Why Health Plans Need A Rebuild

SPEAKER_02 0:00

For years, employers have been told that rising costs, higher deductibles, and a fragmented health care experience was just the price of doing business. But what if the health plan itself were rebuilt around the patient? With clinicians actively guiding specialty care, pharmacy decisions, and risk management? We'll find out on this episode of Shift Shapers.

Announcer 0:23

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's shifts. And now, here's your host, David Saltzman.

SPEAKER_02 0:43

Drew Leatherberry is founder and advisor at Evergent, a benefit solution company that helps employers and brokers build high-performance health plans. A health Rosetta advisor, since 2019, Drew has spent more than 15 years challenging the conventional benefits model and developing more transparent, patient-centered approaches to care. His work has earned regional and national recognition, including the Alliance's 2023 Healthcare Transformation Award. Drew, welcome to Shift Shapers. Thank you for having me. Before we talk about collaborative care, can you take us back to your Shift Shaper moment, that moment when you decided traditional benefits model was no longer good enough?

The Moment Traditional Benefits Broke

SPEAKER_03 1:22

Yeah, happy to. You know, I've always prided myself on bringing an entrepreneurial approach to the health benefits industry. From the moment that I got in, I was coming with no experience other than two failed startups in the technology and hospitality space. I felt like that edge that I had was to look at things with a fresh take, was working with uh a client of mine that had a very high precision manufacturing business and two brothers, actually, who had started this out of uh no kidding, their garage when they were in high school. Uh they manufactured parts for high-end uh luxury jets and uh did it right in the northwoods of Wisconsin, had them as a client for uh several years, and this is several years, several years back, over a decade, and they had done everything that they could to try and control their health insurance costs. They had a predominantly middle-aged male population, uh, they had a high deductible plan, they had implemented an HRA, an HSA, they had done a wellness strategy, and at the end of the day, um, their annual increases were in excess of 20 to 30 percent. Now, while there's an actuarial and underwriting uh answer for that, when that renewal increase came out several years into working with them, it seemed that we had thrown the entire kitchen sink at it. And the only answer I had for them was you gotta just accept it. That's just the way it is. I subsequently was fired from that account. And I went back and I thought, you know, if I can't bring any solution to the table that's gonna help a good, solid American company try to manage their healthcare expenses, something is wrong. And that's when I went searching and thankfully found a lot of movement in the health plan space. One of the movers was uh CEO, co-founder uh Dave Chase with uh Health Rosetta, the CEO's Guide to the American Dream, is what I was about to reference. Read that book, it hit home with me, and I thought this is really what needs to

Defining Collaborative Care Coordination

SPEAKER_03 3:38

happen.

SPEAKER_02 3:38

Aaron Ross Powell So you talk about collaborative care as more than conventional navigation or advocacy. How do you define it? What exactly is it?

SPEAKER_03 3:48

Yeah, I like to think of it as risk-driven care coordination, and not to just throw more of the catchphrases at people. What makes it different is that we really started with a stop loss underwriter view on what goes wrong in health plans. We took 20 plus years of stop loss reinsurance underwriting experience from my chief risk officer, and we evaluated what happened when these high-cost claimants got off the financial rails. Think of it like a forensic analysis and playing back all the decision points in time that happened through the claims and finding where different decisions could have ultimately prevailed, not just in terms of lower costs, but better outcomes. What we ultimately found was that if we could get involved with clinical expertise and awareness of how decisions were going to drive risk forward, get involved in the patient's journey at the right intervention points, we could provide better clinical resources to a plan member and not just to the plan member, but to their attending physician. We could collaborate with them. And really that was the idea that sparked for us. We thought it isn't a matter of applying more prior authorization requirements to the healthcare community. It's actually getting in the weeds with the physician and making sure that they have access to all the resources that they need from the plan side, that they understand that decisions have financial impacts. And then if we took the gloves off, they could make uh the best possible decisions for their physician and get the best outcome. And we've seen some really great patient experiences that have proven that theory.

PSAP And The Knee Therapy Example

SPEAKER_02 5:42

So you talk about a patient-specific accountable practice or a PSAP. What exactly is that? And what makes that model clinical rather than just administrative? I think you've kind of alluded to it, but to deep dive a little bit more for us.

SPEAKER_03 5:56

Yeah, we really felt the industry was low on acronyms. Always a problem. Yeah. So we said, why not throw another one in the mix? So PSAP was really our uh processor chip change, if you will. When we started reconstructing these episodes, one of the problems that we found was in the planned document when the prevailing determination on what is medically appropriate falls onto generally accepted practice guidelines. We thought the GAP is actually the thing that's kind of starting to steer people off course. What if we created language that allowed us, when GAP is not working, to focus more on the patient and the patient outcome and what the physician on the ground sees as the best opportunity? Of course, we need the plan benefit to nondiscriminately apply. And so we created language for it. And that's what we call patient-specific accountability practice, PSAP. It's a mouthful. When you see it in practice, though, it's really common sense. A common sense example that came out relatively early on was a patient who was a spouse on a plan, uh, she ran a retail store, she was having knee injections for pain that she was experiencing. And uh she didn't want to have surgery because she knew that her time for therapy was going to keep her out of the store too often and frankly put her business at risk. So she just kept getting the pain injections. When our nurse got involved and started working with the patient, the history of the patient came to be. And what we saw come out of the story that we couldn't see in the claims was her individual story and the reason why she was having these injections done. We met with the orthopedic doctor, and we asked the orthopedic doctor, what would you do to drive ultimately a solution to this pain problem that is going to be sustainable over time and also help expedite the therapy process? What we came to find out was that uh the physician said, well, this would be easy if the plan would cover Ayavera therapy. We could cut therapy time in half. And we did the cost analysis on it and thought this is a no-brainer, cost neutral if you really think about it, but plans traditionally just don't cover things like that. And so PSAP steps in to save the day on that because what we're able to do is actually avoid what would have otherwise not been authorized for coverage, provide access to plan dollars to provide that therapy coverage, and do it all in a very affordable and high-quality outpatient setting. Um, the win-win was the patient had all of this done for the same or better cost uh in market than what they would have otherwise had the surgery done for. And they got back to work in 50% less time than what the traditional PT track uh would solve. And the plan covered 100% of those expenses. You had wins across the board.

SPEAKER_02 9:13

Yeah, I know you know when you find an alternative to a proposed treatment, or even if you are able to reverse a prior off denial, do you have to do that carefully so you don't appear that you're stepping between the patient and the treating physician, but working alongside?

SPEAKER_03 9:28

Yes. Absolutely. And I think that is probably the most transformative aspect of this. And when I say transformative aspect, again, remember, common sense should be prevailing. What we've built is bureaucratic infrastructures in which physicians don't get to apply common sense thinking. They're always worried about approval. Does this meet the standards? Am I supposed to be doing this? Is this going to be paid? Is this going to get hung up? And the byproduct is we actually have a percentage of patients that remain in symptom. Uh so our edict is really getting, our first edict is getting patients out of symptom. And it's interesting because when you ask the question, that's exactly where my mind goes to is that it's it is the goal of the physician and the goal of the patient, and also should be the goal of the plan to get a patient out of symptom as quickly and efficiently as possible. And when you bring that mentality to the table, the physician is actually empowered and they feel empowered, and they actually see the plan differently. So when I say transformative, that's what I mean is that you're actually having to shift the prevailing mindset that many physicians operate with in today, which is is this going to be covered?

Finding Specialists And Measuring Quality

SPEAKER_02 10:58

I know you guys say that the model coordinates access to more than 4,000 specialists and centers of excellence. What's the process for deciding which clinicians and which facilities belong in that pathway?

SPEAKER_03 11:10

Yeah, that's a great question. On our own, we would have spent years developing the inherent expertise to try and identify those. What we realized was in the true spirit of being collaborative, there were organizations that had already solved that problem. And so we partnered with uh one of the leading organizations out there, included health, and found that they had already put together not just algorithms, but very well thought-out logic in identifying who was leading the charge in terms of medical research, academia, experience. And when we heard their value proposition, it just resonated because basically what they were doing was very in a very patient-specific way, understanding the patient's needs and then combing the landscape to find the best virtual connection so that we could apply expertise where we needed to apply expertise and then relay that expertise back into the local market, aligned with uh the right local physician.

SPEAKER_02 12:22

So that process keeps it from kind of sliding into being a preferred provider list.

SPEAKER_03 12:28

Absolutely, it does. I think the interesting nature of how networks have been built is that we almost have a dichotomy that exists. We talk about preferred providers, but really preferred uh provider in network, out of network has largely been driven off of price negotiation and not qualitative understanding. Now, I know there are a lot of people that would argue with me on that topic, but the realities are very true when you just look inside of the four walls of a facility inside of a subspecialty. You take oncology. You can have two oncologists that have the exact same badge on their lapel, and they have very different results. And this is really what we what we've experienced is that we want to make sure that we are understanding the specific dynamics of the patient and their need, and then finding through a credentialing process, or not a credentialing process alone, but almost like a match.com style review, which physician is going to fit better. You know, David, I'm gonna add something that's gonna seem uh maybe outside of the lines a little bit, but there's a science to hope. And that science of hope has actually shown that when patients have hope in their outcome, uh, they are going to get to a better outcome. That interesting component of the process in connecting patients actually requires that we lean into who we're finding for the physician. Said a completely different way, when a physician knows that there's been a lot of care rendered in finding a physician recommendation, they feel more hope in the potential for an outcome. More hope than going on a provider network search directory or just listening to a physician that they see inside of their current system who recommends a colleague.

SPEAKER_02 14:31

It seems like a no-brainer. Why has it been so difficult with all the talk of transparency to make sure that quality is the first metric that gets looked at?

SPEAKER_03 14:43

Boy, that is the million-dollar question, maybe the billion-dollar question, quite honestly. I think it's I think it's because quality in a lot of ways can be viewed as a subjective metric. And depending on who you talk to in the industry, sure, we have objective qualitative uh measures, infection rates, readmission rates. Certainly CMS is measuring these things. But when you get down to it and you start to talk about what true quality is, you have to really lean into the specialty. You have to look at the very specific condition diagnosis treatment patterns. There are so many variables that I believe it becomes very difficult to set up that objective measurement.

SPEAKER_02 15:31

Let's branch off now and talk a little bit about one of the big drivers, pharmacy.

Active Pharmacy Oversight In Real Life

SPEAKER_02 15:36

It's another part of the model, and it's a big part of the model. What does active pharmacy oversight actually mean in practice? What does it look like?

SPEAKER_03 15:46

It's very much synonymous to the general PSAP vernacular in the sense that question one is not just cost or efficacy of a drug, but it's actually ensuring that a patient has had the opportunity to fully review all options on the table. In other words, is the formulary driving the uh the prescription? Is my physician's bias driving the prescription? Or am I talking to an expert, a pharmacist? And one of the things that I was surprised to find in my recovering broker journey, and I use that jokingly, um, but the last several years have really been a process of relearning the foundations. And one of the things that I was very surprised to learn from a friend and colleague, his name is Dan Strauss, runs a set of community pharmacies in the Midwest, is that pharmacists have significant more education than physicians when it comes to biochemistry. And yet we rely heavily on physicians to make those biochemistry recommendations for prescription drug utilization. In other words, pharmacists deserve a seat at the table. And so that's all we did. PSAP was really just a matter of saying, how do we bring the pharmacist to the table with the patient? Then, and then only when you get people down the right prescription drug lane, you can start to also apply common best practice ideas around pharmacy benefit management agreements. Do we have things like pass-through rebates? Are we paying cost plus and all the things that drive cost savings? But you get people on the right medication, that's the first step, not the last step.

SPEAKER_02 17:44

So what if anything changes for the member at the pharmacy counter?

SPEAKER_03 17:48

You know, that's it's a really good question. It's not easy to disrupt that, that process because there is limited intervention opportunities. And so for us, actually addressing that problem or that challenge of how we didn't create the disruption of the pharmacy counter meant actually designing the plan differently from Go. In other words, we had to find ways to completely make access zero cost for those right choices, and then create or change the expectation of the experience that people would have so that it wasn't a point of sale disruption. Ultimately, you find that when you design the plan structure differently, you set expectations differently, you don't have to disrupt that point of sale experience.

The Risk Curve And Stop Loss Impact

SPEAKER_03 18:52

Boy, that is really it that's really the operative question because when you unbundle a program and you start tackling these components inside of the silos, you still have to put the roof back over the house, right? And for us, it was a matter and is a matter of making sure that we gather accurately and adequately gather all the necessary data points that are going to ultimately impact the stop loss rating and understanding of a group's risk. It's interesting because when we started this conversation, we really started at talking about the history of stop loss underwriting and forensically moving back. This is basically that was the rewind, and this is the fast forward. You take it all the way forward then and you say, okay, so now you've done all of these things. What ultimately have you produced that creates a different picture? For the way that we look at it, we had to actually create a new language, uh, what we call the risk curve and the risk curve score. And that awareness was that risk, financial risk, health risk, happens in shapes. And the shape, the amplitude, the height of the cost, the duration, the time length, those things are all influenced by those decision points. Ultimately, if we are able to show how we're influencing those decision points and reducing the amplitude of the cost, the duration of the cost, that has a downstream financial perspective that underwriting cares about. We had to put that into a vernacular that was easy to understand. And that vernacular is one of several curve types, which ultimately score and then produce a predictive cost value. Our experience has been when you tie all of that together with a population that is large enough, you can actually see the impact. And the impact on this from an underwriting manual perspective is probably anywhere from a 30 to 50 percent cost reduction. In other words, a stop loss underwriter is going to say, when they look at a population that's actively deploying strategies like this, they should be able to say we have more confidence in being aggressive in our rating and not conservative. But I'll tell you this is an unfinished exercise. It's unfinished because the predominant underwriting manuals that exist in the market today actually need to be rewritten to a different base point. And that's our challenge today. We are still in the midst of that challenge.

SPEAKER_02 21:45

Aaron Ross Powell Well, because you know, if you look at the increase in chronic disease, the things that used to kill us don't. And so that's good news, and it's also bad news. Yes. And you know, you kind of need to refigure things. But you know, I I know on your website you talk about a 23% prescription drug spending at about half the national PMPM. And an earlier case study showed a seven to one ROI and 17.5% average planned claim savings. That's huge. If I'm an advisor, what do I ask? What questions do I ask when I'm evaluating those claims?

SPEAKER_03 22:21

Well, one is what's your baseline? What are you comparing this against? This has been one of the challenges with putting numbers like that on the table. Because the reality is you can you can generate savings in a very easy fashion. You can trip over savings if you want to. So for us, we really said, how do we look at not just comparing never events that were not likely to happen, but the actual path that was was most likely to happen and how we deferred uh transferred cost risk. And what was that comparative value? In pharmacy, relatively easy. We know what would have been spent if we didn't adjust the path. Medical, a little bit more difficult. You have to take shoppable procedures like an MRI and say, yeah, okay, well, we know inside of a different facility that cost would have been three, four, five times what it was in a freestanding center. But when you take a cancer episode of care point that the variance can be dramatic. And so we don't want to take the top end of savings. What we want to ultimately do is say, inside of that curve of risk, what were the decision points that we helped with? And ultimately, what was the most likely scenario that was going to happen? When you are evaluating savings claims, that's, I think, the way you need to look at it from the other side. You need to ask, what is this being measured against? Because it's easy to find savings.

Why Advisors Matter More Than Ever

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May wonder whether this model supports them or competes with them. Where does the advisor fit in this model?

SPEAKER_03 24:07

Aaron Ross Powell I am a staunch believer in what uh Dave Chase wrote in his 2017, I believe it was, Forbes article. It's the job that can save America. Why? Because the advisor has what I would argue in the entire schema of commercial healthcare spending in this country, they have what no one else has. And that's the trust of the pocketbook, the check writer. And so the advisor has to take great responsibility with that. For me, that was the reawakening moment. And I realized I have an opportunity to be part of the change. So an advisor should look at strategies that they can deploy, not as competing or not creating competing interests. Do they have competing consequences? Of course they do, because what this is going to mean is you're going to have to make a decision. Ultimately, do I want to have that conversation with the employer about the plans that they've been in, the style of funding, uh the carriers that they've selected versus alternative options in the market? Yes, of course. But you have to keep something in mind if you're an advisor. There is no better way for you to do your quintessential foundational job of negotiating and educating your client than to bring all options to the table. The irony, at least in my experience, has been I go back in time and I sit with those two brothers who own that blue-collar manufacturing company. And I think if I had had the solutions that we deploy today sitting at the table, that net result might have actually been different. I didn't know what I didn't know at the time. Quite honestly, I was afraid. I was afraid of how that would impact the core of what I was advising on and the amount of time and the competing interests in the market. But today, it actually what I've learned is it's opened up a lot of doors. And we actually have clients that cross the spectrum of solutions. We're actually able to provide better advice today because we have opened wide the portfolio and we're not afraid of having those conversations. So even groups that say, you know what, I like that idea. We're not quite ready. That's okay. We actually are showing that we can bring better insight to a more traditional style of program by doing that.

Education First With Empower Roundtables

SPEAKER_02 26:47

One of the interesting things to me that you did is like for the last six or seven years, I don't know if you're still doing them. You've used what you call your empower roundtables to educate HR and finance leaders rather than just simply pitch them. How did that come about? What is that like, and how does that work?

SPEAKER_03 27:04

Yeah, it's quite an interesting backstory, to be quite honest with you, because when I was in my pre-recovering broker days, we I was in a position in which I partnered with a couple of other um advisement type organizations, HR consulting and property and casualty. And we held uh an event that we created and we would bring in topics that would be of interest to the C-suite. And I learned something really interesting about those events. And I what I learned was you could engage in these really healthy business strategy conversations with organizations when they weren't leading with, yeah, we want to quote your business. So when I moved into the arena that we're in today, I had a uh CEO that approached me and he said, What I really would like is for you to come and talk to one of our roundtables, my CEO roundtable. And so I thought, well, let's do this the right way. I know a number of people that are great subject matter experts. Let's let's turn this into an event. And so we brought uh several speakers to the table. We focused entirely on educating people. In fact, the thing that I told uh the folks that were coming to the table was we are here to educate, empower, and equip our attendees, not sell. So no sales pitches. We just simply want you to leave people with something that they probably didn't know walking in the door. The fascinating thing is when people came to the table and they walked away, I had more people that were coming with inquiries on how to actually apply those things. And lo and behold, I found that we walked in the door to these conversations with employers. The edict that has walked away uh from that very single first event was no matter what we do organizationally, and I truly believe professionally, this is one of my callings now. I people need to educate, and I need to be an educator because that's where the gap is today. People can't control something that's out of expense if they don't know first and foremost how to do that. And so the empower events have become uh something that invites that discussion and that dialogue, and it's become one of the best ways for us to connect with our end users.

Three Questions Before You Change Plans

SPEAKER_02 29:39

If an advisor wants to figure out whether collaborative care or virgin one is right for a client, what are the first three questions they should ask the first three questions that they should ask?

SPEAKER_03 29:50

Number one would be, is this employer culturally in a position where they're ready for change? A lot of employers will say, we want to save money. We want the best benefits, we want to save money. But culturally, this strategy is about health care first and foremost. It's not about health insurance, it's not about financing. Yes, that's important, but it's about how you care for people. So culturally, does an organization fit that model? Is that their focus? Is that what they're interested in? Number two, do you have the tools and resources to help you implement change? Uh, you have to be focused on that change management process. I wish I could tell you that there's a silver bullet. There isn't. There's a lot of people that are focused on how to do it. We certainly have our thoughts, but it's a trial and error thing. And you have to be prepared for the change management process because if you don't think about the tools and resources around how to make it a successful transition, it's going to be difficult. Third, do you have the courage to have the conversation? Sometimes it's not just the knowledge, it's actually bringing up different ideas. You may not have all of the answers, all of the solutions. You don't necessarily need that. You don't need to be an expert in pharmacy contracts. You don't need to be an expert in stop loss. You don't need to be an expert in self-funding. You just simply need to know that there are different ways. And in order to be an advisor, in order to bring a solution like a virgin one to a client, you really have to just connect with that employer on organizationally, do we want to do something that is going to transform the way that our people get the care that they need?

A Better Model For Fragile Moments

SPEAKER_03 31:55

I truly believe that a moment, if you will, with that employer, and then the subsequent finding of the CEO's guide and this journey that I've been on, what it's awakened in me is actually a passion, not just for the cost of American healthcare, but the way in which our system, our healthcare system, is serving our citizens. You know, like yourself, I'm I'm sure, and like your listeners here, we probably all have those stories, family, friends, maybe our own personal journeys where we've experienced healthcare and we've experienced the challenges. When I think about those challenges and I think about the people that I've walked through those journeys with, ultimately what they needed was a hand on the shoulder. They needed someone with knowledge, experience to help them make those decisions in those most delicate, emotional, fragile times. That's what health plans should be doing. They should be coming around, connecting all the wires. And if you do that, the amazing thing is it can drive better care outcomes, and it can ultimately fix these gaps that we've created with a fragmented system. We can deliver on the promise of serving people the way that they ought to be served in a very affordable and qualitatively focused way.

SPEAKER_02 33:21

And that's a great place to end our conversation for today. Drew Leatherberry, founder and advisor at Aversion Truth. Thanks so much for sharing your information with us. No, thank you for having me on.

Announcer 33:31

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