EP530: A Wildly Underappreciated Point: Overpaying for Infusions Means Overpaying for Stop-Loss Coverage, With Jake Velie and Keith Hartman, RPh

[00:00:00] [SPEAKER_04] Episode 530, A Wildly Underappreciated Point. Overpaying for Infusions Means Overpaying for Stop-Loss Coverage. Today I am speaking with Jake Velie and Keith Hartman.

[00:00:23] [SPEAKER_01] American healthcare entrepreneurs and executives you want to know. Talking. Relentlessly Seeking Value.

[00:00:34] [SPEAKER_04] Hello all you Relentless Tribe members. Thanks for hanging with me this week. When a self-insured plan sponsor sees an infusion claim hit their high cost case report. And a lot of these infusions are really expensive so many of them hit the high cost claim report. But the typical reaction is to look at those numbers and assume it's like an unalterable fate.

[00:01:01] [SPEAKER_04] But as we have discussed on the show, most recently last week with Dr. Eric Bricker on just how unneutral many site payment policies are. And do go back and listen to that show because we delve into why especially consolidated hospitals are getting paid so much more than other sites of care. I mean consider the episode with even a Krajinovich. Go back and listen to that one too.

[00:01:28] [SPEAKER_04] She gives an example from her union where the exact same, the exact same infusion drug cost a million dollars more at a hospital outpatient facility than at a site literally within walking distance. Lots of you are probably already aware of this and you're already also probably aware that all of this is exacerbated by the mysterious nature of the J code or the Q codes.

[00:01:54] [SPEAKER_04] And just how much margin is hidden in that mystery for a deep dive into the mystery of the codes, which sounds like a Nancy Drew novel that I definitely would have read when I was 13. But definitely go back and listen to that episode with Autumn Young-choo and Eric Davis. Links in the show notes where we really dig into just how these codes work. Or if you subscribe to our weekly newsletter, hey, you would already have these links right in your inbox handy.

[00:02:22] [SPEAKER_04] But all of this being said, you know what I don't hear come up so often? And that's what I am discussing today with my guests Jake Veely and Keith Hartman. That overpaying for infusions, these expensive infusions, isn't just a direct budget problem. There is also a direct, non-dotted line between runaway infusion bills, again, which tend to be quite expensive, and stop-loss renewal premiums.

[00:02:50] [SPEAKER_04] When too many claims breach specific attachment points, stop-loss carriers, I mean, they may just drop the plan. So that could happen. Or the stop-loss premium gets raised. And even just little percentage point increases obviously matter here since everybody knows stop-loss coverage is already usually the biggest plan expense. So that already expensive infusion just magnified itself. Premiums are now going to go up.

[00:03:20] [SPEAKER_04] More stuff is probably going to get lasered. And these are the exact kinds of cherries that nobody wants on top of their already too expensive sundae. So, right, I'm thinking something. I'm thinking that knowing how to pull off site-of-care optimization for infusions or otherwise, right, just for expensive things. Knowing how to do this in ways that members regard as a benefit.

[00:03:47] [SPEAKER_04] I think this is going to be a core skill for plan sponsors just given the site-of-care differentials in things like infusions that can cost 10x in some places than they will in others.

[00:04:01] [SPEAKER_04] If a plan sponsor has not, I'm going to say, embarked up the learning curve here just trying to figure out and then get better at navigating members to the best sites of care for really expensive therapies or otherwise, I don't know. What do I know? But I'd probably say that sooner or later, not knowing how to steer members is going to show up as a problematic knowledge gap.

[00:04:27] [SPEAKER_04] I feel like that day has come just given the medical and pharmacy trend increases that we see and just how many times I hear just was talking to somebody today who said that their medical trend increase became flat after they started really working hard to optimize sites of care.

[00:04:47] [SPEAKER_04] So, you're welcome because we spend the last part of this episode talking about what it takes to actually successfully achieve a well-oiled program for site-of-care optimization for specifically infusions we're talking about today.

[00:05:06] [SPEAKER_03] Hi, this is Cora Upsall. Relentless Health Value is the place to get a deep understanding of all aspects of healthcare. I used it to learn about the complex system of healthcare years ago, and I still learn something new almost every episode. Join Stacey every week to hear practical insights and advice from people who are making a difference. I encourage you to subscribe to the newsletter, follow on your favorite podcast app, and follow Relentless Health Value on LinkedIn.

[00:05:33] [SPEAKER_03] I truly believe it is the collective action of the Relentless Health Value tribe that will change healthcare for the better.

[00:05:40] [SPEAKER_04] My guests today, again, Jake Veely and Keith Hartman. We break down four critical pillars that plan sponsors, many often underestimate. I'm not sure how many amongst this crowd, but many do underestimate. The first pillar is deep clinical oversight. Knowing when it is safe to transition a member slash patient from a hospital to an ambulatory center or to home care and when it isn't.

[00:06:07] [SPEAKER_04] Number two, having a really proactive pre-cert, pre-certification intervention. Meaning, you got to tell clinicians what is going on. Listen to the show with Dr. Suhas Gandhi. Don't be one of the plan sponsors that he talks about trying to do something good for members, but then the doctors are kind of left in the dark trying to literally play a guessing game what the insurance hoop that they need to jump through is.

[00:06:32] [SPEAKER_04] Number three pillar, aligns plan design using $0 copays or less copays or financial incentives. Number four, trust-based member engagement. Listen to the show with Matt McQuide for more on this one. Joining me today, as I have said maybe three times already, are Jake Veely and Keith Hartman from National Integrative Health NIH, who have built a managed services model to handle this entire process.

[00:07:01] [SPEAKER_04] Under one roof, Jake Veely began his career in clinical improvement consulting at systems like Kaiser and Geisinger before spending over a decade as a health plan consultant. Keith Hartman is a pharmacist by education and background who has spent his career leading retail, long-term care specialty infusion pharmacies nationwide. I am Stacey Richter. This is Relentless Health Value.

[00:07:23] [SPEAKER_04] Today, I would like to thank NIH for generously offering to help cover the costs of producing this episode and keep Relentless Health Value on the air. Also thanks to our founding sponsor, Aventria Health Group. And with that, here's my conversation with Jake Veely and Keith Hartman. Jake Veely, welcome to Relentless Health Value. Thanks for having me. Keith Hartman, welcome back to Relentless Health Value.

[00:07:48] [SPEAKER_02] Thank you for having me back, Stacey.

[00:07:50] [SPEAKER_04] As has been discussed many times on Relentless Health Value, most recently, I'm going to say by Ivana Krasinovich on the show, she was talking about how at one site of care and infusion was a million dollars more than at a place literally within walking distance of the location. Just there's so much site of care differentials.

[00:08:14] [SPEAKER_04] But let's talk about the main reasons why a plan can find themselves overpaying for infusions.

[00:08:22] [SPEAKER_00] Yeah, so typically just being on the health plan side for the last 13 years, the obscurity that you speak of, it's embodied in a J code and a Q code. So on the RX side, if you're a self-funded plan, you have access to claims data that in some cases provides you a pretty good idea of what you're actually paying for that medicine. On the medical side, it's completely different.

[00:08:52] [SPEAKER_00] And all you're seeing is a J code and maybe a few other codes for the actual administration care of that med. And employers, TPAs, stop-loss cares have never been able to look under the hood of what is actually going on when an infusion is administered. Who's involved? How is the med being purchased? Where is it being held? And then the scheduling of it and so forth.

[00:09:23] [SPEAKER_00] And up to this point, our industry has kind of let it be because it's been this medical complexity that, listen, I don't want to get in the way. If we got someone here who's going through a cancer treatment or an intensive treatment for a rare disease, I don't want to mess with that. We call those just our high-cost cases and we look at them on a stop-loss report every month and kind of cry a little and then, you know, move on.

[00:09:47] [SPEAKER_04] One thing that's happening, which is just the obscurity of the situation itself, that this hasn't necessarily been something that a plan sponsor is going to deeply look into. We talk about transparency all the time, but it still might show up as one number on a report. You did mention stop-loss though. Can you connect the dots for me?

[00:10:06] [SPEAKER_00] Yeah, so when you build a plan, you create your risk corridors with your specific and your aggregate connection points. So the reason the stop-loss carrier is involved is because that claim or a combination of claims that have happened prior within that benefit year have now hit a spec or an ag attachment point. And the stop-loss carrier is now paying attention.

[00:10:32] [SPEAKER_00] So we all are, you know, most of us are familiar with those high-cost claim reports where we have those members that we're watching and, you know, case management's involved. Everyone's starting to freak out, being like, what do we do here? Compromising the plan's ability to cover its members is one of the first things that this type of treatment can do. And we see it all the time.

[00:10:53] [SPEAKER_04] So you're telling me then there's a direct line between if you have too many infusions and or some of them or all of them are too costly, there's a direct line between what I'm hearing potentially premiums going up or potentially getting kicked off a level fund. Like there's consequences here that may be, that may compound just the cost of the original, maybe overly costly infusion.

[00:11:23] [SPEAKER_00] Yeah, there's a lot of people have kind of been looking at this over the last couple of years of they've watched the cost go up. And they're like, man, there's got to be a dotted line here. There's some type of connection. And I am here to tell you it is not dotted. And there's not some type of connection. It is absolutely 100% directly connected to how premiums are being set now.

[00:11:47] [SPEAKER_00] And most of the premium cost, especially in the lower, lower size groups is actually the stop loss premium. It's the claims fund is not getting the vast majority of the dollars. It's it's the admin around the plan and the stop loss carrier who's taking most of the risk on that plan. And when when the stop loss carriers get uncomfortable, self-funding becomes impossible that you have to then jump around.

[00:12:13] [SPEAKER_00] And then your stop loss history kind of follows you around because it's a somewhat small industry. So keeping your stop loss carrier happy by mitigating risk and by doing the right types of plan design to ensure that care like this ends up in the right place is one of the best ways that you can start getting control and stability within how your plan performs year over year.

[00:12:37] [SPEAKER_04] Stop loss carriers, they're looking at all the claims that breach the stop loss thresholds.

[00:12:43] [SPEAKER_00] And if they and many of them are going to wind up being infusions these days, these infusions and this managed care type of space is a very large portion of what they're factoring in when it comes to the risk for next year's loss ratios.

[00:13:00] [SPEAKER_04] So it sounds like irrespective of whether plan sponsors are recognizing that the cost of an infusion isn't just some kind of fixed cost, you know, members, patients just going to get sick, accidents just going to happen. People just going to get cancer and kind of it is what it is, irrespective of whether a plan sponsor and go back and listen to the show with Lee Lewis,

[00:13:25] [SPEAKER_04] either irrespective of whether a plan sponsor or their senior management believes that to be the case. Stop loss carriers are like, you can do something here. And if you don't, then, you know, you might have a stop loss issue.

[00:13:40] [SPEAKER_00] And it's getting to the point where stop loss carriers are actually starting cost containment initiatives themselves, where historically they have just they have never been involved in that. Their world has always been an actuarial exercise and who can be the best predictors of risk. And that's where your loss ratios either work or you don't. You try to find the best partners who manage their own risk. Now, stop loss carriers have said we can't we can't ignore.

[00:14:08] [SPEAKER_00] This anymore, and we can't keep allowing all these claims to be hitting these attachment points. Their responsibility for payment is happening sooner and much more often in the plan than it used to. It's a different dynamic now.

[00:14:23] [SPEAKER_04] And are you saying that stop loss carriers, they've got cost containment plans that are in place and they kind of march in and say, this is what we got to do?

[00:14:30] [SPEAKER_00] We are seeing nursing teams starting to go from doing just case management, checking on the care plan and those types of things to actually starting to train and develop partnerships with firms like ours that can go in and help them move the patient. They can control the drug supply, where it's coming from, where it's going, how it gets there and actually take control of their own destiny.

[00:14:54] [SPEAKER_00] I would say it is a very early emerging trend where I've only witnessed in a couple instances where the stop loss carriers were actively involved in it. A lot of stop loss GAs are now getting involved to help their stop loss carriers do better and perform better on their stop loss ratios. The data is still very much lacking when it comes to stop loss.

[00:15:20] [SPEAKER_00] And a lot of times, once something has hit that point, that treatment has already started and it's down the road. And it becomes a lot more difficult if the plan isn't designed the right way to begin with,

[00:15:33] [SPEAKER_00] which is really where the stop loss revolution is coming, is in how the renewals are written and what about the plan language can protect the plan from ill-optimized site of care, which is not, it's not clinically optimized at all. It's just in a bad place for the plan and usually not the favorite place for the member either.

[00:16:01] [SPEAKER_04] So if I'm just kind of summing up what I'm hearing here, we've got a lot of confusion, what a plan sponsor is being charged for, if it's accurate. Listen to the shows with Kimberly Carlson, just about how difficult it is to get the bill even after the fact, right? So like all of a sudden a plan sponsor gets a really high bill for something that's unclear.

[00:16:26] [SPEAKER_04] There's, because there is so much mystery, there are a lot of opportunities for, let's call it overcharging or for site of care differentials. You know, again, listen to the podcast with Ivana Krajinovich for almost an hour on that topic. But there is some connectivity with stop loss here. These claims hit stop loss. So if this happens too often, plan sponsor is going to have a stop loss issue. Additionally, then these things start getting lasered and they're really expensive.

[00:16:56] [SPEAKER_04] So it's, I'm not going to say not rocket science to see how we, you can get from here to premium start winding up, going up. And, you know, these are miracle drugs. They are prolonging life. Like, let's not forget that, but they also have a price tag and that price tag has a chance of even getting marked up even way higher than what the original price tag is, depending on where the member goes.

[00:17:23] [SPEAKER_04] So let's talk about what it takes to fix this. Let's talk about the things that many plans miss.

[00:17:30] [SPEAKER_00] In my experience, and I'll just, even though Keith is the pharmacist here, I'm talking from a health plan consultant who now works and has clinicians on my team who have extensive knowledge. What we didn't realize on the health plan side was how nuanced these care plans are and drug combos and why a site of care optimization in a lot of cases isn't even a possibility.

[00:17:58] [SPEAKER_00] So I would say just from my experience, and then Keith can give his actual clinical experience. But from being on the plan side, that was one of the biggest things was realizing that you actually can impact the cost of every single high cost infusion in the plan one way or another.

[00:18:18] [SPEAKER_00] But how you can, and to what extent you can go, and where that member ends up getting that treatment and what treatment they're receiving is all due to the clinicians that are on the team being able to dig deep into those clinical notes and get it right.

[00:18:37] [SPEAKER_04] Extensive clinical capability is something that some plans may miss or underestimate. Why is that the case?

[00:18:47] [SPEAKER_02] Yeah, that's a great question, Stacey. And really, in my experience, what we see is these are very called volatile drugs. When they're being administered directly into the vein, there's a lot of things that can go wrong, particularly when the patient is naive to the drug and has not experienced this medication yet. So it's very important that the site of care is appropriate for that particular therapy.

[00:19:12] [SPEAKER_02] It's also important that the clinician administering that therapy has experience with these types of drugs because of the types of reactions that can occur. And it's very important that they have the tools and the skill set to be able to manage any reactions that could occur. They are very volatile. Even from a patient comfort and a patient experience perspective, it's important to have an experienced nurse who's doing this administration.

[00:19:38] [SPEAKER_02] And that's just something that we've seen every day out there in the real world. And not every therapy is appropriate for home care. Some have to be done in a medical setting. So, you know, we've learned that. And it's just something that we have to continue to be very vigilant about and make sure that the patient experience is of the utmost clinical capabilities. And that's something that we've been very keenly focused on.

[00:20:07] [SPEAKER_04] Yeah, I actually have a friend who's a pharmacy technician who was dealing with radioactive chemicals, right? This is certainly something that you're probably not going to take into someone's house. But then also just given the volatility, given the expense, just given so many temperature, like there's just so many reasons why ensuring that the site of care is appropriate is probably an excellent idea.

[00:20:32] [SPEAKER_04] If you're talking about what good looks like here relative to a clinical team, that a plan sponsor should be looking out for, what would you say that a plan sponsor should have eyes on relative to ensuring that this extensive clinical capability exists?

[00:20:50] [SPEAKER_00] Yeah. So many infusions, especially those that are high cost and high complexity, have different phases of their treatment. There's the initiation of the therapy, which Keith was just talking about. The current site of care in certain places is not appropriate for certain types of drugs because of the type of drug it is.

[00:21:11] [SPEAKER_00] And when it comes to the internal team, we have to be able to take a drug in its current site of care, know when it's time, if there ever is a time based on that drug, to where it can be moved and to what extent it can be moved. If it can ultimately get to the home, then great. In a lot of cases, that'll be your lowest possible cost for treatment.

[00:21:38] [SPEAKER_00] If the furthest you can move it is from its current buy and bill environment into network AICs, then that might be the furthest it can go. But having the team internally who knows when and how and what timing and then every single administration happens in the most optimized way possible.

[00:21:58] [SPEAKER_04] So we've got a clinical team that validates when and where a move is appropriate. So like they have to have the clinical understanding. And as Keith said, some of these things are really complicated. You can't just have somebody, I don't know, just deciding that one one site of care is cheaper than some other site of care. So we're just going to head over there. That would could end horribly. And exactly what you both have said, ability to sequence care correctly.

[00:22:26] [SPEAKER_04] I'm assuming that what is also going to wind up being really important is the ability to have direct coordination with the original prescriber, which is something that gets talked about a lot. Like no one's quite sure what's happening. We just had Dr. Suhas Gandhi on the pod talking about that. So an ability to speak the prescribing doctor's language and to really make sure that that coordination is happening and that there's nothing that's being forgotten.

[00:22:51] [SPEAKER_04] Another thing that you had talked about as a thing that gets missed quite often is network control that avoids further fragments in care. Right. Like care is fragmented already. And if we're moving sites of care around, like what are you looking for as a plan sponsor? What do you got to make very sure it's happening?

[00:23:12] [SPEAKER_00] So the most important part to the member feeling continuity is early, early intervention. So when the member experiences a true carve out, then their provider never gets an approval in the way that they do in a normal network environment.

[00:23:36] [SPEAKER_04] Again, referencing the conversation with Dr. Suhas Gandhi, who says it's so often a clinician gets a this therapy is denied. And the clinician's like, wow, that's this one a one clinical pathway drug. I don't understand. Nobody knows that the drug is not excluded. The employer has set up a site of care restriction. So it's simply that the patient simply that the patient needs to go someplace else for the infusion. But nobody knows this.

[00:24:06] [SPEAKER_04] So if I'm a plan sponsor and I'm doing this, you said it's really important and I can certainly see why. Again, we're talking about fragmenting care and making the patient feel like they're either their care is fragmented or just total confusion. How does that early happen? Like there's clinicians who knows where the patient's going to wind up.

[00:24:27] [SPEAKER_04] What should a plan sponsor be looking for to ensure that a clinician doesn't just, you know, now you've got a patient with a time sensitive infusion that's necessary and they think the drug got denied?

[00:24:41] [SPEAKER_00] Yeah, it's all in the pre-cert process and how that is set up. So when they send a request to start treatment, it is immediately returned to them that National Integrative Health is managing infusion within the health plan.

[00:24:58] [SPEAKER_00] That way we, our team can get in right away, immediately establish ourselves as an advocate to the patient and help the provider realize that this is simply the way this plan works. Then we work with them on, hey, we're going to keep initiation therapy with you. First two treatments will be in your office. We negotiate the rate of what those two treatments are going to be.

[00:25:22] [SPEAKER_00] So it's no longer just their normal J code, you know, being billed to the network and getting ridiculous reimbursement for that. So getting in early, communicating with that provider, them never receiving an approval to be able to have the whole case and nothing but the case, right? And then they know expectations and they're set right away.

[00:25:45] [SPEAKER_04] Dr. Eric Bricker says if you try to do something after the train has already left the station, right? Like after the patient has already scheduled the surgery, et cetera, it becomes increasingly difficult. It's like physics, right? Once an object is in motion, like once a patient is in motion, it becomes really, really difficult to slow that roll. What a plan sponsor should be after is someone who has a very clean, very clear pre-cert process, like probably ask for what that looks like when it goes back to the provider.

[00:26:13] [SPEAKER_04] Because if it's just a fax that says denied, then you're going to wind up with all kinds of issues and no plan navigation, frankly. So that has to happen very quick in the pre-cert process. There has to also sounds like be a communication plan back and forth. Again, going back to what we talked about earlier with a lot of coordination with the prescriber. There's a bit of direct contracting element here as well is also what I'm hearing would have to get locked down.

[00:26:40] [SPEAKER_04] And then also communicating with the patient, making sure that the patient is aware of what's going on. You're going to get your first two infusions here and then you're going to go over there, for example. The third thing that you have said that gets missed and that may take plan sponsors by surprise or they may underestimate is plan design and member financial alignment, which definitely comes up a lot.

[00:27:06] [SPEAKER_04] Why is it so important for plan design and member financial alignment to exist here?

[00:27:12] [SPEAKER_02] Well, the patient's financial alignment is such a critical component. What we see on a daily basis is financial toxicity becoming a barrier to care. And so to be able to mitigate that patient responsibility has been something that is opening doors and allowing patients to get care they may not otherwise have been able to afford.

[00:27:33] [SPEAKER_00] Yeah. So the plan design is the very first line of defense here in making sure that you have your plan designed in a way that the member gets a financial incentive for following the pathway that's set up. So they don't necessarily feel like they're forced. It feels like a benefit, which is what the whole thing is all about. Right. They actually have a benefit and it's covered.

[00:27:55] [SPEAKER_00] So that first thing is making sure that it's the best option financially for the patient to follow this pathway for especially for non high deductible health plan members. You can do medical reimbursement for them without taxation. There's there's so many different options when you don't have that high deductible health plan issue that's sitting out there for the plan and not being able to cover those first dollar costs in any way at all.

[00:28:24] [SPEAKER_00] But that again, that's where plan design comes in, in being very, very effective to make sure that you can get those members dollars back to them, even if they've paid them before. And then just zero dollar copay. I think a lot of us in this industry and who listen to this podcast have heard so many different options within the benefit plan can be offered at a zero dollar cost to the member being the really the only lever that you've got.

[00:28:53] [SPEAKER_00] In a lot of ways, if you're not baked into the plan design, the financial incentive is really the only thing that you do have to try to entice the member away from that that that, you know, least action pathway where, OK, I'm used to doing this. This is how my insurance normally works versus going over here to an alternative.

[00:29:14] [SPEAKER_04] Right. And what I'm understanding is that the dollar saved can be so significant that, you know, if a member pays and this might be a fortune to them. But if you're talking about it in plan renewal kind of language and stop last renewal, three thousand dollars is a rounding error.

[00:29:32] [SPEAKER_04] OK, the fourth kind of like unknown, unknown plan sponsors underestimate the complexity here or the importance of having a partner who knows what they're doing here is this member and influencer engagement engine. This should probably not come as a surprise because in every one of the prior categories, communication has come up. Communication with the clinician, communication with the member.

[00:30:00] [SPEAKER_04] Yeah, I think the why is probably pretty self-evident that if members are not on board, none of this is going to work so well. I also could imagine that there'd be some distrust here.

[00:30:13] [SPEAKER_00] So, first of all, early and proactive outreach to the member as soon as possible is always key. So engagement, we've all seen this across the industry. The better an organization is at engaging the member, the more successful they are all the way around. The second is using the relationships inside the health plan union reps and inside the employer or the TPA that already have a line of communication with the member and their provider.

[00:30:43] [SPEAKER_04] All right. So let's call this the lightning round of problems. So I'm going to list a problem. Right. Like, and these are things that we've all heard there. There are plenty of plan sponsors that have tried to do a site of care, a steerage program, and it has failed. Like there's going to be so many people listening who are like, yeah, that didn't go so well. I'm going to state a common issue or a common. I tried it and it didn't work. And it would be you tell me what are the levers should be pulled or how to fix it. Here's the first one.

[00:31:12] [SPEAKER_04] We tried to move members and couldn't.

[00:31:15] [SPEAKER_00] Yep. Very simply, poor plan design, lack of control at the pre-cert, pre-off level. And you don't have the appropriate infrastructure in place to be able to communicate with those members and intervene early with the provider team on the ground.

[00:31:36] [SPEAKER_02] And also to know that it's clinically appropriate.

[00:31:39] [SPEAKER_04] All right. Here's another one you hear all the time. Members prefer the expensive place because they think that high price equals high quality.

[00:31:49] [SPEAKER_00] Absolutely. Our first message to the member is always this is the same drug. It is the same treatment protocol that the previous care team had. And the reason your plan is incentivizing you is because the place that it takes place in doesn't matter.

[00:32:09] [SPEAKER_00] You are going to be getting the same care and usually more of a white glove type of experience in a more comfortable setting based on being able to be, like I said, either in a smaller type of facility or in home. As a consumer, a lot of times you think if you're in the fancier place, it must be better.

[00:32:30] [SPEAKER_00] But when we're working with their provider and their provider does provide the script to us and gives us the infusion orders, usually the member gets the point like, oh, OK, this must be good because my doctor is going along with it.

[00:32:45] [SPEAKER_04] That leads me to the next common pushback that you hear, which is what about anti-competitive hospital contracts and ASO resistance? And I'm going to add to that maybe a doctor is not going to be super on board with that either. Like, does that doctor want that patient to leave the building?

[00:33:06] [SPEAKER_00] Yeah, well, the reason J codes and Q codes are things that health plans are way overpaying for is because providers are charging way too much for them. And there's an insane amount of spread here. And there's so much that can that can be compressed when it comes to what actually needs to be paid for that. So, yes, we do. We do run into the doctors who don't want to give the treatment up, which is why plan design is so important, because if they have an option, a lot of times they will refuse to release the patient.

[00:33:35] [SPEAKER_00] And even if the patient has a financial incentive to do so, this is why having a closed network that comes along with the managed care is so important. Having the right infrastructure so that the patient has options, even if the provider pushes back and refuses to allow to allow the patient to leave.

[00:33:56] [SPEAKER_04] If you're trying to do this, you really have to understand exactly how that game is played and set up your own infrastructure. And, you know, defense is your best offense here. It certainly sounds like. You had said something earlier about how even if there's an anti-competitive contract, home infusion is excluded from that.

[00:34:15] [SPEAKER_02] We could circumvent, you know, an anti-competitive contract would be to go through home infusion as a site of care option, provided that it's clinically appropriate. That's certainly another tool in the toolbox.

[00:34:28] [SPEAKER_04] Interesting. So if there's some anti-competitive something or other that's embedded in the ASO contract, you know, you can't say a patient can't get infused in their home again. Obviously, clinically appropriate reference or earlier conversation. Thank you very much for that lightning round, because we do have a number of you try something and then it fails to work. And then like, why are we going to try again? Because we already tried it. We spent all this money. We did all disruption. Great. Like you got really sick people who are now being incredibly disruptive.

[00:34:58] [SPEAKER_04] So it is so important in order to nail this. Do you want to talk about national integrative health?

[00:35:04] [SPEAKER_00] So we have built a managed services organization that helps to facilitate the entire process under really one roof. And being able to handle any phase of where an infusion is all the way up to being able to just optimize the pricing in the current facility it's in, not moving the patient, not doing anything different.

[00:35:33] [SPEAKER_00] The nationally integrative health way is to be able to influence that no matter where the patient is in treatment, no matter what type of treatment it is or how complicated it is, and no matter what site of care they can potentially end up in, that we can get the plan the best outcome. We have the network built.

[00:35:56] [SPEAKER_00] We can basically just build it as one cohesive system that you can start light and start to integrate as you go, or you can just start with a full blown carve out from the beginning, or you can never go the carve out right route. And we can just act as a direct clinical services contract and we can act as another option for the member.

[00:36:20] [SPEAKER_04] Where would you direct individuals who are interested in more information?

[00:36:25] [SPEAKER_00] National Integrative Health on LinkedIn. We have our website, nationalintegrativehealth.com. A lot of resources there that you can download and look at.

[00:36:35] [SPEAKER_04] Jake Veely and Keith Hartman. Thank you so much for being on Relentless Health Value today.

[00:36:40] [SPEAKER_00] Thanks for having us. Thanks, Stacey.

[00:36:43] [SPEAKER_01] Hi, this is Tom Nash, editor and producer of the Relentless Health Value podcast. I bet you're wondering, how can I help Relentless Health Value? Well, that's pretty easy. Have you signed up for the newsletter? The newsletter is great. It tells you when each episode is coming out. It gives you an introduction to the episode with all the mentioned links and a way to click through and listen to the podcast. But there's more ways to help. You can always go over to LinkedIn. Are you following the page? You should be. There's great conversations each week on all the episodes.

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