Latest / The Advancing Healthcare Innovation Show / E180 | The Truth About Health Plans That Headlines Get Wrong with Mike McCabe

Transcript

E180 | The Truth About Health Plans That Headlines Get Wrong with Mike McCabe · The Advancing Healthcare Innovation Show

0:11
Hello and welcome back to the Advancing
0:12
Health Innovation Show. I am your host,
0:15
Michael Stamatinos, and if you're new to
0:17
us, welcome. It's great to have you
0:20
here. We're super excited because we're
0:22
having some just honestly fantastic
0:24
conversations with with real leaders
0:26
that are painstakingly reshaping the
0:28
future of healthcare. And we're just
0:31
crazy passionate about a few different
0:32
things. We're passionate about
0:33
healthcare innovation, about access,
0:35
about adoption of these innovations and
0:37
leadership. And if it's your first time
0:39
tuning in, let me just take a quick step
0:42
back and give you a little bit more of
0:43
the lowdown of what we're really trying
0:45
to get done here. So, we're focused on
0:47
bringing real stories of innovation and
0:49
leadership to life. Um, not just stuff
0:52
that you hear and read in headlines, but
0:53
like the real stuff, the little wins,
0:56
the learnings. And the aim is to
0:59
highlight these folks that are truly
1:01
innovating and leading in an an
1:03
incredibly difficult time. And we want
1:05
to share that with our community and
1:07
ultimately bring their story to the
1:10
world. We've got an amazing
1:11
action-packed year. If you haven't
1:13
checked out any of the historical
1:14
interviews, however you're consuming
1:17
this, if you're watching it, if you're
1:19
listening to it, please hit the
1:21
subscribe button now so that any of the
1:24
new episodes come directly to you.
1:28
Really excited about today's guest. Uh,
1:30
our next guest is Mike McCabe, CEO of On
1:35
Advisors. So Mike has spent his career
1:39
inside of health plans, not around them,
1:42
inside them. He's been in the rooms
1:44
where hard calls get made. Um, you know,
1:47
the ones that don't show up in press
1:49
releases, the ones that affect patients,
1:51
they affect doctors, they affect the
1:53
entire communities. So Mike uh has been
1:56
a seasoned healthc care health plan
2:00
executive and he really kind of
2:01
understands how strategy turns into
2:03
action or doesn't. So he's worked across
2:06
growth, operations, transformation uh as
2:10
a CIO and he has seen firsthand how good
2:14
intentions can fall apart um once
2:17
incentives get messy. So what I
2:18
appreciate about Mike is he doesn't just
2:21
talk in buzzwords and jargon like he
2:23
actually tells you what actually happens
2:27
where things break where trust erodess
2:30
and where health plans have a chance a
2:32
real chance to do better um and
2:35
sometimes don't. So this is this
2:37
conversation isn't going to be about you
2:39
know who's right who's wrong. It's about
2:43
what happens when health plans are under
2:46
pressure to deliver.
2:48
What are some of the things that we can
2:51
do, you know, moving ahead in the future
2:52
to continue to innovate and continue to
2:54
drive and add value? You know, maybe
2:57
what they struggle to say out loud and
2:59
you know what's got to change if we want
3:01
a system of people that can actually
3:04
understand and start believing and
3:06
having trust back. So if you work in
3:09
healthcare and especially if you are
3:12
looking at you know putting solutions
3:14
into these types of entities um you're
3:17
going to you're going to really enjoy
3:18
this conversation. So Mike, great to see
3:21
you. Welcome to the show.
3:24
>> Thanks for having me on. I'm excited.
3:25
I've been uh actively reviewing and
3:28
seeing a lot of your cast and it's
3:30
really good and I like the the DNA and
3:33
what you're doing and I couldn't uh
3:35
thank you enough for inviting me and
3:37
looking forward to a conversation.
3:39
>> Awesome. Well, thank you for for those
3:41
kind words. But before we kind of get
3:43
into, you know, titles and org charts,
3:46
um where did you grow up? You know, what
3:48
kind of kid were you?
3:50
>> I uh played a lot of sports. uh very
3:55
large family family uh very underserved.
3:58
Uh we we grew up very poor. Uh and that
4:04
probably through my career gave me that
4:07
>> passion for underserved communities,
4:09
safety nets, critical access, really
4:11
understanding the population.
4:13
>> Uh and didn't even know it. Uh and uh it
4:17
was a I had a great and I went into the
4:19
military which paid for my college and
4:21
that was the route and uh had a lot of a
4:24
lot of fun and uh I enjoy what I do and
4:26
I'm uh guilty of being passionate uh
4:31
around the delivery system and I always
4:33
love a good conversation around
4:34
healthcare.
4:36
>> Right on. I mean, who uh who was outside
4:38
of your parents maybe? Who was sort of
4:39
the first adult or professional in your
4:42
life that made you feel like, hey,
4:44
you've got something here? You've got
4:45
potential?
4:48
Well, I'd say, you know, I have a lot of
4:50
mentors uh uh through my career and
4:56
Jim Donovan is probably the greatest
4:57
mentor and influencer that uh I worked
5:00
with uh to the delivery system and did
5:03
the transition from technology to
5:06
business development and uh it's a it's
5:08
a tough transition and I can't think of
5:11
anybody that's really done that to be an
5:13
expert in the business side
5:16
>> but you know I could name you know a few
5:20
uh off the list. Bill Hen, John Kalin,
5:22
uh Blaine Ferguson, uh working with a
5:26
lot of industry experts uh that have
5:28
said, "Yeah, it's okay. You can
5:30
transition from technology." Technology
5:32
comes to me very easy. And that's a lot
5:34
of the struggle within the business
5:36
leadership or executive leadership is
5:38
>> connecting that. Well, I I do I I do
5:41
that very well. And so when I see
5:44
something that's presented, I'm looking
5:46
at the business impact based on the
5:48
technology capabilities and I can
5:50
usually tell you sooner than later
5:51
whether or not you need to cut and run
5:53
or to be able to deliver. Uh and that's
5:56
been an area of expertise that's
5:58
resulted in billions of dollars of
6:00
revenue in strategic growth for uh a lot
6:03
of health plans uh around the country.
6:06
So,
6:07
>> what's uh what's maybe like a moment uh
6:10
early in your career where you realized
6:13
this this system is uh is way more
6:17
complicated than than people think.
6:21
>> Uh I spent a lot of time in and out of
6:24
capitals around the country. I've been
6:25
in over 30 states uh pushing different
6:28
policy and understanding how the
6:30
delivery system actually transforms for
6:33
payers and providers. and I've driven
6:36
three mile 3 hours to to meet with a
6:38
single provider in northeastern
6:41
Washington just to talk healthcare. Uh
6:44
and so I think it's been a a transition
6:47
over many years and meeting with
6:49
thousands of providers uh and
6:51
representing several large payers and
6:53
small payers being able to understand
6:56
the delivery system and understanding
7:00
health care as local and there's a lot
7:02
of socioeconomic drivers that influence
7:05
a lot of these buzzwords that you hear
7:09
valuebased payment at risk and the
7:12
definitions vary from state to debate
7:14
and uh policy to policy and waiver to
7:16
waiver. Um there's a sense of
7:18
consistency but you know through the
7:21
years I've been able to you know forge
7:24
through and have a very good
7:25
understanding of the delivery system uh
7:28
along the way.
7:30
>> So when when things go sideways and uh
7:34
they do go sideways sometimes where do
7:36
they actually break first where like no
7:39
one really talks about it? They're
7:42
afraid to talk about they're afraid to
7:43
engage on it because of they don't want
7:46
people to know of some stress points uh
7:49
competition wise and uh especially if
7:52
they're publicly traded, they want to
7:53
keep it confidential. The the stress
7:56
points are usually the network. I mean,
7:57
insurance companies, what they do is
7:59
build networks. That's that's what they
8:01
do. Uh and sometimes they're not built
8:03
to the level they need to because the
8:05
providers are trying to get the most
8:08
money they can. Uh, but there's three
8:10
areas that you have to harmonize within
8:12
a health plan. If you're at risk or want
8:14
to go to risk, the claim adjudication
8:17
system has to be configured
8:18
appropriately to pay per the contracts.
8:22
>> And they have to both complement the
8:23
clinical model that you've deployed. If
8:25
you've deployed an outdated clinical
8:27
model, you're not going to get the
8:28
optimal outcome that you would like
8:30
relative to your medical loss and your
8:32
admin loads. So these three focused
8:35
areas have to work together in order to
8:37
get you the MLR of what you need and the
8:40
administrative load you need for a
8:42
foundational growth element. I mean you
8:44
you you need to grow where you're going
8:46
out of business. So you should always be
8:48
looking at growing and optimizing where
8:50
you're at. And some of these systems are
8:52
are running on health systems and payers
8:55
are running on systems that are 101 15
8:58
years old and haven't upgraded them. And
9:00
those are usually where you fall because
9:02
policy is updated sometimes two or three
9:05
times a year. And you have to stay up to
9:07
speed with the capabilities that are out
9:09
there and take better use. Do more with
9:12
less. I mean AI is great, but AI you
9:15
have to check and validate. Can't just
9:17
go, "Oh, I got AI. AI the world's coming
9:19
to an end." Because I think a lot of
9:21
people are starting to realize AI is
9:23
good, but you need a process to check
9:25
and manage and monitor. So what are some
9:27
of those things that you know that
9:29
listen the only thing that's constant is
9:31
change. Are there certain things that
9:32
you know aren't going to be changing
9:34
that you like to keep an eye on and say
9:37
hey these are these are the elements
9:38
that we need it sounds like you know
9:40
building and maintaining and growing a
9:41
strong network optimizing for that
9:44
that's important.
9:47
What else is there that's not changing
9:49
that you're that you're oftenimes
9:51
drifting from? Because I think when you
9:53
and I spoke earlier, we talked about
9:55
this this drift that's happening. It's
9:57
like, hey, we need to kind of get back
9:58
to basics. What are some of those basic
10:01
things that are often overlooked because
10:03
there's shiny object syndrome over here
10:06
and let's go and tooth the dials on
10:07
that, but like what really truly
10:09
actually matters.
10:11
>> Population health management. Getting
10:14
clinicians to work at the top of the
10:15
scale. They we burden them down with a
10:17
lot of administrative tasks that we
10:19
shouldn't. Um things like correct coding
10:23
uh is sometimes overlooked. Um sometimes
10:26
the um M seems to be on automatic pilot
10:29
maybe doesn't have the due diligence it
10:31
should. Um, so better use of of
10:35
community health workers and care
10:37
navigators, programs that safety nets
10:39
have been doing for quite some time need
10:41
to probably be front and center um in
10:45
the delivery system to allow those
10:48
licensed individuals to work at the top
10:50
of their license. It's it's no surprise
10:53
that primary care um there's there's not
10:55
a lot of primary care and they're aging
10:57
out of the population. There's a lot of
10:59
studies that are out right now talking
11:01
of how primary care I is really limited,
11:04
but our population is growing and
11:07
there's a lot of individuals that are
11:09
aging. So, there's not enough
11:11
infrastructure to support the members
11:14
that are there and the members are
11:15
always going to be there and what's
11:16
going to happen is they're going to go
11:17
to the ER and that's may not be the best
11:20
place to get care. We want to push
11:22
individuals to primary care. That's
11:24
where the best care can be uh managed by
11:28
a primary care physician in the office
11:29
and the best preventive care that can be
11:31
done. Uh but unfortunately because of
11:34
the limitation in primary care
11:36
nationally,
11:37
>> right,
11:37
>> individuals are going to the ER and uh
11:40
that's that's having an adverse effect
11:43
running up the cost because what happens
11:44
when you go to the ER? They're going to
11:46
do an MRI, they're going to do this lab,
11:48
they're going to do X, Y, and Z and
11:49
that's how you your cost starts racing.
11:52
So you need a very effective program and
11:55
understanding of the nurse line, MD
11:58
live, primary care, and even incentives.
12:01
If you're building a product, if it's if
12:03
it's a commercial product, incentivize
12:05
the employees on the appropriate use of
12:07
the ER and maybe put a co-ay or
12:10
something. So,
12:12
>> you know, you you just unpacked a lot
12:14
there and I want to just kind of break
12:17
things down a little bit more deeper
12:19
when you're talking about clinicians
12:22
working at top of license and and
12:24
removing some of the administrative
12:26
burden. Is that does that fall on on the
12:30
provider to be able to do that to create
12:31
more efficiencies or does that fall on
12:34
the payer to be able to kind of work
12:37
collaborate you know with the provider
12:39
to be able to do that and and kind of
12:42
just to add on to that is like listen
12:44
you've built networks all over the
12:45
United States
12:47
what is that relationship like truly
12:51
when you're building networks
12:52
>> between hospitals and payers it's pretty
12:54
tough uh those negotiations are are very
12:57
different but it should be collaborative
12:59
in many aspects because there's always
13:01
going to be bodies for the beds and and
13:03
heads in the beds but it's a it's a
13:06
different philosoph insurance companies
13:08
are trying to reduce er and heads and
13:10
beds and then the providers are over
13:12
here trying to increase and have record
13:14
record numbers uh so but in order to
13:18
address it they have to work together
13:19
and that's where valuebased payments are
13:21
a big influencer in the ability to work
13:25
together so if your incentives are
13:26
aligned, you can get to that h happy
13:30
spot as as far as a balanced delivery
13:33
system, but it has to be a joint effort
13:36
uh in order to address that. It has to
13:38
be we usually look the team that I work
13:41
work with, we usually look for CINS or
13:45
or a um
13:47
primary care associations or IPAs that
13:50
are physicianbased uh for valuebased
13:53
payments. uh and in those programs the
13:58
money that's discussed that they don't
14:00
talk about actually comes from the
14:01
hospitals
14:03
uh and that's why it's very difficult
14:04
with the
14:05
>> hospitals
14:07
>> all the money is in in the inpatient and
14:08
the hospitals I mean that's where the
14:10
majority of the cost is and that so when
14:13
we go out and we look and we build a
14:15
network and we do a valuebased payment
14:17
we're doing those total cost of care you
14:19
know some of those value based payments
14:21
were more way more effective with
14:23
primary care practices is uh in
14:25
executing uh and you know if I go out
14:28
and I've met with hundreds of FQAC's
14:32
we put in value based payments on
14:34
readmits and you know appropriate use
14:37
and making sure we're reducing those
14:38
acute events. In fact we just deployed a
14:41
a population health stratification model
14:44
for high-risisk members with with a
14:46
client and we're saving about 1.5
14:48
million a month. uh and it's
14:51
>> wow
14:52
>> if it's not done you're basically fee
14:54
for service you want to move to the
14:56
rigor of managed care and population
14:58
health with that member centric model
15:01
it's easy to do with technology but what
15:03
you see out there is a lot of vendors
15:05
that are selling oh yeah we do this they
15:07
don't really do this uh and so there are
15:10
solution sets that are out there just be
15:12
careful when you're selecting the
15:13
solution set that you check the
15:15
references you get experts to come in
15:17
and say yeah this is what it's going to
15:19
be bike and don't kid yourself. You got
15:21
to you got to spend the money to get the
15:23
money. So, uh
15:25
>> well, I mean, look, you're always
15:27
learning lessons and and I'll call them
15:29
uh there's there's probably been some of
15:31
the expensive experiences that have
15:32
happened in your career. Um maybe you
15:35
didn't fully realize those until years
15:37
later. Are there any that you look back
15:39
fondly on? You like, "Oh man, uh big big
15:42
lesson learned there." And if so, what
15:44
uh any stories come to mind that you're
15:46
willing to share?
15:50
Uh boy, I've been a there's been a
15:53
couple. Um you know, the negotiations
15:56
that take place with uh building a
15:58
network are you have to get them
16:00
actuarily set and verified. Uh that's
16:03
very important when you agree to a rate
16:05
to understand the discharge volumes and
16:08
the DNA of the cohorts that you're
16:10
treating. um adverse selection happens
16:13
and and so there are capabilities to
16:16
understand the acuity level of a
16:18
population and if your actuaries is
16:22
telling you that these rates aren't
16:23
going to work, don't bid on it. Don't
16:25
chase that business or you're going to
16:27
lose money. Um because you sales is
16:30
wanting to push but you got to have
16:33
profitable growth. And there's been
16:35
scenarios in the past where we wanted to
16:37
win the business because it influenced
16:40
uh the stock market and we want to be
16:43
able to put there, hey, we won, you
16:44
know, 4,000 new lives or 100,000 new
16:47
lives because the stock market reaction,
16:50
but at the end of the day, it was not
16:52
profitable growth. And
16:54
>> uh you really need to be have the due
16:56
diligence in balancing sales and growth
16:58
and actuaries to make sure that it's
17:00
profitable growth.
17:02
>> And I think everybody can relate to
17:04
that. There's a always contention and a
17:06
plan we need to grow because everybody
17:08
the salesperson has growth goals and you
17:11
know finance and we have a P&L to manage
17:13
at the same time.
17:16
>> You mentioned around just networks. I
17:18
want to kind of drill on that, but
17:19
what's what's one word you would use to
17:21
describe uh provider relationships
17:24
today?
17:31
>> One word. Oh boy, I could get in trouble
17:33
for this one.
17:35
>> Um, it's a canankerous relationship. It
17:38
really is. It It's uh
17:40
>> Wow, that's a good SAT word.
17:42
Canankerous. Wow.
17:44
It's uh uh I I enjoy
17:49
safety nets in rural areas are always
17:51
welcome and always looking and they and
17:53
they get it. They they want to diversify
17:54
their product lines and have multiple
17:57
streams. So you have the eb and flow of
17:59
health care, you're always going to
18:01
different political positions and
18:04
policies coming out, but if you don't
18:06
diversify your portfolio and diversify
18:08
your contracts,
18:10
>> you're not going to be able to make it
18:11
through those waves. And so when there's
18:13
an event, you're going to feel it more.
18:14
So you definitely need to diversify your
18:16
products. Look to go at risk if you can.
18:19
And I I enjoy the the safety net side of
18:23
what I do a lot, but um you know, the
18:25
large health systems that are inner city
18:28
uh they have a very uh meaningful
18:30
purpose and the services they and
18:32
expertise and specialists they provide
18:33
too. Um but
18:36
>> wow. You know, I I'm just sort of
18:39
thinking because there's a lot of
18:42
misunderstood
18:44
things about health plans. Um, what do
18:47
you think is the most misunderstood
18:50
thing that people get wrong about health
18:52
plans?
18:53
>> A lot of money. Um, you know, the
18:55
margins in health plans are are very
18:56
small and based on their contract that
18:59
they've been able to negotiate in the
19:01
provider, that's the rate.
19:03
So, it's not like the payers are over
19:05
there just saying, "Oh, this is what
19:06
we're going to charge and this is what
19:08
we're going to do." You know, it's it's
19:10
defined on how well how efficient of a
19:12
of a network they can build and
19:14
sometimes they can't build an efficient
19:16
network. Um, so I I think there's a
19:19
little bit of love on both sides. Um,
19:22
you know, the chargemaster, you know,
19:24
scenarios with hospitals is is always
19:27
interesting and and a whole another
19:29
discussion on how those are developed.
19:31
but uh and the lesser of language in
19:33
contracts.
19:35
>> But I I think there's a a little bit of
19:37
a misunderstanding. I hear politicians
19:39
saying, "Oh, the insurance companies are
19:40
making all that money." But that they
19:42
they don't have an understanding of the
19:44
delivery system. And when you start
19:46
pulling back benefits and pulling back
19:49
activity relative to Medicaid or, you
19:52
know, the exchange,
19:54
>> right?
19:54
>> They can go to the ER any time. And this
19:57
happened in the late 90s, early 2000s
19:59
where they didn't have coverage. what
20:00
happened? Our ER skyrocketed in the cost
20:03
and that's not the best care that we can
20:05
provide. So, I think there's, you know,
20:07
an a level-handed that needs to be
20:09
looked at. Um, I think there's a
20:11
duplication of administration between
20:13
Medicare and Medicaid. I'm not a
20:15
Medicare for all person. I'm just saying
20:18
there's administrative simplification
20:19
because there's overlap in in
20:22
>> process and technology and
20:24
administrative policy between Medicare
20:26
and Medicaid and even exchange. Uh so
20:29
it's there's some efficiencies to be
20:31
gained but the payers have to are
20:33
heavily regulated just like health
20:36
systems are too but uh I don't think
20:38
that there there's love to go around
20:41
that arena not stall the insurance
20:43
company. I mean, just given that you've
20:45
seen different seasons, you've seen a
20:48
lot. Are there patterns that you see
20:50
that are that are emerging and what ones
20:53
are reemerging that you're seeing now
20:54
that you're like, "Oh, kind of seen this
20:56
before. Any any insights that you can
21:00
kind of share there?"
21:02
>> No, to me it's a lot of the basics. So I
21:03
think uh providers are going to bill and
21:05
optimize their billing as much as they
21:07
can uh given the the market dynamics and
21:10
the responsibilities the payers to make
21:12
sure that they have the appropriate
21:13
billing per the contract. Uh I think
21:15
that's you know that's been going on. I
21:18
think there's higher use uh of some
21:21
pharmaceuticals that that have up before
21:24
that.
21:25
>> I think we had the heepsi drug before
21:27
now with ompic where it seems like
21:29
there's always going to be an eb and
21:30
flow of some type of control that you
21:33
need to put in uh or options or
21:36
evidence-based step therapy to in the
21:38
process. But seems like something always
21:41
comes up that's going to drive and put
21:42
stress on the MLR. But you have to have
21:44
the reporting and the tools in play to
21:47
be able to respond timely and action
21:49
timely when you see that event. If
21:51
you're monitoring, you know, if you're
21:54
not monitoring or you're monitoring and
21:56
having a latency, you really need to
21:58
monitor week to week, month to month and
22:00
know your key indicators uh and
22:03
proactively manage, especially if you
22:04
have TPA.
22:06
>> If when a TPA is watching out for your
22:09
best interest, that may not be the case.
22:11
your TPA is only as good as your
22:13
contract and how much oversight you
22:15
provide to that uh contract to that TPA.
22:18
Uh so that's really
22:21
>> Yeah.
22:22
>> I mean, but what's something that health
22:23
plans say they want, but maybe their
22:26
behavior says they don't?
22:28
>> I I think
22:30
that's a good question. Um I think
22:34
most of them want almost all of them
22:37
want population health management and
22:39
individuals deliver better quality of
22:41
life. I don't think there's a pay out
22:43
there that doesn't want that.
22:44
>> But from a regulatory standpoint and an
22:47
audit standpoint, they need to make sure
22:48
that coding and billing is consistent
22:50
and correct because they get audited on
22:52
a regular basis and there's rules uh to
22:55
live by. I think there's a rumor that
22:57
well they just deny because they deny.
22:59
No, they have rules that they need to
23:01
follow per the contract and the denials.
23:03
Uh that's why they have a prior
23:05
authorization list. You need to make
23:07
sure you're following that. Uh and they
23:08
have benefit configuration and benefit
23:10
design that need to be adhered to.
23:13
>> So, you know, I I I think all of them
23:15
really want to help individuals and do
23:18
you know member centric care and be as
23:20
responsive as possible. But with the
23:23
financial pressure, you lose a lot of
23:25
staff and there's riffs, reduction in
23:27
force in areas where sometimes
23:30
accidentally a core competency walks out
23:32
the door and there's an unknown. There's
23:34
a lot of volume that has to be managed
23:37
and uh it's a lot to monitor and
23:40
sometimes,
23:41
>> you know, things happen where there's a
23:43
code update that nobody knew about that
23:46
all of a sudden this is denying. It
23:47
isn't it isn't intentional. It's
23:50
insurance companies have technology
23:52
systems that they update code to. So do
23:54
health systems they have health they
23:56
have inadvertent billing because they
23:58
did an upgrade and all of a sudden
24:00
they're billing for you know certain
24:01
procedures where they weren't allowed to
24:03
in the past.
24:05
>> So a a lot of it is unintentional but
24:07
you because the technology is so complex
24:09
you got to stay on top of it or you're
24:11
going to have people are going to assume
24:13
well that was intentional. That may not
24:15
have been the case. So pick up the phone
24:16
and talk to somebody.
24:19
If you can get to someone,
24:21
it's it's hard. It's hard to call an
24:23
insurance company, call someone.
24:24
>> You should always know the leadership of
24:26
of every group that in your communities
24:28
that you're working with should always
24:30
to be able to pick up the phone. So, in
24:34
most all the environments that I was in,
24:36
we had direct contact with the CEO,
24:39
COOs, CMOs, and have monthly meetings, a
24:42
lot of transparency. And that happens
24:44
today a lot with the Joocc's uh where
24:47
they're engaged and they especially if
24:49
they're at risk
24:51
JC's to have that dialogue. So
24:54
>> what's harder? I mean changing
24:56
incentives or ch changing culture.
25:02
>> Culture culture is is is definitely
25:06
a lift in in a lot of organizations.
25:09
um especially when you're an
25:11
organization that's done acquisitions or
25:13
if you're an organization in the whole
25:15
area, you're somewhat confined by the
25:18
resources that are available. Um large
25:21
organizations, they make an acquisitions
25:23
and then you have a group here and a
25:24
group here that with different uh
25:27
acquisitions and they they don't
25:30
necessarily have the same alignment. H
25:35
I want to shift gears a little bit just
25:37
because I'm I'm curious about you know
25:40
you having sat in the seat how how
25:41
decisions actually get made you know
25:43
inside of a health plan you know not you
25:46
know from the or chart version but the
25:47
real version like walk me through that
25:50
walk me through how these decisions you
25:54
know typically get made is it you know
25:56
committees is it you know individual
25:58
like what does that look like
26:00
>> we have quality committees ities,
26:02
clinical committees, medical economic
26:04
committees, uh out of network
26:07
committees, prior offs, monthly
26:09
operations meetings. So, health plans
26:12
have a series of committees and
26:14
dependent on the health plan, you could
26:15
be a provider entity and you have a
26:17
board to report into. And in some
26:19
states, you need to have members of the
26:21
community in a board in that health plan
26:23
locally. Medicaid has some states that
26:26
do that, too. and and always reviewing
26:30
the denials. Are they appropriate? Did
26:32
they make sense? And and the health plan
26:34
gets audited. So you have a compliance
26:36
uh arena that make sure we handle the
26:38
audits that come in and they do an ad
26:40
hoc review of of some ends. The plan
26:43
president is is over it along with the
26:46
uh um chief medical officer and
26:49
operations and network and they report
26:51
into the plan president. But a lot of
26:53
that is structured with policy because
26:56
of regulatory requirements. When you get
26:58
a license to have certain functions in
27:01
place in a health plan and you have to
27:03
submit your process, your model care,
27:06
your grievance and appeal process and
27:08
that gets reviewed by the regulators and
27:11
sometimes on a on a annual basis uh and
27:14
sometimes CMS audits you on different
27:16
dependent on your products that you have
27:18
there. So the decisions at the end of
27:20
the day if it's not a provider is
27:22
usually the plan president who reports
27:24
into a regional president who then
27:26
reports into a president. For large
27:28
plans,
27:29
>> right? state based plans, it's a little
27:31
bit different. Um, you know, where they
27:33
may have a governing board, a community
27:35
plan may have a board. Well, they'll
27:37
present monthly. The quality metrics,
27:39
the P&L, you know, the MLR, the
27:42
enrollment, any kind of clinical
27:44
programs, the valuebased payments, those
27:47
are all presented up through committee
27:49
every month to make sure we're tracking.
27:51
They usually set their baseline and
27:52
goals every year. And when they deviate
27:55
from the goals, you usually deploy a a
27:59
tiger team or a a team to be able to go
28:02
and address those challenge areas. Um,
28:06
but they are focused and they are
28:08
running, you know, focus and managing to
28:10
an MLR and an admin load aggressively
28:12
and they need to. They're not. You need
28:15
to because you know
28:18
>> it's it's interesting that you mentioned
28:20
just around like the myth that like you
28:21
know health plans are just printing
28:24
money and you're like no that's actually
28:26
not always true. So that's fascinating
28:28
to to hear this. The other thing that I
28:31
started thinking about is you know just
28:33
innovation. There's there's no shortage
28:35
of talent. There's no shortage of really
28:37
smart people. There's probably no
28:39
shortage of really good ideas.
28:42
How how does innovation actually work
28:46
you know inside of inside of you know
28:48
larger organizations in the sense that
28:51
if you can only do one or two things how
28:53
how do how do things actually move along
28:56
I mean you talked about how decisions
28:58
are made do you feel like there's a
29:00
pressing matter where you know there's
29:02
this arms race around sort of AI I mean
29:05
is innovation now being forced in a
29:08
sense or it's like hey we we kind of
29:09
have to do this like you mentioned
29:11
there's systems that are 10, 15 years
29:12
old. Like we're running on a chassis
29:14
that probably really needs to be redone
29:17
here. Talk to me about that because I'm
29:20
wondering if there's even more noise
29:22
about innovators from the outside trying
29:25
to come in or do they try to sort of
29:27
trust the group, trust the talent and
29:29
say, "Hey, we can kind of innovate
29:31
internally uh as opposed to having to
29:33
rely on some of these external
29:34
resources." When do they rely on
29:36
internal, when do they rely on external?
29:39
Very few organizations have the internal
29:42
capability to deploy
29:44
new technology or capabilities as new
29:47
technologies because they're just
29:49
running daily operations.
29:50
>> Yeah.
29:51
>> And that skill set isn't there. And if
29:54
it's not budgeted, um
29:57
it's very difficult to get inside uh any
30:00
system really because you're deviating
30:02
from the budget and you need a good ROI
30:05
in order to do that. um if you're
30:08
solving a regulatory problem that's
30:10
different and so that's handled a little
30:12
bit differently in payers. But if
30:14
there's a a problem you're solving for a
30:17
specific problem um meaning you're not
30:20
meeting the HCC demand uh or your
30:24
contracts are are are
30:27
not paying as you you should be paying.
30:31
Right? When you're solving a problem,
30:34
it's easier to to apply a technology
30:36
solution.
30:38
>> There are still payers out there that
30:40
manually adjust everything and instead
30:42
of doing bulk adjustments for 10,000
30:44
claims, it it that's going on and you
30:47
can have AI to reduce the administrative
30:50
drain on what you're doing and save a
30:51
lot of money.
30:52
>> Um, so you're going to be more effective
30:56
if you're trying to engage a payer if
30:58
you're solving a problem. It's very easy
30:59
to know if there's a problem because if
31:01
you're Medicaid, your your caps are
31:03
public and so you know which payers are
31:06
struggling and your solution might be
31:08
able to to be a solution for that.
31:10
That's where there's exceptions that are
31:11
made because this solution is going to
31:14
fix this problem. The problem is is
31:17
which solution do I get? Cuz there could
31:20
be four or five different solutions all
31:21
of which do a great sales delivery but
31:24
which ones actually work,
31:26
>> right? uh if you can somehow get a hold
31:28
of a non-conlicted entity to do an
31:30
assessment or by you know uh of which
31:33
solution is right for you would be the
31:36
best idea and a best approach because
31:38
all delivery systems and all communities
31:40
are different and um everybody's trying
31:43
to to sell to insurance companies and
31:45
health systems but they've been you know
31:48
plummeted with vaporware that didn't
31:51
work or didn't solve the problem or it
31:53
was a good tool. Uh, it reminds me at
31:55
Sutter Health, uh, I shouldn't say the
31:58
name, maybe you can delete that. There
32:00
was there was a a health system that I
32:02
was working with, he had $3 million
32:04
worth of software on the shelf that
32:06
nobody knew how to use. A vendor came in
32:08
and sold it and they never used it. Um
32:10
so they're they're very hesitant to
32:13
engage with vendors
32:15
um unless it's solving a problem and
32:17
it's they have a high confidence going
32:18
to deliver because that person that
32:20
reaches out if it's the CFO, CMO,
32:23
director of IT or director their job is
32:27
or their credibility is at stake
32:28
bringing in a third party to be able to
32:31
do that.
32:32
>> Um so that confidence needs to be there.
32:34
That's why they usually go out to three
32:36
vendors and they get presented and they
32:38
select somebody. Um but uh
32:41
>> so so so then if you could fix maybe one
32:43
structural issue tomorrow, what what
32:45
would create you know maybe the biggest
32:48
downstream impact.
32:59
population health management. It has
33:01
different
33:03
definitions for a lot of different
33:05
payers and a lot of health systems. And
33:06
so that administrative
33:09
confusion
33:11
at the provider level is very confusing.
33:14
They they have a go to this portal, go
33:16
to that portal, this is the billing
33:18
requirement, this is the PAL, oh this is
33:20
the credentiing problem. We put a lot of
33:22
unnecessary, you know, every payer has
33:25
its own intellectual property and they
33:28
believe they do respective processes
33:30
really well and they probably do.
33:32
>> But what happens to the delivery system
33:35
in primary care is they get inundated
33:37
with sometimes 32 different portals that
33:40
they have to go through to get an
33:41
authorization in order to get a basic
33:44
service. And so there's a a a lot of
33:47
load that's put on a provider because
33:49
the insurance companies are regulated to
33:51
be to be able to do X Y and Z. Um and if
33:56
we could somehow figure that out and
33:58
some of them have there's centralized
34:00
credentiing in some states. Uh we need
34:02
more multi-payer type products that
34:05
we're not afraid of poaching members and
34:07
not afraid of infringing on other payers
34:10
or other providers or somebody's
34:12
poaching my members or maybe they're
34:14
offloading their high risk on me. But if
34:17
we could get AI or tools that do
34:19
administrative simplification on some of
34:21
the basics, I think the providers could
34:24
do more. We want providers to do more
34:26
with less because there's not a lot of
34:27
primary care providers coming in. And if
34:30
we can get some level of administrative
34:32
simplification through credentiing,
34:34
value based payments, maybe the model of
34:36
care, the grievance and appeal,
34:39
>> I mean, we each payer did their own
34:41
process and they probably shouldn't
34:43
have. We we should have some type of
34:45
consistency to reduce that or be
34:48
cognizant of the administrative load,
34:50
you know, that we're pushing onto health
34:52
systems.
34:54
>> All right. I'd be remiss if I didn't
34:55
ask, but like tell us how can people
34:57
follow the work that you're doing? Where
35:00
can they sort of uh engage? Uh give give
35:03
us a give us a sense of that so that we
35:05
make sure we you give give the audience
35:08
a little bit of that.
35:10
>> Well, we're on LinkedIn and we have a a
35:12
page on on advisors uh on LinkedIn and
35:15
and also we have a website at
35:16
onadvisorslc.com.
35:18
Just drop us a note. Uh we're going to
35:21
try to over the next couple of years be
35:24
more engaged in the market. We have a
35:25
team of uh retired experts that uh have
35:30
25 years experience that can help you
35:31
cut to the chase sooner than later.
35:34
>> Um we typically get engaged to be able
35:37
to assess and make recommendations and
35:38
sometimes we are the ones that do it or
35:41
sometimes we say hey you really need
35:43
this organization or you really need
35:44
this solution um in order to execute on
35:48
it. uh we'd love to be that partner for
35:50
you, but you know, we understand a
35:52
business is a business and we can
35:54
definitely tell you whether or not it's
35:56
a good idea or a bad idea to take risk.
35:58
Uh and we've done that before and we've
36:00
done those board presentations and broke
36:03
the news. You're a great organization,
36:04
but you can't do risk. Uh so those are
36:09
those are difficult discussions, but
36:11
ones that you know you have to do. You
36:13
have to know when to to cut and run and
36:15
when to double down and go. Um, so
36:19
>> I guess if you could leave sort of our
36:20
community, the hi community with uh just
36:23
sort of a parting idea sentence, you
36:25
know, uh what would that be?
36:29
>> Healthcare is local. Um what's good for
36:32
you may not be good for others. Um and
36:35
uh it's a complex environment and it's
36:37
not as simple as people uh tend to think
36:39
it is. It's very complex. Uh there's a
36:42
lot of
36:43
uh influencers into the ecosystem of
36:46
care. Uh if you push on one stream,
36:49
something's got to give. There's only so
36:50
much money in the system. And when you
36:53
push on one element, yeah, it's
36:55
something else is going to push. So, uh
36:59
>> I guess if there's one thing that I'm
37:00
taking away from this conversation is is
37:02
that um
37:04
just because you read a headline doesn't
37:05
necessarily mean that it's always true.
37:07
you know, I think if there's one thing
37:08
that we take uh really serious, you
37:11
know, uh with the community is just
37:15
allow both sides to have a voice and to
37:19
sort of share. So, it's been really
37:21
wonderful to have an insider come in to
37:23
share, you know, a different perspective
37:26
and just appreciate you being able to be
37:29
as candid as you were and sharing and
37:31
obviously doing it in a very respectful
37:34
and meaningful way. So if you're
37:36
listening to this and you found this
37:37
particular conversation to be helpful,
37:39
would you mind sharing it uh engaging in
37:41
it, letting us know what you felt was uh
37:43
important. If there is a topic that you
37:45
want us to explore uh or even a leader
37:48
uh that you'd like to hear from, you
37:49
know, drop me a note uh or leave a
37:51
comment. This platform it is absolutely
37:54
about community uh and being interactive
37:58
and we can only innovate when we are in
38:01
this type of a of a community. So thanks
38:02
for listening. Keep building with
38:04
purpose and uh we'll see you next time
38:06
on the Advancing Healthcare Innovation
38:08
Show. Thanks, Mike. Thank you.
38:10
Appreciate it.