Latest / Break The Cycle / Are the Claims Really Just the Claims?
Transcript
- Sarah Michaels (00:00): Claims are not just the claims. Just because you have a bad claim here does not mean there's not something we can do about it. Yes, I cannot prevent a NICU claim from happening or a cancer from starting, although I really wish I could. I unfortunately work with people on typically their worst days of their lives. People aren't calling me for a feel good story all the time. Usually it's I have this horrible news and how can you help me? And I absolutely love that. I get to walk alongside them in those moments, but claims are not just claims because the reality is if you dig into the claims, there's a story behind that. Josh Schumacher (00:32): The employee benefits industry has been stuck in a cycle that keeps costs rising and plan members underserved. But there's a better way forward and it starts here. Welcome to Break the Cycle. Sarah Michaels is a nurse by training and chief clinical officer at Kinetiq Health. I asked her point blank why an entire industry keeps repeating the same line, "The claims are just the claims." This episode is a bite-sized version of our longer conversation earlier this season, and we're focusing on the hard questions leaders should be asking. Yeah. So cost of claims are the claims as a way that I've heard you kind of phrase this before. Yeah. So talk to me a little bit about what employers are experiencing with claims. Talk to me about what's really driving the cost of some of these claims because I'm sure many employers, many people listening in the room know that when someone has a NICU baby or when unfortunately cancer hits their plan, it's going to be really expensive. (01:28): But can you talk to me a little bit about what's going on there, what employers are seeing, why we've gotten to the statement, the claims are just the claims? Sarah Michaels (01:35): Well, you've heard me speak about that because I hate when people say that. That is such an old way to look at it. Claims are not just the claims. Just because you have a bad claim here does not mean there's not something we can do about it. Yes, I cannot prevent a NICU claim from happening or a cancer from starting, although I really wish I could. I unfortunately work with people on typically their worst days of their lives. People aren't calling me for a feel good story all the time. Usually it's I have this horrible news and how can you help me? And I absolutely love that. I get to walk alongside them in those moments, but claims are not just claims because the reality is if you dig into the claims, there's a story behind that. I don't think any employer group these days has a data problem. (02:17): And in fact, we have quite the opposite. Josh Schumacher (02:19): So it sounds like a very complex situation where you almost need an understanding of the clinical side of what's going on to tell that story, to tell the story of what's going on in the claims. For those people sitting there wondering like, okay, well, so is it standard practice to have a nurse and a pharmacist have these people on staff to look at that? Because frankly, kind of sounds like without that insight, you don't really understand the story of what's going on. So why have brokers, why have advisors in this space, why do they not all have a clinical team just as a rule to try to dig into that story, try to understand it better? Sarah Michaels (02:56): It's a really good question and I wish I had the answer to it because we've seen over the past six years of doing this, the impact clinicians can have when they're in the claims data. We've been able to keep claims averaging a nearly flat increase and that is against all of these major hospital systems and drug systems that keep increasing all of their rates. So that's a true testament to what you can do. And yes, you're right, it is a challenge, but at the same time, it's not as hard as people think. All we focus on is I have to improve these specific individual's lives. I'm not talking about a thousand plus lives. Sometimes I'm talking about one person. And from an HR side, that's the feel good story. I can share a story. One of my favorite stories last year was we had a member come to us that was diagnosed with a late stage of cancer and unfortunately told by the health center that they're going to have to enter hospice care and palliative care. (03:51): There's absolutely nothing that they can do. And they came to us thankfully and said, "We just want a second opinion." It was somebody who still had a lot of life to live and they just wanted to give their family full news. And so we were able to use referrals, get them to the leading cancer center here in the Midwest within 48 hours of that call, which is just incredible. And not only did they have that appointment, but they left with a treatment plan and they left with news that this diagnosis is not fatal, that they will survive this cancer, and they have been actively in treatment ever since living their life. And so those are the stories that you will never be able to put a price tag on, but that person will always be loyal to their employer group for creating this relationship. Josh Schumacher (04:37): Yeah. So I love the stories that you get to share and you've impacted so many people. I think as a clinician, you're always jumping to, "Hey, here's how we solve this problem. Here's how we solve this problem." And I love that. I want to jump back first though and kind of summarize where a lot of people are probably at right now in the industry where they are still in this mindset of the claims are just the claims, the claims hit and they might not have a clinical team, they might not have access to these solutions. They're sitting there going, "The claims are just the claims. I can't really do anything about this million dollar plus claim that comes in. This is just a part of my experience." What I'm hearing you say is that's not the case and there are things that we can do about it, right? Sarah Michaels (05:17): There absolutely are things. Again, you can't always prevent what has already happened, but you absolutely can influence what's going to happen. And so it's about creating those intervenable moments and figuring out where can I actually take action to be proactive in managing your financial risk, which oftentimes benefits are the second highest line item on any company. And so if we don't have a strategy in place to manage that risk, I think we're doing it wrong. Josh Schumacher (05:46): So we've covered a lot of ground today. We've started with what's broken with the healthcare, the benefits system. We've talked about the fact that every employer, especially those HR people who are on the front lines, want to do something about it. They want to take care of their people. And we've also addressed that there's not a data problem. It's an understanding of what story is that data telling you. So as we walk away from this conversation, what would you advise someone who wants to start to understand the story their data is telling them? Sarah Michaels (06:15): Yeah. So if you already have the data, take the time to actually look for that story within your own group. Ask the question, what is truly driving my claims, whether it be at a group level or at that individual level, and then take it one step further and say, now that I know what I know, what can I do about this? And what people don't realize is by taking that extra step, you might be changing somebody's life because you're improving their lives. And that's the best feel good story you could have. Josh Schumacher (06:45): Yeah, I love that because for anyone listening, they're probably watching their trend line year after year, just keep climbing up and to the right and they feel like there's nothing they can do about it, but that's not true. They can actually get an understanding of their data, get an understanding of their story and start to bend that trend line in the right direction. Well, Sarah, thanks so much for joining me today. I think this has been a really enlightening conversation for me, hopefully for the audience as well. Remember, you don't have to keep repeating the same outcome. You are built for better and we're here to help you see how you can break the cycle. Thanks for joining us for this episode. For more on how to break free from the cycle of rising costs and painful renewals, subscribe wherever you get your podcasts.