Latest / Becker’s Payer Issues Podcast / Chris Gay, CEO of Evry Health

Transcript

Chris Gay, CEO of Evry Health · Becker’s Payer Issues Podcast

• 0:00
  Hello, everyone. This is Jacob Emerson with the
• 0:02
  Becker's Payer Issues podcast. Thrilled today to be
• 0:05
  joined by Chris Gay, who's the CEO of
• 0:07
  EveryHealth.
• 0:08
  Chris, thanks so much for taking the time
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  to be with me on the podcast today.
• 0:12
  Well, thank you, Jacob. Thanks for having me.
• 0:14
  Yeah. Absolutely. And before we dive into everything
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  we wanna talk to you about, Chris, can
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  you tell us a little bit more about
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  yourself, your background in terms of your career,
• 0:22
  and what it is that you're doing today
• 0:24
  at EveryHealth?
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  Oh, goodness.
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  Well, what I'm doing today at Every Health,
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  I'm the CEO.
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  I used to have beautiful long flowing hair
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  in a ponytail. Now I'm bald, which tells
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  you what responsibility does to a man.
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  I enjoy my role, and most of my
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  time though is really spent,
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  overseeing,
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  community and just kinda pushing us forward in
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  population health.
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  I'm a serial entrepreneur,
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  and
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  I I came to health care by way
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  of personal experience.
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  You know, I had friends and family
• 1:00
  that had some pretty horrible health care experiences.
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  And my cofounders and I started this because
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  we feel that in hindsight, when we looked
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  at those shared experiences that a little bit
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  of human attention
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  or a little bit of money
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  at the right point in time can change
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  lives.
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  The challenge is, Jacob, when you step back
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  at it all, how do you do that
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  systemically across the whole nation to be in
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  the right place at the right time
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  with a level of trust with someone that
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  they'll trust you enough to share?
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  They'll trust you enough to accept help.
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  That's the hard part.
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  And it turns out insurers are ideally suited
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  to affect large population health change because insurers
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  control the data. They control the technology. They
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  control a huge portion of the, patient member
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  experience.
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  And, they're ideally positioned to work with,
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  physicians and medical providers,
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  that want to improve population health. So you
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  can think of us as a software company
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  that owns an insurance company.
• 2:02
  Understood. Understood. And, you know, we're gonna talk
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  about something today that is,
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  gonna going to affect, in theory, a majority
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  of the American population.
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  And I'll get into that in just a
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  second. But just so we set some context
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  for our audience, Chris,
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  every health, how many members do you serve
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  and and what markets are you in today?
• 2:21
  Sure. We are a commercial
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  insurer, so we do large group fully insured.
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  We only underwrite right now in the state
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  of Texas. So we're a small insurer with
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  about 5,000 lives. Okay.
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  And, we also own our own medical network.
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  Fantastic. 10,000
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  provider locations
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  are directly contracted by us. Fantastic. No. I
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  appreciate the context there.
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  So so let's dive into a big announcement
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  from from the wider insurance industry.
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  This earlier this week. It was June 23.
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  Insurers announcing
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  a series of commitments to what they call
• 2:58
  it what they're calling,
• 2:59
  streamlining, simplifying, and reducing
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  prior authorization requirements across commercial Medicare Advantage and
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  managed Medicaid plans. I just mentioned that's expected
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  to affect over 250,000,000
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  Americans,
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  and and nearly 50 insurers have committed to
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  this, and that includes EveryHealth.
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  That includes things like standardized submission processes for
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  electronic
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  prior authorizations,
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  reductions to the overall amount of requirements that
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  that providers and and, of course, members have
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  to face, and an easier appeals process among
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  a few a few other things.
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  So we are hearing from stakeholders all across
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  the industry about this.
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  Some some positive, some negative,
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  and some, you know, I think just laying
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  in wait just lying in wait to see
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  what's gonna come ultimately from this over over
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  the next few years or so.
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  But but ultimately, it is being hailed as
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  a significant step forward for the health care
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  system. So from your perspective, Chris, what was
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  the driving force behind the industry's decision
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  to to coalesce around these major changes? And
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  how do you think that health plans and
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  and policy makers
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  all align to make these reforms,
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  a reality?
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  Put me on the hot seat. The
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  well, I can't speak for some of my
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  peers in the industry
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  or AHIP itself. I mean, we're a member
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  of AHIP. We're signatory
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  to this announcement.
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  No. We believe at every that this prior
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  authorization,
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  a voluntary commitment
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  set of standards, it's a step in the
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  right direction.
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  Why did it happen?
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  You know, I think, you know, I'm speaking
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  personally here.
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  I think there is
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  a a large amount of modernization that still
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  is yet to occur in our industry, broader
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  industry of healthcare. And there's still opportunities
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  to improve customer service
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  and reduce any points of friction or latency.
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  And I believe the population
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  has just gotten to the point where their
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  voices are being heard,
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  inside,
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  organizations
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  and outside as the consuming public, and they
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  want better
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  service. And I think that's perfectly understandable.
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  Yeah. No. Absolutely. And I, you know, I
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  well, from our perspective, when when we look
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  at industries being ranked by customer service,
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  quality right now and expectations,
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  it is generally the insurance industry that that
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  falls behind,
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  you know, like I said, in national rankings.
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  So it's interesting you say that. This is
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  a lot of this is coming from that
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  that customer service expectation from from the wider
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  public. Call a thing a thing. You know?
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  It's like, talk about the problem in the
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  middle of the room. Sure. Reason it is
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  so challenging for you know, legacy insurers is
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  they are responsible for a massive amount.
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  Yeah.
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  Compliant, medical quality,
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  and they provide a vital service,
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  but it's hugely complex.
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  And they get pulled and, you know, the
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  big legacy insurers are pulled in 50 different
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  directions by 50 different state legislators. Sure. Legislatures.
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  So it is challenging. They're they're not subject
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  to the same
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  customer service standards that someone is that checks
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  into a hotel. Yeah. Very fair. Give them
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  give them a measure of flexibility. I mean,
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  they're dealing with life and death stuff, huge
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  amounts of evidence based literature,
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  and a lot of complexity that would crush
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  most businesses.
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  But
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  on the flip side, the consuming public doesn't
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  understand that. Yeah. No. That's a great point.
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  It just goes,
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  hey. From my my small point of view,
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  I feel this wasn't good enough.
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  And,
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  you know, the industry has not done a
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  good job over the past thirty, forty years
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  of explaining
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  why population health is necessary,
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  why what we do is vital,
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  and that without us,
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  and the population health, things would be
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  radically different and not in a positive way.
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  Sure.
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  And but the Well You know, there's a
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  gap there between
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  reality and what people believe, and that's causing
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  a lot of frustration.
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  Yeah. No. Certainly. And I mean, you know,
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  when people do interact with a company like
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  yours and and some of the companies on
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  this list, it is, of course,
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  some of the most emotional situations of that
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  they've encountered in their lives. So, of course,
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  you know, there's there's a lot of emotions
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  evolved and often misunderstandings.
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  So your point is well heard.
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  And let's talk a little bit about that
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  complexity because
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  now, let's say over the next eighteen to
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  twenty four months, you and and the wider
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  industry are being tasked with making these reforms
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  or these these promises
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  actual tangible reality for your members.
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  So so from every perspective specifically,
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  what does that actually look like? What are
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  some of the conversations you're having internally? What
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  are what's the technical changes that have to
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  occur for you to meet
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  these commitments?
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  Yeah.
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  You need to take,
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  you need to get to the point that
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  doctors or physicians and their patients
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  get answers
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  the majority of the time in minutes
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  while the patient's still in the room with
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  the physician
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  rather than days.
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  That's the goal. You know, my we're like
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  My goal at Every Health is we wanna
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  drive prior authorization denials to zero.
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  Period.
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  And we're we're really close to achieving that.
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  The broader industry, the challenge that they're fighting,
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  and a lot of my peers are dealing
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  with is
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  the medical provider industry overwhelmingly still run like
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  it's 1980.
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  It's forty percent of the inbound
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  prior authorization requests are still fax.
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  And they're not even good faxes, Jacob. They
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  send them over. It'll be like everything between
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  both sides of a of a Manila jacket
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  folder,
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  a huge stack of paperwork. It'll be skewed
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  30 degrees. It'll have two different person's handwriting
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  on it, stamps on it.
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  And each each state's different with its own
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  regulated form.
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  So Yeah. It's quite a challenge. Technolog
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  you've, you've got to do a lot of
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  inbound
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  document cleanup.
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  It's not just OCR work. You've got to
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  verify eligibility of the member and the provider,
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  check the medical codes against the
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  are those legitimate?
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  Are those are they submitting for the right
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  thing? You know, is the billing code match
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  the procedure code request?
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  Then you gotta compare it to all the
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  evidences,
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  and the if it's not a if it
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  moves on to a medical evaluation, you've got
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  to take a look and see if the
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  the medical information submitted,
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  matches up with the request and the care
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  guidelines, which is all evidence based. It is
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  not a small challenge. And then you gotta
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  get that back to someone
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  Yeah. In minutes.
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  It's a huge lift.
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  Very doable, but it's a huge lift.
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  I can't imagine. I can't imagine. And how
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  are you feeling about the timeline of all
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  of this? Even just, again, from your company's
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  perspective, do you feel prepared to to meet
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  this timeline?
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  Yes. I mean,
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  we've built the technology.
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  We've built software systems that allow us to
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  do this already. We're already compliant,
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  with the things that the company can be
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  compliant with and on these voluntary commitments. We
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  already do this electronically. We already do it
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  in real time,
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  and we're happy to license that software to
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  our competitors.
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  You know, we want population health to increase.
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  Mhmm. And to give you an idea how
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  well that's working behind the scenes, the industry
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  average for prior authorization denials
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  is 25 to 35.
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  Okay. Every health, our prior authorization denials in
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  the past calendar year were only 7%.
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  Wow. And 100% of those were upheld upon
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  appeal, which means we are following the science.
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  It's evidence based.
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  Whereas the industry average for
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  denials being upheld on appeal is probably closer
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  to the mid-50s
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  in terms of percentage like 56% or so,
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  based upon Kaiser
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  or, healthcare.gov.
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  Sure.
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  So it can be done. Okay. It's just
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  it's a hard lift. Yeah. Well, and, you
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  know, it's I I I wanna go back
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  to what you just mentioned that often on
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  the provider side of things, and I I
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  suppose on the insurance side of things as
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  well,
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  often the system is operating like it's the
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  nineteen eighties. But we're, you know, we're obviously
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  not in the eighties anymore. There's so much
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  more technology available,
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  to companies like yours to hopefully make this
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  a little bit of an easier process.
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  You know, I know it's a bit of
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  a simplified question to a very complicated problem.
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  But,
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  do you think that new technology
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  I hate to use the AI buzzword, but
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  can AI make this,
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  a much easier lift compared to the past?
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  Absolutely.
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  We use AI powered tools
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  to do,
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  administrative approvals and administrative denials
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  and to prepare all the case work to
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  summarize things for our nurses and doctors.
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  We never use AI to make a medical
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  denial or a final medical determination,
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  about a denial. Sure.
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  It is really useful. You gotta keep in
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  mind sometimes we get a stack of paperwork,
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  sometimes a 130 pages
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  of medical notes
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  that can span
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  entire patient's history.
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  Sure. They just send us the whole thing
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  over as a fax. And
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  nurses and doctors don't wanna spend their time
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  digging through 130 pages trying to figure out,
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  hey, what is relevant for this PET scan
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  request or what's relevant for this knee surgery
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  request?
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  AI powered tools do a great job of
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  quickly summarizing
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  and tagging what is relevant in in the
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  medical case so that the nurses and doctors
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  can work at the top of their license
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  and get a speedy response back to that
• 12:47
  doctor and patient.
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  And sometimes we found the AI
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  powered clinical summaries and guideline
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  checks, evidence based guidelines,
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  find things that even our nurses and doctors
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  didn't didn't find. Mhmm. It's a great decision
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  support tool, and I think we as an
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  industry should be adopting every technology we can
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  that improves medical quality and population health. Absolutely.
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  Point earlier, customer service. Like, let's get this
• 13:13
  down to minutes instead of days.
• 13:16
  Absolutely. And I can't imagine, you know,
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  you you were talking earlier about the complexity
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  of some of these larger organizations that are
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  signed on to these commitments. I can't imagine
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  what they're trying to sort through in terms
• 13:27
  of, you know, meeting meeting these deadlines.
• 13:31
  But I also wanna ask you about some
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  of the criticism. We've already been hearing from
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  from providers, from from the trade groups that
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  represent them,
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  basically laying out concerns about this, saying that,
• 13:44
  you know, we've heard these types of promises
• 13:46
  in the past from the industry that really
• 13:49
  never came to fruition,
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  or that, you know, a lot of the
• 13:52
  companies
• 13:53
  are are publicly traded and that they still
• 13:55
  have to meet their commitment to investors,
• 13:58
  and and that this will just shift administrative
• 14:01
  burdens to other areas.
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  How would you respond to that? I mean,
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  how do you think that the success
• 14:08
  of these reforms will ultimately be measured?
• 14:11
  I think ultimately they can be measured at
• 14:13
  the denial rates.
• 14:16
  Ultimately, that for me, that's the KPI I
• 14:18
  would focus on over the long term, that
• 14:20
  a prior authorization denial rate should decline over
• 14:23
  time if you're working in partnership with physicians,
• 14:25
  providers, making sure that they're submitting it,
• 14:28
  the best way the first time,
• 14:30
  the quickest way so you can get them
• 14:31
  an answer. The the goal is we all
• 14:34
  serve the patient.
• 14:36
  But I but I understand the criticism.
• 14:39
  Some of that, in my opinion, is
• 14:41
  misinformation
• 14:43
  that people
• 14:45
  don't understand that prior auths,
• 14:48
  it's not about billing.
• 14:50
  You don't make money. At least at EveryHealth,
• 14:52
  we don't make money by denying,
• 14:55
  prior auths. Prior auths are purely driven about
• 14:58
  evidence based care. What is best for a
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  patient given the scientific medical literature? That's it.
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  That's the only goal. That's the only criteria.
• 15:08
  And then we're independently as industry, all of
• 15:10
  us in industry that are part of medical
• 15:12
  quality standards like URAC or NCQA,
• 15:14
  whichever is is a part of,
• 15:18
  we're independently accountable
• 15:20
  on our medical quality, and our prior authorizations
• 15:23
  are reviewed. And you even have, something called
• 15:25
  inter rater reliability.
• 15:27
  So anytime
• 15:29
  you have a a medical quality review,
• 15:32
  independent committee comes in, pulls a statistically random
• 15:35
  sample of your your prior auths and your
• 15:37
  medical decisions and reviews them.
• 15:40
  And, like, the industry standard on that is
• 15:42
  anywhere from you you really wanna be above
• 15:44
  90%
• 15:45
  inter rate of reliability.
• 15:48
  In the industry, you can float between 7294%
• 15:51
  ballpark.
• 15:52
  Okay. We at every health are at a
• 15:53
  100%.
• 15:55
  And that's our target. I hope we can
• 15:56
  maintain it.
• 15:58
  But all this to say, I think the
• 16:01
  a lot of the pushback
• 16:02
  is just misinformation
• 16:04
  about what a prior authorization is
• 16:07
  and what it's meant to do. Yeah. No.
• 16:10
  It's fair. I mean, it's great insight.
• 16:12
  It's really interesting.
• 16:15
  What else were we missing on this, Chris?
• 16:17
  I mean, what have you been hearing the
• 16:19
  last few days since this announcement,
• 16:22
  that that you
• 16:23
  wanna talk about, that you wanna address?
• 16:26
  You've you've got the ears of a lot
• 16:28
  of other health care leaders, a lot of
• 16:29
  other health plan,
• 16:31
  leaders out there, listening in. What do you
• 16:34
  wanna say to them about,
• 16:36
  the next few months and and couple years
• 16:38
  to come around this?
• 16:41
  I think we have a fantastic opportunity
• 16:45
  to address a nationwide
• 16:49
  concern.
• 16:51
  And our industry
• 16:53
  needs to move quickly.
• 16:55
  And if we move quickly and it's an
• 16:57
  opportunity to address that gap again that we
• 16:59
  talked about at the beginning between public perception
• 17:02
  and reality, and that our industry just hasn't
• 17:05
  done a good job of educating the public
• 17:07
  about the necessity and value of what we
• 17:09
  do.
• 17:11
  If we do this as an industry and
• 17:13
  move quickly,
• 17:14
  we have more credibility.
• 17:17
  Our opportunity to educate the public will be
• 17:19
  extended,
• 17:20
  and that can
• 17:22
  reap huge benefits across the industry and society
• 17:25
  if we're seen to be working with providers
• 17:27
  to solve real, tangible
• 17:30
  human problems
• 17:31
  that all of our friends experience around the
• 17:33
  dining table.
• 17:34
  So, I mean, big picture, that's how I
• 17:36
  think of it, Jacob. Sure.
• 17:38
  Smaller
• 17:39
  picture, you know, the smaller stuff, we have
• 17:41
  the technology.
• 17:43
  We can do this. It's it it is
• 17:45
  the beautiful thing about technology is it scales
• 17:47
  to big problems really quickly.
• 17:49
  And,
• 17:50
  you know, we're already doing it here at
• 17:51
  Every Health, and we're happy to
• 17:54
  help power all of our peers to do
• 17:55
  it themselves.
• 17:59
  Fantastic. Well, Chris, I wanna thank you for
• 18:01
  taking the time to chat with me
• 18:04
  and for sharing your your insights and your
• 18:07
  expertise with our audience. We really appreciate it.
• 18:10
  Sure.
• 18:11
  Thank you very much.
• 18:13
  And to our listeners, if you'd like to
• 18:15
  listen to more podcasts from Becker's HealthCare, you
• 18:17
  can visit beckershospitalreview.com.