Speaker 1: 0:00

How can advisors help clients and plans deliver better health outcomes, outstanding member experiences and healthier, happier lives? We'll find out on this episode of Shift Shapers.

Speaker 2: 0:13

Change either 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: 0:35

And to help us answer that question, we've invited Kate Grohall, co-founder and vice president at Holista. Welcome, Kate.

Speaker 3: 0:42

Thank you Good morning.

Speaker 1: 0:44

Good morning. Thanks for being here. We appreciate your time. We always like to start with the question of how your journey began and how you ended up doing what you're doing, because everybody's story is interesting, so would you share some of that with us please?

Speaker 3: 0:56

Sure, I'd love to Thanks for asking my journey. Let's see here. I would say my healthcare journey as a career started when I was doing my undergrad at a state university here in Wisconsin and I was fortunate enough to land a student position in this very large teaching hospital, UW-Madison Hospital and Clinics, and students sort of roamed around and went from department to department, being helping hands in whatever way those departments needed. We were cheap labor at that point and it was on campus so I could get there on the bus and they paid really well and I could eat in the cafeteria. It was a good deal and I was exposed to just a plethora of different specialties and, most importantly, exposed to the patient experience. A lot of times I was escorting patients here and there in this huge hospital. They were nervous, they were feeling a little lost and that hit home with me Fast forward. I took that sentiment into additional career stepping stones of mine. I got my undergrad actually in industrial psychology, which is basically corporate culture. It's not even a degree anymore.

Speaker 3: 2:27

I now hold my master's in quality theory and as I was going through healthcare and different career positions, quality became a huge area of interest for me. And as I got my master's degree in quality. That was due to what I saw patients experiencing along the way, either from the complexities of their insurance, the complexity of receiving care, wanting to be able to trust and understand quality, but having no idea how to identify it. And so what I learned is very simply, this Quality is reducing variation and making something of value more predictable.

Speaker 3: 3:26

Lots of other definitions out there in the highways and byways. I think everybody wants to put their spin on it, but that's the true definition of quality, and you can apply that to variation in cost. We know the US healthcare system. The variation in cost is 15 standard deviations from the mean. It's huge, which makes it unpredictable. And the same thing with quality. I have worked with physicians through my entire career and I have come to understand and this was told to me by an orthopedic surgeon that C still equals MD, meaning that there's huge variation and the consumer has no clue whether their provider is the C student or the A student.

Speaker 1: 4:21

It's like the old story about what do you call a person who graduates last in their class at medical school?

Speaker 3: 4:27

Yes, I've heard that one too. That holds true. So over the years I've taken my observations and my learnings and the skill set that I acquired from my education and I have applied it to healthcare and I've been blessed to take all of that and bring it forward into Holista as a co-founder. So it's all built on reducing variation of cost, reducing variation of clinical outcomes and reducing variation of that patient experience. That package comes together and brings forward not just high quality but immense value at your fingertips.

Speaker 1: 5:20

When you talk about reducing variation, it seems that this entire industry and remember, I've been, as we discussed offline, I've been on the TPA side of this as well so this entire industry is one giant pot of variation. What's the problem you set out to tackle first? How do you even? Do you just eat that the same way? You eat an elephant one bite at a time? And if so, how do you figure out what the first bite ought to be?

Speaker 3: 5:47

Yeah Well, I not to use a cliche here, but I really I do approach it as a three-legged stool. I couldn't choose, is my answer, david. Choose is my answer, david. I couldn't choose where to start because to me the patient experience, the provider experience and quality and the cost of healthcare are all equally important and interdependent. And so I chose all three at the same time and I'm so glad I did, because of the interdependencies.

Speaker 3: 6:29

If we're reducing the variation in the quality of care and we're reducing risk associated with clinical outcomes, then we're inherently going to affect patient experience and the cost of care, going to affect patient experience and the cost of care. So if I had to say where did I focus first, keeping the other two at my shoulders, was providers. Providers have become disenfranchised, providers have been commoditized and that has affected the cost of care and the impact on patients and their experience. So remember, at one point in time folks were talking about the value of the provider-patient relationship, the provider-patient relationship, and then we eroded it and I think that's a travesty. So we set out to pull that back together, looking at quality metrics for providers that go well beyond NCQA standards.

Speaker 3: 7:41

Most folks, ncqa is an insurance requirement, right, and it's a check the box and when we check boxes, we check boxes. We really don't impact anything further than that. So, according to NCQA, you need to credential a provider in order to bring them into your network. And if you looked at the NCQA criteria if I were to sum it up you haven't killed someone in the last 90 days and you have an active license, you're in, you're good Holista. As a licensed TPA, we are held to the NCQA standard, so we go through and we check those boxes. But then we say, okay, that's not good enough and we dig further into how providers follow best clinical practice and we have all kinds of quality metrics that we have available to us and about 15% of the time that we are pursuing a provider to participate in our network, they don't make it into the network because of missing the quality metrics. But they would have gotten into our network if we stopped at NCQA.

Speaker 1: 8:57

So what are some of those additional quality metrics that you're looking at that NCQA isn't focused on?

Speaker 3: 9:02

Yeah. So folks will say oh okay, kate. So you look at things like Medicare and what Medicare puts in place for quality metrics, and the answer to that is yes, that's a piece of our scorecard. Simple things like infection rates, readmission to the hospital after a procedure, all of those things that are already being measured. But again I said, but that's still not good enough. So NCQA, medicare, and now Kate's proprietary formula pulls all that in and says but you know what else?

Speaker 3: 9:46

Quality matters when it comes to how providers work as a team or co-manage patients. Quality matters in how providers schedule patients. Quality matters where that provider is willing to engage their team, their nursing team, with the holistic team to shepherd patients along best clinical practice. We can have all the clinical protocols in the world, but if we don't help patients do their part to reduce their risk of getting an infection, reduce their risk of falling in their kitchen after they've had their rotator fixed, then we're missing out. We need to bring the provider and patient experience together as a team to drive down risk and drive down variation, and so I have devised a system for measuring that stuff too. Now we have a set of metrics that really capture reduced variation and improved member experience, reduced risk of a poor outcome and reduced cost.

Speaker 1: 11:05

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Speaker 3: 12:56

Well, you know what? And yes, it sounds like common sense, but it's a lot of work and folks in this industry are not interested in doing that hands-on work. To be quite frank with you, we have an entire call center of nurses and MAs that are working directly with patients. We've invested in an app because everybody has this thing in their hand. It's the best communication tool for real-time care.

Speaker 3: 13:30

And so, if you think about the experience outside of what I'm describing to you, that we do here in our episodes of Care at Holista, well, oh sure, you can talk to your provider about geez, my pain is significantly increased. I can send a MyChart message, or I can call and go into voicemail and then maybe hear back from the nurse at 7 pm, because that nurse has been rooming patients all day long. Or I can answer a pain question on my app that was sent to me in the morning time and say, ooh, it's increased now and get an immediate feedback. We are a soundbite society looking for immediate feedback and if we don't get that, we're going to end up in the ER. And then, when the nurse calls us at seven o'clock at night, I want to say, oh well, thanks for getting back to me, but I already got my prescription for narcotics and I'm resting comfortably on my couch now. So it's real-time communication and that's hard work and it's an investment.

Speaker 1: 14:38

It's also changing behavior, isn't it? Oh yes, it's also changing behavior, isn't it? Because a lot of folks I've said on this podcast before, a very wise physician back in the old old days when I was still selling, said something to me that I've never forgotten, and he said David, doctors will get off their pedestals when patients get off their knees. We're so accustomed to getting a call back at 7 o'clock because the nurse has been rooming patients all day long. How do you go about helping to change the behavior at the employee level?

Speaker 3: 15:12

Yeah, that's a difficult one.

Speaker 1: 15:16

Behavior always is.

Speaker 3: 15:18

Yeah, it is. Folks are really upset by how expensive health care is, how many dollars they see coming off of their paycheck and still, when they go to receive care, having to pay even more money. But wait, I paid my premium. Well, that's just to get you access. Yes, to go to the provider, not necessarily the provider of your choice, the provider where you're being told you have to go without any quality backing, so on and so forth. And so still today, money talks. Working with folks that are benefit consultants, folks that are benefit consultants, helping them put plan design in place, removing co-pays and deductibles for accessing high-value care, such as what we offer, reducing premiums. We're coming full circle, david, right, this is starting to feel a little HMO-y, right?

Speaker 1: 16:23

I'm sure that's where we got in trouble in the first place.

Speaker 3: 16:26

Exactly so. We need to be careful about that slippery slope. We want patients to be engaged and to change behavior, but not make it so arduous and scary that they slip into old habits. So I call that shepherding and educating and being at someone's fingertips when they need you. So it's quick access, it's education and helping them get where they need to go and save money. I will tell you, the most effective incentive today, beyond forgiving copay and deductible, is, if they participate in the value-based plan or the value-based option, that the money coming off of their check, as in premium dollars, goes down. They see that as an immediate raise, and it is. It's putting dollars back onto their kitchen table. Right, but there are things they need to do to receive those premium concessions. So we work with brokers and our TPA and PPO partners to make that happen.

Speaker 1: 17:48

HMOs weren't inherently evil. The whole notion of having a medical home is something we're still talking about. It was really, wasn't it, when the quants got involved and the accountants got involved and started saying, okay, well, we can make more money if we deny the care, if we don't give authorizations for referrals et cetera. Is that kind of where that erosion that you talked about earlier started?

Speaker 3: 18:11

Yes, it took the care experience away from the patient and the provider and then, as you said, put it in the hands of those that had a vested interest in stakeholders. I'll call them stakeholders.

Speaker 1: 18:27

So give us an example of how a value-based network like what you folks are doing helps kind of reverse that trend. How does that maybe start to mend that relationship a little bit?

Speaker 3: 18:56

Yeah, from a financial standpoint. One differentiator is I am no longer a believer in the financial mechanism called a PEPM, which means folks in the ecosystem, a stakeholder. Maybe it's a PPO who holds the network, maybe it's the TPA, but that PEPM means they're getting paid regardless of producing any work product. Right, that is a number one slippery slope. It also muddies the water of being able to measure work product and the quality of that work product and the value of that work product, because now it's just this is what you're going to get paid. Everything else is kind of loosey-goosey underneath and you're incentivized to do less work so that you get more headroom between your payment and your cost.

Speaker 1: 19:44

Which makes it actually, in a way, worse than what we usually point to, which is capitation being the fulcrum on which this seesaw started going downhill. You believe the PEPMs are even worse.

Speaker 3: 19:58

I do. We do not charge a PEPM, which has been a huge differentiator for us, so the employer will say so in order to get access to better care at a reasonable price. We are not a race to the bottom, but better care at a reasonable price and happy employees because it was a great experience. We only pay for that when we use it. True statement when do we sign? Actually, don't have to sign anything, so it's really realigning incentives according to, as you mentioned, david, behavior change.

Speaker 1: 20:42

That's really the key to all of this, and I suspect that some of it is going to be generational. Baby boomers like myself have a completely other than those of us who've been in the business that are jaded. Baby boomers have a very different view of the system than some of the younger folks do, especially when it comes to using technology. They were born with a mouse in their hand. They were born with a mouse in their hand. They were born with a smartphone in their hand. You know I saw a graphic the other day that if we had to carry around all the gear that a smartphone has replaced, we'd probably need trailers on our cars. It's really crazy, but they're used to it. It's their way of communicating. Fast forward. You know five years. What do you see when you look out over your horizon?

Speaker 3: 21:32

Well, that's an interesting question because everything is happening so quickly. Five years ago I would have not imagined we are where we are today, and that's a good thing. It's accelerated, yay. So five years from now, as far as the healthcare landscape, healthcare doesn't move quickly. We're able to move quickly because we've used technology. But the rest of the healthcare space, I mean we still have providers using paper charts. Okay, we have value-based folks that are still asking providers who are participating in a bundle payment arrangement to submit a paper invoice a paper invoice. So while the concept of having a bundle payment arrangement is kind of new, it's been around for a long time. We're still not leveraging technology. So I would say my hope is that there's more integration with technology and there are some alignments of incentives. That's my hope. I think five years is a short trajectory for that.

Speaker 3: 22:55

I also believe that employers are going to go from being in the back of the bus to the driver's seat and that is going to force everything in between to change their behavior.

Speaker 3: 23:09

Employers have been on the receiving end of horrible renewals year after year after year, maybe getting a fee-for-service-with-lipstick sort of proposal that, by year two, looks the same as the previous plan they were on and that's not good enough, and employers are finally voicing hey, this is not good enough. Employers are starting to do direct contracts with providers. That's making a statement. It's also dangerous. There's been some not so good things happen with that because employers that are, let's say, a printing company what do they know about holding a provider accountable to quality of care? They're really just trying to get a provider that will sign for something that they feel is affordable. So that's a slippery slope, but I understand why they're doing it. They're just so fed up. So hopefully we'll get some critical mass in the next five years of folks that are great partners in the value-based space, supporting employers' ability to be the decision maker and have folks like ourselves helping them make really wise decisions versus desperate decisions.

Speaker 1: 24:29

Well, as somebody once said, power is never given, power is always taken. And hopefully we're coming to a confluence of events where that kind of change that different seat on the bus, to use your analogy will actually happen, because it's way past due. And if it doesn't, I wonder where the bus is going to end up.

Speaker 3: 24:48

Yeah, it's concerning, but I remain hopeful.

Speaker 1: 24:53

And hopeful is a great place to end our conversation for today. Kate Grohalk, co-founder and vice president at Holistic Kate, thank you so much for a really engaging conversation.

Speaker 3: 25:03

Thank you, david, my pleasure.

Speaker 1: 25:10

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Speaker 2: 25:28

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