Latest / The Advancing Healthcare Innovation Show / E168 | Healthcare Price Transparency, Payer Rates & Contract Strategy with Payerset

Transcript

E168 | Healthcare Price Transparency, Payer Rates & Contract Strategy with Payerset · The Advancing Healthcare Innovation Show

0:11
Hello and welcome back to the Advancing
0:13
Healthcare Innovation Show. I am your
0:15
host, Michael Stamatinos, and if you're
0:18
new to us, welcome. Super excited to
0:20
have you here because we are bringing
0:22
some really exciting conversations with
0:25
some fantastic leaders that are
0:27
painstakingly reshaping the future of
0:30
health. And we're passionate about a few
0:33
different key areas here. Passionate
0:35
about healthcare innovation, about
0:36
access, about leadership, and the
0:38
adoption of that innovation. And if it's
0:41
your first time tuning in, let me just
0:43
take a quick step back and tell you a
0:45
little bit more about what we're trying
0:47
to get done here. So the focus of the
0:49
show is bringing real stories of
0:52
innovation to life. Not just things that
0:55
you read, not just things that you are
0:57
theorizing, but people that are actually
0:58
really getting stuff done within our
1:00
space and giving them the opportunity to
1:02
share their stories, share their
1:03
learnings, and to share their little
1:05
wins with our community. And if you
1:09
haven't had an opportunity to check out
1:10
any of our historical interviews,
1:11
wherever you are now, whether you're
1:13
watching this or listening to this, uh,
1:15
ideally binge watching this, and please
1:18
hit the subscribe button now, so any of
1:21
these new interviews come directly to
1:23
you. So today's guests, uh, it's
1:26
actually pretty special because I I
1:28
connected with them right away. The
1:30
first time that I chatted with Jacob and
1:34
Jerry, uh there was actually a very easy
1:37
rhythm to the conversation, you know,
1:39
kind of the moments when you think about
1:40
like, yeah, look at these guys. They
1:43
like them. And at some point in my mind,
1:45
I was like, they're definitely going to
1:46
come on the show. When you know, you
1:49
know. And
1:51
Jacob Little and Jerry Damaso are the
1:54
co-founders of Payer Set. and they kind
1:58
of have a way of simplifying things. And
2:01
anyone who has dealt with payer rates
2:04
knows just how messy that world is.
2:07
Files don't match, claims don't line up.
2:10
Everybody's using different numbers and
2:12
hoping that they're close enough. But
2:14
Payet is doing something that in my mind
2:16
is brilliant. It's simple. It's very
2:19
simple to describe, but it's actually
2:21
really hard to pull off. They take every
2:24
machine readable file from payers across
2:27
the country. They tie it back to actual
2:30
claims and give health systems a and
2:33
medical practices a real view of what's
2:35
being paid the truth
2:38
in one place in a very real way that you
2:41
can actually use. And here's sort of
2:43
what I appreciate what I've taken so far
2:45
from Jacob and Jerry and the rest of the
2:47
team is they're not like, "Hey, let's
2:49
just build another dashboard kind of
2:51
people." They're more let's roll our
2:53
sleeves up. Let's actually try to
2:55
fundamentally shape the question, shape
2:58
the problem, and give our customers
3:01
something that they actually use. And
3:04
I'm going to use the L word here that
3:06
they love. Like there's a very big
3:09
difference in that. And so they're
3:11
helping teams walk into some of these
3:13
contract negotiations with payers with
3:15
data and information that changes the
3:18
tone of the room. They're showing
3:21
leaders where the money is being left on
3:23
the table and they're giving the
3:25
organizations the ability to make
3:26
decisions with confidence and without
3:29
having to rely on guesswork. So under
3:31
their leadership, payers is honestly
3:35
quietly becoming one of the powerhouses
3:39
in the space quietly because people are
3:43
relying on them and they are making them
3:45
quote unquote l making them love them.
3:47
So today we're going to talk about where
3:50
Pariset came from, what Jacob and Jerry
3:53
are seeing across the country, why
3:56
contract clarity has become such a big
3:59
lever uh for health systems that are
4:01
actually trying to protect their margin.
4:03
And maybe we'll even just get into some
4:05
of the mindset behind all of this,
4:07
including how they kind of stay composed
4:09
when things get a little hectic. And if
4:11
you've been in a startup growth company,
4:14
things sometimes get a little chaotic.
4:16
So, Jacob, Jerry, what's up? Welcome to
4:20
the show.
4:21
>> Thank you so much.
4:22
>> What an amazing introduction. Holy cow.
4:24
>> It's being Hey, it's being recorded. You
4:26
know, we're no nothing people up. We're
4:28
trying to we're trying to give your best
4:29
stuff here.
4:30
>> I love it.
4:30
>> So, let's maybe let's start back. Um
4:34
like guys, we we we clicked right when
4:36
we first met and I think there's sort of
4:38
an ease to the conversation.
4:42
um for people that are meeting you for
4:43
the first time like
4:46
who were you before payer set you know
4:49
what shaped the way that you see the
4:51
world and I'll start with uh Jacob and
4:54
then maybe Jerry chimes in after
4:57
>> sure thanks so much again uh for having
4:59
us and for that awesome intro
5:02
I've I've always been a a technology
5:05
nerd I've always been a data nerd um and
5:09
I've always had a real passion for for
5:12
people and helping people. Um I did not
5:15
I did not get excited about technology
5:18
or data uh with my my first stint in the
5:21
corporate world uh which was in banking
5:23
helping with uh socks compliance. So uh
5:28
but got very excited when I switched uh
5:33
switched industries and began my work at
5:36
a children's hospital, Children's
5:38
Healthcare of Atlanta. And that's when
5:41
you saw data in a very different way and
5:44
I got to sit side by side with
5:46
clinicians and look at hey why in the
5:50
world is rhino virus spiking early right
5:52
and these kinds of things as you were it
5:55
also was very
5:57
>> jarring seeing the data that you see you
6:00
know thinking about
6:01
>> children and and some of the things that
6:03
that are happening and how sick they are
6:05
but this is when I got very passionate
6:07
around um healthcare from the from the
6:12
uh care delivery perspective
6:15
and um from that started a health care
6:18
practice uh a healthcare consulting
6:20
practice built a network of uh um care
6:25
delivery organizations across the
6:27
country uh among other kind of
6:29
organizations and more of the life
6:30
sciences space and just really trying to
6:32
understand like how does healthcare
6:35
actually work which was a rabbit hole uh
6:38
to say the least. So that's kind of
6:39
that's how how I got started.
6:42
>> Right on, Jerry.
6:44
>> Yes. Uh yeah, and I' I've uh I've always
6:47
always been into technology. Um I I went
6:51
to Stevens Tech. Uh majored in
6:53
biomedical engineering. So I was always
6:55
kind of like knew I wanted to do
6:57
something with healthcare, but also
6:58
something with engineering and
6:59
technology. Ended up working at a data
7:02
and analytics consulting company, but
7:04
built a bunch of different products. um
7:07
started another business called NAR. Uh
7:11
I don't know if you can see it's blurred
7:12
back here, but that was our that was our
7:15
logo. Um so that was a that was a
7:18
business intelligence tool using some of
7:20
the technology that was built by click
7:23
eventually got acquired by click. Um so
7:26
I've always been into building
7:27
companies, building technology. This was
7:28
a really really interesting challenge
7:30
because the data was so huge and um
7:33
unruly and it was everywhere and it was
7:36
you know it's many terabytes and
7:38
terabytes and terabytes of data. So the
7:39
engineering challenge alone was just
7:41
something that I was really
7:42
>> looking forward to sink sinking my teeth
7:44
into. And then kind of learning about
7:46
how the regulations happened and you
7:48
know why the transparency rules in the
7:49
first place uh existed and and learning
7:52
about how contracts are created and how
7:53
they were like secret sauce for for the
7:56
providers as well as the carriers and
7:57
they didn't want anybody else to kind of
7:59
know about the pricing. Um which
8:01
understandable now that we we learned
8:03
about some of them some of it. So when
8:05
So do you remember the first time that
8:07
you looked at
8:09
>> the payer data rate data and and you
8:11
were like wait this can't be the system
8:14
that we're relying on you know where did
8:17
that realization hit you?
8:19
>> Absolutely. Um yeah it was actually
8:21
Jacob gave me a call. He learned about
8:23
this problem through his network and uh
8:26
I started taking a look at some of the
8:28
data and just kind of looking at um even
8:30
the tables of contents files. We started
8:32
with Elevance, one of the bigger
8:34
>> Yeah.
8:35
>> uh bigger payers. And um I spent a lot
8:38
of time just trying to like dissect
8:40
their table of contents file. And I was
8:42
able to parse it. Finally fig figured
8:44
that figured that out. And then I
8:46
realized that that's not even the actual
8:47
data. That's just like a list of file
8:50
links to all the actual real data and
8:53
it's like 20 gigabytes just the list of
8:55
links. Um so uh so right away I was like
9:00
okay this is more complicated than I
9:02
expected it to be. Um seeing the
9:04
hundreds of thousands of different types
9:06
of plans and then all across the
9:08
different blues and then finally was
9:09
able to start parsing the actual data.
9:11
Um and then looking at the comparables
9:13
and as especially with our early
9:15
customers they'd be like is this right?
9:17
Like one hospital gets reimbured like
9:20
$18,000 for a knee surgery and one gets
9:22
reimbured like $1,500. Like that can't
9:25
be right. It's like nuts. Yes. Right.
9:27
Just it's just what they negotiated at
9:30
what time. So who who was in charge of
9:32
the negotiation over compounded over
9:34
decades and decades and decades uh of
9:36
negotiations. Um sometimes
9:39
>> who was who was in charge of negotiation
9:42
because they're probably not there
9:43
anymore.
9:44
>> They're not. Yeah. Who was in charge?
9:45
But it's been so many years and then
9:47
it's like whoever's you know a lot of it
9:49
is around corporate strategy like hey
9:52
we're going to try and you know acquire
9:53
a bunch of imaging centers so we're
9:54
going to try and increase our
9:56
reimbursement around imaging but for you
9:58
know five six years that leaves the
10:00
other rates kind of stagnant because
10:01
we're not going to try and negotiate
10:03
them higher we're really focusing on
10:05
something else. Um, and just over time,
10:07
especially when you have thousands of
10:08
different, uh, negotiations going on,
10:13
um, just you get this kind of really
10:16
wacky, spiky pricing, uh, for every
10:18
service because it's not really based in
10:20
cost. It's like loosely based in cost.
10:23
It's really mostly based in just who was
10:25
a better negotiator and what did they
10:27
care about at the time
10:28
>> and market and market power
10:30
>> and market power.
10:32
>> So, let's let's frame this up, Jacob.
10:34
frame this up in terms of price
10:35
transparency for those that are really
10:36
not familiar with this and the
10:38
legislation like te tell us more about
10:41
that and why that actually matters now
10:43
and where and what providers were doing
10:46
maybe beforehand and how they can
10:48
leverage this now.
10:49
>> Sure. It's been a journey, but in 2022,
10:52
mid 2022,
10:54
um there was a ruling called the
10:56
transparency and coverage rule that um
11:00
in enforced the uh commercial plans.
11:04
This is just affects the commercial
11:06
health plans to post every single
11:09
negotiated reimbursement rate that they
11:12
have with every uh care delivery
11:15
organization and clinician in the entire
11:18
country. So this is one of the largest,
11:20
if not the largest data sets, definitely
11:23
the largest public data set in
11:24
healthcare that's ever been published.
11:27
And as you can imagine, there was a lot
11:29
of nashing of teeth. There was a lot of
11:31
push back and there was really low
11:33
compliance for a long time. If you were
11:35
looking to get value out of this data in
11:38
2022 or even in 2023, it was definitely
11:42
hit or miss
11:44
>> even with the large insurance companies
11:46
not being compliant. And I wouldn't say
11:48
really in really late 2023 kind of 2024
11:52
you started seeing those improvements.
11:54
The data got cleaner the data got
11:56
accurate and now I mean now we're in a
11:58
world where uh a lot of our our
12:01
customers are our hospitals but we we
12:03
help all kinds of organizations that
12:05
need to understand this data you know
12:07
they can match to the penny with their
12:08
contracts which is really really
12:10
exciting for them and really empowering
12:12
but it definitely did not start this
12:14
way. Um and it's been a journey of uh uh
12:17
additional executive orders, additional
12:20
laws. There were like three executive
12:21
orders, two or three just this year. Um
12:25
really for these large institutions who
12:28
have insane power and huge, you know,
12:31
publicly traded organizations um needing
12:34
to show quarter and quarter over quarter
12:36
growth, really letting them know, hey,
12:38
this is here to stay. This is serious
12:40
and we're going to enforce it. Um, and
12:44
so now we're in this world where um,
12:48
it's our mission to democratize health
12:50
care pricing. And in doing that, it's
12:52
really about number one letting people
12:53
know it's there, it's available.
12:55
>> Um, and and that it's accessible and you
12:58
don't need to spend millions of dollars
13:01
trying to get it, which goes into
13:02
another
13:04
>> kind of challenge back in the day with
13:06
this data with still actually still
13:08
today. There's organizations like us
13:10
that are trying to solve for this, but
13:11
it's um it's kind of uh when you lose a
13:16
bet and you pay with a truck full of
13:18
pennies, right? This is this kind of
13:20
metaphorically speaking the the the
13:23
insurance companies having to post this.
13:25
Obviously, they didn't want to. Um, so
13:27
they do it uh in a way where you would
13:30
have to spend many many hundreds of
13:33
thousands of dollars in infrastructure,
13:35
hundreds of thousands of dollars more in
13:36
people and R&D and teams
13:38
>> and a lot of time to be able to actually
13:41
get it, make sense of it, and put it
13:43
into a format that's usable for analysis
13:46
and for negotiation, market expansion,
13:48
strategy, those kinds of things.
13:51
So, was there ever a time, you know,
13:53
maybe even early on, maybe even now,
13:56
where you thought, man, like what did we
14:00
just sign up for? Um,
14:03
>> I'll let I'll let Jerry answer that
14:04
first.
14:05
>> Take us into that room, Jerry.
14:07
>> Yeah. So, every day, uh, every morning,
14:10
I think. No.
14:13
No, it it it's it is interesting and
14:15
we're we're very fortunate to be able to
14:18
work with a lot of different types of
14:19
companies and they're and we get to kind
14:21
of see the different stages of
14:23
development that we've kind of gone
14:25
through over the years. So, we'll meet
14:27
people who are like on step five, we're
14:30
on step 500 because this is all we do
14:32
all day, right? Just think about how to
14:34
make this more efficient, more cost
14:36
effective, things like that. Um, but
14:39
it's really interesting to be able to
14:40
kind of see that. And like thinking back
14:41
on it, I think I told Jacob this the
14:43
other day is like if if I knew
14:45
everything I know now,
14:48
then I probably would have said this is
14:51
it's not possible for us to do for us to
14:54
do this. Like we'll never get to this
14:55
point. Um, but honestly, it's just a
14:57
matter of keeping, you know, keeping our
14:59
head down and just continuing to work
15:01
with people who are actually getting
15:02
value out of this like significant
15:05
value, especially for their hospitals.
15:06
They're trying to expand. They're trying
15:08
to help more people. Um, you know, and
15:11
they're just honestly looking to try to
15:13
understand what the pricing is is and
15:15
what it's supposed to be. And, you know,
15:17
that kind of keeps us going. I think
15:19
it's,
15:19
>> you know, having these really great
15:20
customer relationships. Um, you know,
15:23
it's not really a matter of
15:25
>> effort. It's just a matter of like are
15:27
we going to keep keep going on this
15:29
mission? And I think it's a worthwhile
15:31
mission.
15:32
>> We seem to be called to do it. So,
15:35
>> yeah. So, I'm just sort of curious like
15:37
what like what actually happens in the
15:39
room like when a health system finally
15:41
sees their rates inside of payer set
15:44
like like the true picture
15:47
>> what happens in the room like
15:49
>> usually usually somebody yells usually
15:51
somebody yells out loud I knew it
15:55
>> because you know a lot a lot of this is
15:58
>> people know people have a feeling people
16:00
know that they're kind of not getting a
16:02
fair a fair um a fair shake but unless
16:05
you can prove it. You know, it's just
16:08
this bad feeling you have in the pit of
16:10
your stomach. But when you can look when
16:13
you validate your own contracted rates
16:15
to the penny and then you start looking
16:16
out in the market and seeing who's got
16:18
these really special deals, um then
16:21
you're just like, "Oh, wow. This is this
16:24
is much
16:27
um the the gap is much larger than I
16:29
even imagined."
16:31
Um so it's it's it's
16:34
it is kind of there's that strong
16:36
confirmation there's a lot of excitement
16:39
then there then there is a okay now I
16:42
know how we can sharpen our strategy
16:45
there's this uh invigoration that
16:48
happens not because you you go and it's
16:51
not necessarily a race to the top where
16:52
you say like look I can see you're
16:53
giving name largest health system in in
16:56
the country this rate we want that rate
16:59
but being able to talk about um the qua
17:03
the quality of care that you provide,
17:05
the value to the community, how you're
17:07
taking care of the community, how you're
17:09
expanding, uh how you're why you're
17:12
important, and and why it justifies um
17:16
increases. I mean, some of these
17:17
organizations haven't had a negotiation
17:19
or renegotiation or increase in seven
17:21
years, 10 years. I mean, we see this all
17:23
the time. It's outrageous, right? Think
17:25
about all the think think about you
17:26
going to the grocery store, right, and
17:29
trying to buy eggs but having the same
17:31
money you had 10 years ago. Like it's
17:34
it's I mean, good grief, it's it's not
17:36
possible to to operate. It's not
17:37
possible to survive. We're talking about
17:39
survival here. We're talking about um
17:41
pillars of a community, organizations
17:43
that are keeping a community alive and
17:46
hopefully healthy. Um and so um it it
17:51
gives them a lot of excitement. They
17:53
know now what they can they know now
17:55
where they can find increases. They
17:57
start also thinking about, okay, where
18:00
do we build out? We've got these really
18:01
great rates here or let's give over
18:03
here. We're going to get an increase in
18:05
these services. Let's go build this out.
18:07
We're going to be able to be profitable
18:09
and the community needs this, etc., etc.
18:12
So, it's just about kind of getting um
18:15
getting that that that compass on kind
18:17
of where you need to go, how it connects
18:19
to your your strategy, to your contract
18:21
negotiation, to the relationship that
18:23
you have with these payers, which goes
18:25
well beyond just negotiated rates. It
18:26
goes to okay, how else are you dragging
18:29
your feet on paying me? Okay, you're
18:32
you're changing the policy all the time
18:34
and these, you know, there's
18:35
overburdensome on the policy, which is
18:37
also slowing down cash getting into our
18:38
business. Okay, your denials are higher
18:40
than everybody else's. I mean this is
18:42
one really important factor in a very
18:44
kind of complicated relationship.
18:47
>> All right. So um whole host of things
18:50
that are flaring in my mind but like no
18:52
politics no you know just careful
18:54
language here just your lived
18:55
experience. What like what is the real
18:59
dynamic between payers and health
19:04
systems today
19:06
>> that
19:08
most people like outside of the room
19:12
would be
19:13
surprised by?
19:15
>> It's untenable and unsustainable.
19:18
It's worse than I could have imagined.
19:21
>> Um
19:22
>> like I knew it was rough, but I was just
19:24
I just wanted to confirm that. No. Yeah.
19:26
name names, right? Just
19:27
>> No, I think a lot of people kind of
19:30
especially I mean what I thought
19:31
beforehand like you think that the
19:33
health systems and or the providers just
19:35
anybody and the insurance companies kind
19:36
of work hand inand you think they would
19:38
have to uh you know I'm paying the
19:41
insurance company and they're paying the
19:44
provider when I need uh care and
19:46
services. So you would you would think
19:47
there is some really maybe a little bit
19:50
of tension um but it's not a little bit.
19:53
It's it's it's bad and it's breaking.
19:55
It's breaking all across the country and
19:58
it's not always one, you know, one
20:00
directional in terms of who's, you know,
20:03
pushing on the other on the other one,
20:05
right? When you have network adequacy
20:07
laws that require carriers to cover
20:11
certain areas, um the the provider has
20:15
more power than the the carrier in that
20:18
in that regard. Most of the time it's
20:20
the other way. But um it's something
20:23
where yeah the the relationship is is
20:25
untenable and now you're having you're
20:27
seeing premiums that are starting to go
20:28
up and patients that are just not
20:30
they're not going to get care because
20:32
they can't afford
20:34
>> you know and then we we have the system
20:36
where you're
20:38
there's an uncertain number of people
20:40
who are going to come to your business.
20:42
It's not really a business you know you
20:44
can't you're not selling things to
20:45
people. It's just when they need your
20:47
service, they have to come to you.
20:49
Hopefully, nobody ever needs the the
20:51
service and we would have to not have
20:53
any care delivery organizations at all,
20:55
but that's not how the world is. So, um
20:57
you have this kind of like unpredictable
21:00
business model. Um and the hospitals and
21:04
the and the care delivery organizations
21:06
are just trying to map out what how how
21:10
who they can keep on staff, how many how
21:11
many people, how what equipment do they
21:13
need? you know, can we invest in in new
21:16
technologies and new equipment? And we
21:18
we can't because we're not getting
21:19
reimbursed enough or our reimbursements
21:21
are dragging for months and months and
21:22
we we have no cash flow and it's, you
21:25
know, it's it's it's just an untenable.
21:26
So, it has to be fixed.
21:28
>> Yeah.
21:29
>> Or redone.
21:30
>> Give give me a give me a specific
21:32
example. You know, you don't need to
21:34
name names, but of a moment when
21:37
like the data completely
21:41
shifted the negotiation or like just
21:44
rewrote that narrative in the room.
21:47
There's so many um just looking at I
21:51
mean just the easy thing to do as a
21:53
hospital just looking at um their their
21:58
impatient rates their DRGs and just
22:01
seeing how much lower they were than
22:03
everybody else in a really concentrated
22:05
and competitive area where there didn't
22:07
make any sense for it to be that much
22:09
lower
22:10
>> and then being able to get serious
22:12
increases. they were able to to, you
22:14
know, project out significant revenue
22:16
because of that. There's there's there's
22:19
kind of the great hospital stories um of
22:21
of being able to get a fair shake,
22:23
especially the smaller hospitals. Um,
22:26
one that's really exciting to me though
22:28
was there was a a smaller practice. this
22:31
was like a multipety practice um that uh
22:36
no longer they were thinking about
22:37
selling to private equity
22:39
and they hadn't renegotiated in a long
22:42
time and one of our customers helped
22:44
them with the negotiation using our
22:46
using our data and our platform. It was
22:48
all just they just hadn't negotiated in
22:50
a long time. It was just an easy win.
22:52
Hey, here's your volume. You do this,
22:54
you do that. You're way under the
22:56
benchmark. We're going to go get these
22:57
increases. They got them. They actually
22:59
ended up not having to sell to PE, which
23:02
like to me that's very exciting. An
23:04
independent practice staying independent
23:07
and focusing on delivering care like
23:10
that that is a huge win
23:13
>> because I mean look, you guys are in
23:14
conversations with some of the best
23:17
>> systems and top performing ones in the
23:19
country. What do the the top performing
23:24
teams do differently aside from using
23:27
your stuff uh when it comes to
23:30
understanding their rates and like
23:32
contract positioning?
23:33
>> They have really good teams. Like the
23:36
team the these managed care groups and
23:38
these hospitals are some of the most
23:39
impressive teams I've seen. Like I've
23:42
been I've worked in hospitals for a
23:43
while. like you kind of have the
23:44
stereotypical idea of a hospital
23:47
employee which I think is you know
23:48
inaccurate and you know definitely a
23:50
stereotype but you kind of have this
23:52
this this maybe you're thinking of kind
23:55
of the wrong kind of people when you
23:57
think of these these u these managed
23:59
care organ uh these managed care
24:01
organizations I mean these these these
24:04
are people who could have been lawyers
24:06
they have JDs they they they are deep
24:08
into contracts um they're working
24:10
closely with the CFO Um so you know for
24:14
for the ones that are performing well
24:16
they have a really really strong team.
24:18
The team is very technology enabled and
24:20
very very comfortable with a lot of
24:22
data. um they're able to build out very
24:26
custom analyses and they're in the room
24:28
with the CFO and other and the other
24:30
leadership thinking about where do we
24:32
expand where do we build and so it's
24:35
very much where I see like the strategy
24:37
from that that seuite really being
24:39
deeply ingrained into that team and kind
24:42
of how they're managing um not only kind
24:45
of where we go uh what new services we
24:48
deliver uh how we negotiate our our
24:51
contracts
24:52
um but also So really, I mean, they have
24:54
to get into the weeds of these
24:56
contracts. They have to get into
24:57
lawsuits, right? And that the lawsuits
25:00
of of one particular hospital in an area
25:02
will set precedent for how all of the
25:04
other hospitals can uh either benefit
25:07
from the outcome of that lawsuit or or
25:09
or be hurt by it. So, it's really just
25:12
about kind of I think number one,
25:13
integration into the strategy. Number
25:15
two, uh really really strong teams with
25:18
really, you know, strong contract
25:19
capabilities. And number three, very
25:21
very uh data proficient.
25:25
I'm curious, Jerry, when you think
25:27
about, you know, you're a technologist,
25:28
you're trying to evolve, you're trying
25:30
to innovate, make things better. What
25:32
like if nothing changes, you know,
25:35
that's probably maybe your nightmare. I
25:37
mean, what's the risk? What um what's
25:41
the thing that nobody wants to say out
25:42
loud if they are hesitant to change or
25:46
just don't want to change about how
25:47
they're going about this?
25:50
>> You know, the the the risk is that
25:54
the the situation gets more untenable.
25:58
The payers are charging more for
26:00
premiums. Um we are seeing a lot through
26:03
technology. we are seeing a lot more
26:06
modern
26:07
like thirdparty administrators for
26:09
employers. I think the I think what will
26:11
end up happening is the employers will
26:13
start to get
26:15
uh they'll start to get involved and
26:19
>> uh more than they are today, right? They
26:21
have a fiduciary responsibility to
26:22
making to to make sure that they're
26:24
spending their funds appropriately. And
26:26
this pricing data is it's becoming
26:28
abundantly clear that they are not. Not
26:31
because they knew about it, but because
26:32
they didn't. they were trusting a third
26:34
party to negotiate on their behalf.
26:37
>> Um, and now you can see all the pricing
26:39
and we do a lot of work with with um,
26:41
you know, with employers and brokers and
26:43
things like that, but uh, you know,
26:45
they're able to see like, okay, well, my
26:47
plan as compared to everybody else's
26:50
plan is not we don't get good rates um,
26:53
at all. So, you know, once your
26:56
employees can start to see that, again,
26:58
like eventually all this stuff is going
26:59
to be accessible and and easy for people
27:01
to see, you're going to start to see the
27:02
lawsuits come in from the employees to
27:04
the employers to say, "You're not being
27:07
responsible with the funds of this
27:09
violating ORISA law." And then that's
27:10
when people are going to start moving uh
27:14
and uh and they're going to put pressure
27:16
on the on the carriers and the carriers
27:17
are going to have to potentially
27:20
negotiate better rates with the with the
27:22
providers. The providers are going to
27:23
have to do something because they're
27:24
going to lose. they're going to they're
27:25
going to start steering people away from
27:26
those providers if they're not being
27:28
reasonable on their rate negotiations,
27:30
>> which is another reason you need to
27:31
bring all the claims data in. And we're
27:33
bringing quality data. So, there's
27:35
multiple different facets to this thing.
27:37
>> Um, but what you need to really we what
27:42
needs to what needs to happen is is
27:44
increase more transparency. We're going
27:46
to have more we need more laws, more
27:48
accessibility um from every aspect. not
27:50
maybe not even just um uh the the
27:54
commercial health plans but especially
27:57
the pharmaceutical data. There is a
27:59
whole treasure trove of of information
28:02
that is yet to be released there and I
28:04
know that that's a very sensitive topic
28:06
for a lot of the PBMs um out there and a
28:09
lot of the a lot of the big carriers u
28:12
but at the end of the day a lot of what
28:14
the carriers do is now automatable by
28:17
technology. Yes, we have the ability to
28:20
automatically process claims. We can use
28:22
AI to to do adjudication probably much
28:25
more efficiently. I mean, some of these
28:27
systems are 30, 40 years old.
28:29
>> Yeah.
28:30
>> Um sometimes on purpose, you know, why
28:33
upgrade the technology? This is just as
28:35
slow as we want it to be.
28:37
>> Um you know, things like that. So, uh I
28:41
I think I think it's just a matter of
28:43
time. I I don't think it's a matter of
28:44
if it doesn't change. It's just a matter
28:46
of when and who who needs to have the
28:48
pressure put on them
28:50
>> to make a change.
28:51
>> I agree with Jerry 100%. I I would say
28:53
our health care system right now
28:56
grossly over simplifying it is built on
29:00
middlemen and secrets.
29:02
>> Yeah.
29:03
>> So we need to expose the secrets and AI
29:07
and technology can remove all of the
29:09
middle layers. It's just you take a
29:11
dollar and it moves through the health
29:12
care system and it's a game of slicing
29:15
that dollar up into millions of pieces
29:17
and people taking pieces of that dollar.
29:19
We have to remove as much of that as
29:21
possible and we can now.
29:24
>> Amazing. Um, going to switch gears a
29:26
little bit here for a moment here. So,
29:28
um, Jacob, I know that you you like to
29:32
roll. You're a Brazilian jiu-jitsu guy.
29:34
>> You put that out there. you go. Any
29:37
anybody who's rolled, they know that
29:38
it's it's controlled chaos. You know,
29:40
you're solving problems when the space
29:43
gets gets really tight. What from
29:48
the mat has shown up in your leadership
29:50
style, especially maybe in moments where
29:54
things get tense.
29:57
>> Thank you for that. Uh decisions under
29:59
pressure, being able to stay calm, being
30:01
able to breathe and wind. uh you were
30:04
feeling that pressure and uh your body
30:07
is is telling you panic run. You're you
30:11
are ex es exciating uh to to to to
30:15
breathe, stay calm and make those slow
30:19
methodical decisions using minimal
30:22
energy and maximum technique. And I
30:25
think you know with a startup you can
30:27
really apply a lot of that. Besides,
30:30
when things uh get really rough, I can
30:33
als I can always say nobody's trying to,
30:35
you know, strangle me right now. And so
30:37
that kind of deescalates how things
30:39
feel.
30:40
>> Yeah. Yeah. I mean, listen, Brazilian
30:41
jiu-jitsu um humbles everyone. I think
30:45
building a company does too. Mhm.
30:48
>> Um I'm sort of curious what's what's
30:50
maybe a moment that you can share that
30:53
maybe your ego got checked uh in a way
30:55
that actually made you like like better.
31:00
So many um
31:04
this this whole journey has really been
31:08
like thankfulness.
31:10
Um
31:14
>> you know
31:14
>> I can say one one for me.
31:16
>> Yeah.
31:17
I don't do I don't do Brazilian
31:19
jiu-jitsu. Yeah, Jacob's trying to get
31:20
me to
31:20
>> I've been trying to get
31:22
>> he's trying to get me to
31:24
>> um
31:25
but actually one of our Yes. So one of
31:28
our one of our first uh one of our first
31:30
customers uh when they were when we were
31:32
actually going through this process and
31:33
we were trying to you know wield this
31:35
like huge amount of data and you know as
31:37
a technology
31:39
as a technologist I was really trying to
31:42
understand what's possible you know we
31:44
have this this 50 terabyte data set
31:46
trillions of rows of data like you know
31:49
what's going to be useful and basically
31:51
the answer was like we need to see
31:52
everything
31:54
>> and that was something where I was like
31:56
I Don't I didn't even
32:00
I didn't think you were going to come
32:01
back with that. I thought you were going
32:02
to I thought there was going to be some
32:03
like small amount of this, but then like
32:06
realizing that the world this healthcare
32:08
world is so much bigger than I than I
32:10
had ever thought it would be and that
32:12
the the smaller practices and all these
32:14
thing they all play a role into how a
32:18
particular market actually functions.
32:19
Like it's not just the big health
32:21
systems Yeah.
32:22
>> that are uh a part of you know the
32:25
negotiation, right? you need to look at
32:26
that. You need to be able to look at
32:27
everything in a market and understand
32:29
the dynamics between them. And that was
32:31
just for me. I was like, "Oh my gosh, I
32:32
know nothing about this world." It was
32:34
years ago at this point, but that was
32:35
like a a moment that I remembered just
32:38
being like, "Wow, I I don't know
32:39
anything about this." And um it's been
32:43
it has been repeatedly humbling.
32:46
>> Yes. You're getting humbled a lot.
32:48
>> Yeah. But uh but growth, you know,
32:50
that's how that's how you grow, I think,
32:52
as long as you're willing to accept that
32:54
you can be humbled and uh that you can
32:57
learn something from basically
32:58
everybody.
32:59
>> Yeah. Yeah.
33:01
you know, uh, I mentioned earlier in the
33:03
opening that, you know, you guys are
33:04
going for the for the L word, like you
33:06
want your customers to to really love
33:08
you and you've built trust with, you
33:12
know, health systems and practices and
33:14
and other groups that don't like easily
33:18
just hand that out. Um, how how do you
33:22
like approach relationships, you know,
33:24
maybe in a world where things seem to be
33:26
very very transactional? Um curious
33:29
about how you approach some of those
33:30
partnerships.
33:32
>> It's radical honesty, a lot of
33:34
education. This in the in in the in the
33:36
in the scope of healthcare and the
33:38
healthcare timeline. This is just this
33:41
just showed up. This transparency
33:43
concept just showed up. It's been around
33:45
since 2022, but it's been a journey to
33:47
get to the point where it's at now. And
33:50
as Jerry said, we've got to make these
33:51
these huge hurdles with employers
33:53
getting empowered. There's so many
33:55
different people. There's so many
33:56
different constituents. Um there's so
33:58
many different story stakeholders that
34:00
need to be empowered. The patient first
34:01
of all that needs to be in the center of
34:03
all this. We've got the employers that
34:05
are funding a lot of this. We've got the
34:07
plans. We've got the the care delivery
34:09
organizations, right? And everybody is
34:12
is trying it needs to kind of figure
34:14
this out. Um so a lot of what we're
34:17
doing at the beginning is asking and
34:20
trying to understand have you seen do
34:22
you understand what the state is? Have
34:23
you used it before? Like where are you
34:25
on this journey? and we start and meet
34:27
them where they are and start there.
34:30
I've told customer or I've told
34:32
customers now that we're prospects,
34:33
"Hey, don't buy this right now." You
34:36
know, and they were like, "What? What
34:38
are you?" Uh because because I found out
34:40
a market they were in where one of the
34:43
one of the carriers, it was one of the
34:44
Blues was not being compliant in that
34:47
market at the time. And you know, we put
34:50
we put our compliance scorecard on on on
34:52
the internets on the public just just to
34:54
show like not only are you following the
34:56
law, uh, insurance carriers, are you
34:59
following the spirit of the law? Are you
35:00
designing barriers to make this hard for
35:02
people to get? Um, and so when they
35:06
told, you know, when they told us what
35:07
they wanted to do, I said, "Hey, just
35:09
wait. Let's do a PC. I'll let you know
35:11
how things are going. I'll I'll continue
35:12
to send you updates. Why don't you
35:13
wait?" Um they ended up reaching out
35:16
soon thereafter and saying no we'll just
35:18
we'll just get go with you. I said I I
35:21
thought I told you to wait. I said why?
35:24
And um they told me we just feel like
35:26
you'll help us more than everybody else.
35:28
And that's just and that is I guess if
35:31
you had to encapsulate what makes us
35:33
different is we do love our customers
35:36
and we're just we're we're we're going
35:37
to help them as as much as we as we
35:40
physic physically and intellectually
35:42
can.
35:45
I know we're almost coming to time here.
35:46
Before we do, um just maybe give a
35:49
moment where where do people go to kind
35:51
of follow the journey uh follow you on
35:53
socials or online how they can um just
35:57
get a hold of you. So go go that route.
36:00
>> Okay. Um Jerry, let me know if I if I
36:03
forget anything here. Uh payerset.com
36:06
www.payerset
36:08
payerset with an e paw s.com.
36:12
Uh we're also on the LinkedIn. Uh I'm
36:15
horrible at social media. I'm not on
36:17
social media myself. So I know we're on
36:19
LinkedIn and I know um um you know our
36:23
website you can get to us directly if
36:26
you if you do reach out to us through
36:27
our website. You know we are going to
36:29
see it. Jerry and I are going to see
36:30
that along with the leadership team and
36:32
we'd be happy to you know talk to talk
36:35
to you about kind of current state where
36:37
things are policy where things are
36:39
going. Um and uh you know Jerry's been
36:41
involved in that and and um kind of
36:44
being in the room talking about kind of
36:47
how the the updates to the um to the CMS
36:51
rules and the transparency rules are
36:53
going to uh what they're going to look
36:55
like and we're really excited about
36:56
where things are where things are going.
36:59
>> Nice. All right. So I just want to maybe
37:01
kind of we'll kind of close with this is
37:03
sort of maybe close your eyes for a
37:05
moment and
37:07
imagine every CFO
37:10
uh managed care leader people in finance
37:13
operations and in the country is
37:15
actually listening right now.
37:18
>> What is the one thing you
37:22
want to say to them? And maybe we start
37:25
with Jerry and then maybe Jacob.
37:29
>> Yes. Uh
37:32
it is possible to see every price for
37:38
every carrier for every provider and we
37:42
can help you get all of those prices as
37:45
well as help you understand how you can
37:49
how you can strategize your pricing your
37:53
your pricing policies and your pricing
37:55
strategies. Uh we can actually help you
37:57
along with that journey. So that that is
37:59
here and the best in my opinion way to
38:04
get to deregulation at scale which is
38:06
what we really need
38:09
>> is through transparency. You can't you
38:11
deregulate without transparency, you get
38:13
bad actors. Um
38:16
>> so
38:17
our our push is for much more
38:20
transparency
38:22
um because that will eventually lead to
38:24
the ability to deregulate uh which will
38:26
take away the red tape and actually let
38:28
the care delivery system that we have
38:31
deliver care to patients. So that's
38:35
>> awesome.
38:37
>> I can't beat that. You sure you want to
38:39
go to me? Well, Mike, if you want to do
38:41
a mic drop, that's fine. Fine. Jerry
38:43
just Jerry just like, you know, it was
38:45
like a fivestar Michelin course, Neil,
38:47
so I think I think we're good.
38:49
>> Um,
38:49
>> agreed.
38:50
>> Listen, um, Jerry, Jacob, like this is
38:53
this was this is a lot of fun.
38:55
>> Uh, I think just came from the first
38:56
time that we chatted, I just I knew that
38:58
we'd eventually have this conversation
39:00
and, uh, today confirmed why I thought
39:02
it was going to be fun. I think you all
39:05
just have a way of u taking something
39:08
that's really complicated and heavy and
39:11
you've made it clear, definable. Um
39:15
approaching it in a very pragmatic,
39:17
calming and usable way. Um, and even
39:20
just the way you talk about pressure
39:23
moments and Jacob, you know, just on the
39:26
mat being in the work, breathing, I
39:29
think that that says a lot about the
39:30
leader that you are and what you're
39:32
aspiring to do as a company. So, for
39:35
everyone listening, uh, if you're
39:37
listening to this, if you found this
39:40
conversation to be useful or if you
39:41
walked away, um, with one thing today,
39:44
my hope is that, um, it's this. It's
39:46
that clarity isn't just data. Uh it's
39:51
it's how you make better decisions. It's
39:54
how you build healthier relationships,
39:56
whether they're with uh with a payer by
39:59
using this information in a way that's
40:01
coherent. And it's how you move your
40:04
organization forward, admittedly, you
40:06
know, well, without losing your mind in
40:09
all this damn noise that we've got out
40:10
there. So,
40:12
>> if this episode moved you in some way,
40:14
shape, or form, um, share it with
40:16
someone, you know, uh, if there's a
40:18
topic that you want us to explore more
40:20
of, or if there's a leader that you want
40:23
to come on to the show, drop a note. We
40:26
we read them, look at the comments.
40:28
Again, the platform that we are building
40:30
here, it's it's not just content like
40:32
this is a interactive, living, breathing
40:35
community and ecosystem. So, thanks for
40:37
listening. Keep building with purpose
40:40
and uh we'll see you next time on the uh
40:42
Advancing Health Innovation Show.
40:45
>> Thank you. Thanks for having us.
40:47
>> Thank you for having us.