Framing The ROI Question

David 0:00

Is attempting to control change and cost through well-being initiatives a viable approach? We'll find out on this episode of Shift Shapers.

Announcer 0:09

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.

David 0:29

And to help us answer that question, we have invited one of my oldest and dearest friends, Ashley Rakowski, Vice President of Sales, at Navigate. Hey, Ashley, what's kacking?

SPEAKER_01 0:38

Hey, David, thanks so much for having me. I'm excited to be here and chat with you more about what I'm doing these days.

David 0:45

It's it's our pleasure. And it, you know, it's something that I think a lot of people misunderstand going in and misunderstand going out and aren't really sure what the outcomes should be. And so we're going to get them all straightened out today and forever they will know what they need to know. So let's start with, you know, one of the things that I always crabbed about all the well-being issues is that it's hard to get a demonstrable, repeatable ROI for folks. Um, and I know that that's, you know, one of the industries, one of the knocks on the industry. And I know it's something that you've been working on, but you know, why do you think that's failed so often? And what has to be different so that it isn't?

Why Old Wellness Models Failed

SPEAKER_01 1:24

So I'd say my core point when I talk through this is well, being failed when it was treated as like an engagement theater instead of being a behavior strain change infrastructure. So so often it was how do we get people on like downloading the app or really just knocking on the door? And it wasn't really to drive actual change. No one was tracking that change. And so historically, when we focused on awareness, incentives, or one-off programs, it's like great, you did some step challenge and now you get dollars towards buying a$25 gift card or whatever the award was, but it really didn't drive any change. People worked the system for that. And awareness doesn't change behavior. Incentives create short-term spikes, not durable habits. So for cost containment to actually work, which I truly believe well-being is the first step in cost containment, it only happens when it's tied to ongoing coaching and clinical prioritization and measurable behavior change. When you treat well-being as part of how care is delivered, not a side benefit, it really does start to utilization, it starts to influence utilization and downstream claims. So I use a lot of examples. If someone has COPD, for example, and they still are smoking, tobacco cessation really will drive those claims. And we look at because a member has participated in tobacco cessation, what else is it affecting? Now we're not seeing as many metabolic disorders or diet anything along those lines because they are participating in something that truly is driving change and they're aware of it and they're do taking the steps to change it alongside a coach, whether that is AI or whether that is a human being.

David 3:12

So how do we get that to translate into an ROI that somebody can go to an employer group and say, this is worth doing?

Behavior Change As Cost Containment

Turning Claims Into Proof Of Impact

SPEAKER_01 3:20

So when we look at it, we can't predict an ever event, right? We all know this. We can't say because I did X, I predicted I avoided this heart attack. But what we can do is show that because these members are going to doctor, they're losing weight, or whatever the different measures are for that particular illness, we're able to track how when claims ingest, how claims are showing that that member doesn't have as high of a cost and that behavior is driving those claims costs down. First year someone does wellness, it's the first year. We're not going to see a ton of movement in claims in first year, but we do the look back going into year two and say, look at what we did change. It's like anything. Stop loss of first year of a self-funded client. We have to be able to do a look back. We don't necessarily know. And so going into year two and year three, as you start to see more members participate, you start to see the claims drivers go down and we're able to show that.

David 4:17

Can you give me an example? I know you talk a lot about condition management coaching. Can you give me an example of like how that works and how that then translates into results?

SPEAKER_01 4:26

Coaching helps people make decisions repeatedly over time, um, that decisions wouldn't necessarily be the same decisions they'd make on their own because they need that education. So most people already know what they should do, right? That's not the problem. I know I should go to the gym and lift weights. The problem is I don't have accountability. And so when I commit to just like in well-being, when you commit to a coach, you have that accountability, that person to talk to. Whereas when I go to the gym gym and I commit to a trainer, I now I'm like, ugh, 8 a.m., I don't want to do this and I don't want to do that exercise. But I've got a person there pushing me. And coaching is very similar. The problem really is consistency, confidence, and decision making under real life pressure. And so, how does that coach give them that knowledge and that support to do that? And it creates all of those things. And it's personalized to what's going on with you, not necessarily what's going on with someone else. My coaching is very different than David's coaching. And that's the point. It should be personalized, especially for chronic conditions. Change happens through really small, repeatable decisions that are supported by someone who understands both behavior and health. Look, again, going back to that COPD example, someone that smokes, that's a behavior, but it does drive health outcomes. But why do they still want to smoke? There's something more intrinsic there. And that coach is there to help with that accountability. And if the member doesn't understand why that still is such a huge desire for them, the coach works through them. And maybe it's mental, maybe it's some other trigger within their own lives, but it really helps them focus on what can they be doing different and why this is driving them to do so. So, cause it's likely not just putting a cigarette in your mouth and the tobacco. It's to make sure that you're covering all facets of life.

David 6:22

So I think most people would understand that intellectually. But then there's the next hurdle of trying to explain to an employer how that actually drives claims, shows up in the claims data in a way that's not bombastic and oversold because they heard that with the first iteration of wellness that we talked about earlier. How do you do that? What's that conversation like?

Coaching For Chronic Conditions

SPEAKER_01 6:44

So, as I said earlier, like it's not, it doesn't flip overnight. Lifestyle doesn't change flip claims overnight. It changes trajectories. Uh, employers always expect immediate claims reductions, which is unrealistic. So we set that everyone should be setting that expectation first and foremost, that it's not realistic. Claims reductions don't happen tomorrow, just like anything else. If you go have ankle surgery to fix your ankle, that's not going to heal tomorrow. It's going to move that forward. When we what we see are leading indicators, medication adherence, control, condition control, fewer acute escalations. So I, as I continue to use COPD as example, there's not a hospitalizations that we don't have the claims for. Over time, that translates into fewer high cost events, delayed progression, and more appropriate utilization. The goal isn't zero claims, it's fewer preventable ones and better managed chronic spend. So a COPD or diabetics, managing those and making sure they're adhering to them. The average time that a member spends with their physician today is seven minutes. It's not that's not enough time if someone is diagnosed with diabetes to have a conversation about what that means. They write them a script, the member goes and takes the script, and that's it. So when we get claims ingestion for anyone with claims ingestion, when is that condition most top of mind? It is most top of mind when you have the original diagnosis, not six months later. So stepping in with a coach that says, do you understand what this means? Do you understand what lifestyle changes you have to make? And most times they don't. So now we're coaching with diabetes to make sure that they understand what they need to eat, the exercise, what that medication is truly doing. And you'll see members now no longer have claims, not just for basic medication, but for other scenarios or other conditions because they're able to keep those under control with diet and exercise. And maybe they still need the medication long term, but really understanding what that disease management is for them, and that's where that change comes in.

David 8:59

You know, we're we're drowning to take the point a little bit further, we're drowning in claim spend on chronic conditions. You know, the it's kind of like the good news and the bad news all in one, right? What used to kill us doesn't. Correct. But we just stay sicker longer. And there's loads of reasons for that. And we can be cynical and talk about the pharmaceutical industry and all of that stuff. But I think since those claims are identifiable, the question is when you start with a client, when you onboard a new client, do you actually look at claims data and identify stuff to work on up in advance and then point that out to the employer? How does what practically how does that work?

SPEAKER_01 9:34

Yeah. So we will, if we can get the claim, the backlog of the claims, obviously we know some carriers are not as amenable to releasing those. But with self-funded clients, especially, this is where we see it happen most often, is we go do the look back and we look at what is going on with the member today or members today and how we can affect change. We will guide them on what programs will work for them, how we integrate with what they're currently offering. There are so many today, there are so many point solutions out there for cancer, for diabetes, for MSK, for mental well-being, for behavioral health. It's how do we integrate with them and how do we use what we're offering? One, to be the most cost efficient for the employer, but also provide the best benefit for the member. And so we work with that employer at onboarding in order to develop what is best for them, because what's best for company A is not going to be best for company B. And we have different verticals that our account management focuses on, and not to talk about navigate specifically, but there's verticals that understand like professional services are different than manufacturing because manufacturing are on their feet moving around all day, and a lot of professional services are not. And so, how do we make sure that those guidelines fit for that company and what is going on within their own claims?

David 11:01

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Setting Realistic Employer Expectations

SPEAKER_01 12:42

So when we talk about GLP ones first and foremost, they're treated as a clinical tool. They're not necessarily just a one-stick solution, pun intended. So they can't be that standalone solution where someone, it's a magic pill, essentially. So they can be effective, but unmanaged creates cost volatility and poor long-term outcomes. We've heard so much about people getting on a GLP one and then gaining all this weight back. Well, what that means is they haven't changed their lifestyle. And so we've put guardrails around where you automatically participate in a coaching management uh platform and with a weight management coach in order to be able to make those changes. I love examples. I know you know this. So I am gonna go back to another example of a husband and wife. They both went on a GLP one. The husband changed his lifestyle. He bought a Peloton. He rode the Peloton every morning before work. And then, because he could only consume certain like amounts of foods, he started eating really lean proteins and leafy greens and being very conscious about what he was ingesting. And he lost weight. At the end, all total, 170 pounds. The wife, GLP1, didn't change her lifestyle. Couldn't eat a ton, decided I'm gonna go lay in bed and eat this ice cream. And she was lost weight, of course, because that's what the GLP one does, but she didn't change her lifestyle. One of them is off of the drug, maintaining or within a small fluctuation, and the other is still on the drug because there's no guardrails put around. Coaching supports nutrition, movement, and tapering strategies so results don't disappear when that medication stops. And the combination reduces the churn, inappropriate use, and long-term dependency. We don't want people staying on these drugs for long term, nor do employers. And so, how can we put those guardrails around and make them participate? And that's what we're seeing become much more prevalent instead of just taking them off of their formulary. Now you have to do these things in order to earn that.

David 14:54

So is one of the things that the coach works on with the with the client the a way to understand that this has to be durable and not medication driven? Is that is that kind of the entry point to say, yeah, you can do this and the medication can help, but correct.

SPEAKER_01 15:11

So the weight loss management program is built for those that take GOP ones and those that don't. So it is teaching them new lifestyle habits that, yes, this drug can be beneficial, but you have to change your lifestyle and how helpfully understanding them, what decisions they're making on a daily basis. For example, I don't buy potato chips because they're in my house and I will eat the whole bag. I know that about myself. So I make the conscious choice to not put them in my house. Do I have a snack every now and again? Yes. Or my dad, for example, same concept. They bought the snack bags. So that way he still gets the satisfies of having the chip, but he limits himself instead of just grabbing handfuls and handfuls. And those are the kind of changes that we teach the members, and that really drives that change, not just a GLP one fix.

Onboarding With Claims And Integration

David 16:03

Well, and it's also practical. I mean, it it's it's it's how you change behavior or you do it a little bit at a time and you find devices that that work for you. It's like remembering what a RISIS stands for by a mnemonic or or whatever. So um that I guess is one of the things that helps rewire your brain to understand what's going on. It's not just take a jab or take now, you can take a pill, I guess, as of last week. Um, there's there's more to it than that. And I when that starts showing up in results, um, do you is that that another way that you got you can, you know, you get the claims information and you'll sit down with an employer or the broker will sit down with an employer and say, okay, kids, here's what we did and here's what the delta is.

SPEAKER_01 16:45

Absolutely. But success isn't just weight loss alone. It's sustainability. Short-term weight loss without habit change is expensive and temporary. Example one, you take the GLP1 shots, you get off of it, you gain all of that plus some back. Real success includes improved metabolic markers, healthier routines, and reduced reliance on escalation. So those metabolic markers are incredibly important. What we found, and I think this is things we automatically know, is that if you lose weight, everything starts to get better. It's not just about the weight loss. It's you're now not no longer pre-diabetic, you, your metabolic disorders have changed. We look at education, engagement, durability, behavior adoption, and long-term health indicators. And those are what we talk about with our consultants and our clients. And that those are information based on the claims, what we go back to that employer and say, this is what we've done, and this is what success looks like. The question is not, did they lose the waste, but are they healthier a year later? And the answer nine out of 10 times with the coach and guardrails, the answer is yes.

David 17:56

So you see a lot of groups and you guys are in the larger group market, so you get really statistically significant samples. What mistakes are employers still making?

Sponsor Message

SPEAKER_01 18:06

They buy tools rather than systems. Everybody can plug in. We know there's an abundance of point solutions and just look at PBMs. There's 66 PBMs. They all have something. If you don't utilize them correctly, you just plug in these tools, then what are we solving for? Employers stack solutions and expect them to coordinate themselves, which is not the case. They have to work together. Without integration, prioritization, and coaching, nothing compounds. And so that's where we at Navigate, and I'm not using this as a commercial because there are other vendors like us that do this, is when we do that, it we work with those vendors together. And how do we create the best possible solution for your membership and what's going on? Cost containment requires the discipline, the guardrails, and patience. As I said before, year one, you'll start to see declines, but those really happen in year two and year three. The mindset shift is moving from what can we add? Because everybody can add something, but how does this actually change behavior and care decisions? Those members need to be making changes in what they choose to do, not just what can we add? Great, we have another benefit, another app to download, another solution that I never talk about.

David 19:32

So look into your crystal ball. What is what does the industry look like three or five years from now? Do you see more in more use of AI? Um, what kinds of things do you think are are coming or that might be being worked on?

Smarter Use Of GLP-1s With Guardrails

SPEAKER_01 19:46

I definitely see more use of AI. The claims integration is a key factor. Obviously, most of our clients are upmarket, and I'm big clients. I'm talking 5,000 plus. So we see the trends start there, right? The bigger the group, the sooner they start them. And so we're seeing a lot more AI, but we are seeing that they're adding in great solutions, not just well-being, but they're really utilizing them, incentive, incentivizing members to utilize those first. A good example is provider finder. If you have telemedicine or you have a virtual MSK solution, they are guiding them to those solutions first and then financially rewarding them for using them first and foremost. And that that's everybody working together. That's the carrier that is your well-being solution, that is your PBM. And now we're seeing PBMs that they're putting in these condition management coachings instead with us instead of doing them in-house because our condition management's run by pharmacists. Understanding the drugs is part of the problem.

David 20:52

If people want to learn more about what you're doing or want to want to further the discussion, what's the best way to get in touch?

SPEAKER_01 20:58

They absolutely can either call me or they can email me at arutkowski at navigatewell.com.

David 21:06

That's great. Thanks for a fascinating conversation. Ashley Rutkowski, Vice President of Sales at Navigate. Ashley, thanks for spending some time with us.

SPEAKER_01 21:14

Thanks for having me. I'm always happy to talk about well-being and coaching. It really is, in my opinion, the start of cost containment.

Announcer 21:23

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