The Granite List Live: Recent Episodes
The Granite List by Connect Healthcare Collaboration
In 1877, the Granite Workers’ Union was the first to offer sick benefits to its employees. They built a way for their community to rally around those who needed medical attention and support to get back on their feet. Today, The Granite List, powered by Connect Healthcare Collaboration, is working to instill that same sense of community by connecting benefits solutions that add real and lasting value to plan members.
Continuing to come to you on the heels of Health Benefits Nation, Cal Beyer, Senior Director of SAFE Workplaces for SAFE Project, joins the show to discuss their mission and strategy for mitigating the risk of opioid addiction and overdose.
To learn more about the risk opioids present and prevention methods, check out these additional resources:
- Safe Surgery for Those in Recovery: https://www.forconstructionpros.com/business/business-services/coaching-consulting/article/22913133/goldfinch-health-avoiding-opioids-and-heal-prior-to-and-after-surgery-for-those-in-recovery
- Optimizing Outcomes and Containing the Costs of Surgery: https://blog.ifebp.org/optimizing-outcomes-and-containing-the-costs-of-surgery/
- SAFE Project 5-Minute Opioid Overdose Reversal Training Video: https://www.youtube.com/watch?v=shwlqCWM4qM
- SAFE Project 30-Minute Opioid Overdose Reversal Training Video: https://safeproject-s-school-262f.thinkific.com/courses/naloxone-training
- Reversing Opioid Overdoses in Construction: A Jobsite Imperative: https://www.cfmabponline.net/cfmabp/09102024/MobilePagedArticle.action?articleId=2014391&temp=5b4a2f4d-b8ed-4bd8-8b5d-c4f998423983#articleId2014391
We're coming to you live from the Validation Institute's Health Benefits Nation! In this week's episode, Stephanie Koch, Director of Human Resources for Hendry Marine Industries, joins the show fresh off being named one of the Top 25 Benefits Leaders in the Country to discuss the work she's done as an HR leader to assess the needs of those on the plan and provide them with a solution that works for them!
Recently it seems that the term 'PBM' has become a dirty acronym in the benefits space. Non-transparent practices and spread pricing have led to increased costs for the plan and its members. Bill Miller, Managing Director of Evo First, joins this week's show to discuss how Evo's approach to pharmacy benefits differentiates them from the "big guys" through transparency, flexibility, and independence.
Underwriting Management Experts is a full-service stop-loss provider who prides themselves on creating disruption through independence, flexibility, and innovation. As we head into 2025, Vince Lewis, Chief Sales and Marketing Officer at UME, joins the show to discuss UME's new captive product Sapient Health set to launch at the beginning of the year!
The Direct Primary Care Model is transforming primary care for both patients and physicans. So in this week's episode, we're talking all things DPC! Alex George, Head of Marketing at Hint Health, Molly Breitenbach, COO of Candid Health Advisors, and Dr. Brandon Alleman, co-owner of Antioch Med, join the show to discuss how Hint Health has worked to make DPC accessible to the masses.
In a recent survey by Society for Human Resource Managers (SHRM), employers rated family-forming inside as one of the Top-5 most important benefits that they should be focusing on. With an increased focus on these benefits, David Adamson, CEO of ARC Fertility, and Eliza Chin, Executive Director of the American Medical Women's Association, join this week's show to discuss why family-forming benefits are receiving more attention and the impact that offering these benefits can have on the workplace.
This week we are joined by Rhett Stover, President of Proactive MD, and Matt Farnum, SVP and Head of Strategic Markets for Proactive MD, as they discuss their roles with the company and how their advanced primary care model brings about significant benefit to any organization.
Advance Care Planning has begun to gain more and more traction in the employee benefits space over the past couple of years, so this week, Joanne Eason, President of Five Wishes, joins the show to discuss what Advance Care Planning is, why it is important for people of all ages to have, and how their Five Wishes at Work program brings Advance Care Planning to organizations as an employee benefit.
Steve Zetzl, Vice President, Client Strategies, and Katherine Lurk, Vice President, Clinical Strategies, of Northwind Pharmaceuticals join this week's show to discuss Northwind's PSA (Pharmacy Services Administration) approach and how it serves to differentiate them from the PBMs on the market.
This week, Andy McMillan, Executive Vice President of Homestead Smart Health Plans, joins the show to take a deep dive into reference-based pricing. Specifically we dive into the savings associated with reference-based pricing, the myths around it, and what brokers and employers need to know as the consider moving to a reference-based plan. Additionally, Andy details how Homestead utilizes reference-based pricing and how they use the customer experience to differentiate themselves from other solutions on the market.
An important, and often overlooked part of employee well-being is financial wellness. With 78% of Americans living paycheck to paycheck, and a significant increase in employees drawing loans on their 401(k), the recent partnership between BrightDime and Kashable looks to equip employees with financial coaching and low-cost loans to help them achieve their financial goals. This week we are joined by David Stedman, CEO of BrightDime, and Jameson Fauver, VP of Business Development at Kashable, as they talk through their partnership and the value it brings.
GLP-1s continue to dominate conversation in the industry, so in this week's episode the expert team at Tria Health joins the show to dive into these medications, common misconceptions, and how they should ultimately be utilized. We are joined by Jessica Lea, CEO of Tria Health, Jenny Edwards, Manager of Health and Wellness, and Austin Morgan, Lead Clinical Pharmacist. In addition to GLP-1s, the Tria team will inform you about their Choose to Lose program which provides participants with pharmacist led interventions and health coaching regarding nutrition and exercise.
This week, Tim Hawley, CEO of Exemplar Insurance Associates, joins our show to discuss how the American healthcare system is broken - primarily due to misaligned incentives. Although the system is 'broken', Tim shares how he and Exemplar are working to provide more affordable, quality care to those they work with.
Kari Niblack, President of Blackwell Captive Solutions, joins this week's show after recently being nominated as one of the Top 50 Most Influential Women in the Captive Industry as well as being shortlisted for the awards of Captive Service Professional of the Year and Captive Manager of the Year. With the awards coming in, Kari explains how transparency and ease of access work to set Blackwell apart from other captive solutions in the marketplace.
True Scripts's new Precision Care Plus Program looks to leverage pharmacogenomics (PGX) to determine how specific medications will metabolize wihtin patient's bodies. Chasity Matthews, Sr. Director of Growth and Partner Relationships, joins this week's show to discuss TrueScript's new program and share some additional, exciting happenings!
Everyday, on average, U.S. hospitals do inappropriate spine surgeries 50% of the time. Ryan Grant, Founder and CEO of Vori Health, joins the show this week to discuss how this frequency of inappropriate surgery suggests that we have a broken care model. He also provides his expertise on using evidence-based appropriate medicine to guide patients to their desired outcomes.
As private equity and hospitals have been buying up imaging chains, it has become increasingly difficult to find affordable imaging with costs increasing more than three-fold. However, this increase in cost impacts not only people's accesibility to imagaing; it has a profound impact on overall plan spend as well. This week, Cristin Dickerson, CEO of Green Imaging, joins the show to discuss how their solution provides needed access to imaging and the impact it can have on your plan.
This week, we are joined by Tim Pratte, the new CEO of Selerix Systems. We discuss what drew him to Selerix, potential growth opportunities, and much more!
Taking care of your employees starts with their feet?
This week, Ty Gilmore, COO of Work Right, and Colin Andrews, Director of Sales, Superfeet, join the show to discuss their strategic partnership and how listening to their members has has allowed them to improve worker health.
We conclude our series of this year's most searched topics discussing chronic conditions with Lee Murphy, CEO of Inspera Health.
Health plan members with five or more simultaneous chronic conditions are a population segment that represents a significant current and long-term liability that is identifiable, but yet remains invisible. You can identify who will be in this high-cost group five years from now making it the only segment of high-cost claimants that can be identified and addressed with absolute predictability.
Continuing our series where we take a deep dive into this year's most searched topics, Ali Goodwin, Director of Corporate Relations for True Scripts, joins to discuss prescriptions benefits:
As PBMs continue to make headlines and come under legal fire, it is no longer enough to accept their marketing frill as a means of protection. Words like “transparency” and “fiduciary” bear no weight without definition and verifiable commitment.
Continuing our series on the year's most searched topics, this week's episode features Ryan Schoenecker, COO of Vori Health, and Tom Armani, Global Benefits Director for Dayforce.
The future of healthcare is not virtual or in-person. It's a hybrid blend that meets people where they are, when it is most convenient, and via a care delivery model that is clinically effective. We will explain the business and clinical drivers behind this shift, the high demand for hybrid in musculoskeletal care, and how Vori Health is uniquely positioned to meet the future needs of employers with the nation’s only hybrid MSK care network. Dayforce's Tom Armani will join us as he discusses why the company chose Vori Health as their MSK solution.
This week, we continue our series of this year's most searched categories. This week features Aaron Oaks, CEO of United Pet Care, and Laura Frances, Marketplace Manager for Employee Navigator/Ease.
UPC is a voluntary pet benefit that is an alternative to pet insurance allowing for instant savings at the vet for employees at a low monthly cost. We are a group product designed with the broker in mind allowing us to be easily integrated into most major benefits administration systems including Employee Navigator/Ease who you will get a chance to hear from!
This week, we continue our series of this year's most searched categories. This week features Dr. David Adamson, CEO of ARC Fertility:
Family-forming benefits have become one of the most valued and demanded benefits for employees because of the importance of families and increasing recognition of the need for employers to help support all aspects of their employees' lives.
This week, we begin our series our selected interviews drawn from our recent webinar series!
To kick it off, we delve into the world of GLP-1 medications, exploring their rising popularity and increased utilization. Jessica Lea, CEO of Tria Health, joins to highlight cost-effective strategies for employers to ensure optimal coverage while managing expenses.
Phil Belcher, CEO of HealthcareTN, joins this weeks episode to discuss exactly what HealthcareTN is and the role that they serve as a coalition that solely represents employer's interests and voice in the value-based healthcare market. Additionally, he shares details on HealthcareTN's upcoming conferences that you won't want to miss!
Culture and people are at the heart of the Homestead brand, and they are also what attracted this week's guest, Andy McMillan, to join the Homestead team. Andy joins this week's show to discuss how the values of the Homestead brand are reflected in their use of reference-based pricing to drive savings for the plan and its members with minimum disruption to providers.
Jake Steepleton, Product Lead at Wellnecity, and Lauren Roberson, Head of Nurse Advocacy for Connect Healthcare Collaboration, join this week's show to discuss how their collaboration results in the improved efficiency of solutions and health outcomes through the use of data.
This week Christi Coleman, Chief Customer Officer at ProactiveMD, joins the show to discuss ProactiveMD's strategic approach as a total health and population solution for employers through advanced primary care. By focusing on high quality care and improved health outcomes, ProactiveMD is able to provide unique cost-savings to employers while providing innovative care solutions to plan members to meet them where they are.
We've all seen the medication commercials on TV, and at the end of each a long list of side effects is sped through and placed in small text on the screen. This week, Anthony Hartley, co-founder of MedAdvisor, joins the show to discuss the benefit of regenerative medicine as opposed to these medications, especially when it comes to orthopedic and autoimmune conditions, for patients, employers, and even clinicians.
Obesity affects 41% of Americans, and with the recent rise in popularity of GLP-1 drugs, more people are looking to use them to achieve their weight-loss goals. However, these drugs are expensive to both employees and the plan overall. This week, Jackie Warren, Director of Data and Reporting for Engagement Health Group, joins this week's episode to discuss how to GLP-1s should be utilized to both achieve weight-loss goals and keep plan costs low.
Surgery has long been part of the orthopedic care continuum. When conservative care is no longer helpful, people were left with two choices: either remain in pain or have surgery. However, Mark Testa, Executive Vice President of Regenexx, joins this week's episode to discuss how orthobiologics - using a patient's own cells - can serve to fill the gap between conservative care and surgery and the benefit that it brings both employers and employees.
Take a trip to your local grocery store and you will find produce, fish, and other consumables from different countries across the world. However, when it comes to medications, especially with increased pharmacy costs, why do we not take the same approach? Bill Hepscher and Casey MacPherson from RxManage/Global Rx Management join this week's episode to discuss the saving that international pharmacy can provide your plan!
Being a parent comes with having navigating the labrynith of babysitters, daycare, activities, and programming so that your child can be taken care of while you work and do the things you need to. With this problem in mind Carleen Haylett founded Enriched HQ, a marketplace of life-skills building programs for kids 5th grade and up. This week, she joins the show to discuss the importance of child care benefits and the Enriched HQ platform!
In 2009, the World Health Organization recognized infertility as a disease. In 2017, the American Medical Association recognized infertility as a disease. With increased discussion about infertility, especially in the employer arena, Dr. David Adamson, CEO of ARC Fertility, joins this week's episode to discuss what infertility is, who it affects, and the impact it has as a benefit on employees.
Blackwell Captive draws their namesake from Dr. Elizabeth Blackwell, the first female physician in the United States. Blackwell Captive Solutions looks to capture Dr. Blackwell's pioneering spirit by providing a unique, single-source solution that makes premiums more affordable, more transparent, and less volatile year after year for clients. This week Kari Niblack, President, Blackwell Captive, and Arleigh Kennedy, National VP Sales, join to tell us more about Blackwell and give us a deep dive into captive solutions.
David Stedman saw a problem with the fact that over 60% of Americans live paycheck to paycheck. After working on Wall Street and operating a hedge fund for a number of years, Stedman had a desire to help people, so he changed careers and became the CEO of BrightDime. This week, he joins the show to discuss the benefit BrightDime and their team of experienced financial coaches brings to employees, how they keep employees engaged, and the overall importance of financial wellness.
Jen Berman, CEO of MZQ Consulting, joins the show this week to discuss the gag clause attestations and their impending December 31 due date. However, these attestations can be tricky for employers as they may be in the dark about provider network contracts, so she discusses eveything that we know and don't know about the deadline and what employers should do.
Beth Holmes, Head of Hint Connect, joins this week's episode to talk Direct Primary Care, how it's different, the benefits it brings to users, and how Hint, through their Hint Connect platform, is positioned to bring the benefit of Direct Primary Care to you and your plan members. She also talks about the recent Hint Health conference - including some key industry takeaways and insights.
Curtis Smith, Chief Customer Success Officer at Medcor, and Nick Patee, President at Work Right, join this week's episode to discuss the partnership between their two companies and the solutions they bring to employers through total worker health.
Informed Surgical allows plan members to know the quality of their providers, and it allows to employers to keep the costs of their plans low - all thanks to robots. Sal Brogna, CEO of Informed, joins this week's episode to explain the innovation at Informed and how they seek to provide benefits to their clients.
Kind Souls provides warmline services for employees and their family members facing work-displacing healthcare events, connecting them with emotional support and local resources. This week Danielle Troxel, managing director of Kind Souls, joins the show to discuss how important their mission is and the impact it has had.
Benny DiCecca, CEO of the Validation Institute joins the show to introduce Validation's new program - FoodMed Certified. Through the program they will certify companies for outcomes, savings, and nutritional value surrounding food programs to help employers discover the ones that deliver the best results for their employees. Listen in to learn more about the program!
Technology continues to push our world forwards, so why not bring it into the world of HR? Matt Donaldson, Senior Director, Global Channel Sales & Alliances, joins this week's episode to detail how Rippling uses technology to streamline workforce management - making them a useful asset to a number of clients and brokers.
Rick Betenbough, CEO of Betenbough Companies, joins us this week as he details how a situation with his own health caused him to take a second look at his company's practices when it came to the health and wellness of his employees. For him, the wellness of his employees goes far beyond their health plan.
Pharmacy spend has steadily been increasing with the rise of specialty drugs, and the employers have been forced to face the brunt of this cost. This week, we are joined by Gentry Hughes and Keith Knowles of CopayAssistRx as they detail their innovative approach to pharmacy spend, the importance of collaboration, and solutions!
John Powers, CEO of Homestead Smart Health Plans, joins this week's episode to discuss Homestead's offerings and how they use reference based pricing and integrated solutions to drive better outcomes and a better member experience.
As we continue our dive into pharmacy, especially specialty pharmacy, we are joined by Steve Boyd, owner and co-founder of Liviniti (formerly Southern Scripts), and again by Joe Huntsman, partner and CEO of FountainRx as they discuss how they work with employers and brokers to provide the best care for the best cost to employees through transparency.
Ryan Rice and Jordan Hytken of Prism join this week's episode to talk all about 340B; including, how they're using it at Prism to connect regional hospitals, pharmacies, and health plans to create a community-centered care structure that works to the benefit of everyone involved.
Wellnecity=wellness + necessity. John Quinn, Wellnecity's founder and CEO, joins Leigh and Sally this week to shine a light on how his company pivoted to the space they occupy now, and how they work to provide companies with all of the better information in order to make them better buyers of healthcare.
What makes TrueScripts so unique? Chasity Matthews, Senior Director of Growth and Partner Relations, joins us for this episode to tell us about how important culture is at TrueScripts. The TrueScripts culture was recently awarded the distinction of being named one of the "Best Places to Work" in Indiana. TrueScripts's culture carries over into their work in the PBM world as well with their unique full-disclosure policy - which you will learn is a lot different from transparency.
What happens when trivia meets healthcare? You get Quizzify! In this week's episode, Al Lewis, former Jeopardy contestant and CEO and Quizmeister-in-Chief of Quizzfy, joins us to discuss their unique approach to healthcare literacy. But Quizzify is more than its name suggests! Tune in to learn more about Quizzify and how they are empowering employees seeking quality care.
This episode, we take a deep dive into the world of pharmacy benefit managers and all things drug-related on the employer side. We are joined by Joe Huntsman, CEO of FountainRx, Zac Hanson, Director of Business Development for RxPreferred, and Josh Butler, President of Butler Benefits Group. They each bring their own unique perspectives to the discussion as they're all looking ot provide the best quality care for employees at the lowest cost for employers.
Jessica Lea, CEO of Tria Health, joins Sally and Leigh in this week's episode to discuss the rising trend of diabetes medications being misused for weight loss purposes. Jessica dives into these drugs, what they do, and how to effectively prescribe them to employees for their individual betterment and to protect the plan as a whole.
In this episode, Sally and Leigh talk to Trevor and Heather Garbers, founders of Voluntary Advantage. They join the Granite List to talk about their FREE Voluntary Advantage program, the trends they're seeing in the industry revolving around voluntary benefits, and how they are bringing about change in the industry with their platform. Make sure you check out their website and subscribe to their free newsletter!
We are wrapping up out You Powered series with the conference's opening keynote speaker and Johns Hopkins professor Ge Bai. Bai stops by to explain the effects of mergers and acquisitions on hospitals and the healthcare system overall. She also explains how patients are forced to shoulder all of the financial burdens of the healthcare system and provides some ways for families to better protect themselves financially.
Continuing our YouPowered series from Miami! In this episode, Wendell Potter, President of the Center for Health and Democracy, stops by to join us. As a keynote speaker for the conference, he discusses his three C's from his speech: Cigna, cost shifting, and consumerism and how they impact the healthcare industry. He also discusses his journey through healthcare and why he stepped away from Cigna to try to affect change in the healthcare industry, primarily by taking control of the narrative. Be sure to check out his newsletter - Healthcare Uncovered - to learn more!
For the next few episodes, we'll be coming to you LIVE from this year's YouPowered Symposium in Miami. We will kick it off with Dr. Mary O'Connor, Co-Founder and Chief Medical Officer of Vori Health. O'Connor dives deep by discussing why it's difficult for the US healthcare system to adopt change. Looking at unnecessary surgeries and procedures, O'Connor gets to the root of the problem when it comes to the US healthcare system.
To close out our ASCEND series, Jay Hoffman, Director of Sales at Walmart Health & Wellness, stops by to talk with Sally about how Walmart got into health and wellness along with the services that they provide. He also discusses how Walmart is looking into non-traditional solutions to better serve their people.
Continuing our ASCEND Conference Series, Ed Ligonde, Executive Vice President of Nielson Benefits Group, stops by to talk with Sally about trend he's picked up while attending the conference such as a push for transparency and the second opinion process. He also discusses how the Mastermind ecosystem has helped him and his career through collaboration and knowledge sharing.
Continuing our ASCEND Conference series, Dan LaBroad, CEO of Ovation Health & Life Services, discusses his journey to where he ended up now. Attending the ASCEND and Mastermind conferences are a major factor in his successes by connecting him with like-minded people who help find solutions, support each other, and want the best for their people. Dan shares 2023 trends into giving his clients and partners better quality care, better access to care while providing lower costs.
Continuing our ASCEND Conference series, Doug Geinzer stops by tell us how Coral is utilizing cost-containment in a way that still provides high quality surgeries for their clients. He also discusses how the ASCEND Conference has allowed him and other advisors to come together to talk bounce ideas off of each other and learn more about what it takes to get win more business.
We're still live from the ASCEND Conference in New Orleans. Mastermind Tammera Hollerich comes to talk with us about trends in the industry she's noticed through the conference and how the ASCEND program is helping brokers stay updated on top of these trends and strategies in the industry.
We're coming to you LIVE from this year's ASCEND Conference in New Orleans. To kick the series off, we sit down with Nelson Griswold to discuss the purpose of the conference and how it plays into his mission to reform and preserve the private health care system.
On the heels of the second annual DEI Summit, Leigh and Sally sit down with the Detroit Pistons' VP of Diversity, Equity and Inclusion, Stefen Welch, to explore lessons learned about the role DEI plays in growing a team....of employees. Stefen shares his personal story of growth as he rose in the corporate ranks. Today, he leans into his past challenges to drive future results for the team of employees around him.
On the heels of the second annual DEI Summit, Leigh and Sally sit down with the Detroit Pistons' VP of Diversity, Equity and Inclusion, Stefen Welch, to explore lessons learned about the role DEI plays in growing a team....of employees. Stefen shares his personal story of growth as he rose in the corporate ranks. Today, he leans into his past challenges to drive future results for the team of employees around him.
Balance billing, out of network claims, and unbundled networks. These are just a few of the terms that are explored during this episode of The Granite List Live. Leigh and Sally sit down with Clay McCormack and Arthur Chapman to learn how Reliant Health Partners' fair market pricing method delivers superior results with minimum disruption to employees.
In this episode, Ty Gilmore of Work Right and Kevin Courtain of Fortis Construction join Leigh and Sally to dig into the topic of workplace safety. Ty brings experience from helping employers identify where there may be holes in a plan to identify unnecessary work comp claims, and Kevin shares the importance of getting buy in from the leadership team and what success looks like with a solid safety plan.
How is Advanced Primary Care different than traditional primary care? Joined by guest Kaley Wilkinson, SVP, Strategic Relationships for Proactive Md, we explore how advanced primary care means a provider is equipped to care for the whole person – mentally, physically, emotionally, and socially – and that person is at the center of the care model. For employers and advisors alike, this is truly a cost containment strategy built around each employer’s unique employee population and claims data. Listen as Leigh and Sally guide the conversation around this important topic.
Live at the SIIA 2022 Engage Conference, we have our special guest Jeff Kelly, President at Buckingham Self-Funded Solutions. During this visit with host, Sally Pace, Jeff explains how gene therapy crosses over into stop loss. "Gene therapy translating into stop loss is the equivalent of profitability versus loss. As a stop loss carrier retaining a set threshold of risk and these gene therapy drugs coming out with the names that we have all heard, these million dollar price tags and such. I mean these are almost automatic claims to a stop so that these gene therapy drugs and the advanced biosimilar companies bringing in these cancer therapies and J codes, G codes, and every other code that we're about to become aware of. So bringing in cost contain measures stop-loss carriers are already acutely aware of this and they're already putting together solutions. So gene therapy is unfortunately here to stay. It will be evolving throughout the future." Learn more in this episode of The Granite List Live.
Live at the SIIA 2022 Engage Conference, we have our special guest Mary Kay Puckett, Vice President of Employee Benefits at Alliant Insurance Services. She told our host, Sally Pace that friction with TPA partners is healthy. She says, "if there's friction, that's healthier because we represent the clients and we have to make sure that it is always within the client's best interest, whatever the decisions are." Her predictions for the near future include more emphasis on controlling the high dollar drug costs. Also, the focus on transparency helps control costs and make better decisions on health plans as companies consider working with us.
Sally asked Mary Kay about the trend in smaller groups seeking self-funding. Mary Kay says, "
Any group size can be self-funded. You just have to make sure you have the right reinsurance levels." Listen to this full episode of The Granite List Live, "
Live at the SIIA 2022 Engage Conference, we have our special guest Monique Burke, Director of Stop Loss Center of Excellence at OneDigital. She told host Sally Pace that they are seeing a lot of new things in pharmacy services. Employers are now wanting options that the largest employers only used to have. They are looking at self-funding and carving out their pharmacies. Most of the buzz she's hearing is about captives, and repricing direct to the consumer. Sally asked Monique about a success story. Monique told her, "We've been able to lower their rates, same coverage, and actually a better contract by just getting additional quotes. So taking it out to market each year. We've also been able to successfully help clients get their 1 million plan repaid in 48 hours."
Live at the SIIA 2022 Engage Conference, we have our host Sally Pace from The Granite List Live with special guests Jeff Toewe, CEO of Medxoom, and Julian Lago, President of Benezon.
Live at the SIIA 2022 Engage Conference, we have our host Sally Pace from The Granite List Live with our special guest Mike Ferguson, President & CEO of SIIA.
Live at the SIIA 2022 Engage Conference, we have our host Sally Pace from The Granite List Live with our special guest Tim Callender, Vice President of Strategic Accounts and Business Development at The Phia Group, LLC.
Live at the SIIA 2022 Engage Conference, we have our special guest Susan Euteneuer, General Counsel and Chief Compliance Officer at Oxford Risk Management Group. Host Sally Pace asked Susan what people should be looking for when considering a captive. Susan says that first they focus on the formation and operation is in a compliant manner. Oxfod does this by guiding their clients to carefully document their file so there's a lot that goes into make sure the file is built up so that regulators can review it and do a thorough vetting and can approve yoru captive. Oxford is able to offer an AM Best A-Rated insurance product. Susan talked about one of their new programs they started offering in the past year, their Limited Lines Program. She says, "...that is particularly to address these hard market challenges around certain business auto coverages, directors and officers, certain property coverages, really expanding that offering with some great clients and great strategic partners."
The Oxford Risk Management Group is the leading provider of captive insurance services.
Live at the SIIA 2022 Engage Conference, we have our special guest Lindsay Harris, President, and CEO of Healthcare Management Administrators (HMA). They are backed by Cambia Health Solutions giving them access to the blue network across the country. HMA has been a member and partner of SIAA for over 20 years. She attended to focus on learning more about transparency, settlement process and resolution processes to see what is new in these areas that she can take back to benefit their clients.
Sally asked Lindsay her take on where the industry is, she says, " I think our industry's been in a state of flux and change for a long time, and I think that's going to continue. First, I would say I think increasingly what we're seeing is the industry is no longer about pain claims and just being a partner in that regard. Increasingly, we have to do more and engage numbers earlier in their healthcare journey to affect change and helping them to make the best choices in their healthcare. (this is done by) Helping them to find the best places so that they can get the best outcome possible for themselves, as well as really ensure that the plans that we're administering are sustainable financially long term."
Live at the SIIA 2022 Engage Conference, we have our host Sally Pace from The Granite List Live with our special guest Brian Olsen, Client Advisor at Sterling Seacrest Pritchard.
Live at the SIIA 2022 Engage Conference, we have our host Sally Pace from The Granite List Live with our special guest Keith Hodges, Sales Analyst at Health Plans, Inc.
Live at the SIIA 2022 Engage Conference, we have our host Sally Pace from The Granite List Live with our special guest Jeb Dunkelberger, CEO of Promise Health Plan.
Live at the SIIA 2022 Engage Conference, we have our special guest Wendy Dine, Associate Director at Strategic Risk Solutions. They have been members of the Captive Insurance Committee within the SIIA for years. This has allowed her to help their sector of the industry and bring those companies together to really help control employer costs and to make sure that caps were being used properly as well.
Strategic Risk Solutions has a very rich Learning Center on their website. Wendy says, "It's always changing and we want to make sure that we continue to make sure to keep them abreast of everything that is going on in the marketplace." Their goal in the group stop loss space is bringing consultants into the loop and really making sure that they understand what they're doing with their build of a group for their clients because they really have to educate their clients. She continues, "And I want to make sure that they understand every element of the group captive so that they're educated and knowledgeable and can share that properly because there is risk and reward but you have to understand how the program mechanics work."
Live at the SIIA 2022 Engage Conference, we have our host Sally Pace from The Granite List Live with our special guest Max Harmon, Sales Account Executive at Imagine360.
Live at the SIIA 2022 Engage Conference, we have our special guest Cassie Bachman, Managing Director of Operations and Legal from Elevate Risk Solutions, LLC.
Sally asked Cassie to explain what her role is at Elevate Risk Solutions. She talked about a specific client as an example, "For example, we have a client that manufactures concrete on a global scale. So I get to go and look and say, okay, what can we do to help them with their P&L?
To help their profit and loss, we help them set up a captive. Then we also give them recommendations and ideas for things like medical stock loss, and workman's comp, which you can't do in a captive for various reasons but you can with a fronting company. Just things like that to help them. And they are so appreciative because their risk management is a big focus. And so it's exciting to go and a sense of joy and say, 'Okay, you're doing all of this. Let's see about these things. How do they help you?' So that's where I use my legal experience for various clients, for operations. I get to talk to all of the members of my company, and I like to know what they're doing. Finance, risk management, administration. And I try to help everyone tie together. So operationally, we have meetings, we have team meetings, and we touch base. Let's see, Hey, you're doing this with this client, but I'm doing this. We should know what we're doing at the same time. So I love people and I love working with people and I love my team. So helping all of them work together is great.
Cassie is also in a special group at SIIA. She leads the SIIA Future Leaders group. Members of the group are under 40 and are passionate about mentoring. Sally told her how exciting it is to watch this group reinvigorating the industry - the self-funded space. Cassie says, "What we wanna do is pool all of our knowledge and resources and help each other and be there for each other. So 20 or 30 years, you're gonna see so and so that you met at the future leaders and maybe you're doing business with them or maybe spot them in a room, and you feel less alone at a conference. Our goal is to make everyone feel welcome if they're of a certain age there."
Live at the SIIA 2022 Engage Conference, we have our special guest Rob Gelb, CEO of Valenz Health. Rob tells us, "Valenz assists employers in identifying and accessing high quality care at a reasonable cost for their employee members and their dependents. In 2019, they launched what they called an ecosystem, which in the market that's what we were going to talk about in this episode of The Granite List LIve. Valenz is a healthcare ecosystem optimization platform.
Rob also talked about their ties to SIIA and why they have become a diamond sponsor. Sally asked him to talk about that relationship. Rob says, "Mike Ferguson, he's become a friend. Mike is an innovator, he's a listener, he's a creator, he's a collaborator. He's a person who brings people together. We saw that in 2019, and so 2020 we went all in and became a Diamond member. We've been a diamond member since. We continue to invest heavily in SIIA and the opportunities and the partnerships and the collaborative approaches that exist from that, I sit on the Diamond member board and that's truly exciting to me.
Like-minded professionals who are really trying to make good and do good in this self-insurance face. They've been just a tremendous advocate and partner for us. They've allowed us to bring our brand to market and bring it to life and bring visibility to it along the way. We meet so many friendships and so many partnerships. It's really been exciting. Listen to the rest of this episode
What happens when you combine a full-service TPA, centers of excellence, and navigation through those centers? The combination affords employers the highest quality care with a wraparound of some of the most efficient cost containment solutions available. In this episode Bob McCollins, Vice President of Sales for Edison Health Solutions, joins the show to talk with Leigh and Sally about Edison Health Solutions' approach to providing the best possible health care to their clients as a burgeoning third-party administrator in the industry.
To learn more about how Edison conquers these issues in their pursuit of the best solution for the patient, listen as "Bald Guy" Bob McCollins breaks it all down.
Want to dig deeper into the services Edison provides? Check out Edison Health Solutions: https://www.edisonehs.com/
In this episode Gwen Cooper, President and CEO of Accessia Health, joins the show to talk with Leigh and Cole about their patient assistance program that benefits employers on the medical benefits side.
Accessia Health is one of six national non-profits that are patient assistance organizations. To help employers, they’ve created a model where employers can create their own employee health assistance fund, put money into the non-profit, and put money back into their employee’s hands, with criteria that the employer has set, to assist employees when it comes to their health care costs. To learn more about their unique program, Gwen dives into this episode to explain how it all works and the benefits it provides. To learn more, check out Accessia Health: https://accessiahealth.org/
The employer groups see their healthcare spending continuing to increase because their employees’ use of urgent care and emergency rooms continues to increase. Leigh and Sally’s guest is Dr. Heather Towery, Vice President of Clinical Strategy and Enterprise Partnerships of Eden Health. In this episode, Dr. Towery discusses longitudinal care and the importance of continuity of care. Eden health is an intentional virtual first primary care platform that takes care of people's longitudinal health needs but also integrates that with mental health and physical therapy and also some in-person offices where people could be seen if they need to be seen. It could be six months or eight months for somebody to get to see a psychologist. Eden Health says they can cut that time to four days. Listen to this episode and consider options to better serve your employees with a continuity of care, without having your costs spiral.
In this episode, Leigh and Sally’s guest, Cristie Upshaw Travis talks about the role of health benefits in employee recruitment and retention. Employers need to know, “What can I do through health benefits to really retain my critical talent that I have now, and then recruit in case some of that talent decides to go elsewhere?” Cristie is really focused on trying to get employers to think about both the short-term and the long-term ways in which they can position benefits for recruitment and retention. Employees are looking for affordable benefits. If they can't make their payroll deduction at a reasonable rate to get health insurance benefits, or they can't afford the deductible or the copays, it's really not much of a benefit for them. Employees typically focus on primary care strategies, where it’s usually just part of the package in most plans. This episode covers accountability, ratings, and what employers need to expect from their providers to best serve their current and future employees. Listen to this episode where our guest answers this question, “If there's one question that you would add to the RFP or recommend that employers ask, what would it be?” as well as this one, “Can you explain what these ratings mean and how the numbers, how the rating system works?” About Leigh and Sally's Guest: Cristie Upshaw Travis has been Chief Executive Officer of the Memphis Business Group on Health since 1994, when she returned home to Memphis after living and working for 20 years throughout the Southeast, including Washington, D.C. During her time away, Cristie earned her Master of Science degree in Health Administration from the University of Alabama at Birmingham. She launched her career serving in health administration and planning positions in Tupelo, Miss., and Tuscaloosa, Ala. She progressed to consulting with continuing care retirement communities, hospitals, and physicians with Ernst & Whinney in Memphis, Atlanta, Georgia, and Washington, D.C. She continued her rise in the healthcare arena as Vice President for a Washington, D.C.-based healthcare consulting firm. Cristie's main objective is to deliver the most promising strategies to Memphis employers to help them manage the cost and quality of their health benefit plans. To help meet this objective, she networks with and is involved in, health care organizations and initiatives at a national level.
Solutions in Mental Crisis Care, Diminished Tasting Abilities, and Getting a Baseline in Your Health
Sally talks to three guests from three companies with unexpected, needed and outstanding products and services. We hope you agree. First is Liftid founder, Ken Davidov. He reveals their three products. Their first product is a focus stimulator with the drugs - it's all based on electric currents. You can find out more here, https://www.getliftid.com/ . Another one about to launch hits home for a lot of people dealing with taste issues due to long COVID symptoms. You'll want to follow their company and listen to his portion of this episode.
Next up is Antu Afswa, Partner Relationship Manager from Mind 24-7. Mind24-7 offers three levels of care: express care, crisis care and stabilization, and progressions. They bridge the gap and alleviate pressures off the healthcare system to benefit the patient quickly. For up to 90 days, they work with patients, one-on-one therapy, medication management. They could either be waiting for placement at an inpatient center. They could be waiting for and needing help maybe for social determinants. For some of our adults, maybe they need help getting into a sober living situation, or maybe a homeless shelter. If they have a family walk into one of their centers, we would have a place to send them that would house them, and take care of their mental health needs as well as physical needs. See if they can help you or your family here, https://www.mind24-7.com/. Finally, BrainCheck's Chief Growth Officer, Matthew Cerullo, Chief Growth Officer joins Sally. BrainCheck provides a tool to primary care physicians and frontline providers that allows them to analyze, assess, and gain access to the data needed to actually get to a diagnosis or understand what's going on with the patient that is expressing mental decline or cognitive impairment. One of the things that they focus on is not just getting to a diagnosis, but really understanding cognitive health specifically in a clinical capacity. A lot of employers are looking to give a solution to their members or their employees that help them understand where they're at and, what they might need to watch out for in the future. The other area that they work with is on the Workman comp side. You can explore all of their services on their site, https://braincheck.com/.
Sally was live on the floor of thINc360 in the Innovation Station for this episode. She had interviews featuring three guests they found to have helpful and interesting products and services. Join her for this 12-minute episode featuring:
Malcolm Frank, Technical Account Manager, Whill Whill provides personal mobility devices globally. https://whill.inc/us/
Dr. Jordan Duval-Arnould, CEO, Readyworks Health, Inc. Readyworks Health is a workforce capacity optimization company. They replace any sort of paper-based tool that's being used by doctors, nurses, and clinical staff in a hospital. https://readyworkshealth.com
Jeremy Lovelace, CEO and founder of HFX training HFX Training is focused on simulation-based executive training. www.hfxtraining.com/healthcare-management
Leigh and Sally asked their guest, RD Whitney, what community means to him. He says, “Community is a home for an area that doesn't have a home. It's a sense of belonging.” This corporate internal community building is becoming very popular for nonprofits, associations, corporations, brands, and media event companies. It was substantially accelerated by the pandemic it's been around for quite a while. QuickBooks is used by a lot of accountants around the world. Their users got together because they can share best practices. The company that created QuickBooks and owns it to it, encourages that, and that community is stronger because people share. Think about a consumer community centering on a product - InstaPot - the most successful one-day launch on Amazon. Think of all of the loyalty and offshoots from the initial recipe community. Join us for this episode of The Granite List Live, “Communities Being Built In the Spirit of InstaPot and Quickbooks.”
About Leigh and Sally’s Guest:
RD Whitney is the Chief Community Officer at Chief Executive Group (CEG) and the Chief Operating Officer for the CFO Leadership Council (a CEG Community).
For over 30 years RD has focused on creating b2b communities that connect buyers and sellers through the gravity of professional training, events, peer learning, and data. He has successfully developed media businesses in multiple sectors through conferences, trade shows, online training, virtual events, industry award programs, SAAS businesses, research, databases, validation, publishing, peer learning, online marketplaces, certification programs, and sponsored/membership businesses. RD has an impressive track record of building and growing b2b community assets and recurring revenue businesses to quickly realize new value for members, vendors and investors.
As the tax season comes to a close, we've all got two things on our minds; "Did I file those right? It felt too easy" and "What kind of returns are we looking at this year?" Leigh and Sally are joined by Amanda Foley to discuss the complicated importance of Employee Retention Tax Credit, and what this new stimulus program that Covid brought us means for you and your business. Lots of money was lost when the pandemic shut down capitalism in a sense, and this year you should know how to get paid back. Find out who is eligible, and for how much, in this episode of The Granite List Live, with special guest Amanda Foley.
About Leigh and Sally's guest - Amanda Foley
Amanda Foley serves as COO of 3P Risk Strategies, a firm built around reducing risk and offering voluntary benefits to the employer space. With over 15 years of experience in the benefits arena, Amanda Foley began her career as an employee benefits advisor. She grew her footprint in the space as a relationship manager focused on health management solutions. Prior to joining 3P Risk, she was most recently the Director of Business Development for LifeSpeak, a digital platform that has been lauded as hosting one of the largest libraries of wellness content.
Today employer health plans, are focusing on self-funded, fully insured, level-funded, and all of the above options. But if you can look at different cash-pay opportunities, prepaid opportunities, having telehealth there, where people aren't just immediately going to urgent care and emergency rooms, you will come out ahead as a company people want to work for and your staff will be better served. Our guests from Medxoom are putting everything in the hand of the member. Leigh and Sally’s guests are Matt Smith and Jeff Toewe from Medxoom. They tell us why cookie-cutter groups aren’t a fit for them because they don’t create enough value for their client base. They want to understand what you're trying to do, the solutions you're trying to utilize to solve, to improve that member experience, and drive down that healthcare spend. Join us for this episode of The Granite List Live, “A unifying experience for plan members is the only way to bring true value.”
About our guests:
Matt Smith - Enterprise Sales, Medxoom
Matt spent the better part of the last decade helping employer groups tackle the challenges of building and executing their employee benefits plans. His focus to balance the needs of employers to avoid increases in benefit costs with the need to reduce the cost burden of the employee led him to his current role working with the Medxoom team as they are continuing to build on their vision of uncomplicating healthcare. Matt draws upon his experience with working with self-funded employer groups, TPAs, Captives, and other digital solutions to help bring best in breed partnerships to his clients as they look for innovative ways to help improve the cost and accessibility hurdles of purchasing healthcare. Matt has a passion for helping to make healthcare the focus rather than the current focus of health insurance for his clients and partners. Matt firmly believes that with healthcare at the center of the purchasing decision rather than health insurance, the power to improve the cost curve is greatly improved through the improved health of employees when they aren’t worried about where to go and how to pay for a doctor’s visit. Working with the team at Medxoom has empowered Matt to be able to help shift that focus back to how to purchase healthcare instead of just health insurance.
Jeff Toewe - Co-Founder and CEO, Medxoom
As a tech start-up veteran with extensive tech aptitude and experience, Mr. Toewe has demonstrated success in strategy, solution design & execution. He has founded and led multiple Digital, Mobile and FinTech companies, achieving multiple successful exits. Recent deals include Cinergy International in the UK, which provides sophisticated point-of-purchase decision systems to mobile telecoms; M-Dot Network, which led the definition of digital coupon standards, won #1 Amazon Startup of the Year and today is used by nearly 20,000 retail stores; and DoubleBeam/GoPago, a payments solutions provider that is now a leading Tablet POS solution. Deeply active in the tech startup community, Mr. Toewe serves as an advisor and participant to multiple tech companies and enjoys mentoring startups. He has been featured and interviewed for Google #StartupGrind and has been a panelist and speaker for CTIA #LetsTalkPayments.
Mr. Toewe earned a BA in Politics from Saint Joseph’s University and an MSIS (Master of Science in Information Systems) from Drexel University. He has also completed Open Courseware in Economics from the Massachusetts Institute of Technology.
Now, Mr. Toewe, Co-Founder and CEO, is tackling the task of “Uncomplicating Healthcare” through this Medxoom platform. Medxoom optimizes the healthcare benefits experience for employers and their plan members through its mobile benefits integration platform.
Leigh and Sally sit down with two renowned thought leaders in the benefits space to discuss what’s new and what’s next for plan design. Allison DePaoli was awarded Top Women in Benefit Advising in 2019 and Ed Ligonde was named 2021 Broker of the Year by BenefitsPro. Here, they share their passion for bringing the right solutions at the right time to fit the growing challenges employers are facing.
About our guests:
Allison DePaoli
Allison DePaoli is a business consultant working with employers who know they have a healthcare problem.
As the daughter and granddaughter of entrepreneurs – manufacturers, car and heavy equipment dealers, insurance! – Allison had a front-row seat on what it takes to run a business and manage risk. She routinely advises employers on how to both control their healthcare budgets and turn their benefit plans into recruiting and retention magnets.
She is also a sought-after speaker and the host of Raising The Bar with Allison De Paoli, a podcast designed to help CEOs and Executive Teams learn and leverage what their peers are doing successfully into their own businesses.
In 2017 Allison was a contributing author to the Amazon Best Seller Breaking Through the Status Quo and is a regular contributor to Employee Benefits News
Edwige Ligonde
Edwige (Ed) Ligonde assists in finding creative ways to blend plan design and cost, enhancing both employer and employee lives.
Named 2021 Broker of the Year by BenefitsPRO, Ed's journey to success in the benefits space has been used as a model for others. He holds a deep belief in the value of personal connections and leveraging technology for the benefit of humans, rather than replacing them.
Ed strives towards the goal that healthcare does not have to be what it has in the past, and by making collaborative partnerships we can change the benefits space for the better. In that world, we build businesses that are true partners and advocates for clients rather than having reactive, transactional relationships.
The computers at Benefits Claims Intelligence (BCI) never get tired. Their goal is to discover ongoing waste, fraud, and abuse not detected after the TPAs or Third Party Administrators have reviewed the data. They work WITH the brokers and count on them to help their clients discover double and triple bills, upbills, and other errors in insurance claims, then take steps to recover those costs. Sally and Leigh's guests from BCI - Edward Cotler and Donald Hutson. Join them for this episode, "Waste, Fraud, Abuse and Level Five Papercuts."
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About our guests:
Don Hutson
As Executive Vice President and Chief Marketing Officer for Benefits Claims Intelligence, he is instrumental in the management of the firm, which is a Software Services entity. BCI, with its proprietary software, helps identify fraud, waste, and abuse in clients’ health care plans and assists in the recoupment of those funds.
Today, Don is tasked with building the marketing channel of associates who are instrumental in the securing of clients for BCI. He is also a partner in the business and serves on the Executive Management Committee. Don is the author or co-author of 16 business books, including his two Wall Street Journal and New York Times best sellers, The One Minute Entrepreneur and the One Minute Negotiator.
Edward Cotler
Edward Cotler is the Chief Operating Officer of BCI. Prior to joining BCI, Ed worked as a consultant for multiple technology startup companies, assisting his clients with operational, strategic and fundraising advice.
Ed was formerly an investment banker at Goldman Sachs, with a specific focus on developing new products and new lines of business for the firm. In this capacity, Ed worked with some of the firm’s biggest corporate clients as well as many emerging early-stage companies. Prior to Goldman, Ed worked to both start and grow new business at Deutsche Bank and at Merrill Lynch.
Ed earned an MBA in Finance and Management from Columbia Business School and an SB in Computer Science & Engineering from MIT.
Think of nurse advocacy as a way to connect with all solutions for the plan member. Leigh and Sally's guest, Lauren Roberson Head of Nurse Advocacy for CHC says, "We sit in the middle of the circle to reach all the solutions so that plan members can get access to the things they need at the time to achieve the best outcomes helping them stay at work, feeling better, healthy, and feeling better at home." The question she answers is why would a company that has access to a nurse hotline want to pay for an additional nurse advocacy service? Learn how 30 minutes of true listening has saved lives in this episode of The Granite List Live, "Predication of Health Problems Through Nurse Advocacy".
About our guest:
After working in the fields of patience-centered home care and on the front lines of contracted nurse lines for some of the largest employers in the country, Lauren shifted her career to change the dialog – literally. She brings her deep nursing knowledge to the job each day, leading the nurse advocacy team at CHC. In her role, she helps connect the vendors that have been brought into the health plan by the broker, and steers employee engagement to ensure that plan members use the right resource at the right time for the best care possible.
Corporate athletes are those that haul, lift, push, reach as part of their day-to-day required tasks on the job. Why would you wait until they are injured to treat them? Why not prevent the injuries by having onsite care, as you would for professional sports athletes? If you are already familiar with the term VP of Environment, this episode is for you. If you have regular workers’ compensation claims due to musculoskeletal issues, this is for you too. Your employees want to work, you need them to work, and you need them to be safe and smart with how they work. Join us for this episode of The Granite List Live where Sally and Leigh visit with Nic Patee, CEO of Work Right, "Preventing Workplace Injuries of Your Corporate Athletes."
Saying a company is data-driven as a key feature has almost become ridiculous. Every sustainable company in every industry needs to be data-driven. That's not to say they all need to collect data and spew out reports. In healthcare, this means taking that data and translating it into a fuller solution story, more options, beyond the patient's health issues they are presenting. Proactive MD will move your heart in this episode as they tell us stories about their patient advocates going beyond a simple office follow-up and check-in. They are adding mountains of humanity to healthcare while increasing the health of their members. Tune in to this episode, "Blending the Data with the Whole Person for the Best Healthcare Solutions." ----more----
About our guests:
Jeremy VanderKnyff: Proactive MD's EVP of Health Data, Value and Validation, Jeremy holds a PhD from the University of South Carolina in Medical Anthropology. After a 10 year career in public health at the South Carolina Department of Health & Environmental Control, he joined Proactive MD, where he built its data science program from the ground up.
Christi Coleman: As Proactive MD's EVP of Employer Engagement, Christi partners with employers to create and optimize healthcare strategies that improve outcomes and drive down cost. She has over 30 years' experience in worksite health design, consultation, and strategy.
Drug spend is on track to account for 40% of total annual healthcare spend for commercial plans by 2025 and 2025 is just around the corner. And that's compared to just 4% in 1995. To date, there are 600 new to market drugs seeking FDA approval by 2022 and of those 70% are specialty drugs. Sally and Leigh's guest is Sarah Kline, Partner/Chief Operations Officer at 44 North. This episode covers the supply chain of markups and discounts that are ultimately paid by the employer and employee. You're feeding the supply chain and everyone's taking a little piece of that cost, which really just adds to the cost increase cycle. Listen to this episode: Everyone gets a slice, but who's paying for the specialty drug cake?
Learn about 44 North >
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The complete transcript to this episode is below.
Sally Pace (01:25):
Thanks, everybody, for tuning in. We are really excited to bring Sarah Kline with ARORx to today's podcast, and we're going to be talking about some really interesting things that her team is doing. It's a topic that is, I'm sure, as everyone's heading into renewal season right now, high on everyone's priority list, and that is the rising cost of prescription drugs.
Sally Pace (01:51):
Before we jump into that though, Sarah, do you mind telling us a little bit about the company? Can you tell us about the genesis of ARORx and why you do what you do?
Sarah Kline (02:04):
Absolutely. I am Sarah Kline and I'm Chief Operations Officer of ARORx, which is a division of 44North. ARORx was really born out of seeing the rising cost of prescription drug spend. 44North is an insurance broker. We focus on employee benefits. Year after year, just seeing our employers, our clients, struggling with the increase in their healthcare costs, it really drove us to find a solution. And that's something that 44North does really well. It's why we became a third party administrator and administering different alternative funding strategies for our clients. The pharmacy space really was a natural progression for us because again, it's the fastest growing expense in healthcare. We knew something needed to be done that we weren't seeing out in the industry. So we decided that we would bring ARORx in to really focus on high-cost drug management.
Leigh Dill (03:01):
You're right. Prescription drug spend is the fastest growing expense in healthcare. What does that look like from y'all's viewpoint? What are you seeing?
Sarah Kline (03:09):
Sure. Well, Sally, what that looks like is drug spend is on track to account for 40% of total annual healthcare spend for commercial plans by 2025, and 2025 is just around the corner.
Leigh Dill (03:23):
That's good.
Sarah Kline (03:23):
And that's compared to just 4% in 1995. So it's on track really to overtake the cost even of inpatient hospital care, which when we think of healthcare spend, we always think of high-cost procedures and high-cost care being something catastrophic you're in the hospital for. Really that's translated more into the pharmacy space, where it's overtaking that cost.
Sarah Kline (03:46):
Certainly a part of that is just due to the increased utilization of drugs. Currently, 11% of the US population is taking five or more prescriptions a month. That sounds crazy to me. That's compared to just 4% in 1995, really more than doubled the amount of prescriptions that we're taking.
Sarah Kline (04:06):
That really is probably not a surprise to anyone because you are sitting on the couch watching TV. Last year, we were all stuck in the house. We probably watched a lot of TV, and there were a lot of prescription commercials out there. We're constantly being marketed pharmaceuticals. Currently, there are 7,000 prescription medications in development, which is manufacturers do what they do best. They develop new drugs, which is great. There's certainly a lot of advancements and treatments of really serious conditions, but that just means that that pipeline of new and more expensive drugs are coming to market. Of that 7,000 in development, there's 600 seeking FDA approval by 2022, which is only a few short months away. And of those, 70% are for specialty drugs. Those specialty drugs average about $55,000 annually, and most people are not aware of what the true cost of drugs are. We like to use, when we're trying to educate, use sources like GoodRx - people are really familiar with that name and that branding - just to look it up and say, "This drug cost more than just your copays, 55,000 annually."
Sarah Kline (05:19):
The number one selling drug in 2020 was HUMIRA. HUMIRA's been around for a while. It's probably on everybody's drug list, their top drug list. That costs $70,000 annually for someone who's taking HUMIRA every month. What that translates to for health plans is for every 150 employees, at least one new specialty drug is being added to their plan each year. So it's a significant cost that just continues to increase. And although it's really minimal utilization, so when I say only one specialty drug for every 150 employees, utilization-wise, volume-wise, it's a small number, but it represents 40 to 50% of total pharmacy spend.
Sarah Kline (06:02):
That's really what we're seeing as the costs are growing. And that disparity is just going to increase more as more of those drugs are coming to market.
Sally Pace (06:11):
So what are you doing, Sarah? What is a ARORx doing to combat those costs? Are they working with the formularies and not allowing some of these high-cost specialty drugs? Or are you going to negotiations with the drug providers? What is y'all's course of action?
Sarah Kline (06:31):
Sure. I'll take a step back a little bit and talk about just some of the traditional things that have been done first and then walk it into where we're focusing because a lot of things have already been done in the market over the years. Things like really pushing generic utilization have been around for a very long time. There was a day when you didn't have a co-pay at all for prescriptions, and then it turned into a $5 co-pay or $10 copay. The health insurance industry has worked towards moving some of that cost and education over to patients and the employees of the employer-sponsored plan so that they at least have a little bit of skin in the game.
Sarah Kline (07:09):
It's done a good job. Between that and things like step therapy, where patients have to take a less expensive drug before they take the most expensive one that maybe their doctor prescribed. But that's probably been over the last 30, 30-some odd years that that's been happening. It's pretty common to see 85%-plus generic utilization. That's something that should already be in place. Whatever generic opportunity exists, it's already being maximized.
Sarah Kline (07:38):
Where ARO comes into play is we really focus on the drugs that can't be impacted by the generic transition, and that's specialty and high-cost drugs, which account for 40 to 50% of the overall prescription spend. What I mean by specialty drugs, these are things that are biologics so they're biologically engineered. They're the most expensive drugs on the market. They're relatively more recent, but they have been on the market long enough that, normally, when you look at the traditional brand to generic transition, most of the time that market exclusivity has dropped off. Well, that isn't the case with biologics because you can't really create an equivalent with the biologics. So you have biosimilars that come to market. It's very hard for those to get approved because they don't exactly replicate what's happening like in the generic space that it can.
Sarah Kline (08:38):
When we look at those specialty drugs, there are about 200 biologic drugs that were approved by the FDA. But when it comes to biosimilars, there are only 23 biosimilars that have been approved because they don't exactly replicate that. Because that process is harder, you don't see as many to market, that competition isn't there. So you don't see those reduced costs like you would see in a generic situation.
Sarah Kline (09:04):
And then on top of that, when they are able to be manufactured, the manufacturers of the brand drugs, the biologics, they've used legal settlements to delay the introduction of those biosimilars. It holds off that competition even longer. So even fewer actually make it to market.
Sarah Kline (09:24):
There really isn't that opportunity just to do things like the step therapies that you can do when you've got an equivalent there. It's even a bigger issue now that gene therapies are there to market, where it's changing DNA and RNA, and those kind of therapies can cost several hundred thousand dollars per year per patient. Sometimes they're administered for life.
Sarah Kline (09:48):
The first approved DNA-altering gene therapy, it treated inherited form of vision loss. It's really, it's an amazing therapy, and it uses these specially-engineered viruses to basically, they smuggle the drug past the body's immune defenses. They permanently alter the part of the genetic code that's responsible for the disease. It's these amazing things these manufacturers are doing, but when this therapy was launched, the cost was $425,000 per eye.
Sarah Kline (10:21):
So again, there's all of these costs that are coming to market, and what we can do to address those can't be the same traditional path that we've used before. What we've seen in the market really with these high-cost drugs, the only thing we've really seen introduced was rebates. You hear that all the time, rebates, when we talk about these high-cost drugs.
Sarah Kline (10:44):
What the rebates really were there for is it was a mechanism for the drug spend being returned to the PBMs. And then you would hope that it was shared with the health plan itself. But when rebates were first being used, really we didn't hear about them. The PBMs were holding onto them.
Sarah Kline (11:03):
When we partner with more transparent PBMs, a lot of those dollars are now starting to be released back to the health plans. Really partnering with transparent PBMs, and more and more transparent PBMs are coming to market and being available and more self-funded plans where they're seeing their actual spend, that's where we're initially seeing some reduction in cost. What ARO does then to complement that and really take control of those high-cost drugs is we get just really hyper-focused on is there a different way that we can actually fund those drugs.
Sarah Kline (11:37):
One of our philosophies at ARO is we don't like that whole idea of you’ve got to try a different drug before you actually get the drug that your doctor prescribes. Step therapy, while it certainly has some merit, and it has a place, we find that there's still these high-cost drugs hitting the plan. If you think about that, somebody went through those steps before they actually took the drug. You went 60 days, 90 days, however long it took to try all those drugs before, to finally get to what was an effective treatment. We don't like really getting in between the physician and the patient when it comes to what drugs they're going to take. Instead, we like to say, "How can we just help fund that drug and get that to the patient?" That's really where we look more at the funding, more so than altering what somebody is taking.
Sally Pace (12:27):
Drug spend is a hot topic as people are analyzing their, their plan design for 2022. Nationally, I would say the other hottest topic is supply chain. Even my eight-year-old has come to understand the supply chain issues that we all might face come the holidays. But that's very different when we talk about supply chain and the way that it works in our industry. Educate us around that and what you are doing to help in that space.
Sarah Kline (12:59):
Yes. As soon as you said that and you talked about the eight-year-old, it took me back to this weekend when I was grocery shopping, and there were no ramen noodles on the shelf. Of all things, I'm like, "Why do I not have ramen noodles?"
Sarah Kline (13:14):
So yes, this is a little bit different than the supply chain of the prescription drug market. The supply chain is complex. There are so many hands that are in the supply chain, and along the line, every hand, everyone is profiting from that. Now, when you look at each piece, every piece likes to talk about how they're able to discount the cost. Whether it's from the manufacturer to the wholesaler, the wholesaler builds in a discount. Then from the wholesaler to the pharmacy, then there's another discount. Or when you're looking at the cost of the PBM, the PBM discounts. Everyone's got all of these discounts built into that supply chain. Well, at some point, the manufacturer, basically they build in that cost to be able to discount it all along the supply chain. What happens is you're just, you're feeding the supply chain, and everyone's taking a little piece of that cost, which really just adds to the cost and continues to cause those costs to rise.
Sally Pace (14:16):
You all have built quite a reputation and built an incredible business around helping to combat the high cost of specialty drugs. For our listeners, we love to share success stories. What has that looked like for you all? And can you point to one or a couple of stories that you're really proud of?
Sarah Kline (14:41):
Sure. We have a health system down in Florida. They've got about 700 employees on the plan. They're actually one of our first clients so they've been with us for a number of years. But they were initially spending about $2 million in prescription drug costs, and they were already self-funded so they were aware of their spend, and they were very closely monitoring it.
Sarah Kline (15:01):
When they came onto the ARORx program, we were able to take all of their specialty drugs on their high-cost spend and pretty much remove of it from the plan. When they were initially paying $2 million in claims, we were able to reduce it down to just under $500,000 a year for their prescription drug cost. So $1.5 million reduction, that's 77% savings.
Sarah Kline (15:28):
Now that certainly has probably been the biggest savings we've provided to our clients, but it's not uncommon for us to see that 40 to 50% savings range. If we drop down to 30%, we're actually surprised if it goes down that far. Definitely. It's pretty common that 40 to 50% savings that we're able to achieve, really just by targeting those high-cost drugs.
Sally Pace (15:50):
We see this a lot with healthcare innovators across the board in our industry. You're up against some pretty well-funded, large, well-known names. What differentiates you in the marketplace?
Sarah Kline (16:04):
You're absolutely right. There are some big names out there. When we look back at the supply chain, those big names, they're starting to merge. There's definitely a compression happening within the supply chain where PBMs are purchasing insurance carriers, and insurance carriers are purchasing PBMs, or they're forming their own PBMs. We've seen a lot of that in just the last few years, 2019, 2020. CVS purchased Aetna for $69 billion. Cigna purchased Express Scripts for $54 billion. And then of course, Anthem, this big name, they created their own PBM. Those big names, they're almost circling the wagons, it feels like. They want to keep as many of those dollars or keep those dollars within that supply chain and then just basically compress it.
Sarah Kline (16:49):
We've even seen more and more insurers that are health systems. That's probably not uncommon to see, really, across the country, but in Michigan, we've had a few health systems merge with carriers. Most recently, just this year, Blue Cross announced they were acquiring an organization that manages over 250 physician practices. So now you don't just have control over the claim that's going through, the cost of the service, but the actual providers that are prescribing the prescriptions are now coming under that umbrella.
Sarah Kline (17:22):
There's a lot out there that's working against us as a smaller, more innovative organization. But what's been great is employers are getting more educated. They are seeing what's happening. There is more transparency. We're seeing more and more of them starting to be willing to self-fund. Even the smaller and smaller employers are doing that because they can see that trend.
Sarah Kline (17:49):
Really, it's educating consumers. It's partnering with other like-minded organizations. I know there's another organization on The Granite List, Drexi, that we partner with quite often, that's a transparent PBM. A lot of education has to be done, where we are basically just showing them what's happening in the industry, describing to them what's happening when it comes to spread pricing and how those profits are being made so that they can't afford to spend $69 billion to buy an Aetna that's out there. Consumers are just becoming much more educated, and it really is our responsibility to help educate.
Sally Pace (18:26):
Are you strictly just in Michigan? Are you national? Can you talk a little bit about your market?
Sarah Kline (18:32):
Even though 44North is our parent company, we connect with a lot of different tPAs on the medical side and a variety of PBMs too. I named Drexi, they are a great partner of ours. But they're not the only PBM that we work with either. As a tPA though, we don't require that you have your medical through us as a tPA. We really will partner with any tPA that will be connected to any of our PBM partners as well.
Sarah Kline (18:59):
It's wide open. While we are located in Michigan, we do have clients all over the country, like I mentioned, our case study example there down in Florida. But we have clients all the way up in Alaska, from all the way down into the Carolinas, over on the east coast, west coast, all over the country, we have clients.
Sally Pace (19:18):
Fantastic. If one of our listeners wants to get in touch with you to learn more about your services, of course they can find you on The Granite List. But can you give us some more contact information or best places to reach you?
Sarah Kline (19:31):
Sure. The contact information on Granite List, our main contact is Vince Babcock. He is the Director of our Pharmacy benefit area and ARORx. His email is vbabcock, V-B-A-B-C-O-C-K, @ARORx.com. Or you can just email info@ARORx.com
Sally Pace (19:51):
One of the things that we love about our community that is drawn through The Granite List is this appetite for always learning more. We love to periodically recommend books to our audience, either through the newsletter or through our podcast. So, Sarah, is there a book that you read recently that has had an influence on how you're doing this?
Sarah Kline (20:12):
Yeah. For me personally, my recommendation, it doesn't relate specifically to the prescription drug spend, but I'm guessing no one will be disappointed that they didn't learn about a book about prescription drug spend. This is certainly more broad. But as travel opened back up, I had flights to California and back, so I actually picked up, I listened to it on audio, and it is It Doesn't Hurt to Ask by Trey Gowdy. I loved, number one, that the audio book was in his own voice so you could hear the real emotion as he really shared some powerful lessons and stories on communicating, persuading, using questions. He used a lot of great stories in there.
Sarah Kline (20:53):
I, as a Chief Operations Officer, certainly more focused on the day-to-day operations, but as I have actually taken on more of a sales role in the company, that it doesn't hurt to ask in the sales process. I picked up a lot of great tips from it, but there were some great stories where you're laughing, but you're crying. So yes, on the airplane, I'm like, "There's dust in the air," pretending that I'm not actually crying. But they're just, it's great stories. I've recommended to several family members and multiple colleagues as well.
Leigh Dill (21:26):
Awesome. Well, now our audience will know about it too, and they will have Sarah Kline to thank for that.
Sally Pace (21:32):
Speaking of thanking Sarah Kline, thank you very much for joining us today. You all are champions in an area that is so needed across our country, for employers and their employees in tackling high-cost drugs by way of specialty drugs. So thank you for the work that you and your team do. Thank you for the broader work that 44North does. And thanks for sharing your story today.
Sarah Kline (21:55):
Thank you, Sally. I appreciate you having me.
Sally Pace (21:57):
Absolutely.
Welcome back to the second half of the interview with Ryan Rice and Chris Ziemke from Prism Health Group. Our conversation continues, but we switch gears to the topic of rebates themselves that are oftentimes set forth in a proposal from a PBM. And what we've noticed in those rates is there's been such a degree of escalation over the last five years. Chris says, "you're getting bigger rebates, but you're also spending a lot more in stepping over a dollar to pick up a needle. And that's really not the advised direction that we would take with folks. And we're going to see more of this."
This concept of the aggregator and the way in which a rebate aggregator works with plan sponsors is emerging in the marketplace, along with the emergence of GPOs or group purchasing organizations.
You will also hear Prism's advice on the one additional question you should ask that is not typically asked in an RFP. Listen to this episode, Bigger rebates aren’t always better.
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The complete transcript to this episode is here:
Announcer (00:07):
Welcome to another episode of The Granite List Live. Navigating a sea of benefit solution is daunting at best, and new vendors emerge every week. Hosts Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spend while improving employee engagement and outcomes.
Announcer (00:36):
Welcome back to the second half of the interview with Ryan Rice and Chris Zieme of Prism Health Group. Our conversation continues, but we switch gears to the topic of rebates themselves that are oftentimes set forth in a proposal from a PBM. And what we've noticed in those rates is there's been such a degree of escalation over the last five years. Chris says you're getting bigger rebates, but you're also spending a lot more in stepping over a dollar to pick up a needle. And that's really not the advised direction that we would take with folks. And we're going to see more of this. This concept of the aggregator and the way in which a rebate aggregator works with planned sponsors, is emerging in the marketplace, along with the emergence of GPO's or Group Purchasing Organizations. You will also hear Prism's advice on the one additional question you should ask that is not typically asked in an RFP. Listen to this episode, bigger rebates aren't always better.
Sally Pace (01:46):
I'm going to switch gears to another hot topic, Rebates.
Chris (01:52):
Oh boy.
Sally Pace (01:54):
That if someone could tell me exactly how they're calculated, I think they would win.
Ryan Rice (01:59):
We're going to need another podcast to answer that one, another podcast and an abacus to answer that one, I have to take my socks off to count to 20. So I don't know.
Sally Pace (02:09):
So we'll save that for another date but direct rebates verse rebate aggregators. There's a shift to move to the rebate aggregators. Can you explain what that is and, and why it's beneficial and why we're seeing that shift?
Ryan Rice (02:23):
Is a really important topic, as when we are running a, what we call our partner alignment or a procurement effort. For example, we see this very plainly is the variance and the difference in the metrics around the rates, so that the rebates themselves that are oftentimes set forth in a proposal from a PBM. And what we've noticed in those rates is there's been such a degree of escalation over the last five years, and I think a lot of that hinges on a couple different factors. Number one, its a more expensive product to market and there's more competition. So between manufacturers and PBMs, there's a lot of stickiness in those relationships where, you know, to avoid the term pay for play, but maybe a more appropriate way of describing it, is that the manufacturers are in a sense going to give more advantageous rebate for placement on formulary as well as for adding a removal of different utilization management, like prior authorization requirements.
Ryan Rice (03:26):
So we see a lot of variance there, but one of the things that is probably most notable is this concept of the aggregator and the way in which a rebate aggregator works with plan sponsors and how a new concept called the GPO or a Group Purchase Organization is also emerging in the marketplace. In a nutshell, what we're seeing is that it's almost a race to who can ever put forth the very best rebate guarantee. And that's all predicated on, sometimes some really a bad underwriting, which is going to prefer the use of branded drugs over more than appropriate generics. We call this, you know, seeking the lowest net cost is what the preferred mechanism is. However, in order to be competitive on the spreadsheet, oftentimes PBMs are going to put forth their nastiest formulary that excludes certain products and the preferred rebate-centric products to win that business.
Ryan Rice (04:25):
But then what we find is there is an escalation of total net cost. You're aggregating bigger rebates, but you're also spending a lot more. It's stepping over a dollar to pick up a nickle, and that's really not the advised direction that we would take with, folks. And we're going to see more of this. We're going to see more of this genuine desire to get as much rebate as you can, as smaller PBMs, oftentimes use a GPO or an aggregator to gain access to collectively negotiate with manufacturers to get better rebates. I think historically, it was a lot of aggregator organizations.
Ryan Rice (05:03):
What you're going to see now are the big PBM;s, the big threes like Express, CDS and Opium RX. They control the majority of share. They have direct manufacturer relationships with drug manufacturers and they've created group purchase organizations. Express Scripts, for example, owns the GPO called Ascent. And so Ascent is also offering up, through Express Pride Therapeutics and others, the ability to tap into those rebate arrangements. I see, and I think we, as a firm, believe it's the desire to partner with these GPOs is only going to increase. You're going to see the big three in a sense, controlling the aggregation services that are out in the marketplace, which I don't think is going to ultimately bend the curve reverse in lowering the cost of products, but also we're going to see this desire to increase the rebates as well.
Leigh Dill (06:03):
So how would that work on your effort RFP? You've got one of the big three that you already contracted with and you've got , lets say, two smaller PBMs that are also on the sheet. Like you said, the HR director of CFO was saying, "who's going to give me the biggest rebates?'. Is the larger PBM in a monopoly state that they automatically get the higher rebates, even though those smaller groups might partner with their aggregator. Are they controlling that at all?
Ryan Rice (06:37):
So super good question, and, I think the answer is yes and no. It really depends upon, I think the opportunity that a group is going after. So let's say there is a 20,000 life municipality, like a states and health plan of sorts for the employees. Lets say Express Scripts or Prime Therapeutics is going to bid on this, who own, or have a part ownership of Ascent, the GPO. So you would think that those entities could have the very best possible rebates or would be the most competitive on the spreadsheet, right? But also you may have a smaller PBM that has a negotiating deal with Express and or Prime or whomever as part of that. One would think that, for sure, if you take out the middle person there, they should be able to write the very best possible offer, the best rebate.
Ryan Rice (07:32):
But what we're finding is that for strategic opportunities, the big ones will go after it. They'll take a loss order to win that business and then try to make it up in years, two, three, or whatever, but its still dependent on how deep they want to go. What is the profitability they're trying to understand, they got to make on a certain case. And we've seen scenarios where the smaller PBMs that are aligned with that same GPO are actually more aggressive because they've chosen that, "I'm going to make my money elsewhere, maybe with an admin fee or maybe with some other. I'm going to maybe earn spread on the network discounts, but I'm going to pass through all the rebates that I'm getting from my GPO". So it's very possible depending upon how the PBM downstream or that smaller entity chooses to set forth their offering, just like it is. It depends upon how the large PBMs who own the GPO, would also put forth their pricing. Very possible that you can see a reverse of what should be intuitively competitive.
Leigh Dill (08:36):
You've got so much experience in this and so much understanding of it. Can a broker bring you guys in during an RFP to help explain, contract negotiations for the client to really see, who has the best value, even though one rebate might be higher than the other?
Ryan Rice (08:53):
Absolutely and emphatically, yes. We heard, its absolutely, well, right? So whether it's a project or an ongoing relationship, we love doing the partner alignment, the RFP process. We feel that we've got a different approach that measures things very differently. And especially with rebates, we actually look at the mix of the products themselves to sort through that concept of lowest net cost. Because the mix of product is what's ultimately going to determine your certain starting points and every PBM is a little bit different in what they, in a sense prefer as their mix of product. So taking the time and the diligence to understand what's going on, to then present multiple options via procurement, via market check. We love that stuff. It would be a genuine privilege and honor, to be able to do that with advisors who think the way we do in vice versa.
Leigh Dill (09:51):
Awesome. So tell us-
Chris (09:51):
I was going to say, if you've seen one PBM contract, you've seen one PBM contract. As Ryan said, we love rolling up our sleeves, to dig down into it, and to find what makes those PBMs unique and explaining and helping our clients and broker friends. I'm a contract geek. I love that stuff. So set up my way.
Leigh Dill (10:11):
So let's take that geek to a new level. I got the nicest way to possible. So we've got both employers and brokers in our audience listening, and you are pushing the ball uphill in a really fast way in this PBM space. If you had a magic pen and could help them write one question that is probably not on their RFP for PBMs, what would that question be?
Ryan Rice (10:37):
Oh boy. That's a good one.
Chris (10:41):
You kind of limited to one question so I-
Leigh Dill (10:43):
Just one, lets get to the one then
Ryan Rice (10:45):
That one thing in the, what could it be? Oh man. Chris, what you think?
Chris (10:52):
To me. I always want to know how someone is making their money. And what I mean by that is you have PBMs, their only source of revenue. So similar to Prism, our only source of revenue is our admin fee that we charge. It's all in. You get everything straight up. This is how it is. You have others that maybe don't charge an admin fee, but there are maybe some other hidden streams of revenue that are deep within the contract. So for me, my one magic pen is how is it that you are making money to help keep the lights on, pay for your employees? It all comes down to the financials, for me.
Ryan Rice (11:37):
I mean, there's lots to things like termination without cause of course I mean to say. Having clarity of terms are also really important. I think the problem with other entities out there. They get this silent approach. You can't look at one particular aspect in a vacuum. You're never going to win a deal on a dispensing fee. You're never going to lose a deal on what kind of ancillary programs that likely will never get put in place, are actually going to be in a sense implemented. So therefore I think the most important aspect for any advisor who's out there, who, or any plan sponsor that's out there, you have to maintain your autonomy, period.
Ryan Rice (12:18):
You need the ability and the right to make decisions for yourself. That means having access to your data, audit ability, the right to terminate. All of these things are critically important. But I think the one question I would ask is, PBM, how are you going to help in a sense, create an autonomous relationship that is not based on exclusivity, in a large sense of things, but that's going to give me the right and the ability to, in a sense, create a solution for my employee benefit plan, that's going to amplify that vision that they have and, and making sure that that is a priority?
Leigh Dill (12:58):
Good questions. So if they don't want to write those questions themselves, how can they get in contact with you guys to help with project work? Can you give us-
Ryan Rice (13:07):
We've got three to 400 other ones that we would be happy to give them too.
Chris (13:10):
Absolutely.
Ryan Rice (13:13):
I think the best way to contact us is a number of different ways. You can reach out to us through our website, which is www.theprismhealthgroup.com. You can reach out and there's a series of different ways to contact. But I think that a great way would be to use your grant list functionality as we are on that list and love being part of it. Those folks do a fantastic job. So you can definitely hit us up through that medium. And they'll direct you straight to Chris, and, or myself. Otherwise, you can hit us up. We'd be happy to share our direct contact information or hit us on LinkedIn. Either way, send up a smoke flare or even a carrier pigeon. We'll take every bit of it. But we would love to work with anyone who believes in some of the things that we've talked about today.
Leigh Dill (14:00):
Fantastic. We really appreciate the conversations today and on a separate note, can you share your favorite book? What are you reading now or what is something that stays on your coffee table?
Ryan Rice (14:12):
Travels with Charlie? I'm a John Steinbeck nerd. I love it. I wasn't a big fan of grapes and wrath. I'll be first to admit, but the travels with Charlie, I think it's such a great and timeless book. It's a classic. And if you like dogs, you would love this book. So go out there. You probably already read it, but it's a good one.
Chris (14:34):
For me. One book that I, I tend to keep reading and have in my bookcase or coffee table, is the, Last Lecture with Randy Pausch, who is a computer science professor at the Carnegie Mellon University in Pittsburgh, Pennsylvania. It hit home. I've had cancer deaths in my family and for him to give his last lecture, terminally ill, and pretty much telling his class to continue chasing their childhood dreams. Really, kind of hit home for me. My childhood dreams has always been to help people. I feel now more than ever, I'm in a position that really allows me to help people, especially ones that want to be helped as it relates to their pharmacy costs. So that one is always kind of, "you know what, I haven't this one in a while. I want to read it again"
Sally Pace (15:24):
Got that. Awesome.
Leigh Dill (15:26):
Thank you very much and thanks audience for tuning in.
Ryan Rice (15:34):
Thank you guys. We appreciate your time.
Chris (15:37):
You’re welcome.
Sally Pace (15:42):
Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribe in our site, thegranitelist.live
Ryan Rice and Chris Ziemke from Prism Health Group represent a new breed of healthcare consultants, poised to impact the entire healthcare spectrum versus the traditional, siloed approach. They saw the needs in the pharmacy industry specifically to navigate the pharmacy benefit management space. Employers needed a better understanding of their pharmacy spending from an unbiased source. That's where Prism Health Group comes in. Listen to this episode, "Drugs and Data – How Analytics Truly Impact Claims Spend."
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Here is the full transcript for this episode:
Announcer (00:09):
Welcome to another episode of The Granite List Live. Navigating a sea of benefits solutions is daunting at best, and new vendors emerge every week. Hosts Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spending while improving employee engagement and outcomes. Ryan Rice and Chris Ziemke from Prism Health Group represent a new breed of healthcare consultants, poised to impact the entire healthcare spectrum versus the traditional siloed approach. They saw the needs in the pharmacy industry specifically to navigate the pharmacy benefit management space. Employers needed a better understanding of their pharmacy spending from an unbiased source. That's where Prism Health Group comes in. Listen to this episode of The Granite List Live: Drugs and Data - How Analytics Truly Impact Claims Spend.
Leigh Dill (01:10):
This is another episode of The Granite List Live, and we are thrilled to have Ryan and Chris from Prism Health Group here today to talk about the ins and outs of controlling pharmacy spend.
Ryan Rice (01:27):
Hi, I'm Ryan Rice. I serve as Principal and Practice Lead here for the Prism Health Group.
Chris Ziemke (01:34):
I'm Chris Ziemke Business Development Lead here at The Prism Health Group.
Sally Pace (01:38):
Ryan, Chris, we appreciate y'all being here today and we know that you are a new partnership. You've just come together to create a new group. Can you tell us a little bit more about what you found value in each other and what you're doing going forward?
Ryan Rice (01:53):
Yeah, absolutely. So we actually started out in this effort about three years ago. I founded the company in partnership with a few others and we were known as the Prism Health Strategists, and we started out really with this notion of, what is it that the marketplace is missing today? And the unanimous decision was is there's not a lot of independence. There's not this agnostic point of view specific to the pharmacy industry itself. There's lots of really talented and sharp brokers advisors out in the marketplace. And there are some larger shops that are out there. But what we found is that there is almost an obsession around coalitions, cooperatives, consortiums, and the like. And not to say those entities are bad per se, but what we found was, boy, there's a better way to do this. And the voice that we hear calling out for help are those of plan sponsors, TPAs health plans who are looking for an independent voice to help amplify their specific message and their strategy to the marketplace, and pharmacy, given our collective backgrounds, made the most sense.
Ryan Rice (03:00):
And that's how Prism Health Strategists was born. Fast forward about a year or so, the company was really picking up steam. We had gathered up a bevy of different client partners and then a group called ScripPoint approached us and it made lots of good sense. And so Prism acquired ScripPoint and became what you see here today as the Prism Health Group. So it's the combination of what we believe to be really smart folks and really solid technology to solve for helping folks really navigate the pharmacy benefit management space. It's a very complex space to have to navigate. And we have made it our mission to deploy innovation, really detailed analytics and expertise, but most importantly, the autonomy and that voice to those [inaudible 00:05:31].
Sally Pace (03:51):
What did ScripPoint add to Prism Health Strategies to make Prism Health Group?
Chris Ziemke (03:58):
I would say ScripPoint when I came on, when Ryan approached me about coming on to ScripPoint and Prism Health Strategies, to me, it was a no-brainer. From where I sat, leading a midsize TPA as their pharmacy director, what I would see in the marketplace, there wasn't a lot of brokers or consultants out that really knew the pharmacy space so to say. They knew a little bit just to be dangerous, but when it was coming to clients and talking to them about their pharmacy spend, they really didn't just focus primarily on pharmacy, which was a passion of mine. And really, it was a no-brainer for me to say, Ryan, I'd love to join up with you and provide that independent voice.
Chris Ziemke (04:42):
What ScripPoint added to the Prism Health Group was not only an additional book of business of client partners, but also a regional brokerage or consulting firm that kind of helps Ryan and the Prism team expand their reach more towards the West and the Northwest of the region. And really now as the Prism Health Group, we feel ourselves as a national presence. And that's kind of how we want to grow, from East Coast to West Coast, we're looking for clients, TPAs, hospitals, health systems that are kind of yearning or, or reaching or wanting to know and understand more about their pharmacy spend and receive that independent voice to kind of help with the market in where pharmacy spends going today.
Sally Pace (05:28):
Let's dive into that a little bit deeper. We talked about pharmacy spend. How is Prism helping plan sponsors and their partners manage, specifically, the Pharmacy spend?
Ryan Rice (05:38):
Really good question, Sally. You know, I think that when we look across the market, the landscape, and part of this missing component, it was this genuine sense of achieving performance transparency. And I'm a firm believer that you can't make a claim unless you can back it up with data. And claims data or data is the lifeblood of being able to make meaningful change because you have to know where you are to know where you're going to go or where you're going to travel to as a self-funded plan, as a hospital, as a TPA, what have you. And so what our firm is very much committed to is that of having very clear and ready access to claims data. For nearly every one of the clients that we serve today, we've got real-time connectivity to that data. We're adjusting it on a daily basis.
Ryan Rice (06:28):
And so we're, we're putting a ton of emphasis on the ability to not only report and measure but then also being able to take near-immediate action. So we developed our own platform called Prism 360, which is a near real-time adjudication and claims data repository that really shows some pretty sleek and fancy-looking reports and all that good stuff. But most importantly, it helps coordinate with nurse case management staff. It helps coordinate high-cost claimants and then alerts out automatically so that you can take action immediately. Reporting and insights, 30 days, 60 days after the occurrence are meaningless. We can all talk and sulk about what we should have done when, darn it, let's go ahead and take the bull by the horn and have the ability to do something reasonable and meaningful with it in near real-time. And that's a very, very important aspect of being able to take control, meaningful control, of the spend itself.
Sally Pace (07:31):
Walk us through what that looks like. An employer group plugs in Prism Health Group. Are you looking at their claims real-time? Are they responsible for looking at it for themselves? Is it the PBM? How does that work once you implement your service?
Ryan Rice (07:47):
Really good question.
Sally Pace (07:51):
And what do you do once you find issues within the spend?
Ryan Rice (07:53):
Right. So technology in and of itself is great. It's like having a Ferrari, but if you don't know how to drive stick, well, it's kind of pointless, right? So what we like to say is not only do we manufacture the sports car, but we also know how to drive it pretty damn well. And so having that ability to not only ingest claims. And so when a new client comes on board with the Prism Health Group, the first thing that we are doing is going through a rigorous, implementation process where, first and foremost, we're identifying the different dynamics of the plan itself, plan design, what provisions are within that contract that govern the performance itself with the PBM. We're taking all of that into account and then also ingesting those claims directly from the PBM. And this is important. We actually apply our own source of average wholesale price to the analytics that we are performing.
Ryan Rice (08:47):
So, said differently, the independence or the agnostic point of view is really important. And that's something that separates the Prism Health Group from others. So when we are taking in those claims, we're not taking the PBM's word for it. We're actually applying our own independently sourced benchmarks of price and of value to ensure that the insights that we're able to then produce and advise our clients are based on independent data. And the best part about that is we're also providing access to the 360 environment directly to our clients. So they can also have real-time access to their data. It's their data. They should have every bit of right to it. And with the Prism Health Group, we provide that latitude and that ability to gain that kind of transparency they require.
Sally Pace (09:37):
So going forward, once you implement that, you reach out to the PBM, the client and say, this is not being adjudicated correctly. We need to fix it. [crosstalk 00:09:47] How does that work?
Ryan Rice (09:47):
Great question. So one of the core tenants of our services that we provide, or that we're doing an audit on a, dare say, on a real-time basis. So because we're collecting those claims transactions on a daily basis, we're able to see how that compares to the guarantees in the contract. So why that's important is we don't have to wait until the end of the year with the PBM to say, why did you miss your financial commitments? You can be doing that in near real-time. And in fact, we perform those audits on a quarterly basis, and then we actually help our clients as part of our service audit the PBM. So it's all included in that ability to not only measure, keep the PBM in check, but then do the negotiation with the PBM to make sure that you're getting all of the dollars that are in a sense owed to you.
Sally Pace (10:39):
Ryan, you said we don't take the PBMs word for it. So I can imagine there are some PBMs who quake in their boots when they hear that a consultant has been brought on to review an audit. But let me ask, conversely, are their PBMs that you have preferred relationships with, that you have exclusivities with? How does that work? Can you guys explain that?
Ryan Rice (11:04):
Yeah, really good question, Sally, and this is super important. We get asked this question a lot and the answer I always provide, we all talk about is we don't have a list. There is no magic list, and that's very much a deliberate action on our part because our independence is really based on this concept, this notion that I don't care who you're with, we're going to make that contract. We're going to make that partner of yours per perform what they said they were going to commit to. And so it's important for us not to be behind consortiums coalitions, cooperatives, and also align with PBMs. That's not to say that we don't have efficient ways of getting a group that may have to make a very quick decision and align with a different PBM. We do have a solid sense of what the market has to offer however.
Ryan Rice (11:56):
Today we work with 23 different PBMs with our different clients from across the industry. And I would say that we know which PBMs tend to agree to the requirements that we set forth in a procurement and or market check or audit. And we also know the ones that don't like to be so compliant. And so I would say that we don't have favorites, but we are very confident in which PBMs are likely to be more compliant and help those plan sponsors achieve performance transparency.
Chris Ziemke (12:28):
I would also add that if it really does depend on what the client wants or what they are ultimately trying to get out of their pharmacy plan. So I think another aspect that we do maybe a little bit differently is taking the time to sit down with the client alone and say, okay, client XYZ, what is it that you want out of your pharmacy plan?
Chris Ziemke (12:51):
What are you trying to achieve for your employees? And sometimes it may be a pass-through PBM. A lot of times, I think we have a couple clients that want to stay more on that traditional model. And I think that's what it's important that Ryan said that we work with every PBM out there and not just a select few, because you never know which client wants to have a certain model or a certain direction with their pharmacy plan.
Ryan Rice (13:15):
Yeah. You know, hospitals are a great example. We serve several hospital providers today where they have initiatives to provide uniqueness of giving access to their home hosts or domestic pharmacies within their own bricks and mortars. There are the right PBMs for entities like that. And there are some that aren't the greatest of fits and it just depends upon, as Chris said, who that client is and what they're trying to accomplish.
Leigh Dill (13:42):
I believe that's one thing that makes you unique compared to other offerings in the marketplace. But can you explain a little bit more about your value and why there is a need for a PBM only consultant?
Ryan Rice (13:56):
You know, we get asked this one a lot too. It's well, what the hell do I need a PBM consultant for? I've already got a really smart broker and you know, what, if that's the case then great, then there may not be a spot for us. But I would say that nine times out of 10, when we get brought in, we always start with a way for us to prove that there be a problem working underneath the surface. We consider this putting our money where our mouth is. I believe that we're one of the only consultants out there, independent or not, that actually put their fees at risk, meaning we are on a one-to-one basis, at least going to put everything you pay us, as a plan sponsor, on the line to make sure that we're delivering on those commitments.
Ryan Rice (14:37):
And I think that it really does serve to our core, our model of our grit, if you will, as part of our core values in that we wouldn't ask anyone to pay for something that we ourselves wouldn't pay for. I'm a big believer in that you got to eat your own dog food before you expect the broader [crosstalk 00:14:57] adoption and we live that every day. So the way in which we work with our client partners is personal because it has to be, we don't get paid unless you achieve those outcomes that we said you were going to set out to accomplish.
Sally Pace (15:18):
You mentioned a couple of clients already, the types of groups you work with. Can you delve into that a little bit further? Do you have a preference on the type of client you work with or who you typically look to for adding new business?
Chris Ziemke (15:24):
Yeah. Great question Sally. I think first and foremost, we work with every single type of client out there, whether you're a Taft Hartley group, a TPA, hospital health system, commercial group, government groups, we'll work with anyone. In fact, our book of business today is compiled of every single type of client that I just listed out there. I think where we're kind of finding our sweet spot is the TPA space. So, coming from a TPA myself, being in that position, it was always difficult for me to have a pulse on every single PBM that we work with. So you have preferred PBM relationships, but as a TPA, you work with every single type of PBM. And Ryan has said this a couple times TPAs tend to be the dumping ground for failed programs that want to be started either by PBMs or some brokers or consultants out there.
Chris Ziemke (16:22):
And so what we found with the Prism 360 platform is it really arms and gives the TPA, the power to make active and decisive decisions as it relates to pharmacy benefits. As Ryan mentioned earlier, being able to access real-time data, being able to take that data or some of the alert systems and work with a TPAs nurse case management team is an absolute powerful program. We've really found success. And maybe kind of back up a little bit from there, some of these regional TPAs, they don't have a pharmacy director or someone like myself that help manage those PBM programs. So we kind of see Prism 360 taking the space of that pharmacy director and our main giving the account managers themselves, the tools, the reporting, the access that they're able to go out to the brokers and the clients that they serve and say, "Hey, here's where your pharmacy spend is today. Here's where we think we can make some improvements over the next year and keep a pulse or a thumb as to how we're going to get from A to B."
Ryan Rice (17:34):
Yeah, I think that's right, Chris. And we really do welcome the challenge as well. So in an addition to the kinds of ongoing retainer-based relationships that we have with clients, it's our product, our RFP and procurement process, which we call partner alignment. So market checks and the audits that we perform. So we're also doing lots of project-based work as well. And some odd ones at that. We've even got some less than traditional business within the correction space. And we absolutely love working with those folks. Government entities are an area where we've done very well as well, anywhere someone is seeking that threshold, that purity of transparency and performance and insight into how things are performing. We're great fit for those kinds of folks.
Sally Pace (18:22):
How does somebody engage with you guys? You mentioned brokers or sometimes through brokers, is it ever direct with the employer? How does it work?
Ryan Rice (18:30):
There's a number of different ways. I mean, you can always just give us a phone call here and we'll definitely, we'll pick up, and we'll get you signed up lickity split. I would say that there are probably two or three different primary ways. As Chris had noted the presence we've developed in the TPA space is very unique because the TPAs we partner with all share a common goal. They want to provide insights and actionable data to their client partners that they serve so that they can be as forward and agnostic as well as doing things in the benefit of their clients. And so by providing technology, by providing our services and in that capacity through natural connectivity is a primary way.
Ryan Rice (19:14):
So TPA says, "Hey Bill, and Ted's Bait Shops, I know that you're struggling with X, Y, and Z on the pharmacy side. We have this group that works with us on a number of things. We really recommend that you take a look at them and look at getting into a long-term relationship." That's been one of a great way for us to generate partnership. I'd say another really powerful way is through advisors. I think of the bell curve of adoption. We're really good fits for those who are forward-thinking, who are early to adopt new concepts, and who know that the puck is going to be someplace else and we want to be where that's going to be.
Ryan Rice (19:53):
But if folks still using the rotary or flip telephones they may be more comfortable with the big houses that have been around for hundreds of years. So I think it's important to know that we are on that front side of that curve. And we see ourselves taking up relationships with client partners who see the value of being able to be at the front end of innovation as well as thought leadership. And broker relationships have been a great partner there for us in that they know they're not experts in pharmacies, like having someone who's really good at corporate tax to do your taxes. You're not going to Turbo Tax that one. Right?
Ryan Rice (20:35):
So it's a way for us to align with a broker in their respective book of business to help provide a deeper threshold of expertise that helps protect their book of business. But it also helps go out and predate or go after those clients, using pharmacy as a lever, to be able to say, "Hey, prospect, I can help you with these things. I bet you there's 20% savings in your pharmacy spend alone." So that's a great way in which we've been able to garner some that additional support.
Leigh Dill (21:05):
All right, talk to you soon. [crosstalk 00:21:08] great rest of the day.
Announcer (21:11):
Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribe in our site, thegranitelist.live.
Breast Cancer awareness is 12 months a year if we are to save more lives and have earlier detection. Sally and Leigh's guests today are here to help. Celbrea® does not replace a mammogram, but gives an interim, non-invasive, radiation-free way to check one of the earliest warning, before feeling a lump and takes only 15 minutes. Every 2 minutes a woman is diagnosed with breast cancer. Every 13 minutes a woman dies IN THE USA. Using liquid crystal thermographic technology, Celbrea basically takes the temperature of the two breasts and compares them. You'll want to hear about this life-saving technology that works alongside other early detection techniques. Sally and Leigh welcome Kelley Ospal and Jaime Pira of Welwaze, the creators of Celbrea, to inspire you to either offer this service in your office, or health plan, or for you the patient to request it. Women, it's the best 15 minutes you can spend between mammograms. You may want to bring your mom, aunt, sister, daughter, cousin, best friends, too. When this is offered as an event in the workplace, the increase in breast cancer screening and preventive measure success increases from 40% to 88%!
Learn more about Celbrea at https://celbrea.com and more about the company behind this technology at welwaze.com.
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The full transcript of this episode is here:
Announcer (00:07):
Welcome to another episode of The Granite List Live. Navigating a sea of benefit solution is daunting at best and new vendors emerge every week. Hosts Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spending while improving employee engagement and outcomes.
Announcer (00:35):
Breast cancer awareness is 12 months a year, if we were to save more lives and have earlier detection. Sally and Leigh's guests today are here to help. Celbrea does not replace a mammogram, but gives an interim noninvasive, radiation-free way to check one of the earliest warnings before feeling a lump, and takes only 15 minutes. Every two minutes, a woman is diagnosed with breast cancer. Every 13 minutes, a woman dies from breast cancer in the USA. Using liquid crystal thermographic technology, Celbrea basically takes the temperature of the two breasts and compares them. You'll want to hear about this lifesaving technology that works alongside other early detection techniques. Sally and Leigh welcome Kelley [Ospal 00:01:20] and Jaime Pira of Welwaze, the creators of Celbrea, to inspire you to either offer this service in your office or health plan or for you, the patient, to request it.
Announcer (01:31):
Women, it's the best 15 minutes you can spend between mammograms or ultrasounds. You may want to bring your mom, aunt, sister, daughter, cousin, best friends too. When this is offered as an event in the workplace, the increase in breast cancer screening and preventive measure success increases from 40% to 88%. Please listen to this full episode. It may save your life or that of somebody you love.
Sally Pace (02:02):
Thanks everybody you for joining us. This is Sally Pace. We are thrilled today to have a dynamic duo from Welwaze joining us to talk about some pretty revolutionary products that they've developed in the space of breast health. As everyone knows, October is Breast Cancer Awareness Month, so there couldn't be a better time for this conversation.
Jaime Pira (02:25):
Hello everyone. My name is Jaime Pira. I am the chief experience officer at Welwaze Medical. We are the manufacturers of Celbrea, a breast screening device. It's a pleasure to be here with you today.
Kelley Opsal (02:39):
My name is Kelley Opsal. I'm the senior account manager for Welwaze Medical and I am representing Celbrea. Yeah. Actually, it's a great time to have this podcast because there's a lot of women that it doesn't dawn on them to go in to get their breast health checked, for instance, ultrasound or mammogram. They've started seeing it more on TV. They started thinking about it. And a lot of times they hadn't even gone in for their mammogram because they just don't like to go in for the mammogram. So, it could have been two or three years before they had even had their breast health checked. So, they have no idea where they're at, at that point in their life, with where they're at with their breast health, but their curious to know, and that's where Celbrea would definitely come in to offer that to them. The screening test is a 15-minute screening test in the office. Make an appointment. Go to a facility. It's in the convenience of the doctor's office or the clinic.
Sally Pace (03:33):
Kelley, I'm going to start with you. Tell us a little bit about your journey, what led you to the Welwaze team, and what you're working on right now.
Kelley Opsal (03:44):
Well, I've always been in the medical field. What brought me to Welwaze was personal experience. With that said, my mother-in-law actually, got diagnosed with breast cancer at the age of 67. She had been going in for her annuals and halfway in between her annual mammogram, she felt a lump. By the time that she had felt it, at the age of 67, which is usually fairly on up in your years for a breast cancer, it had already spread. She fought a good battle for about exactly five years because that's usually the life expectancy. She did go into remission, but I had been with her on that entire journey and it really touched my heart as to what I saw her go through, and the fact that I do think that it could have been prevented.
Kelley Opsal (04:30):
When I was offered this opportunity, I jumped on it because I was invested personally in it, which made me more passionate about it. It's really to give women a fighting chance and it feels though that I'm helping women to make a decision out there to get a handle on where they're at, to check in where they're at with their breast health, and not wait any longer because so many women are just waiting to go get their screenings done.
Sally Pace (04:55):
Jaime, tell us what Welwaze has developed. What is Celbrea?
Jaime Pira (05:01):
Okay. Well, Celbrea is a thermal activity indicator. So, basically, it's a screening device that works as a measuring the temperature of women's breasts, making the comparison between one breast and the other, and determining whether that temperature is okay and everything's fine, or whether there's a significant temperature difference, and by that measurement, creating an alert to her clinician that she needs to follow up with further testing. Celbrea picks up a heat signal that is emitted usually by malignant breast tumors. And that is very important for people to know. It's not the only pathology that generates heat signals, but is the most clinically relevant. So, working with Celbrea, it's fantastic because it has a very strong negative predictive value. The product is very good when it's used as a screening tool. It's not a diagnostic tool. And it's fairly easy to use in the clinic of the physician's office and they can readily do it in 15 minutes or so.
Sally Pace (06:06):
It's hard to describe just how fabulous the product is on a podcast where there are no visuals. I think it's important for the audience to understand the difference in what and how it is administered versus other modes of breast health monitoring. So, I want to know. To me, it is kind of an adhesive disc. Jaime, would you say it's very similar to the adhesive hospital thermometers that people maybe familiar with?
Jaime Pira (06:39):
Celbrea is quite unique in its design, and the way it works, and the whole science behind it. So, there is nothing really a good point to say, this is exactly the same, but if people visit our Celbrea website, they would see the images and we have some videos there that explain how it works and how it's administered. But to your audience today, what I can briefly say is that this device is very simple in its appearance. It is two pads that are applied directly on the surface of the breast. They have to be on the breast for 15 minutes. They are painless pretty much because they tend to simply adhere to the skin with a medical adhesive. After that, they are removed, and from there, we go on to read the test results, and that's pretty much it.
Jaime Pira (07:24):
Important things to know in medical devices is how safe they are. On our clinical trials, Celbrea demonstrated to be very safe and effective. Since it's noninvasive, we don't have any side effects reported to the Celbrea device. So, what I can say, it doesn't generate any radiation to the test. It doesn't generate any infrared or electromagnetic fields that are exchanged. So, it's a very safe simple-to-use device.
Leigh Dill (07:52):
Kelley, can you tell us about who the optimal user would be and who should go to their OB and suggest using this device?
Kelley Opsal (08:00):
Absolutely. The ideal patient type would be women under 40 and also women that are in need of more frequent and additional testing because it may have ran in their family and they have the BRCA gene. Also, women, of course, that have gaps in access to care. A lot of women, in some outer-lying areas, they don't even have other screening tests available in other countries. So, Celbrea is picking up active tumors in women with dense breast, whereas it could have been missed by some other screening test. But the ideal patient really is anybody and over the age of 18. In clinical trials, we had tested it on all walks of life, on all breast sizes, and we have seen it to be really successful ideally in women with dense breasts. And a lot of women that have dense breasts walk away from an ultrasound or mammogram a lot of times, just wondering if it really caught everything it needed to catch.
Kelley Opsal (08:59):
The wonderful thing about Celbrea is that it is skin on skin and you don't even really feel it while it's on. It's literally just the way I like to explain it to patients in the waiting room while I'm waiting to speak to my physicians because they ask about it. They're so interested and just intrigued by it. I basically say, "It's two patches that go on each breast and it's on there for 15 minutes. You really don't even feel that it's on. And then, we will peel it off, lay it flat, and do the reading."
Kelley Opsal (09:26):
What's great is we have a new app that does the reading for the nurse practitioners and the physicians, and they know their results right there on the spot. Whether there is a need for further testing if there is suspicious activity, it's not to alarm the patient because it may not be cancer, but what is occurring that Celbrea is just magically picking up, if you will, is a process called angiogenesis. That is when there is an active tumor. Whether I'd be cancerous or not, it's going to nestle itself into those blood vessels that are located in the breast. And then, immediately, in order for it to grow, we are nourishing it. We are helping it to grow and it's giving off heat, which is rising up to the pad of the Celbrea screening. So, it's going to be able it up if there is angiogenesis occurring, right away.
Leigh Dill (10:19):
I know we're all familiar with the mammogram bands that come around. Can you tell us a little bit of how you work with on-site clinics to administer a free screening for employees?
Jaime Pira (10:32):
Basically, after we go through the whole vetting process of the plan, understanding the benefits of the product, the impact on earlier detection versus later detection, and after they realize the potential savings they can derive from the cost reductions of treating a more advanced cancer versus an earlier detected cancer, usually what the on-site clinics will do is what they Celbrea drives or events during the year.
Jaime Pira (11:05):
Of course, during the month of October, many of these self-funded employers are doing these “Celbrea Drives,” in which they invite their plan members to come and test, typically at the nursery, a facility on the site or at the on-site clinic. So, since this is a rather simple procedure, they don't even need to clock out of their job. They simply go to the infirmary. They are scheduled in 30-minutes intervals and they're applied the test and they have their checkup. To mention here that Celbrea is not intended to replace mammography at all... It's in fact an adjunctive tool that adds additional information to the clinician in an earlier stage of his screening procedure with the patient.
Jaime Pira (11:52):
Another interesting fact that we found with self-funded employers is that before the use of Celbrea, patient adherence rate to the annual mammography... I'll give you an example. We found a self-funded employer that had 40% adherence to the annual mammogram. That's very low, despite of the fact that the health service was fully covered. After the Celbrea test was implemented and the doctor had the opportunity to have a quality conversation about breast health, the importance of screening, and the importance to staying on top of screening, that rate went up to 88%. So, that's really magnificent in the sense that not only are we helping to detect any potential of early breast tumor, but we're also helping getting most of those ladies more conscious and aware of the importance of their annual mammogram. So, a good 88% of them now, after three months of that program, are now compliant with the device. That's a little bit of how we're dealing with this in an on-site and self-insured employer space.
Sally Pace (13:01):
You mentioned the self-funded space, which is really obviously our audience, who listens to our podcast series, both advisor side and the employer side. So, while the month of October lends itself to a focus on breast cancer awareness, what we all know and our audience knows is that it stretches far beyond that one month and has a grave impact on the cost of a health plan. So, Kelley and Jaime, I know as we've had conversations just among all of us, we do talk about that I guess the average cost of cancer in the US at least is about $80,000 a year and it goes up exponentially as the different stages progress. Kelley, you mentioned earlier detection and the importance of that. If you had the opportunity to speak to every woman in the United States and tell them about this product, what would you want them to know?
Kelley Opsal (14:00):
The importance of breast health is just so forefront in a woman's life. A lot of times they're going to think about maybe going and getting Botox, getting their hair done, getting their nails done, and they just keep putting it off because they just hope that nothing's wrong, and another year goes by and they just really don't pay attention to it that often because they're hoping and they just assume, nothing is going on. You can have breast cancer and not feel anything and it's just very frightening and very scary that women just do not realize the importance. It's kind of another one of those silent killers and early detection is key because if you can get it removed, get that cancerous tumor removed, you've just bought yourself another lifetime, so to speak. If you don't do it, the repercussion could definitely be that you're going to be spending, your family's going to go into bankruptcy, trying to take those five years to maybe get it eradicated or go into remission.
Kelley Opsal (14:59):
We think mammograms are very important, but there's a lot of times, too, where there are women that just want to check in halfway through that. For instance, like my mother-in-law, who'd found a lump six months after she had just been given a clean bill of health by the radiologist. That is when she felt it in the shower and it had already spread. So, it's a very inexpensive test to perform. It's very quick. It's easy, painless, FDA-cleared. Again, we just really are trying to promote it as an adjunct. The mammography industry, I know, just loves us because if there is a significant finding, it is motivating that patient to get in there and get your ultrasound. Get in there and get your mammogram. Again, its cost is really not a big factor.
Sally Pace (15:45):
But you've mentioned the financial impact for families, and you're right, it is a nominal cost. I know a study was cited recently. Cancer patients on average are about two and a half times more likely to declare bankruptcy as those without cancer, and 30% of women diagnosed with breast cancer who are working at the time they were diagnosed are no longer working three years later. So, if we think about what's happened in the workforce due to COVID and people being removed from the workforce and being displaced, I guess I hadn't really thought about it in terms of the financial impact and the feasibility for work impact that breast cancer has as well.
Kelley Opsal (16:24):
Yeah. You know what? I really find it fascinating when I do have that one-on-one time to talk to each patient and they're just like, "Wow, I wish I would've known about this sooner," is what the feedback I get or, "I had no idea that this was readily available in the United States." It's fairly new, but there's so many women that said, "I will do this in a heartbeat. I will have my daughter do it. I will have my mother do it." Again, 18 and over, but there's a of women that ask about their daughters because I mean, that's your offspring and you want to make sure that your children are safe and okay and they can live a long healthy life. It is indicated for 18 and over, but it's up to the physician, whether they want your child to get it.
Kelley Opsal (17:05):
Let's say the cancer is just hitting the grandmother or it was the aunt who had it and passed away from it, it can run rampant in family trees and skip a few generations, but they really take it to heart. Before you know it, when I go in and one gets it done, they bring their grandmother in, they bring their aunt in, they bring their best friend and next-door neighbor in. It's just a matter of getting the word out. That's why I think this podcast is such a blessing because so many women do not know that Celbrea is easy, it's readily available, and it's very affordable.
Leigh Dill (17:35):
If I'm a listener and I want to go take the Celbrea test, what do I need to do? What are my next steps?
Jaime Pira (17:44):
Let me just for a moment go back to Sally's question with a little bit of hard data. One of the things I would like women to know is that contrary to popular belief, more than 85% of breast cancer occurs in women without family history. So, that's a very important call for action for you women out there. Simply because we believe that if we don't have it in our family history, we may be okay and we can relax about it. I don't want to create the scare, but the importance of screening for everybody is incredible. That's the key message. The other is that of course, there is a new technology that can get started in your screening process with an easy and affordable test.
Jaime Pira (18:26):
Coming back to your question, Leigh, about how to come about Celbrea, we are slowly introducing the product into the US market. So, any of the people who are listening to this podcast who want to partner up with Welwaze in helping us in this distribution effort and partnership effort, we are absolutely open for business and willing to discuss that with you absolutely. Now, the way we are actually doing it for the primary care and family practices is we have a national distributor that supplies doctors nationwide for Celbrea, so all you have to do is ask your doctor about Celbrea and they will be able to procure the product and apply the test.
Jaime Pira (19:09):
Of course, that is one way. We are also mobilizing to make this a little simpler in times of COVID and the life we're living nowadays. So, we're also going to have an e-commerce platform coming up pretty soon that will facilitate the acquisition of the device once your doctor prescribes the device and offers it to you. So, I hope with that, we answered your question and want to thank the group at Connect for making this possible because we need to get the word out there. There are alternatives and there is other ways for screening that doesn't necessarily have to be difficult or expensive.
Sally Pace (19:43):
That is a perfect note to end on. We are honored and proud that you all have a presence, both on The Granite List, where people can find information about the product and contact you all that way, but Jaime, is there another, for our audience that is interested and wants to take you up on those next steps? How can our listeners get in touch with your team?
Jaime Pira (20:06):
I would share my email address with your audience. It's jaime@welwaze.com. That's spelled J-A-I-M-E, @wellways.com. And we have a website for both our company, Welwaze Medical, at celbrea.com.
Kelley Opsal (20:22):
As women ask me about it in the waiting room if the doctors were not actually stocking it in their office, I just tell them to go to welwaze.com. There are physicians listed on there and see if there's one local to you. If not, you can call the support and give your physician's name and we will contact them to see if they can start stocking It.
Sally Pace (20:40):
Kelley, Jaime, thank you very much for joining us today. I hope that our audience will take you up on learning more about this lifesaving product that you all have developed, and look for ways to incorporate it particularly into their health plans as they were shined the light on October and Breast Cancer Awareness Month as well. Thanks everybody and thanks [crosstalk 00:21:01] for joining us.
Kelley Opsal (21:01):
Thank you.
Announcer (21:05):
Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribe in our site, thegranitelist.live.
Michael Ketslakh, CEO of National Diagnostic Services gives us a broad overview of vaccinating large companies on-site and the costs of weekly and daily testing. Sally, Leigh and Michael discuss being able to implement strategies that provide a safe environment for the individuals to be close together, but also create a model that is sensitive to the cost burden that the employer would have to be able to continue sequential testing for those employees. With OSCHA Compliance in the mind of many employers who require their staff to be on-site without a work-from-home option, the cost can make or break a company. Rapid tests, when provided onsite can cost around $20 - $30. PCR testing is between $100 and $120. By implementing a pooling method, NDS is able bring down the cost of the more accurate PCR test to the range of the less expensive rapid test. Listen to this episode to hear how it works.
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About our guest:
Michael studied Epidemiology at the University of Michigan School of Public Health. In 1997 he founded National Diagnostic Services (NDS), an independent diagnostic testing company servicing Michigan communities. Our traditional services began with management and operations of Primary Care and specialty clinics in the field of Cardiology, Physical Medicine & Rehabilitation, and Neurology.
The complete transcript of this episode is here:
Announcer (00:07):
Welcome to another episode of The Granite List. Live. Navigating a sea of benefit solution is daunting at best, and new vendors emerge every week. Hosts Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what’s new, what’s needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spend while improving employee engagement and outcomes.
Announcer (00:35):
Michael Ketslakh, CEO of National Diagnostic Services, gives us a broad overview of vaccinating large companies on-site and the costs of weekly and daily testing. Sally, Leigh and Michael discuss being able to implement strategies that provide a safe environment for the individuals to be close together, but also create a model that is sensitive to the cost burden that the employer would have to be able to continue sequential testing for those employees. With OSCHA Compliance in the mind of many employers who require their staff to be on-site without a work from home option, the cost can make or break a company. Rapid tests, when provided onsite can cost around $20 to $30. PCR testing is between $100 and $120. By implementing a pooling method, NDS is able bring down the cost of the more accurate PCR test to the range of the less expensive rapid test. Listen to this episode to hear how it works.
Sally Pace (01:48):
Welcome back to another episode of The Granite List. Live. We are thrilled to continue our conversation with Michael around now, really taking a look at how people are adapting in the current environment and Michael, your team is ever, there was boots on the ground in the middle of all this chaos, it's your group. So can you talk to us about what you're seeing in the immediate world that we find ourselves in?
Michael Ketslakh (02:17):
It's been professionally very challenging for last two years have been very rewarding professionally. Certainly it's been very chaotic to deal with it. So we work with a lot of different government entities in the beginning of, actually in the beginning of the pandemic, we were there for the city of Philadelphia to operate their radiology and cardiology departments and our step-down unit. So those step-down units in the beginning where those hospitals were overwhelmed. As overall as healthcare providers and as governments began to get a better handle on the disease and the spread of this disease and that more important than the management of the disease. For us, we've worked very closely with municipalities, counties, essential infrastructure employers, like power companies. Now we're starting to work very closely with certain districts, also essential employee workers and workforce. And the idea for us earlier on the primary focus with COVID was how are we able to put a stop to the spread of the disease?
Michael Ketslakh (03:18):
That's really the question that our government clients came to us with. And that stemmed around a problem that you guys may all remember of the fact that the results for COVID testing took approximately anywhere from six, eight days to sometimes 10 to 12 days, or really the results became completely ineffective from the perspective of ability to manage the disease. By the time those results are to ever come back, those individuals who are potentially contagious would have already spread the disease, the effective outcome of any kind of a testing strategy in a pandemic is very quick turnaround of results. Can we do it within 24 hours, quarantine those individuals and be able to really take control of that. So for that solution, we started to do was really build laboratories that were centrally located to the testing sites for either the residents, the county residents that we were servicing, or the employers.
Michael Ketslakh (04:15):
So we created kind of a hub and spoke model of being able to test individuals and then really provide a specimen analysis right there for within a 12 to 24 hour turnaround. And that became extremely effective from a perspective of being able to identify the folks and in getting them appropriate management of care that they needed. That was a big focus. We were one of the larger providers in the movie production industry right now, because those productions, in order for them to be able to operate, they have to have sequential testing models, meaning that folks that are having intimate scenes or close together need to be monitored, managed for safety on a daily basis. And those results have to be actuated within a very short period of time, short meaning eight to 12 hours. And we've been able to really manage that spoken hub model to, to be able to provide that service. So all of you guys who love sex sessions and love some of those wonderful shows and Warner media are able to watch them.
Sally Pace (05:17):
Okay, you really just got my attention. It has nothing to do with healthcare as a country, we have been thrown into such a topsy-turvy position. And you think about even in the movie industry, the production that you just described, the way that people interact with their colleagues, whether they're on the big screen or in a manufacturing plant, your team has had to pivot a lot over the course of the past year. Can you talk a little bit about where we find ourselves right now impacts not just the medical plan side, but the work comp side and what you're seeing in that space?
Michael Ketslakh (05:59):
For employers one of the realities of being able to exist as a capitalist country, as a country is we have to work. And a lot of the population does not have the flexibility of working from their home. They have to be onsite. They have to be at a manufacturing facility and those manufacturing facilities have to be open because they are also part of our essential infrastructure as it pertains to the overall economy in the United States. So from that perspective, we've been able to take a look and implement strategies that provide the safe environment for the individuals to be close together, but also create a model that is sensitive to the cost burden that the employer would have to be able to continue a sequential testing for those employees. And what I mean specifically by that is we've, in certain cases, we've implemented strategies of using rapid tests in a sequential basis.
Michael Ketslakh (06:52):
They aren't the most accurate tests on earth, but what they do is if in a proper sequential sequence, they do provide a certain level of protection. Right now, most recently our laboratories have developed something called a pooled model where we're able to actually use the sensitivity of the high complexity laboratory tasks. So that, that type of test where you're getting a collection from your national and goes out to a laboratory. So now we're able to maintain that sensitivity of that test, but now we're able to combine five or six samples into one, thus reducing the cost up to 80% of the costs of that sample to the employer. So again, that's a strategy that is being implemented right now on a sequential testing model. A special testing is when the folks getting tested on a weekly basis, but also then reducing that cost and really bring that cost down to the same level as a rapid test, but still maintaining that sensitivity that everybody wants to make sure that their workplace remains safe
Sally Pace (08:01):
When you put dollars and cents to that. If I'm an employer and I'm hearing you talk about cost savings, what does that mean?
Michael Ketslakh (08:06):
So a traditional rapid test when provided onsite, the cost is usually someplace around $20. $20 to $22. When PCR tests that high complexity tests is provided onsite, that traditional cost is, right around $100 to $120 by implementing the pool strategy model that I just described, we can bring down the cost of the PCR test down to that same $20 to $25 range that is there for the rapid testing. So it's quite substantial. Currently without current mandate, that's coming out from the federal government, mandatory testing for the non-vaccinated population and utilizing OSHA as the governing body to enforce that mandate.
Michael Ketslakh (08:49):
It's important for the employers to have the proper tools in order to able to comply with a mandated requirements. Before us, we have the benefit of having our own software development team. We're able to develop software tools for the employers to track individuals who are being tested, their results, track them over time. So in a scenario of an audit situation, they'll be able to retain those records and they'll be able to manage with their own safety, their employer population.
Sally Pace (09:26):
So how would an employer engaged your services to help with this mandate?
Michael Ketslakh (09:27):
People can come or write to our website @ndswellness.com, they're welcome to call our telephone number, my personal telephone number at (248) 739-9717 and call our office number at (248) 476-6980.
Sally Pace (09:46):
And in more detail, what are you offering? Is it your current clients that you're helping test their employees for the mandate that have over a hundred employees? Because you do serve larger groups, or are you going to help with one-off testing? Will you send a mobile clinic weekly to test the unvaccinated? How has the whole logistics of that going to take place?
Michael Ketslakh (10:08):
Unfortunately, because of our infrastructure, we service employers with a minimum employee base of 400 employees. And we have folks with employers at 400 employees and all the way up to 40, 50,000 and serve certainly municipalities has just described that close to 700,000 in those counties, the determination of the clinic or the staff that's needed on-site as depending on the particular project. So it is, again, it goes, it is not a cookie-cutter solution.
Michael Ketslakh (10:40):
We try to customize a solution depending on the needs of that particular client and the space that they have available. So in certain cases like in movie industry where the filming changes locations all the time, a mobile clinic is very applicable in a larger manufacturing plant. They may already have space available, a mobile clinic, maybe an unnecessary additional cost burden. And we can utilize the current space that they have to be able to lower the employer's costs on the service side.
Michael Ketslakh (11:10):
I think from the current regulatory environment is very murky right now. We have a very general described federal mandate. The specificity of that will come out very shortly. We have very comprehensive legal team. That's looking at it and doing analysis, large component that is going to be, I think one of the keys to the success of the mandate is the cost of it. So in a public setting, so the nonprofits, whether they're counties, school districts, those are funded by federal cares dollars right now for these different program.
Michael Ketslakh (11:47):
And I think shortly we will see what kind of funding there's going to be available for employers self-insured employers. And there is discussion right now of some of that funding coming in from the federal government. So at that point in time, we will be ready to help employers find that funding, to take a look at and see if that cost could be offset for them through the current programs.
Sally Pace (12:10):
How long is this, this mandate going to, I mean, are we looking at 2030 people getting tested weekly for something like this? Is this, is there any idea that you have?
Michael Ketslakh (12:23):
I'll give you perspective from a standpoint of panic right now, statistics on this particular disease is from individuals who are vaccinated. There's approximately 136 deaths per every 1 million individuals who are infected, who are vaccinated. So if you look at those statistics, the statistics against individuals who are unvaccinated is about tenfold that, so it's about 1,360 people that wind up dying per million in an unvaccinated population.
Michael Ketslakh (12:52):
And again, that's significant because it is really reduced to where that was six months ago. Six months ago, those numbers, the unvaccinated folks were close to 50, 80 times more higher at risk for having a high complication because of the technology monoclonal antibodies that you may have heard of. And all of the knowledge that the health providers now have to manage the complications of the disease, the outcomes have really improved. So where is it going to go? Will COVID go away? COVID will never go away because it will change and it'll be with us, but from a perspective of the crisis, how it has impacted all of our lives. I think that that's going to really dispay by end of 2022. I'm optimistic. I'm hoping.
Sally Pace (13:42):
We both, we fingers crossed we're in your corner, but thinking about this mandate and looking at costs, you know, obviously it's a risk to a self-insurance employer to have multiple employees as high-cost claimants. Those, you know, the complications that can happen with COVID can be very costly on the health plan side. Employers will be aggressive in wanting the vaccinated to join their workforce so that they don't have to pay for testing and the potential penalty that would come for not testing them. So are we going to see a curve kind of like enrolling in school, you have to show your shot record. Is that going to be a new thing going forward?
Michael Ketslakh (14:20):
So that I think is very difficult at this stage of the game to mandate vaccination for Americans. For a lot of reasons, there are complications from vaccination and the outcomes of frequent vaccinations it's called serum disease. They are there they're significant, potentially we have not seen them in the populations yet, but as the frequency of rate of vaccinations or boosters and your re vaccinations, that certainly creates an increased risk to the individual. So from a perspective of when do you mandate? When do you mandate? This is a very new vaccine is very effective and we encourage folks to get vaccinated.
Michael Ketslakh (15:10):
So it's a long answer to a short question, but I think it's going to be some time until we know some of the facts of the vaccines, and we have a better understanding of this disease. I mean, it's been a very short period of time. I mean, this is only been two years, even two years, year and a half. So I think that it'll take some time before somebody like this could be vaccinated, an example that you gave where it could be mandated across the board. There's a lot of different variables that come into that decision.
Sally Pace (15:40):
Well, Michael, thank you very much. Thank you for your leadership in the industry. Thank you for the way that you and your team are rising to the challenge and the mantle you have taken on as our country has gone through a lot of twists and turns in particular, those, like you said, the frontline defenders that are, that have to show up for work, whether it's in a municipal capacity or in some service level that they have to show up and do their jobs, no matter what's going on in the world around us, we are really honored to be able to share your story with our audience. And I look forward to many, many more continued success stories as you get on this path. So thank you very much.
Michael Ketslakh (16:23):
Thanks guys. Thank you very much. And we hope that we still continue to have opportunity to make a difference. It definitely makes you feel good that's for sure.
Sally Pace (16:30):
Absolutely. Well, that's a wrap
Announcer (16:34):
National diagnostic services. Onsite programs are designed as a supplement to team members, existing healthcare providers, our programs focus on educating participants about their health status, educating them on behavior, change options, and engaging them to additional care when needed. Our scope has expanded to onsite programs for municipalities and self-insured corporations with a goal of removing barriers of participating by delivering a concierge level program at the place where people spend the majority of their time, their work, the demand for this service expanded NDS has reach to a national footprint. Currently servicing employers in 33 states, learn more @ndswellness.com. Thank you for listening to this episode of The Granite List. Live access our entire library by visiting your favorite podcast venue or subscribing our site, thegranitelist.live
One of the biggest barriers to individuals being proactive in their healthcare is the time it requires off of work, especially those in an hourly position. This has a trickle-down effect on adherence to preventive measures such as cholesterol checks, EKGs, and logging in family history when minor symptoms present themselves. By the time an issue escalates, plan members may find themselves needing an ambulance, ER visit, or worse. National Diagnostic Services has a soft spot for emergency workers in municipalities and is dedicated to going to them at their stations, offices, schools to help them stay ahead of their health concerns. Many employers will compensate employees for their time visiting the drive-up medical van because it makes sense. It saves lives, time, money, heartache. Join Leigh and Sally as they start this conversation with Michael Ketslakh, CEO of National Diagnostic Services to learn more.
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About our guest:
Michael studied Epidemiology at the University of Michigan School of Public Health. In 1997 he founded National Diagnostic Services (NDS), an independent diagnostic testing company servicing Michigan communities. Our traditional services began with management and operations of Primary Care and specialty clinics in the field of Cardiology, Physical Medicine & Rehabilitation, and Neurology.
In 2003, Michael and his team developed a Mobile Diagnostic Division, the first company of its kind to be awarded the prestigious ICAVL and ICAEL Accreditations from their National Boards. These high honors reflect the ongoing commitment to the highest levels of quality patient care and customer service and are the keys to NDS’s continuing success.
Michael has frequently lectured on the state of our health care, cost of care specific to manageable conditions, and methods of integration between employers and local health systems. His content focuses on the need to establish program performance goals and guidelines.
The full transcript to this episode is here:
Announcer: (00:07)
Welcome to another episode of the Granite List Live. Navigating a sea of benefit solution is daunting at best, and new vendors emerge every week. Host Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now, to allow for the best plan design possible. By staying on top of trends brokers and employers can in turn stay on top of spending, while improving employee engagement and outcomes.
Announcer: (00:36)
One of the biggest barriers to individuals being proactive in their healthcare is the time at your requires off of work, especially those in an hourly position. This has a trickle down effect on adherence to preventive measures, such as cholesterol checks, EKGs and logging in family history when minor symptoms present themselves. By the time an issue escalates, plan members may find themselves needing an ambulance, ER visit or worse. National Diagnostic Services has a soft spot for emergency workers in municipalities, and is dedicated to going to them at their stations, offices, schools, to help them stay ahead of their health concerns. Many employers will compensate employees for their time visiting the drive up medical van, because it makes sense, it saves lives, time, money, heartache. Join Leigh and Sally, as they start this conversation with Michael Ketslakh, CEO of National Diagnostic Services.
Sally Pace: (01:44)
Thank you for joining us again today everybody. We are excited about the topic that we're going to cover. It's very timely and Michael and his team are some of the leaders nationally in what they're doing around chronic disease and cost containment. So Michael, why don't we start with you telling the audience a little bit about your business model? What does NDS do?
Michael Ketslakh: (02:09)
Yeah, so our business model really took the experience from the traditional healthcare. And right now there's a tremendous amount of articles that are written about the uncontrolled cost of healthcare and that diversification of that cost. So the examples of going and receiving an MRI that may cost manyfold of difference, whether it's done in a particular hospital setting or it's done in a particular outpatient setting. And that's applicable for almost every healthcare procedure.
Michael Ketslakh: (02:37)
What we try to do was to create a concierge, transparent, cost effective delivery of healthcare, primary care services. Really targeted toward self-insured employers, who are able to determine their costs and determine the area of healthcare focus for their population. And then it is becomes our responsibility to come in, to engage those employees, to educate them on the state of risk they may be in for cardiovascular disease, for different pulmonary diseases, chronic diseases, early cancers, depending on their occupational risk. Provide necessary blood work, physical examinations, and then engage them very importantly, appropriately into local area of care. Whether it is a primary care setting or a specialty setting depending on their needs.
Michael Ketslakh: (03:30)
And then expand it from that, we try to continue to have touch points with those individuals throughout the year to make sure that that coordination of care plan, that was determined between the primary care provider, our primary care team and them is continued to get followed. If somebody has had challenges following that coordination of care plan, we try to again develop a different guidance strategy to help them get to that outcome without ultimate focus of really reducing the different risk factors for progression of cardiac disease. Those risk factors are your basic lipids, your sugar level, your blood pressure, your cholesterol, things of that nature.
Sally Pace: (04:11)
I know I've had the privilege of being alongside your team when they've actually been working with firefighters. Describe for those listening, what that looks like. And you're running mobile units, so how does that work?
Michael Ketslakh: (04:25)
The keys to the success of the program, and what I mean by the keys to the success of it, is really having the outcome for those individuals over time of reducing those risk factors, and frankly improving their health. That starts out with the basic promise of lowering the barriers for folks to be able to participate with a primary care provider. So most of us, when we have a tooth ache, when we have a particular pain, we'll seek those healthcare services in an ER setting, physician setting, because they're symptomatic. With most chronic disease, they're frequently are those [inaudible 00:05:01] individuals is at risk factors or already may have the early stages of that chronic disease. They are asymptomatic in a large component of the labor force, especially for the folks who are dependent on an hourly type of wage that we often see in a manufacturing setting. Individuals who are asymptomatic will not seek primary care early on when chronic disease frankly can be stopped and reversed.
Michael Ketslakh: (05:28)
So the key component of our services is... What we did was we build mobile clinics and we take those mobile clinics to the place where people spend frankly majority of their lives, they're employers, and we operate 24 hours a day. So make ourselves available during shift times and the employers compensate and pay their employees to participate in these different services during their work hours. One of that is a form of reduction in the barrier of participation, is a key component of the success of the outcome of the program.
Leigh DIll: (05:59)
So do the employees come to you when they have an issue or are hurt or are they coming to you for check-ins like they would their primary care doctor?
Michael Ketslakh: (06:09)
Yeah. So the program that we're discussing right now is centered around the Annual Wellness Visit. So centered around your basic blood work, your lipids, your hemoglobin A1c, sugar, cholesterol, blood pressure, full physical examination, review of systems by a primary care provider, and really an in depth discussion about what that health history, what the blood work means to those individuals. So that particular program is a plan program. So it's structured individual signup for the program and they participate in it during those work hours. So in that particular program, we do not see acute care patients. The focus of that entire service is really to identify individuals with early stages of chronic disease, educate them, help them develop a care plan and then guide them using our nurses and care coordinators to guide them to appropriate level of care around where they live.
Leigh DIll: (07:08)
So how do you find the appropriate level of care? Do you have doctors in your system that you refer out to, is that part of their network? How do you find the appropriate care?
Michael Ketslakh: (07:19)
So on the mobile clinics, mobile clinics are staff or the providers, one or two providers depending on the size of the program. Nurses and MAs and technologists, depending on what kind of. Whether they're getting x-rays done, whether they're getting ultrasounds done, whatever they may be getting done. Prior to an event, we do determine what area providers are in the provider network of those particular individuals based on their insurance, based on are those physicians still accepting new patients, and we try to create really a soft transition from our unit to coordination of care by a local doctor. Which is important in many cases to make sure to get that individual engaged in that primary care level. So you don't wind up frankly, in ER with a heart attack.
Sally Pace: (08:05)
I mentioned the firefighters earlier. Can you talk about some of the verticals or the types of employers that you see being drawn to these services or that need them that maybe are not tapping into them?
Michael Ketslakh: (08:19)
So the example of a firefighters is very relevant. So the firefighter group of individuals are much higher risk than the general population. So as I just described our traditional program to the general public, involves very basic blood work, you're really looking at your cholesterols, your sugars, your blood pressures, basic physical. In the firefighter space, it becomes something else. Because firefighters are at 12% higher risk for cancer. They are at much higher risk for heart disease because of everything they have to wear and in a breathing apparatus as additional stress.
Michael Ketslakh: (08:59)
So for them, the actual event is a much more comprehensive event and the blood work involves over 90 different points of measurements of the blood work, looking for different heavy metals, looking for the traditional risk factors, but also a more risk factors that are pertaining to them. Firefighters undergo a stress test to determine the level of fitness that they have. Take a look at if there's any kind of EKG abnormalities in their heart. And similar program is actually operated for the police department too, because the police and fire, both of those emergency responders are under a significant risk of heart disease and cardiac events as well as cancer. So some of their testing is a little bit more specific to their particular occupational risks.
Sally Pace: (09:45)
But are you working only with municipalities?
Michael Ketslakh: (09:47)
Yeah well, we work with a lot of municipalities. We work with a lot of cities, city of Philadelphia, Cincinnati, Cleveland. We work with state police departments. We work with unions. Union leadership has recognized and has supported the need for the membership to be identified early for cancer or chronic disease to engage them early. Most of the states with the support of the union have presumption rules now for cancer for firefighters. So in other words, if a firefighter develops cancer after their employment, they are covered under different plans within the state. But like anything else, with cancer, one of the large components is early identification of an individual with cancer has a much higher probability of a cure, of a resolution, whether it's a hundred. Especially in the United States today. The further down the progression of cancer becomes, the higher the cost of that individual and the lower the probability of having a successful outcome. Now frankly, we just had a screening program yesterday and I believe it was in Baltimore. And one of the chiefs we're able to identify a significant early stage of cancer that was asymptomatic, that will be managed.
Leigh DIll: (11:05)
So will you be doing screenings just through blood work for early detection, or is it the ultrasounds?
Michael Ketslakh: (11:12)
There's a different modalities that are beneficial and you look at different things that are appropriate for different people based on their age, based on their sex, based on their occupation. So with us, because we are a traditional healthcare provider and our beginnings started out with diagnostic radiology, where we still provide ultrasound services, vascular services, computer tomography, CT services, MRI services to healthcare systems; what we do is we use a combination of those modalities Leigh. So in certain cases, the ultrasound is a great modality for identification in determination of certain vascular disease and screening for certain cancers. In a scenario where you're looking at lung cancer, CT is the best modality for screening for lung cancer. That's considered to be the gold standard. Also addition of calcium scoring during a CT scanner for folks who are 40, 50 years old. I take a look at blockages, potential calcium blockages in their arteries, in their coronary artery. So we use those modalities too.
Michael Ketslakh: (12:16)
So it really depends on the group. One of the things that we've been able to do, and we've taken this approach from really the beginning of the formation of our business and our company, our services. We're very customized to the needs of the employer. Specifically based on what is their culture, what are their risk factors? Because just like Sally and yourself are different and your health needs are different, same thing in a group setting too epidemiologically in group setting. It's also the same. So it's not really one size fits all. And that's, I think one of the reasons why we have been successful and that's why we've retained our customers and have grown, because we do provide tremendous amount of customization to clients. Not just on the services they're provided to them, on the communication strategies it is really not one solution that fits all.
Sally Pace: (13:13)
So we talked in great detail about the municipal sector and what you're doing. Can you describe on the corporate side, what trends you're seeing with the clients you serve there?
Michael Ketslakh: (13:26)
Well, we've seen in the last seven years in a self-insured for-profit corporate side, is a much larger a awareness of loss of revenue and ineffective solutions and specifically in the healthcare spend. So we've found that with the new analytical tools and software that's available, self-insured employers, and a lot of times were part of those discussions, we're able to take a look and identify the health spends, and take a look at where those health spends are ineffective. Ineffective, meaning they're too high and there outcomes are not particularly significant. And then create a solution, whether it is a annual wellness solution, whether it's a screening solution, whether it's a mental health solution. That's one of the things that we've seen really on a rise in the last two years. We started putting in a lot of mental health providers and providing mental health support for employers, because of anxiety and stress that folks have been dealing with.
Michael Ketslakh: (14:22)
But a lot of it in a self-insured space is actually becomes much more customized. Because employers, with their employees are very different. You may have older population, you have a younger population or population that's predominantly female or predominantly male. And based on those, and not just based on those, but as some of those factors that they should be considered when we're taking a look at trying to present a program. And most programs are multi year programs, you certainly to address healthcare. There's no solution, no cure of chronic disease. It definitely takes time and there needs to be commitment over usually at least a three to a five year period for a particular program to see significant outcomes. But again it's always customized. And I do from a standpoint of the difference between municipalities or government entities and for-profit entities, the for-profit entities are much more flexible. And it doesn't matter the size that they are because we deal with employers that are as large as 40,000 employees. They generally much more flexible and willing to take a look at what they can do and how can they measure the difference.
Leigh DIll: (15:34)
So if an employer wanted to engage you, what would implementation look like? Would you look at their data and say, "These are the lines of service that I can provide to you to help bring down costs." Or do you roll up your mobile clinic and start looking at their patients? How does an employer decide how to engage your services?
Michael Ketslakh: (15:55)
There's different levels of services that we provide. We usually would like to start with a foundational base of the Annual Wellness Visit. The reason we like to start with that particular service, is because it is really the foundational structure of identifying what are the chronic disease and what are the risks in the population. So once we have that aggregated data, then from then we can take a look at additional programs that need be much more targeted toward particular individuals or particular groups. The engagement process usually needs at least a three month lead time. It's got to be effective communication. One of the strategies that we found effective is onsite seminars to the employees, explain to them the differentiation of who we are versus the employer. Making sure that the employee feels comfortable. That their healthcare records remain private and we are a healthcare entity, and by law their personal records are now at shared with their employers. And then educating them specifically on the use of that program and its benefits, and then rolling it out. So usually takes approximately three months lead time.
Sally Pace: (17:03)
So Michael thinking about this incredible business that you've built, can you share with us a success story, something you're really proud of that you and the team have accomplished?
Michael Ketslakh: (17:16)
Well, I tell you, I can't take credit for the success of the company. I will take a little bit of credit for leading and being able to frankly, be honored to be part of such a great team. Folks have been... Most of our upper management team has been with us average 10 years. I think all close to 15 years. Our average's over 10 years for the company. So I'm proud of the fact that the folks from a perspective of leadership, they put their trust in me.
Michael Ketslakh: (17:39)
There's personal success stories. I mean, there's personal success stories that we have. Actually, one of them is I believe sergeant. One of the gentleman. He is actually a firefighter, came to us for physical asymptomatic, was physical and distress, had some stresses in the physical. Were very positive right away. We were able to stack his report, we're actually able to transmit his data right from our mobile unit to our cardiology for a second opinion from primary care. Identify the individual at risk. Rushed him right away to the hospital. And he wound up having a quadruple bypass and survived. And that's on individual level that always stands out significantly with you because it's something that the person would not have been there for his children, for his loved ones if those things were not identified.
Michael Ketslakh: (18:31)
One of the things that... And this happens to us fortunately frequently, unfortunately we don't recognize as a society that first sign of cardiac diseases is frequently heart attack. And that's one of the things that we're trying to avoid. On the level of more aggregate successes, we just had one of our longest clients do a third party analytical review of our service and our programs, and besides the fact that it will identified that the program had a return on investment of almost 1.89 times per year. The program economically saving over $1.4 million every year to the client.
Michael Ketslakh: (19:12)
It also showed tremendous success in the outcomes of a very high risk chronic population. They had me show to the folks that were participating in our programs over the period of four years, that their risk factors and their compliance to necessary conditions really was reduced. Not the compliance, but the risk factors. Compliance was improved. That's significant. And we hear them all the time. Just one of our radiologists just identified a significant mass of one of the individuals recently. So it's always a wonderful when you hear the folks later on and they write letters and it's very nice. It's a very rewarding experience. I can tell you that.
Leigh DIll: (19:55)
So timely too, as people really are concerned about their health these days, and they don't have time to take care of themselves. So being on site for those employers and employees is definitely important right now. We surely appreciate you taking the time to share your story and your company, and all your successes that you've done. For those that want to get in touch with you Michael, can you share your contact information on how to reach you?
Michael Ketslakh: (20:20)
Yeah, I can be emailed at MKetslakh@NDSwellness.com. Folks can just call to our office at (248) 476-6980. Our website is NDSwellness.com, just like the acronyms in the name and the end there's a contact tab there they can just request a meeting. We'll be more than happy to take a look at their specific needs and see what we can do to help them.
Leigh DIll: (20:47)
And one more thing that we love to ask all of our guests, is what is your favorite industry book? Is there a book that you would recommend to our audience that they need to add to their bookshelf?
Michael Ketslakh: (20:59)
One of the great books I've just read, which really opened up my mind, many different ways. It's called When More Is Not Better by Roger Martin. It's a very interesting book that takes a look and analyzes efficiencies and analyzes the dangers in inefficiencies. And I think actually it's pertinent to our conversation today because sometimes when there's focus on efficiencies, there is reduction of focus on quality. And that book takes a look at that across all industries, whether it is finance, whether it is legislative, certainly it's applicable in the healthcare industry. It's very interesting.
Leigh DIll: (21:41)
We thank you for sharing that and we will be sure to link that on our resources page on the GraniteList.com or CHC-now.com. So be sure to pick up your copy.
Announcer: (21:54)
National Diagnostic Services onsite programs are designed as a supplement to team members existing healthcare providers. Our programs focus on educating participants about their health status, educating them on behavior change options, and engaging them to additional care when needed. Our scope has expanded to onsite programs for municipalities and self-insured corporations, with a goal of removing barriers of participating by delivering a concierge level program at the place where people spend the majority of their time, their work. The demand for this service expanded NDS's reach to a national footprint. Currently servicing employers in 33 states. Learn more at NDSwellness.com. Thank you for listening to this episode of the Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribe in our site, the Granite List.Live.
In this episode, Dr. David Adamson, CEO of ARC Fertility covers fertility care from the benefits provider point of view and advises on the importance of learning about the fertility benefits programs that are available so they can better inform their clients about their options and the positive outcomes these programs can bring to their company.
Here is the first part of this interview:
Can Employers Afford to Provide Fertility Benefits? Can They Afford Not to? Part 1 ----more----
Here is the full transcript of this episode:
Announcer (00:09):
Welcome to another episode of The Granite List Live. Navigating a sea of benefits solution is daunting at best and new vendors emerge every week. Host Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spending while improving employee engagement and outcomes. Listen in to this episode today where they welcome Michael Thompson.
Announcer (00:42):
Welcome back to the second half of the interview with Dr. David Adamson, CEO of ARC Fertility. In the first half of this interview, Dr. Adamson dispelled several myths about fertility health benefits, including the concern of multiple births. Reproductive health is a personal life journey that is different for everyone, but infertility is often kept in the shadows. Infertility causes stress, life and work dysfunction, and affects productivity. ARC Fertility empowers forward-thinking companies to help their employees overcome and fertility.
About ARC Fertility (01:23):
The ARC FertilityNow app delivers easy to use extensive evidence-based information when you need it for your reproductive health. The ARC FertilityNow app is easy to use for any stage of your reproductive journey. The app provides access to infertility and fertility care resources based on answers to questions, providing personalized answers and support so people can make informed choices and avoid unnecessary medical treatments, prediction tools, tell employees about their individualized chances of a live birth, cost of treatment, and emotional health status.
Announcer (01:56):
The app is integrated with a specialized concierge support team that can support people in their reproductive journeys and connect them with a center of excellence when needed. Visit arcfertility.com today and download the FertilityNow app from Google Play Store or Apple App Store.
Sally Pace (02:14):
I'm going to switch gears a little bit, Dr. Adamson, and talk about from the provider's perspective. Can you talk to our audience a little bit about what the perspective of fertility care is from the benefits provider's point of view?
Dr. David Adamson (02:28):
Sally, that's a question I really love to answer, and the reason I love to answer that is that when I started our company Advanced Reproductive Care, which now does business as ARC Fertility in 1997, the purpose of the company was to increase access to quality fertility care. The reason we need to increase access is that as I mentioned earlier, only one person in four in the United States gets the care they need because of lack of employer coverage, lack of insurance coverage. It doesn't matter how good your system is.
Dr. David Adamson (03:03):
If people cannot afford to access it, then it's not going to be a successful. You're not going to solve the problem. We think access is the single most important issue to deal with today, and that's why we're so excited about having an employer fertility program that does make this program affordable. Now, once somebody goes for care, it's, of course, really important to get quality care. We're really committed to evidence-based, cost-effective care.
Dr. David Adamson (03:34):
If you don't have evidence-based, cost-effective care, it's not going to be good for the employee, and it's certainly not going to be good for the employer or the healthcare system or society. Quality of care really, really matters. And that's why we really focused on the centers of excellence with board-certified reproductive endocrinologists, who are also especially vetted by known individuals, known doctors who know that these are really good doctors and good people practicing good medicine.
Dr. David Adamson (04:01):
The other aspect that I think is really important to providers these days is we recognize how significant an emotional journey is with infertility. Personally, I had one of my children who had a significant problem getting pregnant, had a late pregnancy loss, and had to do several cycles of IVF. I saw up close, very close, how emotionally challenging and difficult this problem is. We're really focused on providing emotional support. This is not just from the doctor, of course.
Dr. David Adamson (04:35):
In fact, it's from all the staff in the doctor's office, from the receptionist to the billing people, the medical assistants, and nurses and the doctors. And in addition to that, it's really important to have solid information about emotional wellness and tools and information about that, which we do provide for all of the employees who are going through this journey to help them manage this.
Dr. David Adamson (05:01):
And of course, very importantly, you have to be able to have resources, to refer people to mental health professionals, infertility counselors when they need that special help, and also to group sessions, for example, through Resolve, which has consumer groups and self-help groups. You have to be really, really committed if you're a provider to the following and supporting the employees on the emotional aspect of this journey. And finally, we have to make it affordable. This is one of the reasons we have packages of services.
Dr. David Adamson (05:35):
Because by putting in just the services that are needed, not anything extra, by getting a set price, we can make this an affordable price. And we make it affordable not only by increasing access with the employer subsidy, but also in our direct to consumer financing program, if the employer has a subsidy, that's not quite enough to meet all the needs that the employee has, then we can use our best in class direct to consumer financing program to get employees additional funds so they can get the care they really need.
Dr. David Adamson (06:10):
I think the real features that are important for providers are to make sure that the care is accessible, to provide high-quality care, give emotional support so that the employee can have a really good journey, the best possible through their medical care, and then to have programs in place to make it affordable so we can make it happen for them.
Leigh Dill (06:33):
I love how you've thought through all facets of the infertility journey and how you've put together a great center of excellence of your providers. Using your network, would the plan members have to travel to see some of your doctors? Do you have a national presence? Can you speak a little bit about that and how the providers get in your network?
Dr. David Adamson (06:55):
Sure. Very happy to answer that. Our centers of excellence network have been set up by requiring a board-certified reproductive endocrinologist who goes through all the usual accreditation steps. In addition to that, as I mentioned, we have an advisory board. We make sure that for every doctor that comes into our network, we have someone who personally knows them and can vouch for the quality of their care and also the quality of their character, and that they'll practice good medicine.
Dr. David Adamson (07:23):
We now have over 365 reproductive endocrinologists across the country in over 250 locations. We're essentially everywhere across the country. Our clinics provide one-quarter, 25%, of all the IVF cycles in the country. We really are in almost all regions of the country and almost every employee would be able to find one of our clinics very close to them.
Dr. David Adamson (07:51):
In the very unusual situations where there might not be someone close, we will look at adding a clinic in that area if we feel there are very high-quality clinics and/or our clinics can work at a distance sometimes with telehealth and with another clinic in that area where the employee actually lives. Very few employees would not have a clinic that's very close and accessible to them.
Sally Pace (08:16):
I want to go back to perspectives. Because like Leigh said, you've really curated your program and moved from direct to consumer now pursuing a product and a process that is attractive to employers. Can you talk to our audience a little bit? We've got both brokers and employers, but let's first talk to employers. What is the fertility care opportunity for them?
Dr. David Adamson (08:42):
Well, the fertility care opportunity for employers is really substantial. First of all, by having a fertility benefit, they're really going to reduce some of their healthcare costs that they're currently paying but know about in their general medical plan through a miscoding and waste and overutilization of services. They'll start to save some money there. They can potentially save even a lot more money by reducing the number of multiples, which has already been reduced quite substantially.
Dr. David Adamson (09:11):
When the services are provided by fertility experts, the multiple birth rate, now the twin rate, is well under 10% and dropping. They can save money from what they're currently spending now. In addition to that, when they put a benefit in, they're going to have very happy employees. For those who need it, this is really a lifesaver. Those employees will become more productive at work. It will also help them a lot in talent retention and talent recruitment.
Dr. David Adamson (09:41):
There are multiple studies that show that with fertility benefits, employees are more likely to be happy with the employer, appreciate the culture in the company, and more likely to recommend the company as a good place to work. There'll be real talent retention and recruitment benefits to the employer. In addition to that, they'll be able to demonstrate in a tangible way that they're really are committed to diversity, equity, and inclusion, so that all employees who have family-building goals and desires will be able to take advantage of their fertility benefit.
Dr. David Adamson (10:17):
I think there are many, many advantages. And in addition to this, because they can choose the subsidy amount, the employer can really manage their costs and get comfortable with the program as they bring it in. I think there are multiple opportunities here for employers who bring in a fertility benefits program.
Sally Pace (10:35):
So then let's switch gears and, like I said, we have a number of our audiences... It's pretty fairly divided. We certainly have a lot of brokers listening in. How can brokers, benefits advisors best help their clients with respect to fertility benefits?
Dr. David Adamson (10:53):
Well, I think it's really important for brokers just, first of all, to recognize how pervasive the discussion is now about fertility benefits and that there are many, many employees and employers who are now talking about fertility benefits. It's very important for brokers to be aware of this and to learn themselves about these benefits and what's there.
Dr. David Adamson (11:18):
It's also important, of course, for the brokers to know about the programs that are out there for fertility benefits and to inform their clients about the opportunity to bring in a benefit that's going to be very desired by their employees, very positive for the company, and one that's also very affordable and going to be associated with a good experience for the employees and a really terrific outcome. It's important for employers and brokers also to know that there have been myths out there.
Dr. David Adamson (11:50):
Some of the myths are that when you have fertility benefits that are way too expensive, and I hope I'm able to discuss the fact that this is not the case, the fertility benefits can be very, very affordable, especially when one looks at the cost savings associated with them. And another myth is that there are still very, very high multiple pregnancy rates. The multiple pregnancy rates are still coming down, but they've come down from 25 or 30% twin rate a decade or so ago now to well under 10% already and dropping very quickly.
Dr. David Adamson (12:22):
And certainly in our program, we can require a single embryo transfer, which really drops the multiple pregnancy rate to about the same multiple rate as the background rate in the general population. The myths about costs, the myths about multiples need to be dispelled by the brokers when they talk to their employers. And then I think it's important for them to show the options and that there are some very high-quality care with a benefit design in the programs that bring cost-effective affordable care and really, really good outcomes that will be a big advantage to the company.
Dr. David Adamson (13:00):
I think these are the major points that brokers want to inform themselves about and they want to make sure they're talking to all their clients about it as well.
Leigh Dill (13:09):
Well, thank you. I think it's such a great topic right now and for employers and brokers to be educated on it, especially with the platform that you offer, because you are one of a kind. The timing is right for what you have to offer for these employers. In summary, Dr. Adamson, we do ask all of our guests to share their favorite book. What would you recommend or what are you reading right now that you want to share with our audience?
Dr. David Adamson (13:38):
Well, that's a good question. There's a lot of wonderful books out there now and literature on what we need to do to improve the healthcare system. But one of the ones that I think is very interesting and it's also interesting that it was really published over a decade ago, but I think the message is really, really sound today, and it's called The Triple Aim Focus. This is The Triple Aim: Care, Health, and Cost by Donald Berwick and Thomas Nolan and John Whittington, which was published in 2008.
Dr. David Adamson (14:12):
This talks about the important triple aims in healthcare and to transform our healthcare system to be a more cost-effective system with better outcomes. What they talk about is improving the experience of care for patients and employees, improving health outcomes, and reducing per capita costs.
Dr. David Adamson (14:32):
We're really pleased that our program is focused on exactly those three things, improving experience by understanding and educating employees and providing them a lot of support on their fertility journey, by improving health outcomes by using evidence-based and single embryo transfer and reducing multiple rates, and by reducing costs by avoiding waste and overutilization by using only best standards of care, and by having a packaged a services, which include everything that's needed, but not more than is needed.
Dr. David Adamson (15:11):
I think if we focus on these three goals, we're going to achieve a really exemplary healthcare system. And I know that we're working to do that with our fertility benefits. That's The Triple Aim: Care, Health, and Cost by Donald Berwick from 2018.
Sally Pace (15:28):
Fantastic. Well, we certainly share in that vision with you, and I can't thank you enough for spending time with us today. For the audience that is listening, that wants to learn more about ARC Fertility's employer program, I want to encourage all of you to visit arcfertility.com and toggle over to the employer program tab to see how this program and how attention to this issue can really add intrinsic and lasting value both for your plan members and for, as you pointed out, attracting and retaining talent.
Sally Pace (16:02):
So with that, I want to thank you on behalf of Leigh and I for joining us today. Thanks to you, Dr. Adamson. Thanks to our audience. And we invite you to tune in to another episode of The Granite List Live. Have a great day.
Dr. David Adamson (16:17):
Thank you very much.
Leigh Dill (16:18):
Thank you.
Announcer (17:42):
If you missed the first half of this interview, be sure to go back and listen to Can employers afford to provide fertility benefits, and can employers afford not to with Dr. David Adamson, CEO of ARC Fertility. Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribe in our site, thegranitelist.live.
Dr. David Adamson, CEO of ARC Fertility addresses challenges around offering fertility benefits and defines actionable steps for brokers and employers to get started. ARC Fertility benefits empower businesses of all sizes to foster an inclusive workplace culture, positively impact DEI, attract and retain top talent while reducing health care costs.
----more----
Here is the full transcript to this episode:
Announcer (00:07):
Welcome to another episode of The Granite List Live. Navigating a sea of benefits solution is daunting at best and new vendors emerge every week. Hosts, Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spending while improving employee engagement and outcomes. Dr. David Adamson, CEO of ARC Fertility is here addressing challenges around offering fertility benefits and defining actionable steps for your clients and employers to get started. ARC Fertility benefits empower businesses of all types to foster an inclusive workplace culture, positively impact DEI, attract and retain top talent while reducing healthcare costs. Join the Granite List host Sally Pace and Leigh Dill to hear the discussion.
Announcer (01:10):
Reproductive health is a personal life journey that is different for everyone, but infertility is often kept in the shadows infertility causes stress, life, and work dysfunction and affects productivity. ARC Fertility empowers forward-thinking companies to help their employees overcome infertility. The ARC FertilityNow App delivers easy to use extensive evidence-based information when you need it for your reproductive health. The ARC FertilityNow App is easy to use for any stage of your reproductive journey. The app provides access to infertility and fertility care resources based on answers to questions providing personalized answers and support so people can make informed choices and avoid unnecessary medical treatments, prediction tools, tell employees about their individualized chances of a live birth, cost of treatment and emotional health status. The app is integrated with a specialized concierge support team that can support people in their reproductive journeys and connect them with a center of excellence when needed. Visit arcfertility.com today and download the FertilityNow App from Google Play Store or Apple App Store.
Sally Pace (02:18):
Thank you so much. First of all, Dr. Adamson for joining us today, really excited, we love what you guys are doing at ARC Fertility. We think you are hands down best in the business when it comes to both outcomes and also the way you care for patients and care for people. So, let's start at the beginning of all of this. Why does infertility and fertility care even matter?
Dr. David Adamson (02:45):
Well, that's a great question Sally and many people ask that question. They say, "Well, why does it matter, isn't that something that's elective that people can choose?" And the answer is that it's not. In fact, over the reproductive life, one in eight people will suffer from infertility. So, between age 20 and 45 one in eight people, that makes infertility more common than breast cancer or diabetes and yet most people don't know that. In addition to that, infertility is not just a minor problem for someone who gets it, it can be a major life burden. In fact, The World Health Organization states that infertility is the number five burden of disease in the world and in the US in people in reproductive age and over an entire lifetime infertility is the number 12 or 13 burdens of disease. So, this is a problem that's really, really common that affects a lot of people and also carries very serious consequences for that people.
Dr. David Adamson (03:41):
In addition, one of the big issues in the United States is despite all the money we spend on our healthcare, only one person in four who has infertility in the United States gets the care they need and the primary reason for this is that they don't have coverage for infertility benefits at their work. So, it's a very big problem, it's a very common problem and yet most people can't get the help they need to manage it. So, this is why infertility is such a big issue and fertility care because every person has the right to found a family and we really believe that and that's why we're trying to help people get access to care.
Leigh Dill (04:19):
So, Dr. Adamson, you brought up the issue of employer coverage. So, tell us why infertility does matter to employers.
Dr. David Adamson (04:29):
Infertility matters to employers Leigh because this problem has such an impact on an individual's life. It causes a lot of stress and anxiety and difficulties in their relationships with their partner and with this much of a difficulty in their personal life a lot of these problems flow over into the employee's work life. And there are good studies that show that having a significant problem like this affects presenteeism and productivity of the individual at work and so this can result in reduced profits for the company and difficulties with personnel. So, managing this problem by the employer with the employer's help would really help them in the workplace. In addition to that, when there's not a fertility benefit, there are also many studies that show that what happens is somebody trying to get pregnant goes to see their doctor and say they can't get pregnant and the doctor says, well, you don't have any fertility benefits, but they can do some other treatment and code them under different diagnoses like irregular periods or fibroids or endometriosis or pelvic pain.
Dr. David Adamson (05:42):
And so what happens is that the employee gets fertility treatments, but they're not coded properly and so the employer is paying for it, but doesn't know it. And in addition to that, the treatment is usually focused around what they can get covered even if it's not necessarily the best or the right treatment for that employee. And so, the employer doesn't know that they're spending money and they're also wasting a lot of money and often services get over-utilized because of this. So, there's a huge amount of potential waste with this. And in addition to that, when fertility benefits not managed, then there's going to be an increased number of multiple pregnancies which can result obviously in increased maternity costs and NICU costs. So, there are multiple ways in which the employer ends up losing productivity and profitability on the one hand and ends up spending more money on health benefits on the other.
Dr. David Adamson (06:35):
In addition to that, these benefits matter to employers because today, many, many employees expect to see really good benefits package and so, when employers are looking to attract talent and to retain talent, having a fertility benefit can really help them in bringing in better quality people for their company to meet their needs. In addition, fertility benefits address issues of diversity, equity and inclusion. Many people want to have a family can't family and this includes those in the LGBTQ+ community and sometimes single people and so, diversity equity and inclusion goals can be assisted by having a fertility benefit. So, for all of these reasons, it's a great idea for employers to think about having a fertility benefit. It can be very important to them.
Sally Pace (07:29):
But let's talk a little bit more about the health outcomes and lower benefit costs. And is there a way to offer health benefits that meet all the goals that you just talked about while actually resulting in better outcomes and lower benefit-cost or is this a nice to have, a need to have does it actually impact the bottom line?
Dr. David Adamson (07:48):
That's a great question Sally, and the fact is that there are still a lot of myths around fertility benefits. First of all, a lot of people think they aren't that necessary, but from what we've just been discussing here, it can be seen that fertility benefits can be a really essential part of a benefits package for an employer. And there's a myth that infertility benefits are so expensive that they can't be afforded, but that's not true for a number of reasons. First, as we just discussed, by putting in a fertility benefit, the employer can manage the benefit better and they can also save money through less waste than overutilization and if they put in a program that's really focused on evidence-based medicine they get good outcomes, they will definitely reduce the maternity and NICU costs associated with a multiple pregnancy, that will happen if they don't provide some type of benefit in individual just go out and take unnecessary risks possibly in their healthcare in order to get pregnant as quickly as possible.
Dr. David Adamson (08:51):
And so it's possible with a good benefit to cut down the cost provided in a very affordable way because there's good healthcare and indeed there are programs out there like ours, which make it affordable for the employer because there's no per employee per month cost. The employer only pays when an employee actually has medical care and the employer can choose how much their subsidy is. And in this way there's a minimum subsidy of $5,000 but in this way, the employer can really manage their costs and only pay when an employee actually receives a benefit from the actual overall coverage. In addition to that, because there's a lot of emotional support, there will be better presenteeism and better productivity from the employees. So, it is affordable now and it is possible to get good quality healthcare by providing a fertility benefit and the employer will really take advantage of this and have a lot more upside than downside by providing a benefit.
Leigh Dill (09:53):
So to me, and this is a little bit off-script, but I want to dig into the financial piece of this. So, it sounds like the employer only pays when the benefit is utilized. So, it sounds like any employer can pull in your service as an offering and they can cap it as far as how much they want to spend. Is that how it works?
Dr. David Adamson (10:13):
Yes Leigh, that's how it works. Now, we do have a very small annual access fee which the company pays just once a year and those access fees are only about $1,250 for a small company under 500 employees or covered lives and it goes up to several thousand dollars for bigger companies for a year. But, what that access fee does is it enables everybody in the company, all employees to access our very, very robust digital platform website of course and then we have a very robust digital app called FertilityNow, which has specific sections for women and for men and provides questions for the employees to answer and when those employees answer the questions, they get very specific information about their reproductive health, about fertility awareness, about going infertility care and so, for a very small fee annually, all employees can improve their reproductive health and their general health to help avoid even having to go for medical care.
Dr. David Adamson (11:20):
And then when they do go for medical care, as you pointed out, the employer only pays when that employee actually undergoes some treatment. The employer only pays for the amount of treatment that the employee has and they only pay up to what their subsidy amount is. And we have a program that's extremely flexible in that the employer can choose how much subsidy they're going to pay. We have a minimum subsidy of $5,000 for an employee who uses that much a service, the average subsidies about 15 to $20,000 and some companies put in $50,000 or more. It's important to note for the employer Leigh that for 1000 covered lives, if we had a thousand covered lives about 1% of employees would actually have medical care and the employer is only paying for the medical care for that 1% or about 10 people with a thousand covered lives.
Dr. David Adamson (12:19):
So in this way, the employer can really manage their costs, they know there's going to be a small annual fee, this is going to help everybody in the company, it's going to help avoid waste and overutilization, it's going to cut down multiple rates. So there's going to be a huge return on investment for simply having the program in place and then when care occurs, the employee gets the services they need with evidence-based cost-effective care and the employer only pays up to the subsidy level that they've chosen. So, it's a very cost-effective program for essentially all employers to look at.
Leigh Dill (12:56):
Well, what I think is interesting about that and really is a win-win for the employer and the employee is they're getting the right care when they need it, rather than all this exploratory, I have pelvic pain going to multiple doctors that might be specialist and the employer is picking up that on the self-insurance plan that this really directs them to the right point of care at the right time.
Dr. David Adamson (13:19):
That's absolutely true Leigh, just about the most important thing in any medical care is to see someone who can make an accurate diagnosis and work with the employee to get a good treatment plan that's going to provide evidence-based cost-effective medicine. And there's a huge amount of savings to be had by having knowledgeable excellent physicians work with the employee to do the right thing and this is what our program is designed for, all evidence-based medicine, bundled packages of services that include everything that's needed but, does not have unnecessary or unproven or unvalidated services we do not include those in our packages and so, by doing this you can save a lot of money right upfront and then as you pointed out, the employer can control their costs by determining what level of subsidy they'd like to provide for the employee.
Leigh Dill (14:14):
One thing that is so intriguing to me is that fertility care and fertility issues, especially among my generation is a big conversation piece and is it because more people are just talking about it and more information is out there or is there just more happening to people because of the environment? Why is fertility benefits of such interest right now?
Dr. David Adamson (14:43):
Well, that's a great question and it is absolutely true that there's a lot more interest in infertility and fertility care benefits now and there's actually a number of reasons. If you look at the prevalence of infertility just at any given age in our society, it really has not changed much, which is interesting it's not changed much. But there's a lot more discussion and conversation about it and more people going through care for a number of reasons. One of the first reasons is that gratefully women now are getting more education, they're in the workforce more and as a result of that, they've tended to delay childbearing. And the reality of it is as women get older, their chances of getting pregnant at any given point in time start to go down and it's also true that as all of us get older men or women, the chance of us having some type of disease or condition and in particular a reproductive disease or conditions such as endometriosis or fibroids or irregular periods that might reduce fertility also increases.
Dr. David Adamson (15:44):
So, as women are by and large delayed the age at which they get pregnant, they're older or less likely to get pregnant and they're more likely to have some other problem that can reduce fertility. So, this of course means that more people will be looking for fertility care. Secondly, our society has changed a lot about the things we'll discuss. 30, 40 years ago people didn't discuss even breast cancer, certainly a lot of discussion around HIV, people didn't want to talk about that. But, over the last 10, 20 years, we've been much more open as a society discussing these issues, for example, emotional health is much more commonly discussed now and fertility, of course, causes a lot of emotional issues with people. So, fertility care is much more discussed and as a result of that, everybody's more aware of it and when people are more aware of it, they're more likely to come to a doctor and say, "Gee, I'd like to do something."
Dr. David Adamson (16:40):
A third thing is the technology with the assisted reproductive technologies has improved so much. The ovarian stimulation protocols, we have the embryo freezing or cryopreservation technologies that we have, the pre-implantation genetic testing that we have and multiple other advances in IVF have made it much more successful. So, people are now more likely to say, "Well, I'm going to do that because my chances of getting pregnant are really a whole lot better." And finally, the reason that we're seeing more and more people are talking about it is that a lot of us believe that every person has a right to found a family. And historically, of course, a traditional family was a man and a woman who were married and trying to have kids. But today, there are many people because of changes in our society that can be single women or single men or gay couples or lesbian couples who say we would like to have children.
Dr. David Adamson (17:39):
And for people in the LGBTQ+ community many, many, most of them are going to need some type of assisted reproductive technology in order to found a family other than say, if they decide to adopt a child of course. And so, there's a whole new population of people who are now accessing infertility care, who 10 or 20 years ago were not really able to access fertility care. So, there's a number of reasons why we're much more aware of it and just recently, of course, the issues that have come up about diversity, equity, and inclusion that are really transforming conversation in our country, recognize that many people are going to need help with fertility care who are not in a traditional community and so to meet diversity, equity, inclusion needs, fertility care is being talked about.
Dr. David Adamson (18:32):
And then, with the change in demographics and populations, there's a whole population of younger people now in the reproductive age in the workforce who expect to have benefits that are really going to help them with their lifestyle personalized benefits, not the usual traditional benefits. So, there are many, many reasons why infertility and fertility care is now so much more recognized, so much more talked about, and is really just even in the last six to 12 months, really, really picking up recognition, acceptance, and implementation across the country.
Announcer (19:08):
Be sure to listen to the second half of this episode where Dr. Adamson answers Sally's questions about fertility care from the benefits provider’s point of view. Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribing our site, thegranitelist.live
Today, we’re continuing our conversation with Michael Thompson, the president and CEO of the National Alliance of Healthcare Purchaser Coalitions. He discusses the importance of whole-person care with hosts Leigh and Sally. This episode is a continuation of The Big Three, what employers are focusing on now. If you haven't listened to that episode yet, you may want to listen to it first and pick back up here after you’re done.
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About our guest:
Michael Thompson is the President and CEO of the National Alliance of Healthcare Purchaser Coalitions (National Alliance). The National Alliance is the only nonprofit, purchaser-led organization with a national and regional structure dedicated to driving health, equity and healthcare value across the country. Collectively, it represents over 45 million Americans, spending over $300 billion annually on healthcare including a broad cross-section of private sector and public sector employers as well as union organizations. Thompson is a nationally recognized thought leader for business health strategies and health system reform.
Prior to joining the National Alliance, Mike was a Principal at PricewaterhouseCoopers (PwC) for 20 years where he worked as an advisor to employers, health plans, providers, and other healthcare stakeholders. 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. He is also widely recognized as a leading national advocate for mental health and wellbeing and is a Past President of the New York City chapter of the National Alliance for Mental Illness (NAMI).
Here is the full transcript for this episode:
Speaker 2 (00:06):
Welcome to another episode of The Granite List, live, navigating a sea of benefits, solution is daunting at best and new vendors emerge every week. Hosts, Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spending while improving employee engagement and outcomes. Listening to this episode today, where they welcome Michael Thompson, President and CEO of National Alliance of Healthcare Purchaser Coalitions.
Speaker 2 (00:47):
Today, we're continuing our conversation with Michael Thompson, the President and CEO of the National Alliance of Healthcare Purchaser Coalitions. He discusses the importance of whole-person care with host Lee and Sally. This episode is a continuation of the Big Three, what employers are focusing on now. If you haven't listened to that episode, yet you may want to listen to it first and pick back up here after you're done.
Michael Thompson (01:11):
Another thing you talked about partnerships being they can run their course and if an advisory group has long-standing partnerships, they're missing innovation. So just an aside, we have actually launched a marketplace that is akin to open table Vrbo, Amazon, LinkedIn, for these solutions to come and market themselves in a free platform to brokers and employers, because of that, very reason that they can't, they can't get their word out.
Michael Thompson (01:42):
The amount of innovation in healthcare is just unbelievable. The number of new organizations coming out every year, every month, that are trying to get out there. And because there's so much of it, employers don't take people's calls. So they rely on intermediaries to sort through for them. Who should I talk to? And when those intermediaries are "Tied up," because they have partners, where are we going with this? I mean, how do we create a more free flowing source of information that people can look at and try things. And even some of the apps that create marketplaces are vendors. What we have found is that they have a bias towards vendors that have a lot of clients which, of course, is reasonable because they tend to have people who said they're great, but how do the innovators get their clear shot in there. And so I think it's a real balancing act to continue to be aware. And, again, I don't think we need to promote a reward, but we need to give voice to and consider the innovators as they come out.
Michael Thompson (02:55):
And for those of us who've been in the industry for many years, you can, you can tell, not whether something is going to work or not, but is the story plausible? Does it make sense? Is this new? Is this the same thing without the track record or is this something that my clients or my coalition should want to know about, and what is that that's new? Because sometimes they don't even realize what makes them different.
Michael Thompson (03:23):
So I think what makes it great to be in healthcare is it's complex. It's highly changing, it's never boring. If you get bored in healthcare, you're going to get bored in everything because nobody knows it all. I don't care who they are. I don't care how long they've been at it and the shelf life of your knowledge is not that long. You gotta keep on your game. If you're going to do your job, whether it's for your employer or for your client or for the industry, you've got to continually sharpen that saw.
Leigh Dill (03:51):
We have vendors as well in our audience and lots of new vendors who... Everyone that comes up with a new product thinks it's the next best thing since sliced bread, which is understandable and there's a lot of great solutions out there, but like you said, it's hard to get through the weeds of those that have existed for a long time. So what advice would you give to these newer vendors who really do have a great solution and they've solved for something that is needed, how do they get in front of those large-
Michael Thompson (04:18):
Probably the smartest strategic move you can do as a vendor is get a client. First sale is the hardest sale. And if you can get a client, and obviously the bigger the client, the bigger name of the client. I know when I'm listening to a vendor and they say, "Oh, and so-and-so fortune 500 company is using us." Well, first of all, I have such great respect for the people that work at these companies, that if somebody did their due diligence, which I don't have time to do, and they concluded that they should buy them, then I should at least give them the time of day and listen. And so, your ticket to credibility is selling, is actually getting your first but what do you do when you don't have your first, what do you do when you're not there? Well, then you've got to have a way to get the word out. And part of what we pride ourselves on at the National Alliance is really being open-minded to new players out there because we try to stay ahead of the curve. We want to know where it's going, not where it's bent.
Michael Thompson (05:17):
And one of the things that I'm very aware of is that when they get categorized and spreadsheet and rated, well, if you don't have clients, you don't get rated. And if you get categorized, it's essentially saying, you're like them there's nothing new about it. And so we put more emphasis on what makes you distinctive from what's out there, then where do you fit in the world that's out there? Focusing on more what's new than on, "Am I one of them?" Because if I'm one of them, why should I buy you versus them? They've already got clients, you don't have clients.
Michael Thompson (05:54):
So, what's more important is, well, "Why do you exist? Because we already got them, and focusing on what's different and valuable. And what we try to do is then tie it into these broader themes that we think are happening in the industry that we are promoting in the industry and help people to see how this might fit with strategy, not just as a vendor. People aren't out there buying vendors for the sake of buying vendors. In fact, they prefer to have fewer, but if they see how it connects into strategy then I think that can be valuable to them. And the other thing I would say is we try to do it in, and I'm sure you do the same thing, you try to do it in snapshots. People aren't going to give you an hour. You're lucky to get a half-hour.
Michael Thompson (06:37):
And if you want them just to taste it, you got to be able to tell your story in an elevator speech in five minutes, 10 minutes, 30 minutes. And that's what we work on with them, is how to get that, the quick value prop out there so that they become a qualified lead that then you can tell your story in more detail. And then of course, before it's over there, they're going to put you through a due diligence, you're going to have to deliver. But the question is, why should they even take the meeting? Because they just don't have time to take that many meetings.
Sally Pace (07:07):
I Love that. I love that advice. I mean, I swear it sounds like what we all give college students going to interview for their first job, do your homework, you call it strategy. Know the company, know what their values are, know what they're trying to accomplish. And in this instance, I mean, you've got an entire national Alliance of employers that are following your big three strategy. I would love that roadmap. All right, Mike, tell us why you chose to pivot into this particular career path and what has brought you the most fulfillment over the past couple of years in your role?
Michael Thompson (07:43):
Just a little bit on my background, I was 17 years at a health plan. I'm an actuary by background. I was the chief financial officer, I was in charge of marketing, I was in charge of operations, a bunch of different roles, a bunch of different responsibilities at a regional and national level for a health plan. And I left and I became a partner at PwC for 20 years and I was consulting. So I was advising employers but also other stakeholders, so I learned a lot in that process. But in the course of that career, including when I was back at the health plan, I always had a belief system that said, employers play a huge role in influencing the healthcare system, a huge role, much bigger than I ever would have appreciated if I hadn't been there and seen it.
Michael Thompson (08:31):
And they play a role in a micro way, in terms of influencing products and things like that but in a macro way, things like cost-containment and managed care and consumerism and leapfrog, and MCQA. All those things came about because employers made that happen. It didn't come from the industry, it came from employers. And then of course the industry quickly followed. And I've also had a belief that single employers can have an influence, but if employers can get on the same page, they can really move change. They can execute against the industry in a major way, what I call a collective agenda.
Michael Thompson (09:11):
If everybody's saying something different IBMG, GM, everybody's talking at me, I don't hear a word they're saying, but if they're saying the same thing, people stand up and they listen and you can move the system. And it if you're looking in the auto industry, you know that the three big four are at the top of that industry and all the rest of the supply chain pays attention.
Michael Thompson (09:34):
In healthcare, I think employers are part of that supply chain. They're right at the top. They help them move the whole thing. So when you ask me, this is a long way of telling you what attracted me to this. It wasn't for the money because I was making more money before I retired at PwC. But it's a belief that coalitions, employers banding together, working together across the country can help to facilitate a meaningful change in the industry. By working with our coalitions, we're the only organization has this national regional structure across the country. All healthcare has a local layer to it. All health has a local flare to it. It's a very unique value proposition of what we do and we find ourselves leading those changes but then also being able to leverage things that are happening in different parts of the country, and then being able to localize strategies because we have people on the ground across the country.
Michael Thompson (10:34):
And so, what do I love? I love leading change. That's what I love. And we've got some big initiatives underway in a lot of different areas, but one of the bigger initiatives is around mental health and substance use, which is of course a hugely broken system and we are leading an issue around the path forward for mental health and substance use. And again, it's harnessing the purchasing power and the mind share of employers and their representing the best interest of employees and their families across the country. And little by little, you can move it.
Michael Thompson (11:07):
I used to tell people if you want to know where the industry is going, when you're doing a strategic plan for a stakeholder, you're not planning for next year, you're not planning for the next three months. You're not planning for your stock price, you're trying to plan for where is the puck going to be? And I used to tell people, and I continue to tell you, if you want to know where the puck's going to be, look at what the employers are talking about right now. If you want to know where it's going to be in five years, look at what they're talking about right now. Because it may go through fits and starts but before it's over, they're going to have influence and it's going to be there. Helping to influence that future is what turns me on. So, I really enjoy it.
Leigh Dill (11:40):
What are the employers talking about right now? Is it the mental health and substance abuse we’ve been seeing for the past year?
Michael Thompson (11:51):
It's a crisis in access and quality and mental health and substance use and that is an area that has become a top priority. I mean, when I first joined the coal, the National Alliance used to be the National Business Coalition on Health. Frankly, mental health was pretty low in the priorities of the coalitions, today is one of the top across the country. And we know from employers that it's a top three issue for almost every company right now and COVID has only made that more important. But I think the other areas that people are very concerned about is how the industry has evolved with consolidation, the issues around transparency consolidation and that's leading to a lot of the policy issues. I believe if stakeholders in the marketplace abused their privilege of serving communities by overpricing and under controlling their own expenditures, that they need to be regulated.
Michael Thompson (12:44):
I mean, if you act like a monopoly, you got to be regulated like a utility. And it's not every health system or every hospital, but it's prevalent enough that I think we have to start thinking more open-minded that what we call a market isn't much of a market and we need to figure out how to have a more sustainable approach going forward. I do think affordability at its core is critical. And again, as I said before, I don't think it's just affordability for employers. I think it's a crisis for employees and their family. I think people are not getting the care they need when they need it because of what we've done with our plan designs and I think we're going to have to build those plan designs back, but more selectively. And that's where I think our delivery-type strategies are. I think let's guide them to people that are on the team as opposed to the people that are fighting against us and moving that forward.
Michael Thompson (13:41):
And again, I think the whole issue of equity and total person health, that's not going away. It starts with a lens of "It's the right thing to do," which it is. It turns out it's a smart thing to do too, that you get better outcomes if you think more holistically about subsets of your people and support them holistically. I know those are some of the same themes, but that's the way I think.
Leigh Dill (14:06):
Well, and you've got a whole lot of other people thinking that same way which is awesome because, you talked about you're getting away from the siloed approach and getting down to the total person that needs the assistance as opposed to slapping a program on everybody when three-fourths of them may not even need it.
Michael Thompson (14:27):
Well it's always funny. People say, "Well, we treat everybody the same." I say, "We don't treat everybody the same, where there are disproportionate needs you invest disproportionally." You do that today. We're just saying, "Let's put a few more lenses on that and invest disproportionally that way too. Let's not leave people behind and let's not focus on treating everybody the same and focus more on getting to similar outcomes for people across our population."
Leigh Dill (14:55):
I have a big question that you can say in a short answer, Mike, but we've thrown a lot of big words out here; regulation, affordability, transparency, Area fraud, monopoly, and there are so many different vendors out there and it's not really a monopoly yet. You've got your BUCAs that are, but there are so many other players in the marketplace. It sounds like we're trying to go down the right path with those words I just used, how long do you think it's going to take us to get there?
Michael Thompson (15:34):
I don't think there's a there there, I think this will always evolve. I've been at this industry for, I probably am coming up on 40 years, and it's never been a more dynamic period than it is right now. And I'm not sure that in 10 years, it will be still more dynamic. I think the pace of change has been greater, the issues are more complex, we're running out of places to run on the old runways and so we need to build some new runways to figure that out. And when, after we build those runways, we'll be talking about this again in five years in 10 years. But that doesn't mean that we don't have to start building now or that if we stay on these runways, that the whole thing won't break. If people want to support employer-sponsored coverage, we need to work together to solve these issues because I, I honestly think we could break this camel's back if we haven't already. And most of us would like to see it survive, but it can't survive with the trends that have been going on currently.
Michael Thompson (16:35):
I think what we're doing to employees is well beyond what they can afford. What people are doing to us is well beyond what we can afford and our employees can afford, and we need to get incentives aligned so that we're working on the same team towards the same goals, that's the sustainability. Our overall well being is so intertwined with healthcare. It eats into everything else that we could, as a society, afford and do. Sure, of course, healthcare is important and health is important, and everybody wants to get to the right outcomes in healthcare. A dollar wasted in healthcare is a dollar wasted period, and we can do better to build a system that is more responsive to the needs and the values of our society.`.
Leigh Dill (17:21):
I think that's a great ending point for this. Sally. I know you've got one more big question to ask.
Sally Pace (17:30):
And we could use broad strokes with this. This is informational and educational, but Mike, what are you reading right now, either book or publication that is industry related that you think is relevant that the audience might enjoy?
Michael Thompson (17:47):
What I enjoy the most is reading The Economist and that's a little different than... You would think I would be an addict to all these healthcare books, but a lot of times I read the health care books and I said, "I read that, I know that," and I might get a little bit, and it's too much investment for that little extra that I'm getting. I talked to a lot of smart people and I feel like I'm always on my game and I don't necessarily get it through the books, but The Economist, I find, is always interesting.
Michael Thompson (18:15):
And it's so fascinating to see the world view, and look at other industries too. And what's evolving in those industries. And I think it's a mistake to think that we can fix healthcare with this traditional way of looking at healthcare. I think we've got to be open-minded. Look at what happened with Uber, who expected that would happen? Or other industries that have been transformed just with Amazon, with a blink of an eye and suddenly whole industries, when I look at the video industry, God, I remember bringing my kids to blockbuster and they don't even exist anymore.
Michael Thompson (18:50):
I mean, it's just amazing what happens in other industries. Healthcare is slow in that way, but it is really complicated. And I think there's lessons to be learned by looking outside of healthcare. And I personally just find that publication to be so well-written, so timely, so interesting. And I also like hearing the views from other countries looking at us because we're fascinating people here in the United States.
Sally Pace (19:18):
Absolutely that brings us to the end of this episode. Thank you very much for your participation. Thanks everybody for listening. Mike, thank you for walking through this with us. I think your viewpoint is so valuable and valued in our network in particular, because we are dealing mostly with the people who are trying to get in front of your consumer, which is the brokers and the vendors. So, thank you very much for spending some time with us today.
Speaker 2 (19:55):
Thank you for listening to this episode of The Granite List, live. Access our entire library by visiting your favorite podcast venue or subscribing to our site, thegranitelist.live.
Michael Thompson, the president and CEO of the National Alliance of Healthcare Purchaser Coalitions, sits down with Leigh and Sally to discuss the three things employers and consultants should be focusing on now as they adapt to today’s environment for a thriving workforce. He shares how the nation’s premier purchasing coalition is charging their employer members to think broader, viewing the total health care needed for an employee and solving for it within the benefits plan.
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About our guest:
Michael Thompson is the President and CEO of the National Alliance of Healthcare Purchaser Coalitions (National Alliance). The National Alliance is the only nonprofit, purchaser-led organization with a national and regional structure dedicated to driving health, equity, and healthcare value across the country. Collectively, it represents over 45 million Americans, spending over $300 billion annually on healthcare including a broad cross-section of private sector and public sector employers as well as union organizations. Thompson is a nationally recognized thought leader for business health strategies and health system reform.
Prior to joining the National Alliance, Mike was a Principal at PricewaterhouseCoopers (PwC) for 20 years where he worked as an advisor to employers, health plans, providers, and other healthcare stakeholders. 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. He is also widely recognized as a leading national advocate for mental health and wellbeing and is a Past President of the New York City chapter of the National Alliance for Mental Illness (NAMI).
The complete transcript from this episode is here:
Announcer (00:06):
Welcome to another episode of The Granite List Live. Navigating a sea of benefits solution is daunting at best and new vendors emerge every week. Host Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spending while improving employee engagement and outcomes. Listen in to this episode today, where they welcome Michael Thompson, President and CEO of the National Alliance of Healthcare Purchaser Coalition.
Leigh Dill (00:48):
I don't envy the massive task you have of keeping all these massive employers operating to the best standard possible in the benefits space. Just in thinking through some of the things you've accomplished, I want to jump right to the success stories. What are some things as you look at, let's talk pre-COVID and post-COVID, some things that you all and that the Alliance has accomplished in helping guide employers through the twists and turns that we've all seen over the past couple of years.
Michael Thompson (01:23):
Running benefit plans, leading health care strategies for major corporations is a really complex job. And it ranges from very strategic decisions around what amounts to the second biggest expenditure of the organization to a thousand moving pieces around health and healthcare that you kind of have to know and navigate and understand on behalf of your employees and their families. And it's one of the most personal things that you do for your employees and their families. And you're trying to manage that and balance that with the budgetary constraints that the company is under and it's challenging for any organization.
Michael Thompson (02:05):
The good news is that employers are very informed on a lot of topics in this area. And what we try to do at the National Alliance is kind of stay ahead of that curve. Actually anticipate where this is heading and trying to educate both our coalitions and their members on how to be relevant in a changing environment. And that can range anywhere from strategies around how to promote high value, better value care to improve the health of that population through various strategies as well.
Michael Thompson (02:44):
Needless to say, COVID turned a lot of things on their heads. The basics didn't change, the objectives didn't change, but the set of facts that we were dealing with changed overnight. One of the amazing things I think we had to do at the National Alliance is pivot with a pace that we've never had to do before. And the sheer volume of information that people needed to stay on top of this and be in front of it for their employees and their families, as well as their management was critical. And I always say we probably put out more information last year than we did in the last four years. And it was because of the complexity of the environment.
Michael Thompson (03:30):
But the basic tackling around health and healthcare, that's a continually evolving area that I'd like to say we help to shape where it's going by educating and staying ahead of the curve. I think most recently with COVID and some of the racial justice movement, we have refocused on issues of equity as well. And that's been a newer area of focus that I think we have gotten ahead of. And that's part of our mission is to stay ahead, to help employers and coalitions navigate and frankly lead the change in the industry.
Sally Pace (04:10):
Can you give us, look in your crystal ball, I know you've got so much information and are so involved in that universe. I feel like years ago it was the larger corporations were moving to that self-insured plan, raising deductibles, they pulled the, what I would call the big levers. And there are lots of smaller levers still out there. And I know you have to fine-tune them just right. Looking ahead, what are you telling your employers? What's next?
Michael Thompson (04:39):
When you look at the trends in the industry, they tend to have a fairly long runway. We stay on those paths for a while and you mentioned a number of them. First it was managed care and then it was consumerism, right? We're going to give people the money and have them share in the cost and that's going to help them navigate the healthcare system better. I frankly think we're at a, another inflection point, a turning point that we can't push any more of the burden on to employees and their families. At least most companies can't, our deductibles and our co-insurance are out of pockets, have outrun what people can afford.
Michael Thompson (05:16):
Our deductibles are probably, I was looking at data the other day that said that in a decade, wages went up 20%, inflation went up 26%, family premiums went up 52%, and deductibles went up 160%. and now deductibles are about give or take four times what the average person can comfortably afford. Which means that if you have any type of material illness, you are jeopardizing people paying their own bill. We can't keep going down that path. And it is going to require us to pivot. And to your point, where do we pivot? Well, we're very strong believers that we need to focus on delivery and payment reform as a starting point. And that will require more delivery-based strategies in our benefit strategies as well.
Michael Thompson (06:07):
And with us, we focus on a few key areas there. We think we need to reinvest in primary care, and we have a big focus on advanced primary care in that regard. We think that episodes of care or centers of excellence probably is the best we can do, particularly in a consolidated market for more specialized and complex care. And we're very, very concerned about high-cost claimants. This is an area that's just exploded, and we are developing strategies in that area because the re-insurance market has not been particularly supportive of mitigating that risk. And we need to develop strategies that, I actually think that's the biggest threat to employer-sponsored coverage is high cost claiming. And it's not because everybody gets one it's the problem is if you do, and the limit on those is just incredible. And increasingly, as you know, they're ongoing and if they're ongoing, you're going to get lasered and you've got a major problem.
Michael Thompson (07:04):
So that's, on the delivery side, we're very focused in those areas. Obviously, a lot of focus on transparency, but transparency alone does not lead the movement to a higher value. But frankly, we also think that as coalitions, as the employer community, we need to be active in the policy arena too, because with the consolidation of the delivery system, what you effectively have is something acting as if it's a market, even though there are monopolies and oligopolies. And they're exercising that market power like never before. And we know that the commercial side, the employers are potentially overpaying, certainly for institutional care. And it's a problem. And we are activated on the policy front.
Michael Thompson (07:51):
On the health front, I would kind of sound more optimistic note not because we got our act together, but I think we're learning more about what matters and how to approach it. I think our early strategies were much more siloed in their nature. We've got a disease management program for this, and we've got a wellness program for that. And we got the whole spectrum, but we really are thinking holistically around the individual. And I think our focus now is educating and promoting what we think are the strategies that have been outperforming these highly siloed approaches. What we're calling total person health, and sometimes whole-person health.
Michael Thompson (08:34):
And it's really recognizing that people don't have one disease. They often have multiple common diseases. That the behavioral health issues are interplayed with the physical health issues. That, and in fact, if you've got both, the cause and the impact are that much greater and there are underlying social needs that are part of that. And so we're moving to much more hyper-personalized experience for employees that really look at them more holistically. And of course, technology can play a major role in doing that and supporting that broader context of total person health.
Michael Thompson (09:12):
If we kind of evolved from kind of wellness to population health, the culture of health, I really think this total person health thinking more with not throwing the rest out, but really taking it to the next generation where it's a much more personalized experience for the individual is what has worked. It's not that this is something that's not out there, it's out there, but this is what has delivered the better result when we look at things more holistically. And frankly, that plays into the discussion around equity, because if you're considering how to support individuals within your population, some people would say well, we treat everybody the same. Well, that's a losing strategy. But the winning strategy is understanding pockets of people within your organization and understanding the experience they have and how to support them given their realities. Essentially, don't leave anybody behind [inaudible 00:00:10:09] man. And that requires more intentionality to look at the data and understand where we go from here.
Sally Pace (10:15):
So are you finding, I mean, that's so much great information there and I do want to kind of dig into a couple of the points that she just made. But talking about all the vendors that are out there in the marketplace and each one kind of has its niche and tackles a specific disease state. How do employers, I mean, it sounds like another question I want to ask is are they taking on the burden or is the caregivers that are taking on the burden of these additional costs if we're not passing it on to the employee? But how does the employer have this personalized approach? Is there a vendor that does it? Is it a nurse advocate that really gets to know their population individualized? And if some of these large employers, that's hard to touch everybody, but what's the answer for that?
Michael Thompson (11:05):
I think it's such a great question. When we think about it, we actually think it's not one thing. It actually applies in different parts of the spectrum, right? So it applies in the primary care office that looks at you holistically. If it's advanced primary care, they're not looking at you with an eye towards the issue you came in from, they're looking at you with more of a longitudinal and a more holistic view on your needs, your behaviors, your outcomes, right. And thinking longer-term how to support you with that lens. Certainly a number of the advocacy services, part of what made their models more successful was their ability to get to know the individual and their family better. And to use that information to get them what they needed. And to prioritize multiple needs in a way that they were sequenced in a way that, sometimes if somebody is depressed, they're not going out jogging anytime soon, right. So let's work on that depression and then let's help them get back out and be more active and eat right, right.
Michael Thompson (12:06):
And it's that people’s first orientation that tends to get that out. Frankly, if I have cancer and you have a program that manages cancer, well, you might need a specialty program that manages cancer. But if they're not looking at the holistic issues around your cancer, including your mental health and other issues, they're missing opportunities. Even the financial management issues around managing your cancer. So all of that ties into a more holistic view of the individual.
Michael Thompson (12:39):
And so, which vendors should pay attention to this? Yes, all of them should. And clearly, there's overlay between your various vendors and there's some synergy. Some of the solutions now are being built with an eye towards comorbidity, an eye towards building in the social determinants and social needs into the assessment. Building in assessment on behavioral health needs into the assessments and then monitoring progress against them. So it's kind of, you will hear people say, we have to take an equity lens to everything. Well, I would agree with that. And I would also say, well, you shouldn't be taking a total person health lens to everything too. Let's think about how does this optimize for people that have complex lives and complex health needs?
Leigh Dill (13:24):
What about, I love the big, I'm going to call them the big three that you've outlined that you're focusing on when it comes to delivery side. And you deal with negative employers and then some mid-large size, all of them have a bevy of consultants across the benefits spectrum that they work with. And that's frankly, a large part of our audience too, is the broker consultant community. So is there any advice you're giving your employers in the National Alliance? Is there any onus on the broker consultant community to help step up and deliver these big three? Where do you see that relationship playing out?
Michael Thompson (14:04):
You probably know that I was 20 years, I was a consultant in the benefits arena as well. So I've lived in that world and I know the complexities of that environment as well. And I know that brokers play a major role, particularly as you go into smaller and mid-sized companies because they rely heavily on intermediaries to support them in, again, this highly complex environment. And oftentimes to bring clout where they don't have it, to just get people to pay attention and do the right thing. And so I value that.
Michael Thompson (14:41):
Where I have become increasingly concerned has been the emergence of business models that kind of calcify advice to employers based on who my quote partner is and who I'm getting this arrangement and that arrangement with. And so when we talk to employers we say, you need to be your own advocates. Yes, you're going to need to rely on advisors, there's no doubt. But go in there with your eyes open and ask the right questions, both in terms of make sure they are thinking about your unique needs and your unique situation. But also, what's their motivation, how are their business models working. It wasn't always that way, but I think increasingly, and it's true, not just with advisors and the brokers, but increasingly with the plans and others that everybody's got a business model that seems to be helping them. But sometimes gets in the way of truly being that. client first advocate. And I think we need to balance that. And I think good brokers and consultants know that, and they go out of their way to really focus on what that client's needs are.
Michael Thompson (15:48):
Yes, there are best practices but one of the things that I struggle with is there's so much innovation in the system that if you partner for too long, you've effectively fallen out of the innovation cycle, right. Because what was hot four years ago is not hot anymore, right. And something else has emerged. I mean, it's such a dynamic marketplace and requires you to kind of stay on your game, continually upgrade your thinking and then educate and advocate for your clients for the best opportunity. And I think in some ways the coalition movement is a parallel universe that educates on a parallel basis. But with far less of a customized lens than a broker or a consultant will typically bring to you.
Leigh Dill (16:35):
I have two things. What I hear you saying, Mike, and I want to make sure I understand correctly. You talked about transparency and that that is an element of a high-performing health plan. But what I also hear you saying is you're encouraging your employers to push back on the broker community for their transparency, i.e, how do you get paid? Where does your compensation come from?
Michael Thompson (16:59):
Transparency's become a, it's more than a nice to have now. The economics of all the intermediaries have evolved dramatically to the point that what you think their business model is, is a minority of their business model. And if that's the case, then you have to take that, you need to understand that as you are working with them and try to be your own advocate. You can't just turn the keys to the car, you have a fiduciary responsibility to the plan, to your employees and their families, to your company. You need to be your own best advocate in that way. The reality is, I don't know of any employer that doesn't trust their broker and consultant or else they wouldn't use them, right. I just hope that trust is warranted. Better that you're aware of what the economics are and you can guard against what can sometimes be.
Michael Thompson (17:56):
My favorite is, for some reason, everybody has their own PBM coalition and they've all got the best deal. It turns out the people who do the evaluation on who has the best deal, always theirs is the best deal. Even if somebody else does it, that theirs is the best. They can't all be the best deal. And it's clear that there are biases in the marketplace. Let's try to be as transparent as possible in that. And again, I think in the long run, a great consultant, a great advisor, a great trusted advisor has earned that trust and will continue to earn that trust and really values being the type of advisor they want to be, which really put the client's needs first. The business model should take care of itself. Unfortunately, people have found it very profitable to create side deals. And I frankly think it's dangerous when your trusted advisor has a vested interest in one solution versus another.
Announcer (18:54):
Listen to our next episode, why holistic care matters to employers for the continuation of this conversation with Michael Thompson. Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribing our site, thegranitelist.live.
Today, we’re continuing our conversation with Chris Shoffner, CEO of Your Community Health Plan, Adam Russo, CEO of Phia Group, and Rob Gelb, CEO of Valenz discussing the importance of engaging, early and often with your data and how to use predictive analytics to change employee behavior to drive low cost-high quality choices in healthcare decision making.
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Here is the full transcript from this episode:
Announcer (00:25):
Welcome to another episode of the granite list Live. Navigating a sea of benefit. Solution is daunting at best and new vendors emerge every week. Hosts Leigh Dill and Sally Pace spring brokers and employers a solid resource when it comes to uncovering what's new what's needed and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can intern stay on top of spending while improving employee engagement and outcomes. Today, we're continuing our conversation with Chris Shoffner CEO of Your Community Health Plan, Adam Russo, CEO of PHIA group, and Rob Gelb, CEO of Vālenz™ discussing the importance of engaging early and often with your data and how to use predictive analytics to change employee behavior, to drive low-cost quality choices in healthcare decision-making
Rob Gelb (01:25):
It's interesting we come from maybe a different lens or different angle, or I do personally. And then our company kind of does as well. Culture is a conversation we have a lot with customers with business partners, because if you're not aligned culturally, you're not going to, it's not going to work no matter if you have the best products, Adam could be the best at what he does, and we could be the best of what we do. But if culturally, we don't align with the way we make decisions, the way we treat people, how we look at things, it's going to ultimately be an epic fail because something's going to break and then all hell's going to break loose part my English.
Rob Gelb (01:58):
And I feel like when I listened to Adam, part of the challenge we face is the benefit consultant broker community needs to take a step back and really do what they're hired to do, which is understand culturally, how an employer should be looking at health care for their members, healthcare for their employees, how they need to treat their employees. How do they treat their employees? Outside of healthcare is going to be a very clear sign of how they're going to look at health care. Are they going to try and cut benefits? Are they going to try and make sure that they get what they need to be a healthy population? That's delivering a presenteeism to their day every day as an employer.
Rob Gelb (02:29):
So I don't know how you solve for that. Other than one employer opportunity at a time like Adam has done over the past 20 years and the most recent 5 as he points out. But eventually, you get all the participants and all the stakeholders in an individual employer's plan to align culturally about why they'd have to have a why as to why they're putting healthcare, making it available for the employees, how it's going to work and how people are going to access it, get educated. It's what led us to create our concierge Medical or Navigation product, is to start working with the members directly and teaching them what the plan is going to pay for what their plan will and won't allow what a quality provider looks like and where and how you access them. So I'll get off my soapbox, but culture is a key part of what we struggle with to get this universally changed, I think.
Adam Russo (03:20):
A broker or a consultant, they won't get fired if they work with the traditional carriers, right? It's like I said.
Rob Gelb (03:28):
We, we talked about this on, on our webcast, on RBP next-generation right. And one of the things is right as we were doing that, the Wellnet survey had come out. I don't know if you had seen that one, but there were two questions in there. I think they were question 4 and question 30 something. One question was, do the Bupa solve for the needs of your employer, self-insured employers consistently and 85% said No, not at all. 30 questions later. How much business do you place? 85% of them place it with Bupa's. So those two are kind of diametrically opposed. It's illogical to say they don't solve for, but I'm still going to sell them. It doesn't make any sense because there, there's a disconnect. They do. What's easy. And that's, and this is hard stuff.
Leigh Dill (04:11):
How do you change that conversation as a broker, going into an existing client and admitting that your current plan isn't working, it's not solving for our problems. We all know this, but, but how do you start that conversation to, to sway the CFO and the HR department?
Adam Russo (04:26):
So here's the problem. COVID last year, if you did nothing to your plan. Wow, this is so funny thing works. Because people weren't getting treated claim volume down 30 to 40%. People were off steady, their surgeries, right? People were pushing all that off. So, when they walk in to that meeting this year, they say, huh, wow, you guys did a great job. No, that you did it. It's called COVID. It's called no travel. It's called people afraid to go to the hospital. People do not make the doctor's appointments. What people don't realize though, is that when you went to your stop-loss carrier for a quote, the 21, the 2021, what happened? Did they give you a premium discount? No. Premiums went up by an average of 10%, How? Because they're petrified.
Adam Russo (05:17):
All those people that didn't get those screenings for cancer, all those people. Now they started getting on medication for depression, all those people. Now I started drinking more, taking more prescription pills. Think about it. They're petrified of those catastrophic claims that are going to come. People now are starting to get those surgeries. So what they're fearful of is the fourth quarter of this year and 22, those claims volumes and costs going straight up and the behavior of the actual employees has changed. People aren't looking at their drug spend, people are not looking at their out-of-network spend, people not looking at mental health claims, mental health claims right now, boom, skyrocketing. And guess what? Those treatment facilities are not in-network. Those treatment facilities are in Florida and Arizona, all out of network. Yet the plan language hasn't changed. The risk factors have people aren't looking at them and they're just going forward as if nothing happened
Rob Gelb (06:16):
You said it 22. So we've been talking about this and Chris knows this. I said at the end of 2020, when we were talking about a bunch of stuff, I said, 21 is going to be kind of a tough year to think through, because you just don't know when we're going to break open again, and people will start traveling and they will start seeing doctors. But 22 for certain is what I've been terming, the whiplash effect of COVID and that whiplash we're starting to see the stick kind of being pulled back rapidly and move forward. And that whiplash effect is exactly what Adam is saying.
Rob Gelb (06:47):
And if you're not paying attention to your plan design, and you're not paying attention to the trends in your data, and you're not paying attention to what's going on with transparency, laws, and no surprises and how all these providers are going to figure out a way, because just like the member and the plan, the healthcare providers are going like this, now is my moment to make up for all that lost earning I didn't get from all the treatment and all the serious services I didn't provide. And they're going to find a way to get paid. And so get ready. It's common. And you've got to start preparing. You should have been doing it already. You should easily be thinking about your one-on-one now.
Adam Russo (07:22):
But they're not.
Sally Pace (07:24):
Okay. So, that ties into something. And first of all, let me say, we have 10 college interns there from Stanford, Columbia, Notre Dame, all over. They are floored as they are learning about all of this, they are floor. But the one thing they keep saying is we don't understand this brand loyalty. We don't, y'all keep, we've trained to move out with the Bupa's are, and they're like, we don't, we don't get it. We don't understand why your generation cares that much because they're the Amazon shoppers. They're the ones who don't need, they're willing to buy whatever is the highest quality, best price, highest ratings without the name.
Rob Gelb (08:00):
Shameless marketing.
Sally Pace (08:03):
You're here for, I love about the two questions you elaborated on from the recent survey, but I want to go back to data because we put a lot of, and Leigh, you touched on it and Chris you've definitely touched on it too. What a lot of people think about when they hear data is claims data, retrospective claims data. What are the three of you looking at differently? What, and what would you encourage brokers and employers to also be looking at when it, when we use this broad term of data drill-down for us?
Chris Shoffner (08:35):
Well, from my perspective, as fiduciary to the plan, right, is you need to pay the claims data because you got to be able to audit bills and you got to be able to make sure that you're not paying for stuff that you shouldn't be paying for, number one. Number two is then with all this new data that's coming out, right? You've got all the data, you've got paid claims databases. You've got worker's comp paid claims databases, all about the same providers, right? And so how then can you take that? Because giving someone participant, just a network provider list and I have at it, that's not going to the data points that you can find. Right?
Chris Shoffner (09:16):
And my eyes were really opened by Jeff Gasser at Deerwalk way back when, when they were D2 Hawkeye. And he said, Chris, look at all the state that look, would you send your daughter or your cousin or your brother to one of these doctors that are at a hospital. That's less than five miles from you. And if you look at the Medicare data and if you look at the quality rankings and things, you'd go, no, I'm not sending them there at all yet. That's the facility where everybody goes, right? It's that again? Brand loyalty. And why is it? Well, that hospital has got all the business owners in the local community or on their board. They're all doing fundraisers. They're all a part of that.
Chris Shoffner (09:54):
So it's hard to bring that level of transparency and data about quality with a surgeon that might be in your rotary club or in your church. Right. And you're like, Hmm. And you don't obviously you don't put it out there, but those are the data points that are forward-looking. And that's exactly where Rob is. Right. He's already to that point, he's got more data. I think you've got more data than anyone else that I know of.
Rob Gelb (10:26):
We think so. Yeah. Our direct, certainly in our direct competition and Adam, I know you wanted to say something. I,
Adam Russo (10:31):
The only way any of this matters is by incentivizing the employees to care because you can change their behavior. You talk about loyalty brand loyalty. Yes. What we did is if you look at our plan document on page three, right after the table of contents, it literally says, here's how you can make money by saving money for the plan. And what do we do? We give them a percentage of the actual savings by changing what they're doing. So here's a good example, our diapers, the wife's program, okay. The Boston Globe did a front-page story. And the Metro section on our amazing, innovative diapers and wipes program. Think about this. This is not innovative. All we did is we looked at the data and then through predictive analytics, what's going to happen based on the data that you have currently, that has looked back, right. And what we found, not just look at the claims data, but just looking at our population.
Adam Russo (11:28):
A bunch of people were getting married. Our average age was 27 in the office. So what did we see? Huh? People had started having families. So what we said was, how much are we spending for delivering a baby in networks, we have blue cross blue shield at all the network hospitals within our network. Remember the co-pay at the time for our employees for inpatients, they was like $250. So no matter what hospital they went to have that baby $250 is what their cost is and what we found put quality aside for a second, the cost range went from 8,000 deliver that same baby to 60,000 same baby. So what do we do? We identified the lowest cost hospitals at the highest quality metrics and said, you can go to any hospital you want except network.
Adam Russo (12:18):
However, if you choose one of these five We'll pay for my company will pay for your diapers and wipes for your child for two years, 76 children later, 75 of the 76 have gone to one of those facilities deliver that baby we've saved over $750,000 by just doing that. And that was a front-page story. It shouldn't be, this should be basic stuff that everybody does. If you look at your data, predictive analytics, predictive behavior, that it looked at the cost, look at the quality you can change the way fundamentally people behave when it comes to healthcare.
Rob Gelb (12:59):
I'm going to jump on that for 30 seconds and kind of a tag back to where Chris was going. So in the world of our promise of engage early and often, it's tied to this concept that five to 15% of the claims are going to drive 70% of any one years, a one-year plan costs. And so how do you early identify and get in front of so engage early and often to either identify the 5 to 15, we operate under what we call a data-driven clean start, which starts with what we call pre-claim loss. In that pre-claim loss world we're gathering historic paid claim data from the groups that we're talking to the brokers, et cetera. And we're analyzing it for three key things. We're looking at disruption to understand what we can do to change and what we're going to have to do to change behavior to drive into higher quality, lower-cost medical.
Rob Gelb (13:45):
We're going to assess what the overall impact of medical Spin's going to be based on what we would do in that, whether it's contracted and or negotiated discount. And then depending on the quality of the data, which is questionable most days, but on the quality of that data we can do, what's called a Lifestyle Analysis and that's through our predictive analytics and algorithms come into play. We have the five or six key chronic condition, data sets and algorithms that drive that five to 15. And we pre-identify in that population. Those members that we believe are either in or headed towards a high-cost event or a high cost care episode and we start to make recommendations and plans on how you can mitigate and reduce that to get them back under control. So we use data in that fashion and we use it throughout.
Rob Gelb (14:31):
And the reason we operate a proprietary ecosystem of all these services integrated together as time matters to making decisions, speed matters, and data is critically important in decision-making. If you're working with 17 different vendors and waiting for people to populate your warehouse and cleanse it, it could be 14 to 30 days at the time to make a decision and impact prospectively as is lost. We're real-time capturing the data and real-time analyzing it through the algorithms every single day alert action accountability design. So those are all the pieces of data that changed the way you look. And I think that's one of the things that drew Chris, in addition to having this dearth of data paid claim, they charge data, cost, data, transparency, data, quality data, and all everything in between. We use it every day in a way that drives better decision-making and education for the planner, for the member and gives the broker an opportunity to figure out how do you create some Adams point a plan design that route steer incentivize them to do the right thing for them. And the plan
Chris Shoffner (15:29):
That's 700 community pharmacy activists here just in the state of North Carolina and 16,000 across the country. Right? And they are now being excluded from the CVS network. They're being excluded from Express Scripts network. And what they would tell you is they're doing it that because I'm not filling them because I'm doing it at a loss. Right. So when, when I went to them and said, what can we do? They said, well, it starts with generics. Just pay me for the generic med, just reimburse me my costs and then paying me to be in engaged clinically with these patients. Right? And so you say, okay, well, how do we define cost? So when we started your community health plan, we interviewed four PBMs that were referred to me by the North Carolina association of pharmacists. Three of those PBMs walked in the door and said, well, we use an average wholesale price minus the discount, but we're fully transparent and you get all the rebates.
Chris Shoffner (16:33):
And I was like, thanks for coming. We will 10-minute conversations. And they're looking at me like, that's, it I'm like average, wholesale cost. Where's that information coming from, right? You can't pack it it's fiction, right? Just like discounts on your blue cross and blue shield or Cigna rates it's fiction. You can't do that. So they said, well, there's this thing called NADAC N-A-D-A-C. It's the National Average Drug Acquisition Costs. It's a survey-based methodology. It's used in about 38 states for Medicaid. It's out there. It's real data. And those pharmacies agreed. Okay, well, if you just pay us that. So the raw NADAC cost for these 350 drugs that are on our preventative formulary, the most expensive one on a 30 day fill is $2 and 25 cents. And so we said, if it's this cheap, we need to do some repricing.
Chris Shoffner (17:32):
So we went out to employers all over the country and we said, if you've got access, right, if you can get access to your pharmacy claims data, we can reprice it for you. You know how long it took us to find enough employers that even had access to their pharmacy claims. It was unbelievable how difficult that was, but being persistent, if you look at that. So if PAR is a dollar, right, if the industry right now, average wholesale price, minus your discounts, whatever, if that's a dollar NADAC on ingredient costs is only 50 cents. Where's the other 50 cents going, right? It's hidden. You'll never be able to find it, but that was an eye-opening for me to think, generics can be gained 50% in price difference, 17% after we add on. So we pay an $8 dispensing fee, right?
Chris Shoffner (18:37):
And people go, why would you pay that? Most industry only pays 85 cents or $1.25. Well, it's because we want our community pharmacies to act differently. So if the industry has got you in this box that you don't like to be in, but you want to be in a much nicer box where people value your one, people trust their pharmacist more than they trust anybody else in the healthcare continuum. And they are vastly more likely to visit their community pharmacy or their pharmacy more so than they are their doctor. So if you want to talk about grassroots, ground-level disease management, where it matters, the pharmacist has got to be involved. And that's really, our aha moment when it came to pharmacy was the one guy that walked into that meeting and said the word NADAC. And I was like, you got me, tell me what that is. And, and we're in there.
Chris Shoffner (19:34):
Right? And then I went to someone that I really respect in the industry. Gloria Sachdev runs the Indiana Employers Forum. She herself is a pharmacist. Two years ago, I walked up to her and one of her meetings said, Hey, Gloria, how are you doing for tricks? Ad says, Hey, oh, great. You know, Troy? I said, let me ask you, do you know what NADAC as cost for pharmacy is? She didn't know. And that was the second point. I was like, okay. So one of the pharmacist herself leading one of the biggest employers forums in the country, right. Had no idea about this type of methodology and how it can apply in a PBM world. And so I think that's what really solidified our intent on using community pharmacy versus a traditional PBM or this year community health plan. Because if it's smart and I don't have any bad habits to break.
Sally Pace (20:31):
You know, you all have talked about misusing big, good business sense. I mean, that's what it boils down to is treating it like you do every other area of your,
Leigh Dill (20:41):
And I think Rob, you said it best. I mean, I, I feel like the title of his podcast is transparency has be defined, and it did all points of every part of employee benefits. So I hate to stop it, but we are at the top of the hour, if y'all want to go around and just tell us how we can get in contact with you for further questions or exploration, Adam, if we could, if you want to start. And, and your favorite book.
Adam Russo (21:12):
Oh, my favorite book. Yeah. Rob has all these business books. I saw that Rob.
Rob Gelb (21:17):
When you write it, then it'll be my next favorite. But until you're right at the 2 I selected.
Adam Russo (21:22):
I actually, I'm actually writing, I'm writing it. Rob, I'll let you have... It's a, ARusso@phiagroup.com. And my direct phone number by cell is the best is 178284325. And I got my favorite book. I'm a big Cleveland Indians fan huge. There's a book called the curse of Rocky, Colorado. And it looks at the 30-year slump of the Indians and how there was a curse basically on the Indians, by a guy named Terry Pluto. It's a great book about just Cleveland sports history, how we always loose basically. So, that's my favorite book. I love it. It's I got brainwashed as a kid to love the Indians. I brainwashed my entire family as well, but it's a great read. Something fun to read over the summer. And now that's it.
Leigh Dill (22:14):
Great, Rob, and we'll enroll. Wrap it up with Chris.
Rob Gelb (22:17):
Thank you. So it's, rgelb@valenzehealth.com, (All one word with a Z for valenze), (215) 692-0973 is the cell phone. That's the best way to get ahold of me of any time, text or voice. And I had listed too. What got you here? Won't get you there by Marshall Goldsmith. And then Phillip Lindsay only does a series of fables business fables. I love all of them, but the first one I read was the five temptations of CEO long before I ever became a CEO. And, and really both books kind of talk about the same thing, the importance of innovation, listening, collaboration, and really just being humble and understanding that, just because you have the big title, you're not necessarily the one that has all the answers and you really need to listen to the people that do the work and take learning from them. So I'm all about self-improvement self-help. My wife is key to making sure that I improve every day and after 31 years, she's put up with me she's kind of shaped me into what she thinks I should be. So both of those books were very, very helpful to me in my career.
Chris Shoffner (23:23):
chris@yourcommunityhealthplan.com all spelled out at 9193706217. And my book is a business book, but it's an older one and it really did change the way I looked at trying to execute what we're doing today. And that's the innovator's dilemma, though. If you look at innovating in a market, if I'm a big PBM going up against, or a MAMA, infant PBM going up against CVS or Express Scripts or anything, that's going to be a tough nut to crack, right? But if you go to that low, low margin business, for those in those big carriers, there's the small, fully insured groups, the 15 life group, the 25 life group, right? And the brokers that you're dealing with and that level of the market, aren't nearly sophisticated enough to be able to handle self-funding or this type of data talk that we're talking about right now.
Chris Shoffner (24:16):
And so that's really why I focused on these small businesses is that they don't have a board of directors that they've got to go to. They don't have, typically they don't have a CFO. They might have a bookkeeper. They're not going to have an HR staff. They are the ones making the decision. And it's those business people that have to hear the common-sense stories that we're telling them, myself, Rob, Adam, all in the same perspective that they can make the decision to change a lot faster than a thousand life group or a 400 life, city or county government.
Chris Shoffner (24:52):
Any of those businesses are going to struggle with trying to do something new and different and innovative for all the reasons we've talked about. The broker's going to tell them it's a bad idea. The HR person's going to say, it's too much work. The CFO's going to say, well, we got to spend the money anyway. You know, all those things, but this small business owner, when you tell them, Hey, look, this is $250,000. And if you do this the right way, you might only spend $130,000 and your employees are going to get more or less, a hundred percent coverage. They can make that decision. Right?
Leigh Dill (25:26):
Thank you all so much for your time today.
Rob Gelb (25:29):
Thanks to you. This is great, Chris. Thanks for the invite.
Chris Shoffner (25:32):
Thank you both. I appreciate it immensely.
Announcer (25:35):
If you miss the first half of this discussion, please check back to transparency has to be defined part one with Chris, Rob and Adam. Thank you for listening to this episode of the granite list live, access our entire library by visiting your favorite podcast venue or subscribing our site, the granite list.live
Transparency Has to Be Defined
Chris Shoffner, CEO of Your Community Health Plan, sits down with Leigh and Sally to discuss the lack of data transparency available to those designing health plans. Along with guests Adam Russo, CEO of Phia Group and Rob Gelb, CEO of Valenz we cover how to define transparency and the key context points to focus on, including why it’s important and how to use it.
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Here is the full transcript for this episode:
Announcer (00:07):
Welcome to another episode of The Granite List Live. Navigating a sea of benefits solution is daunting at best and new vendors emerge every week. Hosts Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now, to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spending while improving employee engagement and outcomes. Listen in to this episode.
Announcer (00:37):
Chris Shoffner, CEO of Your Community Health Plan, sits down with Leigh and Sally to discuss the lack of data transparency available to those design in health plans. Along with guest, Adam Russo, CEO of Phia Group, and Rob Gelb, CEO of Vālenz, we cover how to define transparency and the key context points to focus on, including why it's important and how to use it.
Speaker 2 (01:02):
Let's kick off today's session. Chris, you have a very interesting story to tell and I'd love for you to share with the audience what your why is. How did you come to even building Your Community Health Plan?
Chris Shoffner (01:16):
Well, it started really in 2008 when I was chosen by our Commissioner of Insurance to sit on a Blue Ribbon Task Force on our state employees health plan. 700,000 lives, almost a $3.4 billion spend. That two-year process really was enlightening for me because I started my career at Merrill Lynch in the retirement plan business, transitioned early 2000 into the health and welfare space. 2008, we had the ACA going on. Barack Obama just got elected. There's a lot of stuff happening in healthcare. So, I said, "Well, gosh, if I can sit in on this two-year Blue Ribbon Task Force on our state health plan, I'm bound to learn a lot and meet a lot of great folks." Really, what that all boiled down to was that at that level, we found out beyond any reasonable doubt, there was no structured oversight over that $3.4 billion spend of taxpayer money, which I thought was amazing, right?
Chris Shoffner (02:16):
You've got the biggest plan in the state blindly paying claims for everybody. It was just a matter of Blue Cross sending them a bill on a quarterly basis to draw money out of the account. And then, settling up 30 days later, and pulling more money, right, because they would always say they never have enough. So, when you see a plan of that size, that has no structured oversight, you start to wonder, "Well, how many other companies out there are in the same predicament?" Right? That's when our State Treasurer then became the resting place for this. At that point in time, that was a $24 billion unfunded liability in 2010. Today, it's $38 billion unfunded liability. Our current State Treasurer, Dale Folwell, sat right next to me the whole two years when he was in the House of Representatives on that same task force.
Chris Shoffner (03:13):
So, when I look at things, I see that and I see a big problem, right, because ERISA is the same law, whether it's a retirement plan or it's a health and welfare plan. On the retirement plan side, there is so much audit structure, detailed data in place that you can review everything, but on the health plan side, you don't have the same structured oversight. There's no enforcement. I hate to call it stealing, but in many cases, that's exactly what it is. So, that's where my path brought me to, the realization that, "Well, if we're going to really change this, it's got to start from the bottom up and the bottom up in healthcare are small businesses." So, from a size standpoint, 50% of all people that get a W-2 paycheck in our country are receiving that from a business that has fewer than 50 employees. These are the people that are getting hurt the worst by this health care system, if you want to call it that, that we have.
Chris Shoffner (04:17):
So, fast forward to 2017, I start working with two North Carolina networks, one in primary care, one in pharmacy, to deliver them a solution. We really laid down some key points or key items that we wanted our plan for these providers to have. Number one, it had to be transparent. Number two, we had to do something different with the PBM and the drug structure that is quickly becoming 20%, 25% of total plan spend in some cases. We're getting new drugs that are hyper-expensive being approved every day, may or may not show any clinical efficacy. It's difficult. And then, you've got the data piece. I'm not talking about just paid claims data, which even our treasurer to this day can't get paid claims information out of the plan because he is statutorily denied access to it. He's not allowed to have it, not allowed to share it. That's a little bit crazy, right?
Chris Shoffner (05:24):
And then, the last point is we need to use a consistent rule-based law and ERISA is there. And through a level-funding structure, which is what we've designed... ERISA is the same in every state, so we don't have to go through state departments of insurance to check and make sure that something's up to their codes. We don't have to worry about any state regulator or association plans or anything like that. We can do the exact same thing for anyone that wants to participate anywhere in the country. So, that's kind of where we got to, and that has led me to great relationships with folks like Rob Gelb and Adam Russo, experts in their field.
Chris Shoffner (06:07):
Again, that's me being the collaborator and the fiduciary to the plan saying, "Let's do this. Let's use best of breed. Everybody doesn't need to make the same decision multiple times." Right? It can be put in a nice package for them, which is what we believe that we've done at Your Community Health Plan and continue to monitor everything and report out to those employers because at the end of the day, it's their money and it's their employee's money that they are choosing to defer into the plan in lieu of getting W-2 wage. Right? That's the key trade-off that most people really don't think about. "Oh, it's my employer's money." Well, at the end of the day, if we do our jobs as fiduciaries and partners to the plan, 75% of all the savings that are derived revert back to the employer group. So, that is something that also makes us unique because I don't know of any other level-funded product across the country that will do more than 50% and the transparency that those have maybe a little bit less than the transparency that we offer.
Speaker 4 (07:15):
Elevator pitch. Talk to us about what Your Community Health Plan is and what audience you're intending to reach with it?
Chris Shoffner (07:23):
Your Community Health Plan is a level-funded, self-insured plan for groups with as few as five employees, up to really a hundred in the level-funded scenario. But then we can take that same platform, the same chassis and go up to several thousand employee lives with our PBM and our TPA partner.
Speaker 4 (07:45):
You talked about transparency and now you have two people with you that also believe in transparency from very different angles. Chris, you talked about what you're seeing in the marketplace and what has led to a need for transparency. What do you see going forward? How will you operate differently? And why do these partners matter to you?
Chris Shoffner (08:10):
Well, transparency is a tricky thing, right, because it's not just transparency into the dollars being spent in your plan, it's transparency into the quality of the providers that you're sending your plan participants to. I think that's really Rob's key point is... What we used to think as just plan data, there are now so many external data points that we can pull from to help engage our participants because giving someone a list of in-network providers is not really doing much for them, but having them have a resource like Vālenz that they can call and say, "Hey, my doctor said I might need this procedure done," or, "I might need this extra test done." We want to make sure that, that participant goes to the right place at the right time and gets the best quality for whatever procedure or information we're trying to gain from this next step in the process.
Speaker 2 (09:11):
Chris, just so I understand how your two platforms work together, will Your Community Health Plan put together a narrow network within the region that the employer is in, or do they engage Vālenz to do that for them, or is that an additional service that has pooled into work together?
Chris Shoffner (09:30):
Well, it's really work together. Your Community Health Plan are using, what I'll call, direct private payments. Some people might refer to it as reference-based pricing, but we are not creating narrow networks. We are utilizing Rob and his team at Vālenz. If there is a narrow network that we can benefit from in an area, yes, we will use them, but at the end of the day, we want our people not to be bound by anything that might be an artificial barrier in what we call, a traditional network.
Speaker 4 (10:02):
Rob, do you mind telling us why you've stepped out on a limb? I mean, Chris is... Yeah. You're a trailblazer in this space as well, Chris. So, Rob, what has attracted you to work [crosstalk 00:10:13] what Chris is doing?
Rob Gelb (10:14):
First of all, thanks for having us. And Chris, thanks for inviting us in. I know that I speak proud when I say, we're honored and flattered to be a part of the conversation with you because it's an important topic. I think what attracted us to Chris is there... Healthcare is kind of like a river right now. It just keeps flowing and it's evolving. If you go to the bank of a river at one o'clock in the afternoon, it looks one way, and you'd see it at two o'clock and it's completely different. It's changed. That's kind of what's happening in our healthcare environment today.
Rob Gelb (10:38):
So, as we've been building an ecosystem, since I joined and took over our organization, we've been putting in the pieces of what has to work together to make fundamentally our customer who's really the self-insured employer and their member. We always have to remember who our endgame customer is. It doesn't matter if we work through a TP or stop-loss carrier or whoever the stakeholder is. That's really what we're looking at. There is an opportunity to incorporate his model into our ecosystem design and plug it in where it makes sense. So, while we're building high-performance narrow networks, while we're engaging concierge medical, and building out and understanding what quality providers look like, communicating and educating the consumer or the member about that, there's a piece of direct primary care that really is emerging as critically important, more efficient, more cost-effective, more improving outcomes at the front end. That's really what attracted us to Chris in what he's kind of championing in this space.
Chris Shoffner (11:39):
I think that's great. I mean, fundamentally, when you look at building a house, you start with the foundation. And when you start with a health plan, the foundation of that health plan is the plan document. So, you need to make sure that you are very intentional about how you put your plan document in place and that everything else around the plan understands how you structured the plan document. Right? I think that no one can speak any better to this than Adam Russo. Adam?
Adam Russo (12:17):
Here we go. Let the games begin. Go ahead.
Speaker 2 (12:21):
We've had some issues with some clients really having a hard time getting data and we all know that the providers want to hold onto it as close as possible, especially the PBMs. So, as you are building these plan documents and looking for transparency, do you have any tips or pointers to our listeners who are brokers and employers and other vendors even, how to get access to that data? What is really needed as you're building that foundation?
Adam Russo (12:48):
First, I just want to say thank you for having me today. I appreciate the opportunity. Again, I'm Adam Russo, co-founder, and CEO of the Phia Group. Getting to your question first, the first thing I would advise every employer, every broker, every CFO, every CEO is actually read your contracts. Nobody reads them. So, you hear all these stories of people complaining that they don't have access to data, or they can't get this, they can't get that. Well, they signed off on that in many situations. So, what I tell people is work with partners. Work with vendors. Work with administrators that actually give you access to your claims data. They exist. For every organization, every carrier that won't give you data, there's another administrator that will give you all the raw data that you want based on your own plan.
Adam Russo (13:40):
Here's what I tell people about designing a plan document. You cannot design a plan document that's going to meet the needs of your own population at your own organization, unless you actually know what the risk are. The only way you actually know what your risks are from a healthcare standpoint, from a cost standpoint is by having access to that claims data. So, you get access to that claims data. Identify what the actual risk are. Where do you people are going? Where aren't they going? What type of needs do they have? What type of specialists did they go to? What are the PBM issues or the pharmacy issues, all that stuff. And then, you designed a health plan to meet those needs. How do you design that plan? What we believe is you actually empower the employees and the family members to actually care about the cost of healthcare. That is the fundamental problem that we have in this country.
Adam Russo (14:30):
I'm going to give you a very simple example. People believe, all of you, everyone listening, that when you go see a specialist at a hospital, what is the actual bill? An employee believes the bill is their copay, their out-of-pocket, their deductible. What does the employer think? The employer looks at it almost the same way. What is their out-of-pocket up to the stop-loss specific deductible? Right? Up to the stop loss aspect. They're looking at it as well. "It's a $200,000 bill, but I'm only on the hook for the first $50,000." So, if you really look at it, the only entity in this whole ecosystem that actually cares currently about the entire bill is a stop-loss carrier or a reinsurer. The funny part is they're not looked upon as health insurers. Okay? They're not health insurers. That's the key issue.
Adam Russo (15:28):
You brought up a question earlier about the why. At my company, when we started this company back in 2000, it was really simple and it's been simple ever since. Healthcare is too expensive. Prices go up all the time. And what we're seeing is employers are forced to offset all those costs onto their employees and their dependents. How do they do that? Higher copays. Higher deductibles. We see that year after year. As we build these plan documents, that's all we see consistently. We don't see people trying to innovate. We don't see people trying to empower their plans. All we see is, "All right, we'll make deductible higher. We'll make the copays higher."
Adam Russo (16:12):
So, what we have as the purpose for our organization is to make health benefits affordable for all the employers, for the employees, and their family members. Why? Because every single person deserves access to, not only low cost, but high-quality care as well. And the only way you can do that, having the data, analyzing that data, and then designing a plan that meets the needs of that population. Because what I can't believe is right now, you'll have a carrier, let's say in Oregon, the plan design for a 10,000-person teachers' union is the exact plan design for a 500-life truckers' union or a 300-life yoga instructor plan. They have different needs. They have different risks, yet every plan design is exactly the same and that is what I-
Rob Gelb (17:05):
I'd like to comment on some because Adam went back to the why. The funny story is we actually went through an exercise organizationally last year, using Simon Sinek as the backbone of what is your why? We went through an exercise organization of the why, what, how in getting to that Golden Circle and really think things through. Our why is actually in every presentation we do. It's very, very simple. We exist to live our brand promise to engage early and often using data as a source of that to drive smarter, better, faster healthcare decisions. And we live the translation of our brand, which is to be strong, vigorous, and healthy as a company, as a partner, and collaborate to drive membership.
Rob Gelb (17:45):
It's very, very simple. So, that's our why. That's our purpose. It's the why we exist. It's why 94.5% Of our employees wake up every morning, because we just did an engagement survey and they said, they totally understand what their role is in response to what we're trying to accomplish as a business. That's what we're rolling forward with. Data is critical. Data is the fuel that drives all this.
Rob Gelb (18:09):
One last point, I'll let Adam go because if you know anything about Adam and I presenting, we will play off each other now back and forth. Transparency has to be defined because transparency is more than just what. It's, why is it important and how do you use it? If you don't get those second and third dimensions into the transparency discussion with members or anybody that's looking at the quality metric, and say, "Well, this provider had 85 episodes of a similar service and they scored 97.5..." If you don't understand what that means, why it's important, how to use it, transparency by itself is just a data point. That's a key thing that we try to make sure we do in what we build with partners like Chris and partners like Adam said let's all make sure that whoever's looking at this has context around what it is they're looking at and why it's important for them to evaluate and use it wisely.
Adam Russo (19:01):
I know we're talking about transparency, but I really think that, that's just one step. I mean, even if you have all the data out there, here's the problem. Okay? We see it on a daily basis. Most CFOs still believe that healthcare expenses are not part of their realm. It's like, "All right, the broker's handling that, right? That's not something that I could control. That's not something I can change [crosstalk 00:19:25].
Rob Gelb (19:24):
It is what it is. It is what it is. I mean, we have this mentality. It is what it is. This is going to be.
Adam Russo (19:29):
Right. That's why when you look at my company, it's all about empowering plans. It's getting those CFOs to look at their healthcare dollar spend no different than all the other stuff on their expense side on the P&L. Here's what we say all the time. Let's say you have an employee making $50,000 a year. Think about what an employee has to... You guys know what an employee has to go through to get a raise. Peer review, self-assessment, via annual reviews, training, blah, blah, blah. All of these things, and then maybe they'll get a 5% raise. Yet, with healthcare spend, that same employee could go see a specialist for knee replacement surgery, and then spend $100,000 when they could've spent $20,000 at a higher quality provider. Nothing is being done by employers to actually get their employees to care about the cost of care. They care so much about wages, all this other stuff, but when it comes to healthcare, "It's out of our control." That's fundamentally what's wrong with our healthcare system. We need the C-suite to realize they can do something about-
Chris Shoffner (20:40):
Well, I think that's a key point you made about plan design. Right? And your company, Adam, I know that if they go through the chosen path, all the cost-share has been eliminated, right? Company's paying it a hundred percent. That was fundamentally one of the things we did. We said, "Okay, we don't like high-deductible plans because there are so many wrong things that happen when everybody gets stuck in high-deductible plans." People avoid care. People don't go and do anything that they should be doing normally.
Chris Shoffner (21:08):
So, that's why we have, primary care, no cost share to the member. You go to your primary care doctor, plan's paying a hundred percent. You go to your community pharmacy for $100 to $350 or so generic meds that we've got on our preventive formulary, there's no cost to the member. Right? That's great access versus where they might have been in a high-deductible plan today. And then, as we get into the procedural-driven stuff, we've done the same thing. We have eliminated cost-share, if they go through and choose one of the providers or a few of the providers that Rob and his group have laid out that are high quality, low-cost, deductible way. No cost-share to participants.
Chris Shoffner (21:53):
These are things that we can do because we started with a clean sheet of paper. We didn't have any legacy, bad contracts that we were involved in before we started down this road. That's, I think, where a lot of much larger employers are today. They've got the CFO that's, "It is what it is. I don't have any control of spend." They've got legacy partners with a broker or a PBM that they really can't get out of. And, "Too much disruption for my employees." So, I think that's good for us that we could start with that blank sheet of paper and get to a place that any employer today of any size should be doing these exact same things.
Adam Russo (22:38):
You have a CFO first. "You have to see if I were you." But here's the problem, it's human resources too, right? Because all this stuff that we're talking about, it's not easy. It takes work. So, if you have an HR department that says, "Well, I'm just picking one, right? Well, we have Blue Cross. We don't want to disrupt anything. There's a lot of training involved, a lot of education involved." It's more work for people to make all these things successful. To lower the cost... Let me just share a simple story. You mentioned deductibles, right? We represent 15 million lives nationwide. We write plan documents for about 5 million lives and we get the schedule of benefits that we see year over year what happens. So, all we're seeing is less benefits, more higher deductibles, higher out-of-pockets consistently. And then, when it comes to deductibles, people aren't even educated as to when they should use that deductible and when they shouldn't.
Adam Russo (23:36):
For example, urgent care. Many times, you're better off paying cash walking into an urgent care than showing your ID card and then paying the deductible price for your network. People don't realize that. So, the lack of education, the lack of transparency, the lack of actually knowing... Forget about the hospital because every hospital has a great surgeon and a bad surgeon. We don't want to go down to the actual specialist level, understanding of the quality metrics of every specialist within a facility and their costs.
Adam Russo (24:09):
I mean, that's why we've been able to, in our organization... I think there are 10 other companies in the country, healthcare is free. There is no cost to the employee or their family members. Was it easy to do? No. It took five years, but changing the behavior of the employee population to get them incentivized, to care about the cost of care, it's a great way then to recruit new employees, retain employees where they see that the employer has buy-in for their actual care, their well-being, the well-being of their families. It changes that mindset versus an organization that says, "Oh, yeah. [Joe 00:24:49] in accounting, his kid needs a specific prog."
Adam Russo (24:53):
Do you guys understand? The number one most requested inquiry to my company from brokers isn't how to lower the cost, isn't, "Are there alternatives?" The number one question we get is, "This is expensive. How does the plan not cover it?" Think about that. They actually ask how not to cover something that can make a family member or an employee healthier. It's sad, but that's what we've come to as an industry. That's what we're trying to change and that's what we've been successful of changing over the past 20 years.
Speaker 4 (25:29):
I would say, you've probably never met an employee who wouldn't prefer to have make more money and spend less on healthcare. It's just a lot of it centers around quality education, healthcare education.
Adam Russo (25:44):
We believe in mandatory workshops. People don't do it. I mean, you have these annual enrollments. "Here's your network. Here's how you sign up." Mandatory workshops talking about all the different cost between the metrics, all the different measures, things they can do to make their healthcare spend lower. Mandatory. No different than when you have HIPAA training at a company or any type of training that you might do. These are mandatory things that we're doing that we just don't see at a-
Chris Shoffner (26:14):
I think, it [inaudible 00:26:16] me. I think that goes to, again, the absolute split in ERISA covering retirement plans, right, which under 404(c) says, you have to do participant education. You have to deliver them the tools and everything to make sure that they can manage their own risk tolerances, that they become self-aware of what they're investing in, that the investments are broad enough in spectrum that they can be diversified. Right? All of that is required by ERISA. None of it makes it over into the healthcare world and it's the same law.
Announcer (26:55):
Be sure to listen to part two of this episode. Transparency has to be defined as Leigh and Sally continue their conversations with Chris, Adam, and Rob. Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribe in our site, thegranitelist.live.
The Critical Importance of Data Analytics
Navigating a sea of benefits solutions is daunting at best, and new vendors emerge every week. Hosts Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what’s new, what’s needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spend while improving employee engagement and outcomes. Listen in as experts across all spectrum of the benefits universe share their secrets of success on The Granite List. Live.
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Here is the full transcript from this episode:
Announcer: Welcome to another episode of The Granite List Live. Navigating a sea of benefit solution is daunting at best and new vendors emerge every week. Host Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, [00:00:30] brokers and employers can intern stay on top of spending, while improving employee engagement and outcomes. Listen in to this episode today.
Sally Pace: Welcome, everybody. Welcome to our introductory episode of The Granite List Live. This is Sally Pace, and I'm here with Leigh dill. Leigh, tell our audience a little bit about yourself before we jump into what The Granite List is and why we're doing this podcast.
Leigh Dill: Yes, thank you. I'm so excited to be here and excited [00:01:00] to share with you all of our vendors that we've been interviewing. My background is in accounting, and I found out pretty quickly that tax returns were not for me. I was at the right place at the right time to join a large local company when they were going from a fully insured platform to a self-insured platform. We had over 400,000 lives that we were managing.
So it really was its own ecosystem, which was really interesting to me, looking at the medical, dental, vision, and disability plans and seeing the [00:01:30] different risks associated with it and the different disease states that were happening. We were doing analysis and reporting on what was going on and plan recommendations. And of course, being that large of an employer, we had multiple vendors coming to us with their ideas. So after being there for a couple of years, I was lucky enough to join Sally at Connect Healthcare Collaboration doing data analysis.
Did that for a couple of months, and then COVID hit, which changed our direction [00:02:00] not completely-
Sally Pace: Pretty completely.
Leigh Dill: ...but a nice 90-degree turn. And so here we are.
Sally Pace: Well, I'm pretty sure we're the lucky ones to have the awesome team that we have under the CHC banner. My background is actually in marketing and communications as an executive in the financial industry. The irony is I don't like numbers, you do, but I spent the better part of my career helping to tell the story behind [00:02:30] them. That's why healthcare makes so much sense to me because it is a numbers game in many respects, and it's, unfortunately, one that so many employers see those numbers climbing year over year.
We've been fortunate to be aligned with and work with a lot of brokers and also vendor solutions that are working to combat that day in and day out. So like you said, we've looked at what our business model was and how we could add value to the entire benefits arena. [00:03:00] I love how this journey has taken us in places that we never dreamed of back in 2019.
Leigh Dill: Back in 2019 and before, everything was in-person. You receive lots of business cards, going to conferences. You found out what was out there. It's a relationship game, and it still is. Brokers and vendors trying to find each other. It's a referral service, what you've used before, what you're comfortable with. Fast forward into 2020 [00:03:30] and really beyond, who knows what's going to happen after this?
Sally Pace: True.
Leigh Dill: Thanks to everything, technology really is amazing, but the healthcare world is behind as far as how people find each other. Brokers and vendors are both looking for new connections and new ideas. That's really why we built The Granite List was to bring them together, and we definitely don't want to leave out the employer audience as well, because those are who are in clients are. At the end of the day, the sense of community [00:04:00] at The Granite lists, finding each other at point of interest is what we've built and why we're here today.
Sally Pace: One of the questions as we talk to those three different constituents, vendors, brokers, employers, that always comes up is, how'd you come up with the name? I love the story. As you and I know, it's certainly a labor of love and a lot of thought went into it. But for those of you in the audience that haven't heard it, I'd love to share a little bit about why we came [00:04:30] up with The Granite List. Of course, granite is a solid foundation.
It's firm. It's solid. But in our discovery, what we also found was that The Granite Cutters Union back in 1877 was the first group in the United States to offer plan members sick benefits. Now, obviously, it was gruesome work. I'm not sure as it has advanced. It's still a very tough job, but what we loved beyond just the obvious need for sick benefits and caring for people was this [00:05:00] whole other component that was uncovered, and that was the true spirit of community that you alluded to, Leigh. We found that The Granite Cutters Union had a newsletter.
I like to think of it as kind of the precursor to modern-day GoFundMe. And if you had a colleague that had a need that extended beyond the need for their sick benefits, you could submit their story to your supervisor and that story would get published and The Granite Cutters could rally around their colleague and really help improve their quality of life, their family [00:05:30] member's quality of life in whatever way they had a need.
Today, The Granite List, which is powered by Connect Healthcare Collaboration, we're really doing work to continue to instill that same sense of community and add real value and lasting value to plan members, but doing it in a very modern way. We're really excited about The Granite List Live.
It gives us the opportunity to sit down with many of the vendors you'll see on the site as you search [00:06:00] and get them to tell their story to you in a way that is meaningful, that hopefully inspires you, our audience, to learn about a new component or a new solution that you may not been aware of before, and really think about this community that we're building and how you can use The Granite List and by way of The Granite List Live to improve the quality of your plan.
Leigh Dill: I think that's a great way to summarize it. We'd love for you to join our community and listen in. [00:06:30] Listen to the stories that everybody has to share, because everybody has a great story to improve the lives of others. It's been a fun journey. We're just beginning.
Sally Pace: You can find us online at www.thegranitelist.com. Tune in to our next episode.
Announcer: Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or [00:07:00] subscribe in our site, thegranitelist.live.