Speaker 1: 0:00

Plan design has evolved beyond things like reference-based pricing and other first-generation alternatives. What's new, what's coming down the pike, and how has a personal experience informed one of our industry's foremost disruptors? We'll find out on this episode of Shift Shapers.

Speaker 2: 0:18

Change either energizes or paralyzes. The choice is yours. Energizes or paralyzes, the choice is yours. This is the Shift Shapers podcast, bringing the employee benefits industry interviews with individuals and companies who are shaping the industry shifts. And now here's your host, David Saltzman.

Speaker 1: 0:40

And to help us answer that question, we've invited David Contarno, president and founder of ePower Benefits. Welcome, david. Hi, david, thanks for having me. Oh, it's our pleasure. Thanks for being on the podcast.

Speaker 3: 0:51

I'm honored. Thanks for having me.

Speaker 1: 0:53

It's our pleasure. We've talked a lot and frequent listeners to the program know that I'm a huge advocate for direct primary care. I think I may have written my first column about it 15 years or more ago in Life Insurance Selling Magazine, which doesn't exist any longer. How do you scale that? Because we have a paucity of DPC practices, although the docs who are in it and do it well love it, because that's why they went to medical school was to practice that way, not to deal with all the malarkey of the insurance carriers. But we also have DPC deserts and lots of them. So how as attractive as that sounds and as much sense as it makes and it certainly makes sense how do you scale it?

Speaker 3: 1:34

Well, I will tell you, those deserts are getting smaller and far, far less frequent than they used to be. As a matter of fact, I would argue, the only place where we truly from a reasonable standpoint and listen, some employees' expectations are just not reasonable, and I'll explain what I mean by that in a second was in Grand Forks, north Dakota. There was nobody for hundreds of miles, and there are some really fantastic either mobile units or virtual DPC options that are almost as good as the in-person, and I want to segregate that from telemedicine. Virtual DPC is you're going to establish a relationship with a doctor. You're going to reach the same doctor every time, and when something needs to be done in person, like they need to listen to your chest or they need to draw blood, they're going to coordinate with someone locally on your behalf to get that part done.

Speaker 3: 2:27

It's not ideal. For a lot of people, especially my generation and older, they prefer that in person, but it's actually relatively rare. So let's talk about there are less DPCs than there are traditional primary care doctors. For sure. One of the things that I never saw occurring in my career that brings me a lot of satisfaction is when I happen to come across an employer that has enough employees or patients in an area where I can convert a fee-for-service provider and help them open their own DPC practice. And now I'm actually improving the lives of doctors, which is not anything I ever foresaw as being part of my career in this industry.

Speaker 1: 3:03

Well, and that's a back to the future thing, I mean, if you go all the way back to places like Kaiser, it was onsite and nearsite. It was clinic-based, which I guess is probably a distant cousin to direct primary care.

Speaker 3: 3:14

Yeah, and listen. There are some brokers out there that regularly work with employers that can do onsite clinics. We've done a few Most of my employers. They can't justify it. They either maybe share a clinic if there are a few employers in the area or it's just not an option for them. But let's pretend for a minute that their traditional primary care doctor is 10 minutes down the road and the closest DPC is an hour away.

Speaker 3: 3:38

Well, you have an 11 o'clock appointment with your primary care doctor. Now let's assume that you called because you were sick. It's what. An average of 17, 18, 19 days to even get that appointment. So you're waiting two to three weeks before you even get that appointment.

Speaker 3: 3:51

But you show up for your 11 o'clock appointment and what happens? You're there for, let's say, a urinary tract infection, but you're sitting in a waiting room full of sick people and it's 45 minutes past your appointment time. You're 45 minutes past your appointment time. You finally get called into the exam room. You wait in the exam room for another 10 or 15 minutes. The door opens and who walks in? Not your doctor, but a nurse practitioner, a physician's assistant. They do the intake, then they take it, they go out, and then now, an hour and a half past your appointment time, if you're lucky, your doctor finally walks in. You get 7 to 11 minutes and then you're out the door. So it's a total, including travel time, of a two, two and a half hour process and you've spent seven to 11 minutes with your doctor.

Speaker 3: 4:29

Versus a direct primary care office that's an hour away. You spend an hour driving there although you'll have to physically go there far less often than you would a traditional primary care doctor but you spend the hour getting there. You don't sit in the waiting room at all. You get brought right back into the exam room, you get as much time as you need with your doctor and then you drive back. You're probably back to the office in almost the same amount of time as you were before, but now you've spent 30, 45 minutes, maybe even an hour, with your doctor. You've gotten real, genuine care and, by the way, you've paid no copay, no deductible, nothing out of your pocket.

Speaker 1: 5:00

It's the real, genuine care piece that I think really matters. Not too many years ago I was up in New England and I had a direct primary care doc in York, maine of all places who was fantastic and who kept me from having a huge medical procedure called a Whipple procedure because the geniuses at MassGen, even though there were no cancer cells, thought that I had pancreatic cancer and Peter said I don't know what you've got, but I know your history. I know it's not pancreatic cancer and it took him four months to figure out what I had and it was easily treated with some long-term steroids. If I had been in a regular physician's or what we consider a regular physician's office, I would have been on the operating table at Mass General.

Speaker 3: 5:42

Yep, well, and I want to say, none of what I just said is either recent, new or game-changing. But when the doctor is directing the care from the beginning and, more importantly, it's a provider that has more time than traditional fee-for-service providers and more of an awareness of the path they're sending the patient on from a clinical and a financial perspective, that brings you an opportunity to bring education to that provider, to help direct that patient down a path where not only are the clinical outcomes better, but that cash pay environment exists. And so we work with vendors, with partners within our plan that are able to pay providers same day, help us negotiate bundled procedures in the event that we don't already have one. So in the path of this methodology and we can use it in the traditional RBP environment too. It's just a little bit more resistant and you don't get the same uptick. But imagine for a minute my back is hurting. I go to my primary care physician. First thing is we try a couple of things non-surgical. But as soon as they determine that, hey, it looks like surgery is necessary and I'm not a surgeon, they're able to refer me to a surgeon that we have given them, armed them with technology in their hands. That allows them to perhaps find someone they're already familiar with. But if not, they can actually look up providers that are operating in a high quality environment where we can show them what their outcomes are compared to their peers in terms of mortality, morbidity, readmission, reinfection rates and, at the same time, have already agreed to accept a cash pay price bundle. And then you pay them quickly. You have to have a mechanism. One of the mechanisms we use is where the member can actually walk in with what appears to be a debit or credit card on their phone and actually pay for the service the same day.

Speaker 3: 7:50

From a reference-based pricing perspective, we have had employees who are turned away at point of service. I'm sure that every single advisor, if they're using reference-based pricing, has had a provider where the patient shows up and the billing office says you're at a network with us, we don't take plans that we don't participate with. So please go and have another good day. But imagine for a minute if there was a way, even in the reference-based pricing plan without DPC because again some employers are hesitant to force employees to change their primary care physician If you were able to go and say I need to see an orthopedic surgeon. Even I want to see this specific orthopedic surgeon. And then you had a team of people that immediately reach out and say, hey, what's the best cash pay price you can do and can we schedule an appointment for this patient? And what comes back, usually within a day, to that patient is hey, your appointment is scheduled with this provider that you requested on the date and time that you said you were available. When you go, please go show this debit card. And we're now paying on average for an office visit consult, a hundred bucks total and the plan pays a hundred percent. The member pays nothing, but from the provider perspective, they're getting paid cash same day point of service, even at the office visit level, whereas so much of my quote disruptive time.

Speaker 3: 9:09

I was waiting to capture that at the time of pre-cert of some sort of significant procedure or imaging. It's so much harder to change the flow at that point. And so my experience with my surgery said hey, if you start with cash pay from the beginning, if there's a way to do that, but still embed it into employer's plan, you're going to get people who get better access to better care quicker, for nothing out of their pocket and for less money, oftentimes even than reference-based pricing out of the plan's pocket. It's one of several things that is rapidly evolving. Cash pay has been there for a while. That's not what is different here. It's one of several things that is rapidly evolving. Cash pay has been there for a while. That's not what is different here. It's capturing that pathway from the very beginning from the office visit, consult or before when it's being scheduled. That's really what's starting to change this and still allowing employees to have choice.

Speaker 1: 10:02

Well, and you raised an issue tangentially a little while ago, and that is employers or plans, fiduciary duty. One might argue that to not do something like this when presented is a pretty you know, it's a pretty bad thing to do straightforward breach of their duty to the plan.

Speaker 3: 10:21

It's much like the 401k. I mean, imagine for a minute if some employer took a specific Vanguard fund and agreed that their employees would pay a 5% management fee when some other employer was using the same exact Vanguard funds and paying a 1% management fee for their employees. There would be a breach of fiduciary responsibility. There they're getting the same thing, but one employer's employees are paying a lot more for it than the other. That's a breach of fiduciary responsibility. But that happens in healthcare all the time, and let's not forget the law that doesn't allow that. On the 401k side it's not similar to the law on the healthcare side. It is the exact identical law and it's not being enforced. That's the problem.

Speaker 3: 11:04

And so one of the things that I hope and actually, interestingly enough, just last night I was at a small function with the governor of North Carolina. I'm pretty close with our attorney general as well, and we're looking to make enforcement of this, or revocation of nonprofit status for hospitals that aren't embracing this, as well as enforcement at the employer level, a much more real reality. And that happened on the 401k side. What was it now? 10, maybe 12 years ago? And it radically changed both the transparency and the fees that employees are paying in their 401ks. It needs to just be enforced. Nothing needs to change, it just needs to be enforced and I think it would bring that level of responsibility and awareness to employers. How important it is.

Speaker 1: 11:45

The thing that needs to change is perhaps more difficult to change, which is getting both advisors and I know you work with a ton of advisors getting advisors to understand this and understand the mechanics of implementing it, and then getting an employer who thinks, okay, anything new is weird and this is like really weird because they already have insurance. Why would we get insurance? Getting them able to explain this so that mere mortals can understand how do you do that?

Speaker 3: 12:17

You know, I consider myself to be a pretty strong communicator and orator, and yet I still struggle to condense this down. It has been, I think, intentionally made to seem complex. But if you really boil it down to what it is that we do in almost every solution we bring, is we're really just changing who's cutting the check and how the amount of the check is determined and who it's determined to go to. I mean, it's really that simple. But getting employers to understand and, I think at the HR level, getting them to help employees understand this even more so this isn't being done to them, this is being done for them.

Speaker 3: 13:01

I think what's harder for me to overcome than the education that needs to go around this is this legacy of false promises that both brokers like myself and carriers have made over the years that have not resulted in the impact that they said it would result in, whether it's wellness programs, hras, hsas, consumer-driven health plans. I mean programs, hras, hsas, consumer-driven health plans. I mean the list goes on and on and on. Icras now boggles my mind because, again, an ICRA is not addressing the money coming out of the plan. And even with the governor last night in North Carolina I said and he's a Democrat.

Speaker 3: 13:35

So I used how Biden lowered the cost of insulin for seniors, right, and I said let me tell you Josh Stein is his name Biden did not lower the cost of insulin. What he did was he lowered the out-of-pocket that Medicare beneficiaries pay. But who picks up the rest of that? Well, medicare, which ultimately is the taxpayers, which ultimately is the very same people that they're trying to lower the out-of-pocket. It's not about who's footing the bill. It's about why is the bill so much? And these politicians don't get that, or at least they don't think that's what's going to speak to their constituency.

Speaker 1: 14:14

And now a word from our sponsor. You're not just an advisor, you're a game changer. Forget cookie cutter, off-the-shelf solutions. That's yesterday's news, it's 2025, and it's all about delivering bold, custom-crafted plans that truly make a difference. At the core is a razor-sharp self-insured framework, but the real magic that's in the high-impact point solutions you strategically layer in to slash costs and supercharged member outcomes. But let's be real, that's where the headaches start Hours wasted sifting through endless options, wrestling with integration issues and fighting data-sharing roadblocks. It's a time suck and it's holding you back Not anymore. Meet Benapower, the AI-powered game changer that builds killer plans in minutes, not hours. Benapower doesn't just curate the best point solutions. It makes them work together seamlessly, streamlining communication and driving collaboration like never before. With Benapower, you're armed with an end-to-end AI-enabled solution that makes you unstoppable. Spend less time piecing together a patchwork plan and more time selling your clients. Get unmatched ROI and you become the go-to advisor that everyone's talking about. Want to take your game to the next level? Visit bennaowerai or schedule a demo at info at benapowercom. Find your power with Benapower.

Speaker 1: 15:49

And now back to our conversation. Uwe Reinhart talked about this all the time when he was at Princeton. He called it hydraulic medical economics and he said look, if you've got a U-shaped tube and it's got water in it, it and you put pressure on one side of the tube, the water is going to go up the other side of the tube, but the amount of water in the tube hasn't changed, it's just been redistributed. And I think that that seems to me to be the hurdle that we've got as an industry to get folks to understand.

Speaker 1: 16:17

Where you rightly came into the story some time ago was what should be insured. That is to say, you know, I'm an old TPA, so if I've said this once, I've said it a zillion times there's only three things you can do with risk you can take it, you can share it or you can give it away. If you start with what risk should be given away and what risk should not, because each of those risks has a different cost and different outcomes, you stand a chance. I mean, is that the approach that you guys take when you try to educate folks?

Speaker 3: 16:50

It has to be. And then you also need to educate them that paying less for health care doesn't reduce the quality of care. As a matter of fact, in many cases higher quality care costs less money. There's an inverse relationship, and that does require education because it doesn't apply in most other things. You pay more for a car, you better get a better car. You pay more for a house you get a better house.

Speaker 3: 17:10

But in healthcare we find the metric that drives both cost and outcomes is frequency the more frequently that they do a particular procedure, the better they do it, the more efficiently they do it. And even within the specialties, we find subspecialties. I mean I don't want to get hand surgery from an orthopedic surgeon who mostly does feet and ankles, and so there's a lot of education that goes into it. But helping employers understand not that they need to personally be responsible for putting at least benefit design that incentivizes those outcomes, but putting the right resources in place and or rules and regulations is a responsibility and an opportunity that they have Now. Having said all that and I know we're over time on your typical podcast length there was another side effect of this that really does not get addressed, and that was the mental health side of things. A lot of people struggle with mental health in general, but I can tell you personally, when you're dealing with chronic pain and major medical issues that are either a direct or an indirect result of that chronic pain, not only does that have massive mental health effects, but every time I tried something to solve that sciatic leg pain, I think, naturally I became hopeful that it was going to work, and every time it didn't work, there was this disappointment that I didn't even understand was causing a degradation of my mental health. It was impacting both physically and mentally, my ability to run a business, to be a resource to my clients, to be a husband to my wife, to be a parent to my children and even under the best of circumstances, even with a plan that tries to cover as much mental health as possible…. Admitting, you need mental health. There's a stigma.

Speaker 3: 18:59

Accessing mental health is sometimes even more difficult than getting access to traditional medical professionals and then getting the right level and the right type of care and so another thing and when you implement plans that fundamentally lower costs for employers, it frees up a lot of resources to put into other things. One of the things that I say to employers they often ask me about wellness programs because Lord knows it's been spoken about for so long, and I say to them wellness program is not going to save you money. Just ask Al Lewis. He's offered millions of dollars to companies that can prove it. Not one has. But if we can save you money, then you can use some of that money to invest in the wellness of your employees and I think that's the way it should be looked at.

Speaker 3: 19:45

And when it comes to mental health, most people think there's two options there's going to see a psychiatrist or psychologist once a week or there's going inpatient. And those are the two options. And getting to that outpatient mental health provider especially if you have a traditional health plan and have the thinking that the only way I can get healthcare is by going through the health plan, you're going to struggle to find a provider that accepts it, is accepting new patients and can see you in any reasonable amount of time and, more importantly, is well-educated and well-trained. No question reached out to a lot of traditional types of care and I don't want to speak to those traditional types of care. I want to speak to two non-traditional types of care for a minute.

Speaker 3: 20:47

The first and I'm going to mention this company by name because I don't know of anyone else that does it, but I believe there's a level of care necessary that is somewhere between doing nothing and seeing a psychiatrist or a psychologist.

Speaker 3: 21:03

And there's a company out there and I will disclose that I'm on the advisory board because I believe in it called Shoulder, and it's spelt like a shoulder but without the U, and they're trained. They're not psychiatrists or psychologists trained, but they are trained, not psychiatrists or psychologists trained, but they are trained. And it's that level of care which, believe it or not, is the majority of care. That is, sub-psychiatry, but above, speaking to your friend and you develop a relationship with this person, you speak with them regularly. It's virtual, no-transcript Health Parity Act, so they're covering mental health now, but this is a way that's more accessible, more applicable to more people and less expensive, and so I would recommend maybe other solutions will develop, but Shoulder out there, is a great resource and I know they'd be willing to speak to any employer or advisor who's interested in finding out more about that.

Speaker 1: 22:31

Well, I mean they have to cover it, but when you start doing mental health parity reports, one of the things that is the most predominant point of failure is access to providers.

Speaker 3: 22:41

Yeah, and they may have a network which meets network adequacy and they may cover it the same as they cover a primary care physician's office. It may meet all the rules of mental health parity. But if you can't get in to see that provider, it's much like when I say to oncologists who say I shouldn't have to worry about the cost of care, and I say I completely disagree, because if you prescribe a treatment to save someone's life from cancer and they can't afford it, why did you prescribe it anyway? There's no point. And so, yeah, there's a lot of reasons to do that.

Speaker 3: 23:12

Again, sharing a personal story, I try to access and I have resources more more than many to access some of these more traditional mental health solutions and while they definitely had some benefit, there is a solution that is being talked about but doesn't work for everybody, more and more. But what I was surprised as I did research, was the clinical research that's already been done behind this, including by our own government, and that is psychedelic therapy. I am not a holistic frou-frou hippie, you know, make my own dream catcher and have my own wind chime guy. That's not the type of person that I am Watch it.

Speaker 1: 23:55

Watch it junior. That was my generation.

Speaker 3: 23:59

But anyone listening to this. I have undergone psychedelic treatment and it has changed my life. It has been a reset to a time of brain processing that was certainly pre the 18 months of this chronic pain and other things that I went through, but even addressed things that existed earlier on that I didn't know about. And there's a woman out there. Her name is Sherry Race. She owns a company called Enthea that has programs to bring this type of treatment into employer plans.

Speaker 3: 24:38

From a personal perspective, I was really struggling with mental health issues over the last year and a half and again I did all the traditional stuff and it had some level of help. I don't want to claim it did nothing, but for anyone, and I think in particular anxiety, depression, substance abuse, ptsd and even now Parkinson's and dementia, there are therapies out there that some people might consider fringe or untested or unproven, some of which are legal here in the US, some of which are not quite yet approved, and I just want to make people more aware or at least more willing to do some research into some of these psychedelics, and there are ones. Just to name a few, there's psilocybin, there's MDMA, there's ketamine Ketamine is the most commonly used in the United States, but there are other ones out there too that aren't legal here in the US. But it's something that I want to be a part of making more available to more people, especially through the employer sponsored plan, putting the right people in place, making it sure done in the right way, in an appropriate way, in a clinical way, for the right person at the right time. But it's something that we don't.

Speaker 3: 25:53

We barely talk about mental health, let alone some of these other things, and I think we have a mental health crisis. It's not just in the US. I think it's around the world. I think it's particularly bad in the US, but imagine for a minute if you're able to create a health plan that is doctor-led not carrier-led or TPA-led, but doctor-led. That incorporates better access to a better variety of mental health from an employer perspective.

Speaker 3: 26:29

So, from an employer perspective, think about what that does for your employee, and it's easy to measure claims dollars spent on an employee prescription, dollars spent on an employee, days they've taken time off, that their finances are a mess. They can't lose their job, right if they're under financial pressure, which so many Americans are, so they're desperate to show up every day and be at that job, but how good of an employee are they being? And then, when they get home, how good of a parent or a spouse are they being? And this is something we just don't talk. We know it's the undercurrent there, but we're so busy addressing the most expensive drugs on the drug list or the most expensive procedures or the most expensive chronic conditions we forget about not only these other things that can dramatically improve the quality of life but in many cases can prevent the need for those large things, and so I encourage anyone listening to this to, even if it's on their own, explore their own mental health options, recognize and not be embarrassed.

Speaker 3: 27:25

I have struggled with mental health. Let me say that again. I have really struggled with mental health and there is help out there, and if we can bring this into employer plans, that might be the most game-changing legacy I could possibly leave on this industry, which is what I want to do.

Speaker 1: 27:43

And that is an awesome place to leave our conversation for today. David Conterno, old friend, president and founder of ePower Benefits. David, thank you for your insight and for sharing your personal stories with us.

Speaker 3: 27:54

It was my pleasure. And anyone that wants to reach out, even on a personal level, it's easy to find me that wants to reach out, even on a personal level, it's easy to find me.

Speaker 1: 28:05

I want to give a quick shout out to our sponsor and our producer, hatcher Media. Hey, if you need podcast production or professional graphic design, josh Hatcher is the expert to contact For more information. Visit him at hatchermedianet. That's H-A-T-C-H-E-R Media dot net.

Speaker 2: 28:23

This Shift Shapers podcast is copyrighted content and may not be reproduced in whole or in part without the express written permission of Shift Shapers Solutions LLC. Copyright 2024.