Latest / Becker’s Payer Issues Podcast / The New Era of Healthcare Transformation: How Payers Can Leverage Data for Continuous Improvement

Transcript

The New Era of Healthcare Transformation: How Payers Can Leverage Data for Continuous Improvement · Becker’s Payer Issues Podcast

• 0:00
  Hi, everyone. This is Lucas Voss with Becker's
• 0:02
  healthcare. Thanks so much for tuning in to
• 0:04
  the Becker's healthcare podcast
• 0:06
  series.
• 0:07
  A very exciting topic today, the new era
• 0:10
  of healthcare transformation
• 0:12
  and how payers can drive continuous improvement
• 0:15
  in the health care ecosystem by leveraging price
• 0:18
  transparency data,
• 0:20
  interop interoperability,
• 0:21
  and robust data analysis.
• 0:23
  And joining me for today's discussion,
• 0:26
  very excited to have her on, Arti Karamchandani,
• 0:29
  chief growth officer at Mackerel Health. Arti, thanks
• 0:32
  so much for being here today.
• 0:34
  Thanks, Lucas. Great to be here.
• 0:36
  Absolutely.
• 0:37
  And before we start, could you give our
• 0:39
  audience just a little bit of an overview
• 0:41
  of yourself and your background in health care?
• 0:45
  Sure. Yeah.
• 0:47
  I'm the chief growth officer here at Macro
• 0:49
  Health. Been here for a few years now,
• 0:52
  three plus years, and, been in the health
• 0:55
  care payer industry for,
• 0:57
  I hate to admit it, thirty five years.
• 1:00
  And, so I'm a I'm a bit of
• 1:02
  a veteran in this in this industry,
• 1:05
  working,
• 1:06
  within the blues for several years,
• 1:09
  working at IBM health care and helping to,
• 1:12
  you know, to bring a lot of the,
• 1:14
  the technology enablers that you hear about IBM,
• 1:17
  participating in, in health care on.
• 1:20
  And then spent a good chunk of time
• 1:23
  in the early stage kinda innovation arena
• 1:26
  with a few,
• 1:27
  companies,
• 1:29
  which kinda caught me the bug
• 1:31
  related to, you know, innovation in health care
• 1:33
  using technology.
• 1:35
  Three decades of experience. That's why that's why
• 1:38
  we have you on.
• 1:41
  And this is really one of one of
• 1:42
  my personal favorite topics because, again, without good
• 1:44
  data, we can't really do a whole lot.
• 1:46
  We need data. Data is important.
• 1:48
  And my first question is,
• 1:50
  how can payers effectively utilize, especially price transparency
• 1:54
  data, to really drive continuous improvements
• 1:58
  in the quality of care
• 2:00
  while, and this is important, also reducing health
• 2:02
  care costs?
• 2:04
  Yeah.
• 2:05
  Super great question.
• 2:07
  Well, the price transparency data,
• 2:09
  is kind of the newest form of data
• 2:12
  that has entered into,
• 2:14
  the health care data landscape.
• 2:17
  And,
• 2:18
  as as kind of is normal, we we
• 2:20
  see that being governed by
• 2:22
  the federal regulations,
• 2:25
  and those regulations have now resulted in,
• 2:28
  even a doubling down of that by the,
• 2:31
  the newest administration.
• 2:33
  And that data has gotten better over time.
• 2:35
  Initially, it wasn't the best, but it was
• 2:38
  it has gotten better over time.
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  And what we see,
• 2:42
  payers doing,
• 2:44
  leveraging that type of data is, you know,
• 2:47
  some of the the normalized use cases that
• 2:49
  you might,
• 2:50
  expect. We see payers and providers
• 2:52
  looking to leverage,
• 2:54
  that kind of data
• 2:56
  to do price negotiations
• 2:58
  or,
• 2:59
  you know, work through, like, what's what's a
• 3:01
  normalized cost for a particular type of service,
• 3:04
  mean,
• 3:10
  that's
• 3:16
  that's what, you know, some of the more
• 3:17
  normal use cases are that we're seeing, but,
• 3:18
  I mean, that's that's what, you know, some
• 3:19
  of the more normal use cases are that
• 3:21
  we're seeing, but I I think some of
• 3:23
  the more interesting ones that we're starting to
• 3:25
  experience and that we're helping, our clients with
• 3:28
  is combining,
• 3:30
  all the various forms of data that a
• 3:32
  customer might have,
• 3:34
  within their own four walls with that price
• 3:37
  transparency
• 3:38
  data.
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  And by taking that data, those two datasets,
• 3:42
  if you will,
• 3:43
  and looking at them side by side, you
• 3:45
  can start to identify where there there might
• 3:47
  be cost variances,
• 3:49
  within the payer's own kinda cost structure, health
• 3:52
  care cost structure
• 3:54
  that kinda place their costs outside of the
• 3:56
  market norms.
• 3:58
  And then, you know, looking at different types
• 4:00
  of providers,
• 4:01
  networks, or even solutions that might be helpful
• 4:02
  in bringing
• 4:04
  that
• 4:13
  optimize them, so that their networks, their provider
• 4:16
  networks, which are, you know, the primary reason
• 4:19
  Americans
• 4:20
  look to health insurance is to be able
• 4:22
  to get access to high quality,
• 4:25
  affordable health care.
• 4:27
  And so by doing this kind of optimization
• 4:30
  allows the payers to be able to deliver
• 4:33
  a high quality,
• 4:34
  fully optimized,
• 4:36
  provider network
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  and thereby, you know, starting to move the
• 4:40
  the total cost of care continuum
• 4:42
  towards at least market norms and hopefully over
• 4:45
  time
• 4:46
  to be just much more, cost effective.
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  Then the the kind of the most interesting
• 4:51
  use case from my perspective is how we're
• 4:54
  seeing our clients,
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  use that data to empower
• 4:59
  the the member or the consumer
• 5:02
  to make really effective decisions.
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  So again, once you combine,
• 5:07
  the payer's data with the price transparency data
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  and you can, you know, put that out
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  on a website,
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  members can start to look at,
• 5:17
  any service that they're looking to get,
• 5:20
  identify,
• 5:21
  not only the the different prices that they
• 5:24
  might be paying at various providers for those
• 5:27
  services,
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  but then then also combining their own data
• 5:31
  with, the the payers data with it. The
• 5:33
  member can also see what their cost share
• 5:35
  might be relative to those services.
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  So we're kind of bringing in the Amazon
• 5:40
  like retail
• 5:41
  experience
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  into into health care. And, ultimately,
• 5:45
  all of us, kitchen table economics tells us
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  that we need to save money, and this
• 5:50
  is a way to to help them do
• 5:52
  that.
• 5:53
  Yeah. And you mentioned a lot of different
• 5:55
  pieces to this. There's a lot of movement.
• 5:57
  There's comparisons that are happening. You mentioned sort
• 5:59
  of the the the pieces that the gears
• 6:01
  that sort of work together to make this
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  work and being able to make data available
• 6:06
  to certain groups, to certain people.
• 6:08
  And this goes into my next question that
• 6:10
  I wanted to ask on on interoperability,
• 6:13
  which is really important when we have all
• 6:15
  of these moving pieces.
• 6:16
  In what ways does improving that interoperability
• 6:19
  help payers
• 6:21
  really identify those areas for improvement, some of
• 6:23
  which you've already mentioned, but then also optimize
• 6:25
  work flows, and then really what we just
• 6:28
  talked about benefit patients.
• 6:31
  Yeah.
• 6:32
  Well,
• 6:34
  you know, health care is a rapidly changing
• 6:36
  industry.
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  And as you and many of your listeners
• 6:39
  know,
• 6:40
  US Health Care economy is on pace to
• 6:42
  be
• 6:43
  a 5,000,000,000,000
• 6:45
  industry in The United States by the end
• 6:47
  of twenty twenty five. Mhmm. You know, if
• 6:49
  you think about what health care payers' responsibility
• 6:52
  is in that industry, it's like they have
• 6:55
  this tremendous responsibility
• 6:57
  to figure out how they can,
• 6:59
  make health care more affordable
• 7:01
  for for their members,
• 7:04
  you know, the American people at large.
• 7:06
  And,
• 7:07
  we we are also very fortunate in our
• 7:09
  industry to have a barrage of innovation
• 7:13
  that is coming into
• 7:15
  our industry to help,
• 7:17
  control
• 7:18
  diseases,
• 7:19
  to help people live longer.
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  And And ultimately, there's a there's a cost
• 7:24
  associated with that, and payers are combating those
• 7:28
  those initiatives that are, you know, could be
• 7:31
  considered as driving costs up. They have to
• 7:33
  figure out ways on how to they can
• 7:35
  drive those costs down.
• 7:37
  And there are plenty of innovators that are
• 7:39
  helping them do that as well.
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  And and that's great. And it's it's a
• 7:44
  benefit that we enjoy in this industry.
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  The challenge that we find our customers facing,
• 7:49
  our payer customers facing, is that
• 7:52
  there are so many
• 7:54
  innovations that they're not sure exactly
• 7:56
  which ones to pick that would be perfect
• 7:58
  for their their unique member populations.
• 8:02
  And, you know, what they do find is
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  that their customers,
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  employers,
• 8:08
  groups may start to, you know, have done
• 8:10
  some of the research and then come to
• 8:12
  them and tell them
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  these are the partners that we want you
• 8:15
  to help us integrate with.
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  And then all of a sudden, you're starting
• 8:19
  to look at multiple partners
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  that the payer may want to integrate with,
• 8:24
  partners that their customers
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  may want them to integrate with. And that's
• 8:28
  not easy for, you know, an industry that
• 8:31
  has been
• 8:32
  rattled with legacy systems. Right? And Yes.
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  It's hard to connect with these, with these
• 8:39
  various partners.
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  Forget about just connecting, but then to be
• 8:42
  able to truly interoperate
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  with them, to serve the member better, to
• 8:47
  help drive down cost becomes an even greater
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  challenge. And what our clients tell us and
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  and what we try to help them with
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  is to leverage an,
• 8:58
  an easy,
• 8:59
  integration
• 9:00
  capability
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  that allows them to to not only identify
• 9:04
  those partners that might be best for their
• 9:07
  their member population,
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  but that allows them to
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  interoperate or connect with those members from a
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  data,
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  from a process, and from an insights perspective.
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  So ultimately, all of that being surrounded and
• 9:21
  and focused in on the member so that
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  the member can not only
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  not feel the differences of all of these
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  various disparate entities that might be serving them,
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  but also be able to get the the
• 9:32
  right data and insights and the care ultimately
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  that they that they deserve
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  as they're working through a very complex health
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  care ecosystem.
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  That's where the data really helps. I was
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  gonna say it's that's where the data comes
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  in.
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  Yep. For sure. That's where the data comes
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  in. And and, ultimately, we're here to help.
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  We as a payer industry are here to
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  serve these members and make sure that they're
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  getting to the right place with their data
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  being available at the right place at the
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  right time.
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  So it's a it's a much better member
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  experience for for their members and the patients
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  ultimately.
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  Yeah. So we've collected the data. We now
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  have the data. We're working on the research
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  that you just mentioned to try to identify
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  those area. Now we have the data collected.
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  We have it there.
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  How
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  can
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  now
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  robust data analysis looking at that data really
• 10:22
  be leveraged by payers to identify those trends
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  that you've that you've talked about, those insights
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  that we really are looking for that can
• 10:30
  then drive long term improvements
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  for that ecosystem that we talked about.
• 10:36
  Yeah. This is where the fun happens if
• 10:38
  if we bring it all together. Right?
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  So if we had a system where,
• 10:43
  you know, you can use the price transparency
• 10:45
  data and your own payer data
• 10:48
  to identify the areas where you have potential
• 10:51
  for optimization
• 10:52
  and cost reductions,
• 10:54
  and you had the ability to identify partners
• 10:58
  that can help service,
• 11:00
  those cost areas and help not only provide
• 11:03
  great quality care, but do it in a
• 11:05
  in a in an affordable manner.
• 11:07
  And if you had that system that could
• 11:09
  then interoperate with all of these third parties
• 11:12
  that are making up your system,
• 11:15
  your healthcare ecosystem as a healthcare payer,
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  and it was centralized around the member and
• 11:20
  patient experience
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  so that data is being shared in a
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  real time manner,
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  then what you would have
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  is a a continuous improvement
• 11:30
  ecosystem
• 11:32
  of common entities
• 11:34
  working to service the member
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  and always looking to look you know, identify
• 11:38
  areas for cost innovation or cost optimization.
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  Right? Because the data is flowing
• 11:44
  seamlessly across this ecosystem
• 11:46
  of partners,
• 11:48
  that are, you know, working in collaboration with
• 11:50
  the payer to look for areas of cost
• 11:53
  optimization, identify those partners
• 11:56
  that can help drive down those, the total
• 11:59
  cost of care,
• 12:01
  easily integrate and interoperate with those partners so
• 12:05
  that the member is serviced
• 12:06
  and the patient gets the care that they
• 12:08
  need.
• 12:09
  And then that data then continues to flow
• 12:12
  through that system where it's continuously doing that
• 12:15
  cost optimization or or outlook
• 12:17
  to help drive down the the cost of
• 12:19
  care.
• 12:20
  And so that's, you know, to us,
• 12:22
  at at Macro Health,
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  that is a,
• 12:26
  a system that we envision and that we
• 12:28
  aspire towards with our payer partners.
• 12:31
  And,
• 12:33
  it's, you know, it's something that we're looking
• 12:35
  to bring to life,
• 12:36
  on a day to day basis.
• 12:38
  Yeah. If that's brought to life, then we
• 12:40
  can take in that optimal process that we've
• 12:43
  talked about. Right? And and we know this
• 12:45
  isn't necessarily
• 12:46
  always the case, and I think a a
• 12:48
  lot of folks are in the process of
• 12:50
  doing these things. We've touched a little bit
• 12:52
  on sort of the third party piece and
• 12:54
  bolt on solutions and trying to go here,
• 12:57
  trying to go there, trying to integrate, right,
• 12:59
  trying to find what works and what doesn't.
• 13:02
  What are some of the key challenges
• 13:04
  that you're seeing that payers face right now
• 13:08
  to really implement some of these things that
• 13:09
  we've touched on, transparency, right, interoperability,
• 13:12
  and then ultimately improving their data? What what
• 13:14
  are those key challenges
• 13:16
  that you're seeing that are happening?
• 13:18
  Well, some of those challenges include,
• 13:21
  internal to the payer,
• 13:23
  obviously.
• 13:25
  We talked a little bit about touched on
• 13:27
  the the legacy systems that,
• 13:30
  payers have been fraught with. And, gosh, in
• 13:32
  my three plus decades of being in in,
• 13:35
  the healthcare industry,
• 13:37
  you know, it's every few years that I
• 13:39
  hear about the same payer potentially,
• 13:41
  looking at
• 13:42
  implementing a whole new, you know, claim system
• 13:45
  or a whole new finance system, and that
• 13:47
  sucks up a lot of resources.
• 13:50
  So I think this is one of the
• 13:51
  reasons why
• 13:52
  we see our, our payer partners looking to
• 13:56
  identify solutions that are outside,
• 13:59
  you know, their four walls to help drive
• 14:01
  down,
• 14:01
  the total cost of care. So internal organizational
• 14:05
  barriers can be a challenge for payers.
• 14:08
  Obviously,
• 14:09
  price transparency
• 14:10
  data has not been,
• 14:12
  the best.
• 14:14
  And,
• 14:15
  and while it's getting better and the Trump
• 14:17
  administration
• 14:18
  is focusing in on that
• 14:20
  much more robustly,
• 14:22
  it's still we we still find there to
• 14:24
  be gaps in the data. And so supplementing
• 14:27
  that data with the clients' with the payer's
• 14:29
  own, information and other third party
• 14:32
  vendor partners that have data,
• 14:35
  available to them that's, you know, publicly available,
• 14:38
  helps really create this robust
• 14:42
  dataset that can then be utilized.
• 14:45
  So now you have a good dataset, integrating
• 14:47
  it into a into into the system is
• 14:50
  is,
• 14:51
  difficult.
• 14:52
  And, you know, that's that those are areas
• 14:54
  where where payers are challenged with as well.
• 14:57
  And then,
• 14:58
  you know, interoperability is a challenge in and
• 15:00
  of itself as well.
• 15:02
  You know, we don't have great standards in
• 15:04
  the payer industry.
• 15:06
  We tried that with,
• 15:08
  the, you know, the EDI transactions that we
• 15:10
  had back in, gosh, I hate to say
• 15:13
  back in, like, the nineties and February.
• 15:16
  And what we know now is that you've
• 15:18
  seen one EDI transaction, you've seen one EDI
• 15:21
  transaction. And so, you know, you have to
• 15:23
  meet the payers where they're at and help
• 15:26
  them.
• 15:26
  They they need to kinda be thinking about
• 15:29
  interoperability and API standards are certainly something that's,
• 15:32
  becoming a critical enabler
• 15:35
  and having, data standards like FHIR and others
• 15:38
  that can help get payers to that to
• 15:40
  that place
• 15:42
  using the transaction sets that they're currently at,
• 15:46
  you know, helping them mobilize into that into
• 15:48
  the new modern world,
• 15:50
  is a challenge. And and, you know, they
• 15:52
  look for,
• 15:53
  for individuals and partners who can help them
• 15:56
  kind of achieve those infrastructure challenges themselves. So
• 15:59
  that's what we see as some of the
• 16:01
  the challenges that our pair partners face.
• 16:04
  Yeah. And with what you're seeing. Right? If
• 16:07
  you had to
• 16:08
  if there was one thing that you could
• 16:10
  tell them, like, hey, here's what I want
• 16:12
  you to do. This is the one thing
• 16:14
  that you need to start doing.
• 16:16
  What is the one thing that they can
• 16:18
  do to overcome
• 16:20
  some of these barriers or the barriers that
• 16:21
  you are seeing? Yeah.
• 16:24
  Well,
• 16:25
  you know, it's a it's an interesting question
• 16:27
  because,
• 16:29
  it does require a bit of a of
• 16:30
  a of a shift in mindset, right, to
• 16:33
  be thinking about rather than, you know, solving
• 16:36
  an individual
• 16:38
  problem to now solving a a series of
• 16:41
  issues and creating a system
• 16:43
  where you, you know, you are, like, continuously
• 16:47
  improving and being able to integrate with and
• 16:50
  and constantly be looking at,
• 16:52
  ways to reduce cost, create innovation,
• 16:55
  drive patient satisfaction, you know, seamless member experience.
• 17:00
  We call that platform based thinking. Right? So
• 17:02
  thinking more from a platform based perspective
• 17:06
  and and really shifting towards that more modern
• 17:09
  mindset, if you will, and
• 17:11
  and and thinking about things, related to how
• 17:14
  can I use that platform based thinking to
• 17:17
  to get to more data standardization,
• 17:19
  to get to real time connectivity,
• 17:21
  and to take a holistic approach to managing
• 17:25
  the health care problems and challenges that my
• 17:28
  unique member population has and the ever changing
• 17:31
  needs that they're gonna constantly
• 17:33
  have and building in, you know, strategic insights
• 17:35
  into that?
• 17:36
  We we call that a a system that
• 17:39
  is
• 17:40
  that has those capabilities,
• 17:42
  that is a platform based approach to solving
• 17:45
  healthcare's largest problems.
• 17:47
  We call that a marketplace
• 17:49
  and one that is constantly,
• 17:51
  you know, looking for economic efficiencies
• 17:54
  within the marketplace,
• 17:56
  that, you know, embeds data interoperability,
• 17:58
  data and analytics, and real time insights Mhmm.
• 18:01
  And easy integration. We call that an intelligent
• 18:04
  health marketplace.
• 18:06
  And those and the platforms that service that,
• 18:09
  you know, sir can certainly,
• 18:11
  help to drive down the the kind of,
• 18:13
  I guess, the retail mindset that we see,
• 18:16
  our consumers employ in in platform based businesses
• 18:20
  like Uber or like Amazon
• 18:23
  and,
• 18:24
  bring those those realities to to our industry.
• 18:28
  Yeah. And I think the key is, as
• 18:30
  you said, that this isn't going anywhere. Right?
• 18:32
  That consumer mindset is most likely going to
• 18:34
  continue. And I love that you mentioned the
• 18:36
  mindset piece because that's something that needs to
• 18:38
  change for a lot of folks is really
• 18:40
  thinking about those type of trends, those types
• 18:44
  of issues and being able to do that.
• 18:46
  Arty, thank you so much for being here
• 18:48
  today. I feel like we could go on
• 18:50
  for another half hour. I love this topic.
• 18:52
  It's so interesting because it really shapes the
• 18:54
  future. Thanks so much for being here today.
• 18:57
  Yeah. No problem. It's great to be here.
• 19:00
  Great to have you. And we also want
• 19:01
  to thank our podcast sponsor, Mackerel Health. You
• 19:04
  can tune into more podcast episodes from Becker's
• 19:06
  Healthcare by visiting our podcast page at beckershospitalreview.com.