn't exactly have a functioning commercial small group or large group marketplace either. To a certain extent, it's no wonder big employers don't change plans that often. Why would they bother, given probably fairly incremental differences between these big payer carriers? I realize I'm scrambling out on a limb here and making assumptions, but to achieve more than incremental improvements, a BUCA (Blue Cross, United, Cigna, Aetna) would need to invest all kinds of resources into being that shining star. And why would they do that when nobody can take down Kaiser? And for all the reasons that we just talked about, it's a hard row to hoe to grab new clients. There's a lot of ramifications to this, but this show can't be seven hours long. You can learn more by connecting with Dr. Asher on LinkedIn. Jacob Asher, MD, completed a residency in otolaryngology–head and neck surgery at the University of California, San Francisco, after receiving degrees from Brown University and the Boston University School of Medicine. Dr. Asher then practiced as an ENT (ear, nose, and throat) surgeon with Kaiser Permanente in Northern California and also served on the board of directors of The Permanente Medical Group, where he focused on physician compensation reform, member satisfaction initiatives, and retirement benefits. After transitioning to full-time health plan management, Dr. Asher served as a California commercial market medical director between 2008 and 2022 for Anthem Blue Cross, Cigna, and UnitedHealthcare. In those roles, he supported membership growth and retention in both fully insured and self-funded product lines and promoted value-based reimbursement, including capitation. He has led utilization management teams, collaborated with internal and external population healthcare advocates, and worked to develop clinical initiatives that sought to achieve the Triple Aim. In his role as the clinical face of the health plan to the local market, he worked with network colleagues on accountable care organization partnerships and hospital and physician contract renewals with integrated pay for performance, supported Obamacare exchange participation, engaged in quality improvement collaboratives, and supported regulatory compliance efforts. Currently, Dr. Asher is serving as a mentor for the Stanford Master in Medical Informatics program while exploring innovative solutions to healthcare delivery. 10:00 What is the competitive picture of California's health plans? 11:28 What was everyone doing in order to get market share? 15:07 EP387 with Betsy Seals. 15:22 EP379 with AJ Loiacono and EP397 with Paul Holmes. 15:26 Why is it difficult to take market share? 16:16 Who was Dr. Asher pitching to and why? 18:49 Did employers ever buy plans for quality? 22:43 What does this look like from the payer perspective? 27:01 What improvements have there been to engagement in health plans? 29:07 Have plans gotten better at communicating with employers? 30:38 Why is it hard to compare the Kaiser world to the non-Kaiser world? 33:00 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD. You can learn more by connecting with Dr. Asher on LinkedIn. @JacobAsher18 discusses California's #commercialpayer marketplace on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak

Encore! EP293: Game Theory Gone Wild: Co-pay Cards, Co-pay Accumulators, and Co-pay Maximizers, With Dea Belazi, PharmD, MPH, President and CEO of AscellaHealth

Play Episode Listen Later Mar 2, 2023 33:54

Well, this episode is suddenly incredibly relevant again just with all the stuff going on with co-pay maximizers. If you're gonna understand maximizers, though, you really have to start here. In a nutshell, this whole thing is a battle royale between co-pay cards and patient assistance programs offered by pharma companies versus co-pay accumulators and co-pay maximizers deployed by health plans and PBMs (pharmacy benefit managers). I just want to start by getting everyone grounded on a few really key points. #1: Drug abandonment is a thing. Patient goes into the pharmacy to pick up their Rx and the out of pocket is too expensive, so they leave without their drug. This can happen on the first fill, like, “Oh, wow, I guess I don't really need that new drug my doctor just told me I should pick up.” Or it can happen downstream, like in January when, all of a sudden, a deductible kicks in. But in all cases, we have a patient getting sticker shock on the out of pocket for a med and then going without the drug … or pill splitting or rationing or doing other things to save money. #2: How PBMs shake rebates out of pharma manufacturers is to use what I just said (that whole abandonment possibility) as a leverage point. Pharma goes into a PBM that controls access for drugs for, I don't know, 100 million lives. The PBM says, “Hey, you, Pharma! If you want to be on our formulary, you gotta kick out this much in rebates.” Pharma says, “No, that is too much rebate. I cannot pay it.” PBM says, “Well, then … OK, you're not on formulary or you are poorly positioned on formulary. And let me translate what that means. Now the out of pocket for your drug will be so expensive that patients are gonna walk out of the pharmacy without your drug because I, the PBM, have control over patient out of pocket and I will make it very expensive.” From a pharma's standpoint, all those patients that aren't picking up the drug … that means a loss of market share. And that market share can translate into a lot of lost revenue for the pharma company. And thus begins the whole war of the co-pays/out of pockets. So now, let's fast-forward through the past, say, 10-plus years. It'll be like one of those movie montages with the action sped up so fast you don't need words to see what's going on … except this is an audio podcast, so I guess you do need words. Alright, so this is what happens next: Pharma starts raising its prices combined with there's more super expensive specialty pharmacy drugs. Reaction by the PBMs to this was to try to get more aggressive with Pharma demanding increasingly high rebates and other concessions, keeping in mind the prize and leverage point that the PBMs offered Pharma to secure those PBM rebates was lower co-pays or out of pockets for patients. Again, it's a well-known fact that the higher the patient out of pocket, the lower the market share of the drug because the higher the patient cost, the more patients abandon at the pharmacy counter. It's the old supply and demand curve at work. At a certain point here in all of this, the pharma companies start to get really pissed about their dwindling net prices as rebates start going up and up and their market share kind of doesn't because the PBMs are keeping the money and maybe not passing it along to plan sponsors or patients. It's a zero-sum game fight over the money, and Pharma feels like the PBMs are getting more than their share. And they're pretty smart, these pharma manufacturers. So, Pharma comes up with a Houdini move to escape PBMs holding Pharma hostage for rebates by using their control over how much patients pay or don't pay at the pharmacy counter. Fasten your seatbelts and let the games begin. Pharma decided to hand out co-pay discount cards. Then Pharma doesn't have to pay PBM rebates to get lower patient out-of-pocket costs. They can finesse lower patient out-of-pocket costs all by themselves. Take that, PBMs! Except now, the PBMs see this—and they raise. Enter co-pay accumulators and also co-pay maximizers. For this part of the extravaganza of game theory at its finest, I'm gonna let Dea Belazi, PharmD, MPH, my guest in this episode, explain further. However, one more thing to point out before we begin. In the olden days, this whole war of who has leverage over who transpired in the context of small molecule drugs in competitive markets a lot of times. So, like Lipitor versus Crestor and the brands all cost, like, $100 a month and, maybe, there was a generic equivalent. If the health plan made it too expensive for a patient to get one of those drugs, they usually made another one in the same class attractive financially. So, the patient had (theoretically, at least) options; and the stakes were also a lot lower. The dollar volumes that we're talking about here were a lot lower. Now this same war is being fought on the specialty side of the house, where drugs cost thousands or tens of thousands a month and the patient may have but one option. So, if it's made to be financially toxic for a patient to get that one drug, the patient has to choose between their family's health and dipping into their 401k in order to afford their out-of-pocket costs. Or going bankrupt. Or dying. And when I say “or dying,” that is not hyperbole. There are studies that clearly show the mortality rates for patients who have trouble affording their meds are worse. In these cases, Pharma can be, sort of authentically, a hero who steps in and helps patients who are functionally uninsured because they can't afford the co-pays and deductibles that their plan sponsors have put in place to actually use the insurance that they are paying handsome premiums to have. Pharma can step in and help via these co-pay discount cards or coinsurance programs or through patient assistance programs helping those with lower incomes. So, there's no question in the short term that when a patient desperately needs a drug and their insurance is insufficient, a pharma manufacturer can be a knight in shining armor financially. But only if this were so simple, like this is some kind of spaghetti western with the good guys and the bad guys. Now let's think about this co-pay/out-of-pocket assistance offered by Pharma with a longer timeframe or a more systemic timeframe in mind. How is it that Pharma can have prices that are as high as we all know they are? Right?! It's because enough patients don't abandon the med at the pharmacy counter or, these days, in the infusion clinic. So, the lower Pharma can drive the patient out of pocket for a really expensive drug, the more they have a certain amount of impunity to raise the drug prices. This is a lot of the argument against price caps on out of pockets just in general, by the way. They matter for patients. They save lives. But they also have the consequence of kind of getting rid of what is often seen as a big control point checking pharma prices from zinging even higher than they already are. Bottom line, we have a catch-22 on our hands—and the patient is stuck in the middle. If you're a patient and you need your miracle drug (and a lot of patients call these drugs their miracle drugs), Pharma is your hero … at least right now. However, Pharma is also now able to raise their prices even more next year; and now you really need their out-of-pocket support because the price of the drug is so high your employer/taxpayers can't afford the rising drug spend and even more cost gets shifted onto patients. It becomes like Stockholm syndrome. But again, no white hats and black hats here. This whole thing is one of those incomprehensible art house films with lots of plot twists and in every other scene, you start to feel for the character you just hated 10 minutes ago … because while Pharma is getting busy raising prices, you have PBMs and nothing-for-nothing plan sponsors also up to their own machinations. Like, hey, here's one that's quite a marvel: PBM double-dipping. If the PBM can get Pharma to pay the patient deductible and then also get the patient to pay the patient deductible … Hmmm … By the way, that was a backdoor introduction to accumulators. And then later on, maximizers showed up on the scene. I just want to say that with maximizers, not all are created equal. I can certainly see their value for patients when they are deployed by companies and plan sponsors as part of their benefit designs with an explicit goal of helping members and the plan itself (nothing for nothing) afford expensive drugs it's clear that the patients need. But … I have to say, and I'm not well versed enough yet in how this maximizer business has evolved to comment on whether some of what is going on is still a net positive for some members and patients. Some of these PBMs have opened up entirely separate maximizer companies, which, for sure, they are upcharging employer plan sponsors to use. And the whole point of these separate entities is to get as much cash out of Pharma as possible while they, I don't know, may or may not pass that cash on as savings to patients and members. I need to do a show on this coming up. There's a new bill in the House, by the way. It's called the HELP Copays Act, which I don't think is just aimed at accumulators. If you didn't understand what I just said, you will after you listen to this episode. With that, here's Dea Belazi. Dea is president and CEO over at AscellaHealth. He is a pharmacist by training who has worked for Pharma, and then he worked at a health plan, spending a lot of time in the PBM space. In other words, he's seen this tangled web from pretty much every angle. We kick right into the conversation talking about accumulators. You can learn more at ascellahealth.com. Dea Belazi, PharmD, MPH, has led the development and management of AscellaHealth's global specialty pharmacy benefit and healthcare services for nearly a decade. As a visionary and architect of change, leading the AscellaHealth shift from pharmacy benefit management to specialty pharmacy solutions, he has played a key role in the company, achieving a staggering four-year growth of more than 1556%. Previously, he served as a senior executive and played a key role in the growth and expansion of PerformRx, a PBM owned by Keystone First Health Plan. Additionally, Dea held a leadership position at FutureScripts, an Independence Blue Cross company that was sold to Catamaran. A respected industry professional and thought leader, Dea is often invited as a reviewer for multiple medical journals and holds a seat on the board of directors for numerous healthcare-related companies. Based on his impressive career and growing reputation, he was chosen to serve on FierceHealthcare's Editorial Advisory Council. Dea was most recently recognized as an Ernst & Young Entrepreneur of the Year 2022 Greater Philadelphia Award Finalist; he is also a 2022 Philadelphia Titan and a 2021 Philadelphia Business Journal Most Admired CEO honoree. Dea holds a PharmD from the University of Rhode Island. He completed his dissertation at Brown University, earned a Master of Public Health from Johns Hopkins University, and served as a post-doc health outcomes research Fellow at Thomas Jefferson University. 11:06 “The concept of co-pay accumulators wasn't just a … PBM thought, but it also came from their customers, whether it was health plans or employer groups.” 15:50 “[This is] literally a math problem based on, ‘Do I spend it now? Do I spend it later?'” 17:20 What reason do employers and payers have for doing this? 21:13 “This is another mechanism for payers to push down additional cost to both the patient and now the pharma company.” 22:24 EP241 with Vinay Patel. 22:59 “I don't think accumulators are really forcing Pharma to be more competitive.” 25:06 How co-pay maximizers are different from co-pay accumulators. 28:09 Who doesn't like co-pay accumulators and maximizers? 30:01 How patient advocacy groups are a different model. 32:10 What is the biggest challenge facing employers right now? You can learn more at ascellahealth.com. Dea Belazi of @AscellaHealth discusses #copayaccumulators and #copaymaximizers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #copay Recent past interviews: Click a guest's name for their latest RHV episode! Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356)

EP394: Spoiler Alert: It Is Counterintuitive Which Hospitals Offer the Most Charity Care, With Vikas Saini, MD, and Judith Garber

Play Episode Listen Later Feb 16, 2023 34:08

You would think that hospitals with the most money would offer the most charity care—trickle down and all of that. If my health system is big and I have lots of money and profitable commercial patients, I can stuff more dollar bills into the charitable donation balance sheet bucket, right? Except, in general, it's a fairly solid no on that. Let's talk about some of my takeaways from the conversation that I had with Vikas Saini, MD, and Judith Garber from the Lown Institute. During the conversation, there's also mention of a powerhouse of a New York Times article. So, let's circle up on but a few of the more interesting (according to me) reasons why some rich hospitals fail to offer the level of charity care that you might think they could or should: #1: Chasing commercial contracts because they are very profitable means building in areas where there are frankly not a whole lot of poor people. You see hospital chains doing this all of the time and saying at the 2023 JPM (J.P. Morgan) conference that they intend to do more of it, opening up in a fancy suburb with no affordable housing. When this happens, there is just less opportunity to offer charity care. The need for financial aid in that ZIP code is just less. #2: The Ambulatory Surgical Center (ASC) movement, which is weird to say because, in other respects, I'm a big fan. There are a lot of services and surgeries moving out of the hospital into ambulatory surgical centers or just the outpatient setting, and this is going on for a bunch of reasons, including Medicare and employers being very on board with this to save facility fees. But here's a consequence: Surgeons and other docs are now not in the hospital. So, indigent patient shows up in the emergency room and needs an emergency surgery or some intervention. But wait … those physicians and their teams are no longer in the hospital. And now the hospital doesn't have the “capability or the capacity” to serve that patient. I heard from a surgeon the other day, and when he's on call at his hospital, he's getting patients shipped to him on the regular from hospitals in other states. Now, about this “oh, so sorry … we can't possibly help you so we're gonna stick you in an ambulance and take you to another state” plan of action. I called up emergency room expert Al Lewis. He told me that if this “ship 'em out” is being done routinely as a pattern by hospitals who have an ER, you could call it evidence of an EMTALA (Emergency Medical Treatment and Labor Act) violation on several levels. You can't have an emergency room and then routinely not be able to handle emergencies, especially when the emergencies you can't handle always seem to be of a certain kind and for a certain kind of patient. Speaking of violations, one more that reduces the need and level of charity care is canoodling with ambulance companies to take the poor people to some other hospital and the rich people to your hospital, which was allegedly transpiring in New Jersey, based on a recent lawsuit. #3: [play some foreboding music here] This last one is the big kahuna underlying reason why some very rich hospitals may not offer the level of charity care which you'd think they would. This was superbly summed up by Tricia Schildhouse on LinkedIn the other day. She knew a physician leader who would go around saying, “Non-profit and for-profit is a tax position, not a philosophy.” Bottom line, this whole thing boils down to what has been normalized as OK behavior at some of these rich hospitals. You have people in decision-making roles taking full advantage of their so-called tax position to jack up their revenues—revenues which they have no interest in frittering away on charitable causes. Why would they do that when they can use the money to, I don't know, stand up a venture fund or make Wall Street investments? Don Berwick's latest article in JAMA is entitled “The Existential Threat of Greed in US Health Care.” And, yeah … exactly. Back to that New York Times article that we talk about in this healthcare podcast, here's what it says about a hospital in Washington State. It says: “The executives, led by [the hospital's CFO] at the time, devised … a program called Rev-Up. “Rev-Up provided [the hospital's] employees with a detailed playbook for wringing money out of patients—even those who were supposed to receive free care because of their low incomes.” All of this being said, there are hospitals out there who are, in fact, living up to their social contract and serving their communities well with very constrained resources. You also have hospitals just in general working within some really whack payment models that we have in this country, which easily could be a root cause precipitating this suboptimal-ness. Dr. Saini and Judith Garber mention three direct solves for hospital charity shortfalls and also the larger context of the issue. So, there's, of course, better reporting and better auditing, which is pretty nonexistent in any kind of standardized way right now. I also really liked one of the solutions that Dr. Saini mentions on the show: Maybe instead of all the hospitals doing their own charity care thing, they all should pool their money regionally and then put a community board in charge of distributing it. That way, if there is a hospital in an area where the charity care is really needed, even if the rich hospital nearby doesn't have a facility there, they can help fund this care that their larger community really needs—including, by the way, public health needs, which is currently a big underfunded problem. As mentioned earlier, I am speaking with Vikas Saini, MD, and Judith Garber. Dr. Saini is president of the Lown Institute. Judith Garber is a senior policy analyst there. They've studied hospitals from a number of dimensions, not just charity care. You can learn more at lowninstitute.org and lownhospitalsindex.org. Vikas Saini, MD, is president of the Lown Institute. He is a clinical cardiologist trained by Dr. Bernard Lown at Harvard, where he has taught and done research. Dr. Saini leads the Institute's signature project, the Lown Institute Hospitals Index, the first ranking to measure hospital social responsibility. The Index, first launched in July 2020, evaluates hospitals on equity, value, and outcomes and includes never-before-used metrics such as avoiding overuse, pay equity, and racial inclusivity. In his role at the Lown Institute since 2012, Dr. Saini led the development of the Right Care series of papers published by The Lancet in 2017, convened six national conferences featuring world-renowned leaders in healthcare, and guided other Lown Institute projects such as the “Shkreli Awards.” Dr. Saini also serves as co-chair of the Right Care Alliance, a grassroots network of clinicians, patient activists, and community leaders organizing to put patients, not profits, at the heart of healthcare. Prior to the Lown Institute, Dr. Saini was in private practice in cardiology for over 15 years on Cape Cod, where he also founded a primary care physician network participating in global payment contracts. He also co-founded Aspect Medical Systems, the pioneer in noninvasive consciousness monitoring in the operating room with the BIS device. Dr. Saini is an expert on the optimal medical management of cardiologic conditions, medical overuse, hospital performance and evaluation, and health equity. He has spoken and presented research at professional meetings around the world and has been quoted in numerous print media, on radio, and on television. Judith Garber is a senior policy analyst at the Lown Institute. She joined the Lown team in 2016, after receiving her Master of Public Policy degree from the Heller School of Social Policy. Her research interests include hospital community benefit policy, overuse and value-based care, and racial health disparities. She has authored several white papers, journal articles, op-eds, and other publications on these topics. Judith previously worked at the Aspen Institute Financial Security Program, the Midas Collaborative, and Pearson Education. She has a bachelor's degree in American studies and political science from Rutgers University. 06:50 Why does America need socially responsible hospitals? 08:23 What standards are hospitals beholden to with their charitable spending? 08:47 “It's the honor system, essentially.”—Dr. Saini 11:38 What is fair share spending? 13:43 Which hospitals are paying their fair share? 15:05 Why do hospitals that are financially more strapped tend to give back to their communities more? 17:25 Why is it hard for hospitals with the most privately insured patients to do the most for their community? 18:56 “These outcomes … are the outcomes of the [current system].”—Dr. Saini 21:23 “A key problem here is [that] systems have gotten so big.”—Dr. Saini 22:30 What's the solution to fixing the problem with hospital charity care? 23:52 EP374 with Dave Chase. 29:21 What would be the level of acceptance with changing the system as it stands with hospitals? You can learn more at lowninstitute.org and lownhospitalsindex.org. @DrVikasSaini and @JudiTheGarber of @lowninstitute discuss #hospitalcharitycare on our #healthcarepodcast. #healthcare #podcast #hospitals Recent past interviews: Click a guest's name for their latest RHV episode! David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari

EP391: Lessons for Private Equity and Others Trying to Do Right by PCPs and Their Patients, With Scott Conard, MD

Wing It - A Digital Marketing Podcast

Play Episode Listen Later Jan 19, 2023 35:20

On Relentless Health Value, I don't often get into our guests' personal histories. There are a bunch of reasons for this, which, if you buy me beer, we can talk podcast philosophy and I will tell you all about my personal, very arguable opinion here. Nevertheless, in this healthcare podcast, we are going rogue; and I am talking with Scott Conard, MD, who shares his personal story. You may ask why I decided to go this route for this particular episode, and I will tell you point blank that Dr. Conard's experience, his narrative, is like the perfect analogue (Is analogue the right word [allegory, composite example]?). His story just sums up in a nutshell what happens when a PCP (primary care provider) does the right thing, manages to improve patient care for real, and then at some point gets sucked into the intrigue and gambits and maneuvering that is, sadly, the business of healthcare in the United States today. Before we kick in, I just want to highlight a statement that Scott Conard makes toward the end of the show. He says: So, this isn't about punishing or blaming aspects of care that are being overrewarded today. It's really about what's the path forward for corporations, for middle-class Americans, and for primary care doctors who don't choose to be part of a big system. We have to figure out how to solve this problem. I hope people don't hear this and think that there are horrible people at some not-for-profit hospital systems, for example. There are some great people at not-for-profit health systems, but they have some really screwed-up incentives. A few notable notes from Dr. Scott Conard's journey and words of wisdom that I will just highlight up front here: He says that as a PCP, you actually can produce high-value care in a fee-for-service model … if you think differently and you change practice patterns. I have heard this from others as well, including most recently David Muhlestein, PhD, JD, who says this in an upcoming episode. Now here's a surefire way to fail at that, though: Be a physician who is getting asked to basically do everything a patient needs done alone and by themselves with little or no help and being told to do all of this within a seven-minute visit. This surefire way to not do well also could mean working on a team that's a team in name only because it's more of a marketing thing than an actual thing. As Dr. Scott Conard says later in this episode, healthcare organizations must embrace the art of medical leadership. So, I guess that's a spoiler alert there. Another point that Dr. Conard makes very crisply toward the end of the show is that doctors can kinda get pushed and pulled around in this mix. You have docs just trying to provide good care, and they work for one entity that gets bought and now it's some other entity … and what's happening upstairs and the prices being charged or somebody somewhere deciding not to make prices transparent, or deciding to sue low-income patients for unpaid medical bills or what charity care to offer or not to offer. These are not doctors in clinics making these calls, and we need to be careful here not to homogenize what some of these health systems are choosing to do like some kind of democratic vote was taken by everybody who works there. Health systems, hospitals, are many-celled complex entities. And a third takeaway—there are a bunch of takeaways in this show, but a third one I'll highlight here from Dr. Conard's story—is the old fiduciary responsibility code word being used by health system administrators as a euphemism for strategies that might need a euphemistic code word because the strategy has questionable community benefit. In the case study that we talk about today, the local health system managed to raise healthcare spend in North Texas by $100 million year over year. Employers and employees in North Texas, communities, wound up paying $100 million more year over year in healthcare one particular year. This was prices going up. It also was removing a big systemic initiative to keep heads out of hospital beds. Reiterating here, we are not talking about doctors here particularly because, of course, the vast majority of doctors are trying to prevent avoidable hospitalizations. But suddenly in North Texas, physicians did not have the population health efforts and the team really standing behind them helping to prevent avoidable hospitalizations. That sucks for everybody trying to do the right thing, and, as has been said, burnout is moral injury in a cheap Halloween costume. Moral injury happens when you have good people, clinicians, doctors, and others who realize that what is going on, at best, is not helping the patient. You can learn more by emailing Dr. Conard at scott@scottconard.com. Scott Conard, MD, DABFP, FAAFM, is board certified in family and integrative medicine and has been seeing patients for more than 35 years. He was an associate clinical professor at the University of Texas Health Science Center at Dallas for 21 years. He has been the principal investigator in more than 60 clinical trials, written many articles, and published five books on health, well-being, leadership, and empowerment. Starting as a solo practitioner, he grew his medical practice to more than 510 clinicians over the next 20 years. In its final form, the practice was a value-based integrated delivery network that reduced the cost of care dramatically through prevention and proactive engagement. When this was acquired by a hospital system, he became the chief medical officer for a brokerage/consulting firm and an innovation lab for effective health risk–reducing interventions. Today, he is co-founder of Converging Health, LLC, a technology-empowered consulting and services company working with at-risk entities like self-insured corporations, medical groups and accountable care organizations taking financial risk, and insurance captives to improve well-being, reduce costs, and improve the members' experience. Through Dr. Conard's work with a variety of organizations and companies, he understands that every organization has a unique culture and needs. It is his ability to find opportunities and customize solutions that delivers success through improved health and lower costs for his clients. 05:26 What triggered Scott's career journey? 06:02 What caused Scott to rethink what is good primary care? 06:42 Why did Scott realize that he is actually a risk-management expert as a primary care doctor rather than someone who treats symptoms? 07:56 Encore! EP335 with Brian Klepper, PhD. 08:24 How did Scott's practice change after this realization? 08:35 What is a “Whole-Person Risk Score”? 09:39 Scott's book, The Seven Numbers (That Will Save Your Life). 11:37 “You start to move from a transactional model to a relationship model.” 14:02 Did Scott have any risk-based contracts? 14:39 Why is it so important to look at total cost of care and not just primary care cost? 19:39 Scott's book, The Art of Medical Leadership. 20:44 EP381 with Karen Root. 29:14 Why did Scott move over to help corporations? 31:42 EP364 with David Muhlestein, PhD, JD. 32:22 “Everybody thought they were honoring their fiduciary responsibility, and the incentives are completely misaligned.” 33:02 EP384 with Wendell Potter. 33:15 “It's the system that's broken; it's not bad people.” You can learn more by emailing Dr. Conard at scott@scottconard.com. @ScottConardMD discusses #privateequity on our #healthcarepodcast. #healthcare #podcast #PCP #patients Recent past interviews: Click a guest's name for their latest RHV episode! Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372)

Insurance Providers: How to Improve Broker Communications - Wing It Podcast Episode 83

Play Episode Listen Later Jan 13, 2023 37:55

This week on the Wing It Podcast Michael and Jennifer discuss how Insurance Carriers and MGAs can use marketing automation to effectively manage broker communications.

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EP389: The Clapback When Hospitals Cannot Constrain Their Own Prices, With Mike Thompson

Winning Isn't Easy: Long Term Disability ERISA Claims

Play Episode Listen Later Jan 5, 2023 34:41

For the past few shows and in a few coming up, we are circling our wagons around a theme: In healthcare in this country, there are two teams. One team is employers, taxpayers, patients … those trying to keep healthcare prices down. Then on the other team, we have those looking for healthcare prices to continue to go up, meaning, as just one example, some health systems and some hospitals. There was a New York Times article recently, and Peter Hayes wrote an interesting comment about it on LinkedIn. He wrote: “This article is troubling on so many levels and clearly demonstrates that patient health and well-being are not the top priority of many in healthcare leadership in our hospitals. Unfortunately, it is much more about patient revenue than patient health. … The non-profit status of our health facilities is a huge hidden tax and wealth transference from every taxpayer that is estimated to be about $39 billion annually.” Look, for sure, not talking about everybody in healthcare leadership here, and increasingly I'm kinda thinking we need to maybe have more than one word for hospitals and their leadership because lumping them all together into a homogenous blob is really unfair to those rural and safety net organizations contending with all kinds of adversities—which is very, very different in circumstance to those so-called “well-resourced” hospital chains in suburban markets really raking in the cash and virtue signaling in very well-resourced press campaigns. And the irony of this whole thing is that a reason hospitals (that want to) get away with doubling down on profit-centric business models is actually their nonprofit status. This is a major loophole. If you are a nonprofit, you get to be excluded from some of the powers of the FTC (Federal Trade Commission), for example. But then there's also the lack of financial discipline, as Mike Thompson puts it in the show today. These nonprofit organizations have never had to run efficiently. They have never been asked to justify the new building or the other adds to their infrastructure that ultimately increase their costs of doing business in ways that, on the whole, might not benefit patient care. And I say “might not benefit patient care” fairly confidently because there is absolutely no correlation between high prices and high quality in healthcare. In fact, it can just as easily be the opposite. But if you overbuild and you buy too many MRI machines or whatever, then you gotta feed the beast. And then the downward spiral starts, and the anticompetitive, financially toxic behavior really kicks into high gear—which, again, is tough to regulate because our laws and legislation expect nonprofits to, you know, behave like nonprofits. In this healthcare podcast, I am thrilled to speak with Mike Thompson, who is the CEO and president of the National Alliance of Healthcare Purchasers. Interestingly, Mike is an actuary by background; and I am sure that that has come in handy as more and more data is becoming available for purchasers and also regulators. The National Alliance has created a playbook to help employers get a fair price from hospitals. In short, the playbook's five strategies to do so include (1) looking up what the fair commercial price is for your local hospital, which is really easy to see if you go to dashboard.sagetransparency.com. This Sage Transparency dashboard was created by the Employers' Forum of Indiana. Not to drown you in acronyms, but the Sage Transparency dashboard very elegantly combines RAND data showing what hospitals are actually charging employer plans and compares that to what's called the NASHP commercial break-even price. NASHP is the National Academy for State Health Policy, who crunched a lot of numbers to figure out this commercial break-even price. Once you know the fair commercial price for hospitals in your area, then one way to go could be (2) using an RBP (reference-based pricing) strategy and paying based on the fair commercial price plus a markup. Another strategy is to (3) start monitoring your ASO/TPA (administrative services organization/third-party administrator) carefully and see that they are paying this fair price and getting performance guarantees to hold them accountable to do so. Yet another strategy is to (4) gang up with other employers in coalitions, which is often necessary, given how much market power some of these hospitals have consolidated and all the anticompetitive practices they've managed to tuck into their FTC-exempt quiver. And last is to (5) regulate through legislation. One point that Mike makes very clear is that if nonprofit hospitals cannot remain true to their mission and if they are also not subject to market dynamics, that's a lose-lose for their communities. At that point, a very viable option is to regulate them like utilities. This is also what I talk about next week with Chris Skisak and Gloria Sachdev. The sad part about this whole thing is that hospitals and communities really should be sitting on the same side of the table working together to improve the health and well-being of their communities. And that should include—according to me, at least—keeping financial toxicity in check, especially just given everything we know for sure about how financial toxicity negatively impacts patient health. Oh, hey, here's a thing: Turns out I had a fever when I recorded this show, so yeah, Mike deserves a little extra kudos for very eloquently just going with it when occasionally my questions sort of ended without, you know, actually asking a question. You can learn more at nationalalliancehealth.org. Michael Thompson is the president and CEO of the National Alliance of Healthcare Purchaser Coalitions (National Alliance), the only nonprofit, purchaser-led organization with a national and regional structure dedicated to driving health and healthcare value across the country. Prior to joining the National Alliance, Mike was a Principal at PricewaterhouseCoopers (PwC) for 20 years. He is a nationally recognized thought leader for business health strategies and health system reform. Mike has worked with major employers and other stakeholders on sustainable cost reduction, integrated health, wellness and consumerism, retiree health, private health exchanges, and health reform. Known for developing and promoting collaborative cross-sector health industry initiatives, Mike participated on the steering board of the World Economic Forum's “Working toward Wellness” initiative and co-founded the Private Exchange Evaluation Collaborative. Prior to PwC, Mike served as an executive with diverse roles with Prudential Healthcare for over 17 years. Mike is a Fellow of the Society of Actuaries, serving on the Health Practice Council, and chairs the Medicare Sub-Committee of the American Academy of Actuaries. He is board president of the Innovation and Value Initiative. He is also widely recognized as a leading national advocate for mental health and well-being and was past president of the New York City chapter of the National Alliance for Mental Illness. 05:37 Check EP372 with Cora Opsahl; EP358 with Wayne Jenkins, MD; EP388 with Merrill Goozner; and EP346 with Peter Hayes for a deep dive. 05:48 Why should an employer health plan be concerned about how much area hospitals are spending? 07:01 How are hospitals quantifying their prices? 08:10 “I think we're not paying a fair price is the end game.” 10:45 How do we bring rigor back into the market? 11:12 What is NASHP? 15:10 What does the NASHP commercial breakeven take into account? 18:24 Why are hospitals conflicted when it comes to building a health system based on value and health? 20:17 Why is the onus on hospitals to defend the way they've spent the money they have? 21:58 “Where there are market dynamics, we typically see prices in that fair price range.” 25:06 What can employers do from a market standpoint, a program design point, and a policy standpoint? 27:11 What is the National Alliance of Healthcare Purchaser Coalitions playbook? 30:15 Why is changing the dynamics in the press important to changing hospital pricing? 33:02 How fundamental is the employer's role in making sure that they're paying a fair price for the healthcare services their employees are receiving? You can learn more at nationalalliancehealth.org. @IWLMikeT of @ntlalliancehlth discusses #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #hospitals #healthcarepricing Recent past interviews: Click a guest's name for their latest RHV episode! Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371)

More On ME-CFS & Fibromyalgia - How Disability Insurance Carriers Will Use & Misuse "Limited Disability Period" Clauses In Your Disability Policy.

Play Episode Play 30 sec Highlight Listen Later Nov 22, 2022 15:27 Transcription Available

Listen in as Nationwide Long Term Disability ERISA Attorney Nancy L. Cavey talks about the many disabling conditions that disability insurance carriers and other issues you may have regarding your Long Term Disability policy coverage.Nancy is known for helping those with specific conditions fight the disability insurance company for the rights of her clients.Resources Mentioned In This Episode:LINK TO ROBBED: https://caveylaw.com/get-free-reports/get-disability-book/LINK TO PROFESSIONAL BOOK: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/FREE CONSULT LINK: https://caveylaw.com/contact-us/Need Help Today?Need help with your Long Term Disability or ERISA claim? Have questions? Please feel free to reach out to use for a FREE consultation. Just mention you listened to our Podcast!Review like and give us a thumbs up! We love to see your feedback about our Podcast!

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Encore! EP351: Everybody in the Healthcare Industry Getting Up in Everyone Else's Business, With Eric Bricker, MD

Play Episode Listen Later Nov 16, 2022 34:49

This episode was one of the most popular episodes in the past 12 months. Since it aired, there was a show with Kevin Schulman, MD (EP366), that added some context, which I would recommend, and also one with David Muhlestein, PhD, JD (EP364). Those two shows and this one are a good three-pack. And hey, here's something new that we're going to try out. Coming up in December, Dr. Bricker and I will host a smallish virtual chat to discuss the topics covered in this episode. It will be a conversation, not a presentation, so therefore the “why” behind the “smallish.” If you are kinda thinking this is something that you'd like to do, go to our Web site and scroll down to the “Join the Relentless Tribe.” When we get our act together, we'll send out the details for how to sign up in a future email. I'm thinking it will be very cool to get a chance for the great people who support our show enough to actually get a weekly email to talk amongst ourselves! In this healthcare podcast, I'm speaking with Eric Bricker, MD, about how so many entities in healthcare are getting up in other people's business and swimming in other people's traditional lanes. We kick off the conversation talking about the payer, PBM, and hospital system horizontal consolidation that has transpired over the past decades (that's plural). Horizontal consolidation is pretty much the easiest way to decimate all competition in your own swim lane so that you can charge more and not worry so much about patient/customer/member experience because the patients/customers/members have no better alternative. They effectively have nowhere, or few other places at best, to go if they leave you. So, what's the impact of horizontal consolidation? Commercial insurance costs have gone up 4x the rate of other benchmark goods and services. Let's spend a moment, shall we, on the human impact of all this extreme consolidation. The impact is your sister, your neighbor, your son, your friend. So many feel so much pressure financially in our country today because of healthcare costs. Even families earning significantly more than median household income are forgoing care because of costs. This was in a recent paper. (The authors are Alyce S. Adams, Raymond Kluender, Neale Mahoney, Jinglin Wang, Francis Wong, and Wesley Yin.) But the direct observable financial toxicity resulting from high healthcare patient costs is really only the tip of the iceberg here. As Dave Chase from Health Rosetta has said a million times already, high healthcare costs have a multitude of effects on employers, big and small. One big one is, if healthcare costs more, then there's less money for salaries. Dave, citing lots of evidence, has long attributed wage stagnation in this country to accelerating healthcare costs, which became even more rampant during periods of industry consolidation. Dave Chase leads Health Rosetta, by the way. Here's another human toxicity: Listen to episode 337 with Oliva Webb on the impact on her life as a result of the undeniably and unquestionably common non-excellent treatment by the PBMs and SPPs that she has to deal with. Because, as Dr. Bricker also says, no competition means basically not a whole lot of concern about patient experience. Why should a for-profit business spend money to improve something when there's nothing really to be gained for them financially to do so? I mean, the best a patient can do most of the time is hop from the frying pan into the fire. That's what happens when there's no competition or no real competition. Also consider the burned-out clinicians who have to get stuck in the middle of this nobody-really-cares-at-the-monopoly customer service paperwork quagmire. By the way, here's a sidebar that might come as a surprise to some people, but please take this in the spirit with which it's intended. All of us innovators and lifelong learners, we want to update our beliefs when the facts show us an updated conclusion. So, I have learned that all of this consolidation was going on long before the ACA (Affordable Care Act). My point here is to please look into this well-documented trend line before reflexively tweeting that the ACA drove consolidation. Dr. Bricker and others like Dr. Mai Pham have told me that, in their opinion, low interest rates, cheap debt, and a desire to eliminate competition are wildly powerful drivers of consolidation. Anyway, about eight minutes into the interview with Dr. Bricker, if you're one of the ones who knows all you care to know about horizontal consolidation, we get into vertical integration, vertical consolidation—and this is where things get interesting. And when I say interesting, I mean it in a “we live in interesting times” kind of way. The vertical consolidation conversation segues into whose swim lane that the digital health and other innovators or, dare I say, disrupters are diving into and whose lunch they are aiming to eat. Dr. Bricker probably needs no introduction. He is the force behind AHealthcareZ, which you can find online, on Twitter, YouTube, and LinkedIn. He has worked as a clinician, in healthcare finance. If that weren't enough, he's also been an entrepreneur—a very successful entrepreneur, I might add. He started one of the first healthcare navigation firms. You can connect with Dr. Bricker on Twitter at @DrEricB and on LinkedIn. Eric Bricker, MD, is an internal medicine physician and former cofounder and chief medical officer of Compass Professional Health Services. Compass is a healthcare navigation service that grew to 2000+ clients, including T-Mobile, Southwest Airlines, and Chili's/Maggiano's restaurants. Compass was acquired by Alight Solutions in July 2018. Alight is a 10,000-person employee benefits and HR outsourcing company that separated from Aon in 2017. Dr. Bricker has since started AHealthcareZ.com, with 300+ healthcare finance videos with approximately 120,000 views per month across all platforms. In 2022, he became medical director of SimplePay Health, an alternative health plan that empowers employees with high-quality care, concierge support, and easily understood payment. He is also the author of Healthcare Money Campfire Stories. 05:50 What is this “megatrend” happening in healthcare right now? 07:11 How has consolidation changed the healthcare landscape? 09:41 What is vertical integration within healthcare? 11:07 Why doesn't inorganic growth benefit patients? 12:52 “What is best for the patient does not necessarily make the most money.” 14:02 “It's not that it's above the law … it is just intentionally obscured.” 18:16 “Healthcare is glacial. It is slow.” 22:36 “The largest source of healthcare costs is hospitals.” 25:00 EP330 with John Marchica. 28:20 “What have the historical priorities been of the administrators of those hospitals?” 28:35 “Every hospital CFO knows that they need sick people.” 29:21 EP343 with David Carmouche, MD. 30:01 “The payment change has to come first.” 31:19 “The money wins.” 33:16 “You've got to put the financial incentives in place … to make people actually behave the way that they should.” You can connect with Dr. Bricker on Twitter at @DrEricB and on LinkedIn. @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth What is this “megatrend” happening in healthcare right now? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth How has consolidation changed the healthcare landscape? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth What is vertical integration within healthcare? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth Why doesn't inorganic growth benefit patients? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “What is best for the patient does not necessarily make the most money.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “It's not that it's above the law … it is just intentionally obscured.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “Healthcare is glacial. It is slow.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The largest source of healthcare costs is hospitals.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “What have the historical priorities been of the administrators of those hospitals?” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “Every hospital CFO knows that they need sick people.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The payment change has to come first.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The money wins.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “You've got to put the financial incentives in place … to make people actually behave the way that they should.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman

EP386: What You Need to Know About ER Bills Post the No Surprises Act, With Al Lewis

StudioOne™ Safety and Risk Management Network

Play Episode Listen Later Nov 10, 2022 32:21

First of all, let me thank those of you who have left a podcast review in 2022. There was one from Best Healthcare Podcast Around on Apple Podcasts the other day that thanked Relentless Health Value for being singularly responsible for providing a 400-level education in so many complex areas of healthcare, which I personally really appreciated because we aspire to be a master class in healthcare industry strategy, such that those looking to do right by patients understand the dynamics well enough to succeed. This also echoed a review from February of this year that said that Relentless Health Value distills complex healthcare issues into a highly intuitive and highly accessible narrative that helped the reviewer's Fortune 500 company get everybody in the C-suite the understanding needed to confidently make some pretty key healthcare-related decisions. Thanks so much to those of you who left a review for taking the time. As I have said on earlier shows, we really have a Relentless Tribe here working hard to make the healthcare industry in this country much more accountable to the patients that we serve. And you leaving a rating and a review might be the best thing that you can do if you're into helping us achieve our mission, because the ratings are so entwined with helping others find the show. If you consider yourself a listener who has gained value from this show and you haven't yet left a review or a rating, could I ask that you do me a favor and do so? If you don't know how to do that, there are instructions here for how to do so. *** In this healthcare podcast, I am talking with Al Lewis. Al has been on the show before. One thing I did not realize about Al is that he went to Harvard Law School. Today we are discussing using the Quizzify Consent Form in the emergency room. This Quizzify Consent Form quite simply gives patients convenient ways to remember the exact and specific words they need to write on any financial forms they are presented with and told to sign in the emergency room. These words negate a hospital system or ER staffing firm's claims that the patient agreed in a blanket statement to pay whatever they are charged. In the past (ie, before the surprise billing legislation that went into effect at the beginning of 2022), this Quizzify Consent Form helped prevent the old $11,000 COVID test somebody got in the emergency room or the million-dollar heart attack. For more on the legislation itself, listen to the show with Loren Adler (EP307). While it is far from perfect in a few respects, on the whole, the No Surprises Act is good for patients. It's been terribly bad news, however, for certain private equity–backed ER staffing organizations who used surprise billing as a business model, meaning specifically—and maybe there's others, but Team Health and Envision are certainly the big dogs here. This wasn't any sort of cloaked-in-the-shadows secret, by the way, as far as business models for these two entities. I recall one of them saying without equivocation that the No Surprises Act would be very detrimental to their business. And it turns out, they were right. Here's from Fierce Healthcare, quoting Moody's: “Envision ‘faces significant social risk' due to ‘significant negative publicity relating to the patients … receiving surprise medical bills' and will remain financially challenged by the No Surprises Act.” Moody's downgraded Envision's corporate debt, suggesting that they are at risk of going bankrupt over the next 12-18 months. To further attenuate my sympathies, both of these companies, Team Health and Envision, cut doctors' pay during the first COVID-19 wave while simultaneously spending millions on political ads to protect surprise billing practices. Anyway, sad … not sad. Getting back on track here, the good news in all of this is that patients don't have to worry about surprise bills either by private equity–backed entities or just your run-of-the-mill hospital down the street who, pre–No Surprises Act, were not opposed to a little surprise billing action of their own or not opposed enough to do anything about out-of-network docs sending these bills in a lot of cases. But the No Surprises Act doesn't make going to the ER a safe space from a financial standpoint for patients or their employers, and this is what I talk about today with Al Lewis. This whole conversation reminded me of something that David Contorno has said more than once: Every hospital bill, every physician bill is a surprise bill if the patient does not know ahead of time what the charges will be. You've listened to this podcast before and heard guest after guest talk about how payers … frankly not so good at negotiating with hospitals, most of whom have emergency rooms. (Listen to EP346 with Peter Hayes, for example.) If you're a patient and you go to the ER, you're gonna see this lack of great negotiating in all of its glory. So, for example, if a payer “negotiated” $10,000 for an emergency MRI or CT scan or some other test or service and the patient has cost sharing, yeah, that patient just got hit with a very, very big bill. Or the whole upcoding thing. This whole thing is what I talk about with Al Lewis today: post–No Surprises Act, what's happening in emergency rooms and how can we protect patients/members/employees from excessive financial toxicity that is still rampant when it comes to going to the emergency room in many cases. Al talks about how the employers can really help employees and members protect themselves from profiteering hospitals or physician staffing companies the patient doesn't even realize are gonna be sending bills. You can get and learn more about the Quizzify Consent Form as well as Quizzify's Doctor Visit PrepKits here. Another episode along these lines to listen to is EP328 with Marshall Allen. You can get the free version of the card by emailing al@quizzify.com. You can also connect with Al by emailing al@quizzify.com, visiting the Web site at quizzify.com, on LinkedIn, or on Twitter at @quizzify and @whynobodybeliev. Al Lewis wears multiple hats, both professionally and also to cover his bald spot. Hat #1: Employee Health Literacy. He is the founder and “quizmeister-in-chief” of Quizzify, whose mission is to help companies teach their employees to utilize health care services appropriately, using a format best described as “Jeopardy meets Choosing Wisely meets Comedy Central.” Quizzify is the only vendor authorized to display the Harvard Medical School “Veritas” shield and has received excellent reviews from users. Quizzify is also well known for its ER Sticker Shock Prevent Consent, which has been endorsed by Dr. Marty Makary and Dave Chase, among others. It can be taped to an insurance card, used as a stand-alone card, or downloaded into your Apple or Google Wallet and will “pop up” when you enter an ER. It limits ER bills (both in- and out-of-network) to 2x Medicare, which is less than half of most “negotiated” rates. His quiz-specific background includes authorship of the best-selling Newsweek Presents the Ultimate Trivia Game, which Games magazine lauded as having the best questions of any trivia game; hosting two quiz shows on Boston network affiliates; and appearing on Jeopardy. Hat #2: Outcomes Measurement. As an author, his critically acclaimed category best-selling book on outcomes measurement, Why Nobody Believes the Numbers, chronicling and exposing the innumeracy of the health management field, was named digital health book of the year in Forbes. Cracking Health Costs, written in conjunction with Walmart alum Tom Emerick, was also a trade best seller. He was the cofounder of the World Health Care Congress's Validation Institute. His expertise in outcomes measurement got him named one of the unsung heroes changing healthcare forever. He graduated Phi Beta Kappa with honors from Harvard, where he taught economics as well. He also graduated from Harvard Law School, albeit with no honors that time—other than winning their annual trivia contest, of course. 06:34 What is the evolving problem around surprise bills? 07:08 What are the two issues with the No Surprises Act? 9:13 Why are ER bills in network still so high? 17:27 How does the Quizzify Consent Form work for patients with insurance who unexpectedly visit the hospital? 20:50 “They're basically saying, ‘We don't abide by federal law.' Good luck with that.” 22:20 “The better question is, why aren't other vendors copying it?” 23:56 How would Quizzify affect the hospital bottom line if employers start utilizing it as part of their employee healthcare? 27:35 Is there any potential downside to Quizzify? You can get the free version of the card by emailing al@quizzify.com. You can also connect with Al by emailing al@quizzify.com, visiting the Web site at quizzify.com, on LinkedIn, or on Twitter at @quizzify and @whynobodybeliev. @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast What is the evolving problem around surprise bills? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast What are the two issues with the No Surprises Act? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast Why are ER bills in network still so high? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast How does the Quizzify Consent Form work for patients with insurance who unexpectedly visit the hospital? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast “They're basically saying, ‘We don't abide by federal law.' Good luck with that.” @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast “The better question is, why aren't other vendors copying it?” @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast How would Quizzify affect the hospital bottom line if employers start utilizing it as part of their employee healthcare? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast Is there any potential downside to Quizzify? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas

Ep. 253 Auto Insurance Carriers Struggle With Inflation

Play Episode Listen Later Nov 4, 2022 5:58

Rancho Mesa's Alyssa Burley and Account Executive Jeremy Hoolihan discuss how auto insurance carriers are struggling with the effects of inflation. Show Notes: Subscribe to Rancho Mesa's Newsletter. Director/Host: Alyssa Burley Guest: Jeremy Hoolihan Producer/Editor: Lauren Stumpf Music: "Home" by JHS Pedals, “News Room News” by Spence © Copyright 2022. Rancho Mesa Insurance Services, Inc. All rights reserved.

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EP383: Direct Contracting as a Health System Business Strategy, With Nick Stefanizzi

Winning Isn't Easy: Long Term Disability ERISA Claims

Play Episode Listen Later Oct 20, 2022 32:55

The show on direct contracting with Doug Hetherington (EP367) and also the one with Katy Talento (EP350), both of these experts have said that if an employer direct contracts with a provider organization, in general, the employer gets about 20% savings over the status quo. This makes sense—just cut out the middleman with an MLR (medical loss ratio) of plus or minus about 15% and you're at three-quarters of the way there. You might be thinking, “Well, maybe not so fast here, because then wouldn't FFS (fee-for-service) rates go up? Is it not Slide 1 on most carriers' sales decks how great they are at leveraging their vast buying power to negotiate discounts with hospitals?” Hmmm … if you think this, you're about to be shook. Turns out, carriers are not so good at negotiating rates with hospitals. For more on this topic, follow Leon Wisniewski on LinkedIn. Or check out an article entitled “Hospital prices vary widely, often higher with insurance than cash, The New York Times finds.” The big concerns for employers looking to direct contract, I think, are going to be threefold. And right now, I'm just speaking in general. This has nothing to do with the conversation that follows. But I think the three big concerns are this: Let's say the employer gets actual fee-for-service rates that are 20% less than average carrier negotiated rates. So, great … but will utilization go up if the wolf is watching the henhouse, so to speak? Especially if PCPs are owned by the hospital system and incented, as many are, to drive downstream utilization. It's been estimated that PCPs can drive $1,000,000+ of revenue when they refer in network to profitable service lines. What happens when this is unfettered, meaning no third party to do prior auth stuff for utilization management, for example? Some employers, for sure, could and certainly do hire a third party to do utilization management; but sometimes one of the contractual requirements of a health system direct contract is an easing of, let's just say, at least the most aggressive PA (prior auth) requirements. So now, all of a sudden, are more plan members getting more services that, even at a 20% discount, add up to a greater total spend? A counterpoint: I've heard more than one person who would know say that most PA programs don't actually do a whole lot except defer spend at best. Here's a quote from Scott Haas. He said, “The only value I have observed of the prior authorization process is the accumulation of data that is required of the stop-loss industry to establish known risk for them to laser risk. Cost shifting at its best. Other than that, I have rarely observed value to the patient, provider, or the plan sponsor.” One thing I am noticing is that those providers offering direct contracts are aware of this whole line of questioning and fear of the health system driving overutilization because incentives and might be doing things (the health system looking to direct contract) to mitigate those fears. Some are discussed later in this podcast. So, I don't know about whether plan sponsor spend would net-net go up if you get rid of PAs and profit-driven utilization management or go up enough to offset all of the admin costs and care gaps that crappy prior auths or prior auth processes slam patients and providers with. Big concern for employers (besides even if the price goes down will utilization go up—and then what's the net effect of that?): Will the provider's PPO (preferred provider organization) network be too narrow if I go with a direct contract with a health system, either legally running afoul of network adequacy rules or run afoul of employees just getting pissed off because their doctors are no longer in network? I guess there's a bunch of ways you can do things if you are a plan sponsor that might mitigate this, but I could still see it certainly being a concern. By aligning the plan sponsor with the provider, including getting all the data and just from a pop health perspective being able to align around priorities, does care quality, preventative care stuff, social determinants of health, and equity concerns … does this stuff actually start to improve patient health? There are plenty of examples—some that Nick Stefanizzi talks about in this podcast, including a great one with Whole Foods—where this is certainly the case. But as we in healthcare all know, not all cases are the same. As soon as any party in the mix starts trying to maximize their revenue with little regard to its impact on patients and clinicians, things can go south. For example, just speaking in general here, but I might bring up the whole “remember consolidating health systems?” They promised all kinds of care quality improvements as a result of owning the entire patient journey and consolidating data and … yeah, not so much with that. As we know, hospital systems who consolidated have no greater or better quality on the whole as unconsolidated health systems, despite the fact that their prices went up a lot. Now, I just have to say, this is not a parallel situation. When the health system consolidated, it was just providers consolidating, which may have actually exacerbated relationships with plan sponsors and payers as opposed to driving greater alignments. So, as I said, not a parallel situation. I think the point that I'm making is just because better patient care is theoretically possible doesn't necessarily mean it will happen when there are profits at stake. However, when incentives do align and true collaborations can occur amongst payers and providers or amongst any of the other stakeholders along the patient journey … yeah, some great stuff can happen. As I mentioned earlier, I am talking with Nick Stefanizzi, who is CEO over at Northwell Direct, which is Northwell's stand-alone, for-profit entity looking to direct contract with employers and their TPAs (third-party administrators). The board of Northwell, meaning the tax-exempt hospital system mother ship, that same board also oversees Northwell Direct. Northwell Direct has two main categories of product offerings. One is that they offer on-site and virtual clinics for employers. The other is that they offer a network to direct contract with. According to Nick Stefanizzi, a health system can offer significant price reductions because—and this mirrors a lot, as I mentioned earlier, what Doug Hetherington (EP367) and Katy Talento (EP350) said in earlier episodes—you can get rid of a ton of administrative burden that payers place on hospital systems, plus you get rid of the middleman carrier profit margins, plus the health system can drive additional volume, I'm assuming to profitable service lines with profitable commercial patients … patients who are profitable despite the 20% cut because, yes, commercial rates are still way higher than Medicare even if you cut 20% off the top. It's also, as Nick talks about in this episode, more possible to do value-based things and care for populations because there's plan sponsor/provider alignment and far better data capture. You can learn more at northwelldirect.northwell.edu. Nick Stefanizzi is the chief executive officer of Northwell Health's direct-to-employer organization, Northwell Direct, which supports businesses through a full spectrum of customized employer health services. Prior to joining Northwell Direct, Nick served as chief administrative officer and later as interim chief executive officer of Formativ Health, a for-profit joint venture aimed at enhancing the patient and provider experience of and access to care. Nick also spent over eight years in various leadership roles within the Northwell Health system, focused on human resources (HR), organizational effectiveness, talent management, and HR technology. He was a leader within the health system's ambulatory network of over 450 physician offices and ambulatory locations, where he was responsible for the direct development, coordination, and administration of central administrative services, as well as the integration of the health system's network of clinical joint ventures. He also served as the chief of staff for the health system's chief information officer. Nick received a degree in international relations from Boston University and his MBA in healthcare administration from Hofstra University. 07:22 What do Northwell Health's main services look like? 08:05 How does Northwell Health save their clients 20%? 12:53 “Look, it is a selective network.” 13:22 What are the factors that allow Northwell Health to provide this 20% discount? 13:36 How does getting rid of the payer help the patient and provider relationship and reduce costs? 17:00 Why Northwell Health is selective, not narrow, in their network. 18:28 How does Northwell Health operationalize their direct network? 19:39 “Communication and change management and engagement.” 22:17 “Providers also want to be a part of this. They also have ideas.” 23:04 Where does the TPA fit into this model? 25:05 EP127 with Kris Smith, MD, MPP. 25:54 What are Northwell Health's must-haves for their TPA partners? 30:27 What's different about Northwell Health's approach? You can learn more at northwelldirect.northwell.edu. Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems What do Northwell Health's main services look like? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems How does Northwell Health save their clients 20%? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems “Look, it is a selective network.” Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems What are the factors that allow Northwell Health to provide this 20% discount? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems How does getting rid of the payer help the patient and provider relationship and reduce costs? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems “Communication and change management and engagement.” Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems “Providers also want to be a part of this. They also have ideas.” Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems Where does the TPA fit into this model? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems What are Northwell Health's must-haves for their TPA partners? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems What's different about Northwell Health's approach? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar

WIE Season 2: How Disability Insurance Carriers Cherry-pick Claims For Justifications For Denial

Play Episode Listen Later Oct 18, 2022 33:01 Transcription Available

On This week's episode of Winning Isn't Easy learn How Disability Insurance Carriers Cherry-pick Claims For Justifications For Denial from Nationwide Long Term Disability ERISA Attorney Nancy L. Cavey.

claims denial justification disability insurance insurance carriers

Encore! EP335: Why Private Equity Is Willing to Pay $55,000 per Patient to Primary Care Start-ups, With Brian Klepper, PhD

Restoration Domination Show for Contractors & Entrepreneurs

Play Episode Listen Later Oct 13, 2022 33:13

This show was one of the most popular episodes in the past 12 months, so enjoy this encore while I am in Chicago moderating a panel on pharmacy benefit management at the WTW Conference Board. But while I have you, I just wanted to thank everyone for listening. You really are a part of our Relentless Tribe, and I could not thank you enough for your commitment to doing the right thing for patients and for this country—and that dedication is evidenced by you listening as often as you do to Relentless Health Value. Our show has the largest following of individuals who are truly pushing hard for patients over profits, and since, according to LinkedIn anyway, 40% of our listeners are at the “highest level of seniority in their organization,” I'm guessing that we have the muscle to do this thing. Thanks for being part of the Relentless Tribe and for all that you do. In this healthcare podcast, I'm talking with Brian Klepper. If you haven't heard of him, Brian's a longtime healthcare analyst and former CEO of the National Business Coalition on Health. This interview takes off like a shot, as most of my conversations with Brian Klepper do. We're talking about primary care and its various iterations. We start out with Exhibit A—the HMO version of primary care from the '90s. This is a great comparator to really get a handle on what's going on today. During the heyday of HMOs (back in the '90s), primary care was basically a glorified gatekeeper kind of doing two things. On one hand, they were restricting access. It wasn't an accident that it was really hard to get an appointment with a PCP. On the other hand, it also wasn't an accident that, once you got there, the PCP only had 7 minutes to spend with you, which basically meant that you left with an appointment to see a specialist at, of course, the health system that probably had just bought that PCP practice. Everybody's happy then, right? Specialist volume goes up, they make a ton of money for the health system, plans make a ton of money because they make a percentage of total healthcare spend … Oh right, everybody's happy except the patient who can't get care and the PCP who can't do their job. By the way, for more information on why the '90s version of the HMO industry crashed and burned, listen to my conversation with Alex Jung on this exact topic. A big part of the “why” really actually took me by surprise. But back to primary care … Today, in broad strokes, we have three kinds of PCPs. And when I say three kinds of PCPs, we're not really counting urgent cares or what amounts to urgent cares in that mix—meaning, not counting a lot of the retail clinics because they don't really manage patient care like you'd hope a PCP would manage care. Last I checked, none of them were managing much more than an episodic visit. You can't manage a chronic condition in 15 minutes. So, like I said, there's three kinds of PCPs that are around today; and let's call the first kind the original PCP. This version of the PCP office is primarily fee for service (FFS). Maybe they have a couple of capitated contracts. But the distinguishing factor isn't really what their payer mix is. It's that they're not taking on much risk or any risk of real consequence. Second, we have direct primary care doctors. This group tends to cut out insurers and work directly with either employers or patients themselves. They take a monthly fee, and, in general, a patient can see them however much they need to. Again, no risk or little risk is assumed here beyond the primary care services themselves that are rendered. Third, we have what Brian calls industrialized primary care—or some people call it advanced primary care, or APC—but I'd probably call it something different. I'd call it “taking risk for the full continuum of care” primary care. Maybe I wouldn't even call it primary care at all because this third category really is starting to color outside of the lines of primary care. This third iteration requires many things to accomplish. It requires an unimpeachable relationship with the patient; you cannot be successful with this otherwise. It requires great virtual/digital capabilities. It also requires data—data to help ensure that care gaps are filled but also to make sure that patients are referred to high-quality, high-value specialists downstream who will actually create outcomes. It also includes optimizing specialty pharmaceutical usage, for example. Brian gets into this and how a state employee health plan is on track to save $1.3 billion in this fashion. Brian believes that this third iteration of primary care—this APC industrialized primary care—is the third leg of a three-legged stool that is needed to transform healthcare. If you must know, the second leg is identification and the use of high-performing specialty services; and the third is value-based reimbursement environment. Most of the second half of this conversation with Brian is about why there's just a flurry of investment into various forms of these advanced or just maybe even regular primary care models and how they might evolve moving forward. I ask Brian about Carbon Health and their recent claim that they can do primary care with about 25% to 30% EBITA, even at Medicare FFS rates. So, there's that. One last thing: We'll be posting an “Ask an Expert” with Brian Klepper, where he gives the backstory about how the RUC—that AMA committee—basically killed primary care. So, come back for that show after you're done with this one. It's a plot full of intrigue, that's for sure. You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. Brian Klepper, PhD, is principal of Worksite Health Advisors and a nationally prominent healthcare analyst and commentator. He speaks, writes, and advises extensively on the management of clinical and financial risk, on high-performance healthcare, and on realizing the potential of primary care. His current focus is on high-performing healthcare organizations that consistently deliver better health outcomes at lower cost than usual approaches in high-value niches and how, integrated with advanced primary care, they can be configured into turnkey comprehensive high-value health plans that can disrupt the status quo. 05:59 Is the HMO model of primary care a good model? 08:36 “Industrialized medicine is exciting.” 09:44 What does primary care have the opportunity to do? 10:06 “The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.” 11:00 Where does direct primary care and advanced primary care fit into this model? 14:19 “At the end of the day, what primary care really needs to be about is … the management of life issues as well.” 14:48 EP295 with Rebecca Etz, PhD. 15:03 “Better relationships quantifiably translate to better care.” 22:21 “Almost nobody in healthcare wants any of this to happen.” 24:30 Why the huge amounts of money being invested into primary care is actually a big problem. 28:43 “We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending.” You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Is the HMO model of primary care a good model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Industrialized medicine is exciting.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What does primary care have the opportunity to do? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Where does direct primary care and advanced primary care fit into this model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “At the end of the day, what primary care really needs to be about is … the management of life issues as well.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Better relationships quantifiably translate to better care.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Almost nobody in healthcare wants any of this to happen.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Why the huge amounts of money being invested into primary care is actually a big problem. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Recent past interviews: Click a guest's name for their latest RHV episode! Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert

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055: Homee & The Entrepreneurial Mindset w/ Brandon Donatelli & Anthony Russello

Play Episode Listen Later Jul 28, 2022 69:29

Welcome to the Restoration Domination Podcast Episode 054 With your host, Rico Garcia Jr. In this episode we are joined by Brandon Donatelli & Anthony Russello from Homee. In this episode we discuss what Homee is, how it can benefit restoration companies and all things entrepreneurial mindset. Biggest Takeaways:1.You need to identify who are the farmers and who are the hunters then position and nurture them accordingly.2.To be a successful entrepreneur you need a growth mindset, to never stop learning, growing and adapting.3.Homee matches contractors with low complexity insurance claims without charging to be part of the network Find our GuestWebsite: www.homee.com/dominate Phone Number: 1-855-964-6633Instagram: https://www.instagram.com/homeeinc/ LinkedIn: https://www.linkedin.com/company/homeesolutions/ Linkedin: https://www.linkedin.com/in/brandondonatelli/ LinkedIn: https://www.linkedin.com/in/anthony-s-russello-0ba322169/ Email: info@homee.com mpartial leverages geospatial data in both risk engineering, and machine-assisted claim settlement. They believe that both Claims Professionals & Contractors deserve to have access to a platform designed to enhance communication, and address the unique demands of our industry. Use DOMINATE60 for 99% off Enterprise Plan https://bit.ly/3tz2Xwz CompanyCam is a cloud-based photo app that allows you to take unlimited time & location-stamped photos can be notated & can be easily annotated/tagged. These photos are easily attached to specific projects and are an easy way to be able to share the file with other pros working in your own company or other pros working on the same projects and are great for documenting an insurance project. Special Offer: Get 14 days FREE & 50% off of your first 2 months https://bit.ly/3FNmJb2 sureti Corporation is a Third Party Fund Control company that establishes payment rails from Insurance Carriers to Restorers, getting you paid faster and in full. Learn More: https://your.sureti.com/dominateC&R Magazine is one of the oldest publications in the water & mold restoration industries. It is run by Michelle Blevins who has completely shaken up the magazine and made it into something that is practical, exciting, and useful for the readers. Subscribe for FREE here: https://bit.ly/310KLjp Our Platinum Legal Sponsor Brittany Alexander, known online as Lawyer Britt, shares tricks carriers use to deny claims she learned from her time defending them. She is now an attorney for property owners and restoration companies across Florida. Learn More: https://bit.ly/3kKxzFZ Our Platinum Public Adjuster Sponsor Carlos Machin from Policyholder Advocates, Inc.. shares the secrets he learned after seven years of being an adjuster for the carriers and puts his knowledge to help the policyholder get their claims paid. Learn More: https://bit.ly/3w8iXps

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WIE Season 2: How Disability Insurance Carriers View Disability Claims For Hearing Loss, Tinnitus, and Meniere's Disease

Winning Isn't Easy: Long Term Disability ERISA Claims

Play Episode Listen Later Jul 5, 2022 28:48 Transcription Available

Listen in as Nationwide Long Term Disability ERISA Attorney Nancy L. Cavey talks about "Winning Isn't Easy: How Disability Insurance Carriers View Disability Claims For Hearing Loss, Tinnitus, and Meniere's Disease" and other issues you may have regarding your Long Term Disability policy coverage. Nancy is known for helping those with specific conditions fight the disability insurance company for the rights of her clients. Resources Mentioned In This Episode:LINK TO ROBBED: https://caveylaw.com/get-free-reports/get-disability-book/LINK TO PROFESSIONAL BOOK: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/FREE CONSULT LINK: https://caveylaw.com/contact-us/Need Help Today?Need help with your Long Term Disability or ERISA claim? Have questions? Please feel free to reach out to use for a FREE consultation. Just mention you listened to our Podcast!Review like and give us a thumbs up! We love to see your feedback about our Podcast!

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Interview with John Turner Annuity Sales Expert and President of Selax Brokerage

Influential Entrepreneurs with Mike Saunders, MBA

Play Episode Listen Later Jun 16, 2022 14:58

John has 25+ years brokerage experience. He has developed and expanded relationships with Broker Dealers, RIA's, Insurance Carriers, Banks and other Wall Street firms.In his most recent role, John provided Executive leadership growing production from startup phase to $250 million in annuity sales within three years.Prior to that John worked for an IMO where he created a system to grow the annuity business from approximately $300 million to more the $750 million during his tenure.In the early part of his career, John spent 13 years with Charles Schwab & Co Inc., where he managed over $180 million AUM, and learned how to allocate annuity solutions as part ofa complex client's portfolio.John attended Columbia Union College (WAU) on a sports and leadership scholarship and The University of Alabama Financial Planning School of CHES. In addition, he holds the AccreditedAsset Management Specialist (AAMS) designation from The College of Financial Planning and The Accredited Investment Fiduciary (AIF) from fi360.John has been passionate about Diversity, Equity, and Inclusion, since the beginning of his career. As a Sr. Executive in the industry his mission is to continue to be a catalyst for inclusive changewhile creating technology that will revolutionize how we do business.Learn More: https://selaxbrokerage.com | https://www.JohnTurner360.comInfluential Entrepreneurs with Mike Saundershttps://businessinnovatorsradio.com/influential-entrepreneurs-with-mike-saunders/Source: https://businessinnovatorsradio.com/interview-with-john-turner-annuity-sales-expert-and-president-of-selax-brokerage

Interview with John Turner Annuity Sales Expert and President of Selax Brokerage

Business Innovators Radio

Play Episode Listen Later Jun 16, 2022 14:58

The Building BITE: Innovation in Construction Technology, The Boost Program

The Building BITE

Play Episode Listen Later Jun 1, 2022 40:32

Please tune in to this episode of The Building BITE Podcast as we hear from industry experts about key topics to help you be successful. The Building BITE host Mike Diercksen, CRIS, welcomes Parker Mundt, Operating Director for Suffolk Technologies, and the Managing Director of their Boost Program. Parker starts us off by sharing his professional career and his road to his current position within Suffolk Technologies. Starting as a “Career Start,” Parker was exposed to several sides of the construction industry. He worked as a Project Engineer, Superintendent, and project manager while working on one of the larger projects in Boston. A few years into his tenure with Suffolk, Parker was offered the opportunity to work within a new team of Suffolk Technologies and act as the connecting bridge from the Suffolk Construction Team and helped drive Suffolk Technologies on where to invest and helping to add value to all stakeholders. From there, Parker proceeds to identify his three main takeaways on closing the gaps within quality management: 1. Innovation in the Construction industry requires buy-in and absolute alignment across stakeholders: Rarely are all the various stakeholders, such as Insurance Carriers, Architects, Engineers, and the clients, perfectly aligned. That is how the Boost program came to be, as it provides an opportunity to generate some equity early in the project. Once that has been deposited into the project, it creates a greater sense of purpose, enhancing alignment. 2. Learn to fail fast: We have seen many companies face hardships and be forced to make difficult decisions early on. When you can assess the situation quickly and understand that you may not be able to achieve your goal, shutting the project down quickly provides the ability to innovate and try something new given what you have learned. 3. Reverse Mentorship: Be open to learning in a variety of ways. While there are great lessons to be learned from traditional mentorship, we often find that younger professionals who may be more inclined to challenge the status quo may offer a different viewpoint, leading to unique solutions. These types of new questions and thoughts will be what help drive the construction industry forward! To learn more about how you can better prepare your firm for the challenges ahead, listen to our full podcast episode with Parker Mundt, Innovation in Construction Technology, The Boost Program. Please like, share, and subscribe to this podcast!

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Must Have Insurance Carriers: Americo with Andrew Kostus. (Ep. 117)

senior account executive americo insurance carriers

Play Episode Listen Later May 18, 2022 47:41

If there was a product that could move the needle in your business, would you want to know about it? We at the Life Insurance Academy Podcast thought so. We've also heard from some agents that you would like some more insight into the carrier side of the business. So we found a way to bring you both. In this episode Roger sits down with Andrew Kostus, Senior Account Executive from Americo Financial Life and Annuity Insurance Company, and takes a look under the hood at the two simplified issue products they have seen tremendous growth in: simplified issue final expense, and simplified issue term for mortgage protection.

Episode #7 Part II: Healthcare Rationing - Dealing With Health Insurance Carriers

Who The Health Cares?! With Dr. Bellavia

Play Episode Listen Later Jan 28, 2022 33:05

Join us for Part 2 of "Rationing Healthcare" of Who The Health Cares With Dr. Bellavia! In this episode, Dr. Bellavia speaks directly to the major factors that effect health insurance for patients, why patients run into issues in dealing with insurance carriers, and what options are open to them. He also explains what you can do to secure your own financials while seeking healthcare in the country today. Do you want to participate as a listener? Take our poll on this episode or reach out to us via email at bellaviawhothehealthcares@gmail.com with any topic suggestions, comments, or questions you have for us.

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COVID Vaccine Genocide: Massive Spike in Deaths Could Sink Life Insurance Carriers

TRUNEWS with Rick Wiles

Play Episode Listen Later Jan 3, 2022 72:05

On this edition of TruNews, something very morbid is happening in the USA. Deaths among 18- to 64-year-old people are up dramatically. There is no explanation for the dramatic spike in deaths. The rise in mortalities is evident in reports showing that the death rate in America is the highest since the 1790s and that the lifespan of the average American has dropped almost by 2 years. Now the life insurance industry is warning that a tidal wave of deaths threatens the financial solvency of insurance carriers. Rick Wiles, Doc Burkhart. Airdate 1/3/22

MMM [Insurance] Here's Why You Should Treat Your PPO Insurance Carriers Like Every Other Marketing Strategy

The Dental Marketer

Play Episode Listen Later Nov 1, 2021

In this episode Lisa Weber talks to us and really makes us think! Would you ever create a coupon, that can be used over and over again, and never expired in order to reach your new patient numbers/ goal? That's they way Lisa encourages us to view PPO insurance. She tells us how to evaluate each carrier, what to do instead of adding another associate in our practice, and is your insurance carriers creating more barriers for attracting new patients.‍‍You can reach out to Lisa Weber here:Email: lisa@unlocktheppo.comWebsite: https://unlocktheppo.com/‍If you want your questions answered on Monday Morning Marketing, ask me on these platforms:‍‍Email: michael@thedentalmarketer.site‍My Newsletter: https://thedentalmarketer.lpages.co/newsletter/Ground Marketing Facebook Group: https://www.facebook.com/groups/738965052973156‍The Dental Marketer Society Facebook Group: https://www.facebook.com/groups/2031814726927041

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AOTC EP 30 - Insurance Carriers: Here's How To Successfully Implement A Digital Roadmap

Ahead of the Curve

Play Episode Listen Later Aug 13, 2021 29:35

What does customer service mean today? It means being proactive and reaching out to the customer. It means making it easy for the customer to do business with you. The insurance industry has not been a leader in adopting this kind of customer outreach platform. In fact, the industry has been a laggard. But that's changing quickly, as more insurance-specific digital platforms become available and technology solutions providers guide insurance carriers along their digital pathway. In this episode, we examine both the theory and the application of a digital roadmap for insurance carriers so they can put their customers first. Our guests include Donn Vucovich, Gerent's Insurance practice lead and Robert Rudy, an industry veteran with hands-on experience in digital implementation and founder of Paradox Advisors, a company that offers technology guidance to the insurance industry. Our Guests Donn Vucovich – Donn is Gerent's Insurance Practice Lead, taking the message of digital transformation to the insurance industry. Donn has held senior management positions for more than 30 years in insurance, designing and guiding implementations to streamline operations within numerous insurance companies. Robert Rudy – Robert is the founder of Paradox Advisors, offering technology know-how and guidance for insurance firms. He has years of experience in creating new revenue streams by developing innovative products, services, and capabilities to grow customer and distribution channel relationships. Key Ideas 0220 – Digital Roadmap defined in simple terms 0603 – Why new insurance products are necessary for a digitalized insurer and for the customer 0934 – How one company set out alone on a digital roadmap…and got lost 1857 – The first benchmark of success on the roadmap: bringing in outside expertise

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#OSNow: Insurance carriers dropping Orlando homeowners and political appointments = too much power for governor (Ep. 659)

Orlando Sentinel Conversations

Play Episode Listen Later May 25, 2021 12:10

Orlando Sentinel Now afternoon update for Wednesday, May 26, 2021. Metro Orlando homeowners among 53,000 to be dropped by property insurance carriers (:31) Too many political appointments = too much power for Florida’s governor | Editorial (6:11)

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The Age of Insurance Personalization and What It Means for Insurance Carriers

PC360 Perspectives' Podcast

Play Episode Listen Later May 11, 2021 13:59

Customers are demanding more personalized and meaningful experiences from their insurance carriers, and they’re willing to go as far as switching providers to get that experience. A recent survey found that three-quarters of insurance customers reported wanting more personalized offers, messages and recommendations from their insurance carrier. Delivering this type of experience requires carriers to better understand customer behaviors and leverage that knowledge to create deeper connections and better anticipate needs. We recently spoke with Justin Silver, Senior Director, Solution Consulting at Duck Creek Technologies, about data-driven personalization and the impact it has on the insurance market. He explains what carriers have to gain from harnessing the right data and what’s on the horizon for data-driven personalization in the insurance space. To learn more, hit play.

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Beauty Queen! How to Make Your Construction Company Attractive to Insurance Carriers

Construction Genius

Play Episode Listen Later May 11, 2021 35:58

Every company wants lower insurance premium costs. But with a hardening insurance market, how can construction companies lower their spending on insurance? What are actionable steps contractors can make to become more attractive to brokers? In this podcast episode, I talk to Mary Grandy, Senior Vice President at Epic Insurance Brokers and Consultants. She gives us a brief look at the insurance market today and how it is affecting construction companies. We ask her for some tips on how contractors can become more appealing to insurance agents. She also shares her expert opinion on what makes good partners and improving trust between agents and contractors. There’s a lot to discover and learn from this episode. Check it out today! Discussion Points: 0:00 Introduction2:20 Hardening market in insurance3:20 What is social inflation?4:25 How is the construction industry affected?7:21 Advice on addressing the challenges of insurance premiums8:46 Defining total cost of risk9:25 Contractor programs to address the total cost of risk11:17 Who and when to delegate risk management13:42 Responsibility of contractor to build relationships with insurance companies15:18 Difference between a good and bad partner17:24 Most effective way to build trust20:54 Look for an insurance broker that understands your language22:50 How construction companies can become more attractive to insurance carriers?24:27 How long will it take for contractors to improve?29:50 Three action items to facing insurance challenges About the Guest: Mary Grandy is Senior Vice President at Epic Insurance Brokers and Consultants. With over two decades of experience in the insurance industry, she brings a unique approach in representing the construction industry with her expertise in litigated construction claims. She focuses on the design and implementation of insurance and risk solutions for all aspects of her commercial, property and casualty and workers’ compensation insurance clients. Resources: Do Your Project Executives Need to Become Better Leaders? Book a 10-minute call with Eric Anderton (https://10minutes.youcanbook.me/) Connect with Mary Grandy Contact: mary.grandy@epicbrokers.com Phone 530-559-3435 LinkedIn: https://www.linkedin.com/in/marygrandy/ Recommended Restaurant Hawks Restaurant: https://hawksrestaurant.com/ Connect with me on LinkedIn. For more podcast episodes, you may also visit my website. Tune in and subscribe to the Construction Genius: A Leadership Master-Class Podcast on Apple Podcasts, Spotify, and Stitcher. Thank you for tuning in!

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April 28, 2021 - Online Insurance Carriers

Insurance Talk

Play Episode Listen Later Apr 28, 2021 6:29

April 28, 2021 - Online Insurance Carriers

online insurance carriers

#134: How Insurance Carriers Provide Digital Consulting to Insurance Agencies

Closing the Gap

Play Episode Listen Later Apr 7, 2021 39:31

Welcome to Westfield Workshop. Our colleague, Stacey Bruce, shares what workshop is and the value it brings to our insurance agency partners. Including a few simple steps to enhance your digital presence. Know your numbers Define your goals on your digital platforms Build a simple content calendar Ask your current providers what free or low cost offerings they may have to improve your digital footprint Want to learn more? Reach out and connect! Staceybruce@westfieldgrp.com LinkedIn - Stacey Bruce | LinkedIn We welcome your review of Closing the Gap on Apple Podcasts. Learn more about Westfield's independent agency partners.

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Arturo: how AI on aerial imagery is empowering the entire value chain for the property insurance carriers

Brains Behind AI

Play Episode Listen Later Apr 5, 2021 46:56

On this Episode of Brains Behind AI, Ari and Natalie had the chance to sit down and speak with John-Isaac Clark, “JC”, the CEO of Arturo. Arturo is an AI property analytics company that helps insurance carriers improve the accuracy and speed of decision making across claims, underwriting, pricing, and renewals. JC possesses more than ten years in geographical and location-based analytics with a start-up background and experience. In this episode, we learn how Suncorp, one of Australia's and New Zealand’s leading insurance and banking companies, selected Arturo to process property characteristics across the country by utilizing Artificial Intelligence with aerial imagery. From founding the product market, to overcoming trials and tribulations, tune in to hear how Arturo provides structured AI data observations and predictions for commercial and residential properties using satellite, aerial, drone and ground-level imagery. https://arturo.ai/

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How Insurance Carriers and Insurance Brokers look at your Data /Zander Galloway

Business Blind Spots: Exposed

Play Episode Listen Later Feb 11, 2021 58:07

We all have blind spots. In business, your Blind Spots are what hold you back from achieving success, on your terms. Hear business experts and veterans speak about blind spots they have seen and how it held the business back. If it applies to you, find out how to identify and push through. Our guest on this episode, Zander Galloway.

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100: Helping Consumers Skip Insurance Carriers | Dutch Rojas, CEO, Sano Surgery

Trendbreakers

Play Episode Listen Later Jan 22, 2021 41:06

Connect with Dutch: https://www.linkedin.com/in/dutchrojas/Connect with Steve: https://www.linkedin.com/in/steve-watson-cpa/*************************Are your employees okay with another year of insurance rate increases?Visit Trendbreakers.com to find out more about how I was able to lower the cost of benefits by 1k/employee which allows us to invest those savings back into the company and the employees.

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Episode 16: The Games That Disability Insurance Carriers Will Play Concerning The Last Day A Policyholder Was At Work When Trying To Avoid Paying Their Disability Benefits

Winning Isn't Easy: Long Term Disability ERISA Claims

Play Episode Listen Later Dec 15, 2020 29:08 Transcription Available

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InsurTechLA - Troy Korsgaden, President of Korsgaden International

InsurTechTalk by InsurTechLA

Play Episode Listen Later Dec 6, 2020 39:37

Episode #9 2020In this episode, Troy Korsgaden will talk about his latest book, "Inflection point," and his experience consulting insurance agencies and insurance carriers and other life hacks.Troy's career spans over three decades. He has instructed and spoken with hundreds of thousands of executives, agents, brokers, and staff members.Korsgaden is a highly sought-after speaker and consultant. He authored six books promoting his mission to help the insurance industry to wake up to the radical transformation that is taking place.

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Episode 13: How Disability Insurance Carriers Will Use The Mental/Nervous Policy Limitations To Limit The Payment Of Benefits To Disabled Policyholders

Winning Isn't Easy: Long Term Disability ERISA Claims

Play Episode Listen Later Nov 23, 2020 23:20 Transcription Available

In this week's episode - Nationwide ERISA Long Term Disability Attorney Nancy Cavey talks about "How Disability Insurance Carriers Will Use The Mental/Nervous Policy Limitations To Limit The Payment Of Benefits To Disabled Policyholders" and much more!Resources Mentioned In This Episode:LINK TO ROBBED: https://caveylaw.com/get-free-reports/get-disability-book/LINK TO PROFESSIONAL BOOK: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/FREE CONSULT LINK: https://caveylaw.com/contact-us/Need Help Today?Need help with your Long Term Disability or ERISA claim? Have questions? Please feel free to reach out to use for a FREE consultation. Just mention you listened to our Podcast!Review like and give us a thumbs up! We love to see your feedback about our Podcast!

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Episode 10: What You Need To Know About How Disability Insurance Carriers Handle Breast Cancer Disability Claims

Winning Isn't Easy: Long Term Disability ERISA Claims

Play Episode Play 26 sec Highlight Listen Later Nov 2, 2020 36:59 Transcription Available

In this week's episode - Nationwide Long Term ERISA Disability attorney Nancy L. Cavey talks about What You Need To Know About How Disability Insurance Carriers Handle Breast Cancer Disability Claims.Resources Mentioned In This Episode:LINK TO ROBBED: https://caveylaw.com/get-free-reports/get-disability-book/LINK TO PROFESSIONAL BOOK: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/FREE CONSULT LINK: https://caveylaw.com/contact-us/Need Help Today?Need help with your Long Term Disability or ERISA claim? Have questions? Please feel free to reach out to use for a FREE consultation. Just mention you listened to our Podcast!Review like and give us a thumbs up! We love to see your feedback about our Podcast!

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63: Inside View of Insurance Carriers | Trey Smith, Partner, SGL Partners

Trendbreakers

Play Episode Listen Later Oct 28, 2020 59:40

Connect with Trey: https://www.linkedin.com/in/trey-smith-6291a17/Connect with Steve: https://www.linkedin.com/in/steve-watson-cpa/*************************Are your employees okay with another year of insurance rate increases?Visit Trendbreakers.com to find out more on how I was able to lower the cost of benefits by 1k/employee which allow us to invest those savings back into the company and the employees.

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Episode 8: How Disability Insurance Carriers Take Advantage of Their Policy Holders and the Preexisting Condition Exclusion

Winning Isn't Easy: Long Term Disability ERISA Claims

Play Episode Play 21 sec Highlight Listen Later Oct 19, 2020 20:50 Transcription Available

Episode 8: In this week's episode - learn from Nationwide Long Term Disability and ERISA Attorney Nancy L. Cavey about How Disability Insurance Carriers Take Advantage of Their Policy Holders and the Preexisting Condition Exclusion.Resources Mentioned In This Episode:LINK TO ROBBED: https://caveylaw.com/get-free-reports/get-disability-book/LINK TO PROFESSIONAL BOOK: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/FREE CONSULT LINK: https://caveylaw.com/contact-us/Need Help Today?Need help with your Long Term Disability or ERISA claim? Have questions? Please feel free to reach out to use for a FREE consultation. Just mention you listened to our Podcast!Review like and give us a thumbs up! We love to see your feedback about our Podcast!

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On the Job with Ken Bull

Trusted Advisor Podcasts by The Iroquois Group

Play Episode Listen Later Sep 29, 2020 11:44

This episode comes to you from the Trusted Advisor Vault. Recorded before the world crashed into a pandemic, Ken Bull gives us a look into the daily life of an Iroquois Regional Manager. Join us as Ken shares his secrets for creating great long-term relationships between our Carriers and our Members.

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Senior Healthcare Direct - Active and Fit Program for Members

MedicareBob

Play Episode Listen Later Jun 24, 2020 5:27

Compare Medicare Supplement Plans Here: https://www.seniorhealthcaredirect.com/quote-3/ "Medicare Done Right with MedicareBob" Senior Healthcare Direct adds Gym and Home Workout Programs for Members Starting July 1st, anyone who has a Medicare policy with Senior Healthcare Direct will get access to the new Active and Fit Program. This program will allow members to access over 11,000 gyms and over 1,500 digital workout videos. This month, there isn't an enrollment fee! Insurance Carriers have had similar health programs. However, their health programs have been restricted to a particular carrier. The great thing about the Active and Fit program is it is not restricted to just one insurance carrier. For more information on your options, please call: 1-855-368-4717 or visit one of our pages: Website - https://www.seniorhealthcaredirect.com/ Facebook - https://www.facebook.com/MedicareBob/ Podcast - https://anchor.fm/MedicareBob Twitter - https://twitter.com/MedicareBob YouTube - https://www.youtube.com/c/RobertBache?_confirmation=1

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P&C Insurance Carriers Aim To Accelerate Digital Claims Disbursements

PYMNTS Podcasts

Play Episode Listen Later Jun 23, 2020 9:01

Tom Reuter of Deluxe discusses how P&C insurance carriers can ensure business continuity and security as they transition to digital disbursements.

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Insurance Carriers & Brokers: Parasitic Or Symbiotic Relationship?

The FS Club Podcast

Play Episode Listen Later Jun 17, 2020 48:42

Absent investment income and capital gains, has the global insurance industry made a profit over the past 15 years? What is the true extent of under reserving? Turnover amongst Insurer's shareholders is greater than ever. The advent of computer driven trading, options and ETF's results in companies and shareholders not knowing each other. insurers cannot know who their shareholders are from day to day. Investors may not know the identity of their investments. Almost daily insurers exit classes of business overnight. Buyers have to make investment decisions over time scales of years not knowing the cost of their insurance coverage, or whether coverage will be available at all. Industry consolidation amongst carriers continues at a furious pace, disturbing relationships even further. The industry's claims performance is still not as good as it needs to be. Carriers complain at brokers' commissions and fees, but it is the client, the buyer who decides what their broker earns. The reality?........insurers are legally obligated to place their shareholders' interests above the interests of the policy holders. The brokers role is as valuable to insurers as it is to buyers. The existence of the brokers permits the insurers to react to volatility without creating a political backlash. Speaker: Dennis Mahoney is a 50 year veteran of the insurance industry. He started his career in 1968 at Lloyds insurance broker Price Forbes. That firm then merged with Sedgwick Collins and then Bland Payne to create the Sedgwick Group, now part of Marsh& McLennan. During his career Dennis was fortunate to work in most classes of both insurance and reinsurance. After graduating from the Harvard Business School PMD program, he was appointed deputy chairman of Sedgwick North America. In 1984 he was recruited to lead Alexander Howden the Lloyds broker acquired by US broking giant A & A ( Alexander & Alexander). Following the acquisition of A&A by Aon in 1997, Dennis was appointed as Chairman and CEO of Aon's Wholesale and reinsurance operations. Dennis relocated to Bermuda in 2007 as Chairman of Aon Global. He retired in 2010. Appointed as an independent director of Ironshore in 2012, he chaired the underwriting and risk committee. Following the sale of Ironshore to Fosun, he remained with the company until its sale to Liberty Mutual in 2016. In 2015 Calera Capital acquired RFIB (Robert Fleming Insurance brokers ) and Dennis joined as co-investor and Executive Chairman. RFIB was acquired by Odyssey capital (Integro/Tysers ) in 2019 and Dennis stepped down. He remains with the group until his contract expires in 2021. Interested in watching our webinars live, or taking part in the production of our research? Join our community at: https://bit.ly/3sXPpb5

Episode 17: The Best Insurance Carriers for Telesales - Part 2

insurance prosperity life insurance carriers hot list telesales insurance carriers

Play Episode Listen Later Apr 29, 2020 67:40

This week, we wrap up our Hot List of the BEST final expense telesales carriers, their products, app process, & underwriting profiles. Listen to learn which carriers these are, why you should have them and how you can add them right away to your arsenal of tools to serve clients. For more information and cliff notes of each episode, visit liapodcast.org. The Life Insurance Academy Podcast takes you out of the classroom and into the conversations of top-producing agents in life insurance sales so you can level up your business. Subscribe and follow-us at @LifeInsureAcad.

072 Dr. Ken Wiltbank: Working Effectively with Dental Insurance Carriers

The Dental Clinical Companion

Play Episode Listen Later Apr 22, 2020 38:17

Dr. Ken Wiltbank describes his work previously as a consultant to the dental insurance industry, common misconceptions about dental insurance, strategies for working effectively with dental insurance carriers, ways to optimize coverages and improve communication and common insurance pitfalls to avoid. Ken Wiltbank attended Dental School at the Oregon Health and Sciences University and graduated in the class of 1998. After seven years working in Beaverton/Tigard as a general dentist, he returned to school at the University of Texas, Health Sciences Center at San Antonio, where he completed a residency in Endodontics (Class of 2007). Dr. Wiltbank and a business partner own two private endodontic practices, one in Tigard, Oregon and one in Warrenton, Oregon. He is a Diplomate of the American Board of Endodontics. He is a member of and volunteers in the American Association of Endodontists in the capacity of a representative to the American Dental Association's Codes Maintenance Committee and to the American Association of Dental Consultants. He is also on the AAE's Board of Directors. Dr. Wiltbank serves as an Adjunct Assistant Professor of Endodontology at the Oregon Health and Sciences University, School of Dentistry.The Dental Clinical Companion Podcast (DCCP) is provided for general informational purposes only. The DCCP, MounceEndo, LLC, and Dr. Richard Mounce personally have no liability for any clinical, management, or financial decisions or actions taken or made by you based on the information provided in this program. The DCCP is not intended to offer dental, medical, legal, management, investment, surgical, tax, clinical, or any other professional advice. Reliance on the information in the DCCP is done entirely at the listeners own risk. No guarantees, representations, or warrantees are made with regard to the completeness, accuracy, and/or quality of the DCCP. The DCCP takes no responsibility for, does not endorse, and does not imply a relationship/affiliation to any websites, products, services, devices, individuals, organizations which are hyperlinked to any DCCP component or mentioned in the DCCP. Third party materials, hyperlinks, and/or DCCP content does not reflect the opinions, standards, and policies of MounceEndo, LLC (owner of the DCCP, Dr. Richard Mounce, the guest, or show sponsors). The DCCP makes no warranty that the Podcast and its server are free of computer viruses or other destructive or contaminating code elements.The Dental Clinical Companion Podcast expressly disclaims any and all liability or responsibility for any direct, indirect, incidental, special consequential or other damages arising out of any individuals use of, reference to, reliance on, or inability to use, this podcast or the information presented in this podcast. http://www.dentalclinicalcompanion.com/ Support the show (http://mounceendo.com/)

Episode 16: The Best Insurance Carriers for Telesales - Part 1

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Play Episode Listen Later Apr 22, 2020 76:52

This week we discuss the elements that make an insurance carrier and their products good for telesales. We also dive into four specific carriers, their products, app process, & underwriting profile. Listen to learn what these carriers are and how you can get them in your tool arsenal of tools to serve clients. For more information and cliff notes of each episode, visit liapodcast.org. The Life Insurance Academy Podcast takes you out of the classroom and into the conversations of top-producing agents in life insurance sales so you can level up your business. Subscribe and follow-us at @LifeInsureAcad.

Quid Pro Quo Clarice - Will Workers Compensation Insurance Carriers or Short Term/Long Term Disability Insurers Have Your Back if You Contract COVID-19?

Walking Papers

Play Episode Listen Later Apr 5, 2020 23:29

So, you’ve received the unfortunate news that you have COVID-19. Maybe you’re one of the essential workers or you contracted it from someone else. No matter how you got the virus, your health and personal finances are going to be affected – the latter, more so, at a time where cities are enforcing stay-at-home policies. Are there any laws (https://www.ncemploymentattorneys.com/podcast/employment-rights-job-protections-coronavirus-covid-19-pandemic/) that can help support you financially during this time? In this episode of Walking Papers, attorney Josh Van Kampen of Van Kampen Law explains quid pro quos on employee benefits and which can be used in relation to the Coronavirus pandemic (https://www.ncemploymentattorneys.com/blog/covid-19-workers-compensation/) . One of these is the workers’ compensation benefit, which provides coverage when employees are injured or contract a disease. 04:01 He discusses what you can expect to receive from your workers’ comp, the process involved to make a claim and protections afforded to you. 06:40 Additionally, he talks about other options that can help you recover lost wages such as short-term and long-term disability policies. 16:21As employees, you are entitled to obtain copies of your Summary Plan Descriptions, so you know what you can expect if you file a disability claim. 19:02 Atty. Van Kampen encourages citizens to contact their local government officials and senators and ask that the workers’ compensation law be amended to apply to essential workers, like those working on the medical front lines. Contact your North Carolina legislators here: www.ncleg.gov/FindYourLegislators (https://www.ncleg.gov/FindYourLegislators) Connect with us: Our website: www.ncemploymentattorneys.com (http://www.7mileadvisors.com/) Follow us on (https://www.youtube.com/user/vankampenlaw) . For more information on how Van Kampen Law can help you, call 704-247-3245 or contact the us online by filling out our confidential online intake form (https://www.ncemploymentattorneys.com/client-intake-form/) . The Walking Papers is a bi-weekly podcast by Van Kampen Law, a plaintiff-side employment law firm based out of Charlotte, NC, This podcast aims to give listeners, who are on the wrong side of some sort of situation at work, practical advice on how to turn the tables on their employers. This podcast is just an educational resource. It does not constitute legal advice and is no substitute for consulting an employment attorney about your unique situation before making legal decisions. Visit our website for more online resources and videos at NCemploymentattorneys.com, or better yet, call (704) 247-3245 for a free initial intake interview so Van Kampen Law can evaluate your case.

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Episode 12: Must Have Insurance Carriers: Foresters Financial with Bruce Burak

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Play Episode Listen Later Mar 25, 2020 82:25

If you are an agent in the Mortgage Protection or Final Expense insurance markets there are going to be a lot of insurance carriers and products you can choose from to recommend to your clients and write business with. Today kicks off a series of carrier spotlight episodes that we will be doing over the next few months featuring some of the best and must have companies to not only give your clients the best insurance benefits but also to give you access to the best lineup of products, underwriting processes and customer service levels to provide you the highest probability of success! We’re so excited to be joined in-studio on this episode, with the highly engaging, passionate, and tireless front man for Foresters Financial, Assistant Vice President, Bruce Burak. Bruce brings an energy to this industry, his company and product offering like no other! You will not be disappointed in the information and agent value in this very candid conversation. We talk about everything from marijuana to tornadoes in Tennessee. This one is a MUST LISTEN! Visit https://liapodcast.org/ep12 for show notes and more information on Foresters financial.

John Powers | Advanced Medical Pricing Solutions

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

Play Episode Listen Later Dec 6, 2019 49:59

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...

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The Insurance Carriers Are Not Your Adversaries

Smart Injury Doctors Podcast

Play Episode Listen Later Apr 30, 2019 10:43

In this episode of the podcast, Dr. Cronk runs down how to have a productive working relationship with the insurance companies you deal with daily. There is nothing to gain from setting yourself up as their adversary. The market is shifting and Dr. Cronk offers up meaningful, actionable tips to help you stand out in a good way from the others in the personal injury marketplace. You can learn more on my website and register for a FREE webinar where I go much deeper into this subject and explain exactly why you would want to specialize your practice in the spinal injury market: https://smartinjurydoctor.com/

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MN089 What's The Difference Between Plan F & High Deductible Plan F

Medicare Nation

Play Episode Listen Later Apr 15, 2019 34:08

Hey Medicare Nation! www.TheMedicareNation.com More than 10,000 people a day are turning 65! While qualifying for Medicare Part A and Part B, Medicare Beneficiaries are VERY confused as to what type of plan to enroll in, to "supplement" Original Medicare. By zipcode, a Medicare Beneficiary may have over "100 Plans" to choose from to help supplement their Original Medicare. That's an ENORMOUS amount of research to do! If you have the time and enjoy doing all that research.......go for it! If you're like most Medicare Beneficiaries, you are retiring and you want to ENJOY LIFE! You don't want to "waste" time researching Medicare Plans. Call a "Medicare Consultant" or "Medicare Specialist" to assist you in finding the plan that will fit YOUR unique needs. How do you do that? "Google" "Medicare Consultant" or "Medicare Specialist" and add your city or zipcode to that search. As an example, you would search....Medicare Consultant Tampa FL......or........Medicare Specialist Dallas TX....... Google will then populate the "Ads" first. Businesses PAY to be on the top of the 1st page of Google. SCROLL down past the "ADS." Just because a business "Pays" for an ad DOES NOT mean they are the best option for you. You will start seeing local businesses and names of Medicare Specilaists. You should be checking out these "Brokers" and "Medicare Specialists" or "Medicare Consultants." I'm speaking specifically about Medi-Gap Plan F and the High Deductible F Plan. The Supplement F Plan to Medicare, is an Insurance Policy you take out on yourself. Medi-gap Plans are NOT part of Medicare. Medi-Gap Plans are an insurance policy that an Insurance Carrier sells to you. You are "purchasing" a policy, where you pay a monthly premium to the Insurance Carrier to protect some or all of your out-of-pocket costs associated with Medicare. Medi-Gap "F" Plan pays the out-of-pocket costs YOU are responsible for. The "F" Plan will pay your "medically necessary" out-of-pocket costs. Plan F pays for your Part A In-Patient Hospital Deductible. Plan F pays your co-pay for being in a Skilled Nursing Facility. Plan F pays your Annual Part B deductible and Plan F pays your 20% co-insurance under Part B. Plan F pays for all of this, for one monthly premium. ALL Medicare Plan F Plans have EXACTLY the same benefits. It doesn't matter if you live in Tampa, FL......San Francisco, CA.....or Salt Lake City, Utah.....The BENEFITS under Plan F are the SAME! What IS different..is the MONTHLY PREMIUM! In YOUR ZipCode.......there may be up to 50 DIFFERENT Insurance Carriers that offer Plan F....EACH one of those Insurance Carriers offer a DIFFERENT Premium for the SAME Plan F Plan. You should find the LOWEST Monthly Premium from the Insurance Carrier that has an "A" Financial Rating. An "A" financial rating means the company WILL pay your claims. That's the Insurance Carrier your looking for. Plan F is the "Peace of Mind" Medi-Gap Plan. There is NO Network of Doctors and Facilities....because......Plan F is NOT part of Medicare. Original Medicare has NO Network.....Original Medicare allows you to see ANY Doctor....or go to ANY Medical Facility in the U.S. that ACCEPTS Medicare! YOUR Health Insurance IS......Original Medicare.....NOT your Plan F! So.....if you're looking for a Medicare Supplement Plan that will cover ALL your Medicare Necessary out-of-pocket costs...Then Plan F is for you. Now.....let's take a look at the High Deductile F Plan. The High Deductible F Plan.....has a DEDUCTIBLE! For 2019.....the annual deductible is $2,300.00 That means......you WILL pay-out-of-pocket until......you reach the $2,300 DEDUCTIBLE. When you reach the $2,300 deductible, the plan will then pay all your "medically necessary" out-of-pocket costs that you are responsible for under Medicare, for the remainder of the calendar year. You will NOT pay the "Cash" price......you will be paying the Medicare Allowable price....BIG difference. If you go to a cardiologist, and the visit under Medicare, costs a total of $150, Medicare will pay 80% of that amount.... which is $120. you would pay the remaining 20%, which $30. You would continue to pay out-of-pocket until you reach $2,300. If you don't see many doctors or have any diagnostic tests, you will ONLY pay for the services you use. For a healthy person, this could be a very viable option. If you are a person with a chronic illness, let's say for example...Diabetes......Asthma.....or high cholesterol with high blood pressure.....this plan may NOT be a good choice for you. It's important for you to take into consideration your own health history, what medications you take, your financial status and what doctors you see, before enrolling in a Medicare Plan. Next time, I will go over the differences between Plan G and PLan N. If you are turning 65....or.....you are getting ready to come off of your employer plan and you need to figure out what Medicare Plan will suit your needs best..... Contact Me! Reach out to me by email - Support@TheMedicareNation.com or..... by phone....... (855) 855 - 7266. I will help you find the plan that fits YOUR unique needs. Go to my website..... www.TheMedicareNation.com for more information. Until next time.....have a very happy, a very healthy and Prosperous week! Diane Daniels

Do Insurance Carriers Want What's Best For You?

Agency Nation Radio - Insurance Marketing, Sales and Technology

Play Episode Listen Later Feb 19, 2018 19:57

Or are they just hoping you'll eat up their flavor of the week because you're starving? It's possible it's been a long time since a marketing rep from one of your companies showed up and asked you what kind of business you wanted to write. For too long they've made it about what they want and how we should try and give it too them. What if there was a better way? What if carriers and agents came together to discuss strengths and weaknesses on both sides and how they can be maximized. That's what I talk to Seth Zaremba, of Zinc Insurance, about this morning as he shares his collaboration secret. P.S. Did you know Seth is going to be presenting this data and more at Elevate 18?

elevate insurance carriers seth zaremba zinc insurance

Do Insurance Carriers Want What's Best For You?

Agency Nation Radio - Insurance Marketing, Sales and Technology

Play Episode Listen Later Feb 18, 2018 19:57

elevate insurance carriers seth zaremba zinc insurance

You CAN Disenroll From Your Medicare Advantage Plan NOW! MN079

Medicare Nation

Play Episode Listen Later Jan 19, 2018 34:26

Hey Medicare Nation! It's January 2018! I hope everyone made informed decisions regarding your Medicare Advantage Plans for 2018. If you missed the last episode, go back and listen to it! I discussed the Medicare Premiums, co-pays and co-insurance for 2018. Many of you have sent me emails "asking me" if you can change your Medicare Advantage Plan in January. The answer is......yes....with specific guidelines. Currently, it is the Medicare Advantage Plan "Disenrollment Period." The current Disenrollment Period runs from January 1st through February 14th each year. During this time, you can "drop" your Medicare Advantage Plan and go back onto Original Medicare. You do this by contacting MEDICARE by phone 800-633-4227.....and telling the Medicare representative that you would like to "Disenroll from your Medicare Advantage Plan" to go back onto Original Medicare. Medicare may also help you with a Part D prescription Drug Plan if you'd like. On Original Medicare, you are covered under Part A and Part B of Medicare. Under Part A....you are covered for Medicare benefits where you would stay at a location as an "inpatient." The most common location is .....The Hospital. Another location where you stay overnight as an inpatient is....a Skilled Nursing Facility (SNF). A SNF is NOT a Nursing Home. An SNF is a location where you are admitted as an inpatient to receive medical care and rehab 24hrs a day. Also..... if you are diagnosed with a terminal illness, your doctor may suggest you enter Hospice as an inpatient. All the services covered in the Hospital, SNF and Hospice are covered under Part A of Medicare. There is a "Deductible" each time you are admitted to the Hospital. The Deductible cost for being admitted as an inpatient in the hospital is $1,340.00 in 2018. The Deductible is due EACH benefit period you are admitted. Part B of Medicare is for "Outpatient Services." Benefits under Medicare for Outpatient Services covered under Part B include, but not limited to: * Doctor Vists * MRI's * Laboratory Blood Draws * Outpatient Same Day Surgery * Oxygen in your home There is an "Annual Deductible" for Part B of $183.00. After you pay your $183.00 annual deductible, you will be responsible for the remaining 20% Medicare Allowable Charges for services under Part B. What does that mean? Let's say you already visited your Cardiologist and had bloodwork drawn at Quest or Labcorp. We'll say your out-of-pocket costs for both cost a total of $183.00. That takes care of your annual Part B deductible for 2018. Now....let's say three months later.....you need to have an MRI. We'll say the Medicare allowable cost is $1,500.00. Medicare Part B covers 80% of the $1,500.00, which is $1,200.00. You will be responsible for the remaining 20%, which is $300.00. You will pay 20% of ALL Part B Medicare Allowable Charges. There is NO Cap! You may also need Prescription Drug Coverage. Prescription Drugs are NOT covered under Part A or Part B in general. Prescription Drugs will be covered while you are admitted to one of the facilities under Part A. If you want Prescription Drug coverage, you WILL need to enroll in a stand-alone-prescription-drug-plan. You can find which Prescription Drug Plan (PDP) is available in your area, by going onto the Medicare.gov website and "hover" over the FIRST Blue Box named "Sign Up/Change Plans." A column will appear and go down to where it reads..."Find Health & Drug Plans." "Click" on that box and it will bring you to the Medicare Plan Finder site. Type in your zipcode and follow the instructions. If you are comfortable with the costs associated with Original Medicare Parts A & Part B.....then that's all you need to do. If you'd like to add additional coverage to protect you against the on-going out-of-pocket costs associated with Original Medicare, you can purchase a Medicare Supplement (a.k.a. Medi-Gap) Plan. A Medicare Supplement Plan is an Insurance Policy, where you pay the insurance carrier a monthly premium and the plan will pay Medicare out-of-pocket costs that you have pre-determined. Medicare Supplement Plans "VARY" in coverage and in premiums. The "Medicare Benefits" they pay for you, are the SAME, no matter where you live in the U.S. So.....if you chose a Supplement Plan "F," which is the policy which pays ALL your out-of-pocket costs for Medically Necessary services under Medicare, and you live in Seattle, WA.......you will be covered for the EXACT SAME Medicare benefits as a person living in Tampa, FL. What is different you ask? The difference is in the PREMIUM you pay. Insurance Carriers that offer Medicare Supplement Policies charge DIFFERENT Premiums! You NEED to know what the difference in Premiums are by EACH Insurance Carrier for the SAME TYPE OF PLAN. Here's an example: Mary is turning 65 in March of 2018. Mary has a history of heart problems and would like to remain on Original Medicare and purchase a Medicare Supplement Plan "F" so that she can see ANY Cardiologist that is contracted with Medicare.... in ANY State. Mary also wants to have a budget for her out-of-pocket health costs and having a Medicare Supplement "F" plan will allow her to do that. Mary lives in Miami, FL and calls her Medicare Specialist Diane. Mary discusses purchasing a Medicare Supplement with Diane and asks for her expertise and guidance. Diane tells Mary that the 3 lowest premiums in her zipcode have the following montly premiums: 1. $239.00 From Acme Insurance Co. 2. $250.00 From Beta Insurance Co. and 3. $275.00 From Delta Insurance Co. These premiums are for the EXACT same Plan with the SAME benefits! Why would you pay Delta insurance company $275.00 a month, when you can pay Acme Insurance Company $36.00 a month less....for the SAME benefits! That's why it's soooo important to speak with a Medicare Specialist or Medicare Consultant like myself. I speak MEDICARE! I care about YOUR best interests! I have NO loyalties to ANY Insurance Company! You can also STAY on the Medicare Advantage Plan you are enrolled in. Do your Due Dilligenct to ensure you are doing what's best for your health and out of pocket costs for 2018. I'm hear to help you if you need me! You can contact me by email at Support@TheMedicareNation.com You can contact me by phone: 855-855-7266. I will even answer your question by email if I can answer it in ONE paragraph! If I have to do any kind of research, you need to hire me as your consultant. My time is valuable and I want to do what's best for you! Thanks for listening Nation! Would love a Review if you would take a minute to do it for me! Leave me a "Voice" review at www.TheMedicareNation.com or ...... an iTunes review. Go to iTunes or Stitcher and in the SEARCH bar type in MEDICARE NATION MY show comes right up. "Click" on Subscribe and then click on Rating or Review. Leave me your feedback and if you can.....give us 5 stars! Thank you and have a Happy, Peaceful & Prosperous Week! Diane

Winter Auto Insurance Claims Processing

processing insightful insurance claims auto insurance policyholders estra insurance carriers

Play Episode Listen Later Dec 16, 2015 18:00

With today being the first day of Winter, car accidents on ice, rain, sleet, or snow is common. What isn't so common is Policyholders being prepared for what is to come. Feel like Insurance Carriers are holding most of the cards so to speak? Insightful experiences can be invaluable while processing Auto Insurance Claims. The journey begins at the scene of an accident and ends at the time of claim closure. ESTRA has been through this process with several Auto Insurance Companies. Join her in this episode to gain understanding from an injured person's perspective. Avoid costly mistakes made early in the process.

Winter Auto Insurance Claims Processing

processing insightful insurance claims auto insurance policyholders estra insurance carriers

Play Episode Listen Later Dec 16, 2015 18:00

One Day Car Accident Planning

planning barack obama plan congress one day employers car accidents insurance carriers

Play Episode Listen Later Oct 12, 2015 21:00

Taking one day to plan for possibly the worst unexpected car accident in your life is one of the most important things to accomplish. Everyday this tragedy happens to thousands of people. Yet, most are unprepared and ill-equipped to face struggles before them. Furthermore, they have no idea the snake pit about to be entered. Insurance Policyholder snares can be found at almost every turn. Today ESTRA will walk you through ideas to help make this terrible day better and hopefully aid through recovery, insurance, medical, and legal issues. 2015 Car Accident Awareness Month's mission is to create greater understanding of what Insurance Policyholder's face during these hard times and how Congress, Secretary Burwell, and President Obama can help make this easier for those involved in a collision. If you are one of the folks facing these struggles in the past or right now, please call Congress at (202) 224-3121, tell them you support Insured Civil Rights Legislation and ask will they do the same? Together we can stop needless hurting by standing for Insurance Benefits currently not being paid by Insurance Carriers and Employers. 2015 October Car Accident Awareness Gift Code for today's show is: Plan. Just click on Talking About You with ESTRA Email Link during the radio show, type the word "Plan" and your email to receive copy of Car Accident Book and 2015 Car Accident Weekly Planner. Only shipping and handling applies.

Self-Help on Finding Good Faith Insurance Companies