Today, Evan Anderson and I are talking about carrier networks, how they started, how it's going. Because irrespective of whatever the plan was at the very beginning, any given network, especially talking about the big status quo networks, has evolved into what I'll call a three-headed monster. Probably there's many heads, but we'll limit ourselves to three right now.
For a full transcript of this episode, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
So, in the conversation that follows, Evan Anderson and I, we first describe said monster; and then we get into the and so, now what?
I'm gonna say this episode is a bit of a primer. It's a bit of a survey of the general map of the landscape, and it also gave me the opportunity to kind of stick on that map links to many other episodes for anybody looking to take a deep dive at any point along the journey. Just, yeah, making sure that we have laid down the breadcrumbs to additional information because it's really easy with some of these topics to go down some pretty deep, dark holes.
And when you do, just please know that there is a community around you. Listeners of Relentless Health Value are the village in a lot of it-takes-a-village equations. So, if you find yourself in need of a hand to lift you up, please do reach out to the guests who have been on Relentless Health Value or head over to LinkedIn, check out who is commenting on our posts, and find your tribe.
All right, let's take it from the top, shall we?
Evan Anderson and I are going to describe first the three-headed monster, as aforementioned, that your average big status quo network has grown into. These networks are, lest we forget, built on a fee-for-service model that structurally aligns incentives in ways that are, a lot of times, misaligned with members and plan sponsors.
The three heads of the aforementioned many-headed monster are the contractual illusion of discounts—that's the first head we discuss.
Second, payment integrity, meaning even if you can figure out what the contracted price should be, you can't usually see what was actually billed that aligns with that, what it should be.
So, there's almost no way to confirm that you are getting what you signed up for, at least without a lot of work. What complicates matters are old mainframe-based adjudication systems and high billing error rates that compound the problem.
The third head of the monster that we discuss are wild variations in site-of-care costs for the exact same drugs and/or services—like, one site of care can cost literally hundreds of thousands or a million dollars more than somewhere else that you could walk into. Both may be in the same exact network.
After describing our monster, then we get into what are the solutions here. The discussed solutions are, first of all, change networks. And a little bit good luck with that working extremely well for a bunch of reasons that Evan Anderson and I talk about later on.
Second possible way forward here is direct contract. And there's a couple of different flavors of direct contracting, which comes up in every single show lately. Primary care is one of them, direct contracting for primary care. And then also Center of Excellence–type specialty care. Listen for a bunch of nuances.
Third, steer and tier to the optimal site of care. And for reasons aforementioned, this is starting to exceed just this is our preferred institution and become site-of-care optimization for stuff like infusions where a member might go one place for the right diagnosis and treatment plan and maybe the first two infusions or something like this but then go somewhere else for the continuing series of infusions.
And number four, last thing we talk about, is bundling. But more than that, it's the aggregation of bundles into alternative health plans basically and the pushing of the market toward a care episode where the quality can be measured or the outcomes can be measured, the appropriateness can be measured.
Listen to the show with Ahilan Sivaganesan, MD (EP505) for a lot more on this. Or actually you could go back if you want kind of the primer on bundles and listen to episode 434 with Ben Schwartz, MD, MBA.
So, yeah … how was all that for, like, the spoiler of the century? Sorry, not sorry.
My guest today is Evan Anderson. Evan has spent a career in the healthcare industry, and today he works on product strategy, general strategy, and operations for Handl Health.
Speaking of Handl Health, big thanks and much appreciation for sponsoring today's episode and helping to offer up some of the financial assistance to keep the show on the air.
Also, thanks to our founding sponsor, Aventria Health Group, and the team that tirelessly, week after week for the past 12 years, does all that needs to be done for each episode to get recorded, scheduled, edited, produced, the graphics made, proofreading, links created, posts written, newsletter sent.
It's a lot, which is also why I appreciate the folks who have left a tip in the Tip Jar or do any kind of recurring donation. I see your names, and it is very restorative when my motivation starts to flag. You lot rock. Thank you, all.
And here is my conversation with Evan Anderson.
Also mentioned in this episode are Handl Health; Alex Sommers, MD, ABEM, DipABLM; Astia Health; Ahilan Sivaganesan, MD; Benjamin Schwartz, MD, MBA; Aventria Health Group; Katy Talento, ND, ScM; Kimberly Carleson; Mark Cuban; Craig Gottwals; Preston Alexander; Andrew Tsang; Jim Jusko, JD; Eric Bricker, MD; Ivana Krajcinovic, PhD; Jacob Asher, MD; Mike Hopkins; Yashaswini Singh, PhD; Lori Smith Guliano; Patrick Nelli; Ryan Jacobs; Jake Velie; Keith Hartman, RPh; Suhas Gondi, MD, MBA; Adam Stavisky; Leo Spector, MD, MBA; Ryan Wells; Health Here; Steve Schutzer, MD; and Tom Nash.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more at handlhealth.com and on their LinkedIn page.
You can also follow Evan on LinkedIn.
Evan Anderson is a seasoned healthcare strategist and operator with 20+ years of experience across medical devices, digital health, and AI. A three-time company founder and former biomedical engineer, Evan leads business development, operations, and strategic deal-making at Handl Health. He previously led product strategy for devices and AI at Teladoc Health.
Evan holds a bachelor's degree in biomedical engineering from Johns Hopkins University and a master's degree in biomedical engineering from Case Western Reserve University. He is also a co-instructor in bioengineering at Stanford University.
00:00 Introduction to this episode.
02:21 An overview of today's conversation.
05:12 EP505 with Ahilan Sivaganesan, MD.
05:17 EP434 with Benjamin Schwartz, MD, MBA.
06:31 The conversation with Evan Anderson.
06:40 What is a network?
06:50 Article by Katy Talento, ND, ScM, on carrier contracts and healthcare price competition.
08:15 The reality of contracts and carrier networks.
08:50 LinkedIn post by Mark Cuban.
12:18 LinkedIn post by Craig Gottwals.
13:19 The contractual illusion of discounts.
13:31 Health Affairs article on hospital cash prices versus negotiated prices.
14:20 EP482 with Preston Alexander.
15:38 EP480 with Kimberly Carleson.
15:49 EP521 with Andrew Tsang.
16:31 Article by Jim Jusko, JD, on healthcare provider networks.
17:20 EP529 with Eric Bricker, MD.
18:13 EP501 with Ivana Krajcinovic, PhD.
19:11 EP472 with Eric Bricker, MD.
21:17 What does a good solution look like right now?
23:16 EP398 with Jacob Asher, MD.
24:35 How incentivizing providers can open opportunities.
25:04 LinkedIn post by Mike Hopkins.
25:09 EP528 with Yashaswini Singh, PhD.
25:23 LinkedIn post by Lori Smith Guliano.
25:28 LinkedIn post by Patrick Nelli.
25:29 EP509 with Patrick Nelli.
26:44 How COE and steerage architecture plays into this.
29:24 EP530 with Jake Velie and Keith Hartman, RPh.
29:37 EP523 with Suhas Gondi, MD, MBA.
30:09 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky.
32:35 EP294 with Steve Schutzer, MD.
34:02 The different role of the broker and EBC in this model.
35:59 What Handl Health is and does.
Recent past interviews:
Click a guest's name for their latest RHV episode!
Jake Velie and Keith Hartman, Dr Eric Bricker, Yashaswini Singh, Mark Cuban and Cora Opsahl, Dr Cristin Dickerson, John Quinn, Dr Suhas Gondi
NOTE This file was generated by Descript
00:00:00 --> 00:00:06 Today, Evan Anderson and I are talking about carrier networks,
00:00:06 --> 00:00:08 how they started, how it's going.
00:00:08 --> 00:00:14 Because irrespective of whatever the plan was at the very beginning, any given
00:00:14 --> 00:00:20 network, especially talking about the big status quo networks, has evolved into
00:00:20 --> 00:00:24 what I'll call a three-headed monster.
00:00:25 --> 00:00:28 Probably there's many heads, but we'll limit ourselves to three right now
00:00:28 --> 00:00:32 So in the conversation that follows, Evan Anderson and I, we first
00:00:32 --> 00:00:38 describe said monster, and then we get into the and so now what?
00:00:39 --> 00:00:41 I'm gonna say this episode is a bit of a primer.
00:00:42 --> 00:00:49 It's a bit of a survey of the general map of the landscape, and it also gave
00:00:49 --> 00:00:55 me the opportunity to kind of stick on that map links to many other episodes
00:00:55 --> 00:01:00 for anybody looking to take a deep dive at any point along the journey.
00:01:00 --> 00:01:06 Just, yeah, making sure that we have laid down the breadcrumbs to additional
00:01:06 --> 00:01:10 information because it's really easy with some of these topics to go
00:01:10 --> 00:01:13 down some pretty deep, dark holes.
00:01:14 --> 00:01:21 And when you do, just please know that there is a community around you, listeners
00:01:21 --> 00:01:26 of Relentless Health Value are the village in a lot of it-takes-a-village equations.
00:01:26 --> 00:01:33 So if you find yourself in need of a hand to lift you up, please do reach
00:01:33 --> 00:01:37 out to the guests who have been on Relentless Health Value or head over to
00:01:37 --> 00:01:42 LinkedIn, check out who is commenting on our posts, and find your tribe.
00:01:43 --> 00:01:46 Hi, I'm Alex Sommers, physician and founder of Astia Health.
00:01:47 --> 00:01:50 What I appreciate about Relentless Health Value is that it doesn't simply
00:01:50 --> 00:01:51 talk about what's wrong with healthcare.
00:01:52 --> 00:01:54 It brings together people who are doing the hard work of fixing it.
00:01:55 --> 00:01:58 The conversations are honest, practical, and focused on creating
00:01:58 --> 00:02:01 better outcomes and greater value for patients and employers.
00:02:01 --> 00:02:05 It's a resource I regularly recommend to others working to transform healthcare.
00:02:05 --> 00:02:07 I highly recommend signing up for the weekly newsletter.
00:02:08 --> 00:02:11 It's a great resource because it includes all the links mentioned in the show, plus
00:02:11 --> 00:02:13 a full transcription of Stacey's intro.
00:02:14 --> 00:02:16 And forward this episode to someone who should be listening.
00:02:17 --> 00:02:18 All right.
00:02:19 --> 00:02:21 Let's take it from the top, shall we?
00:02:21 --> 00:02:27 Evan Anderson and I are going to describe first the three-headed monster, as
00:02:27 --> 00:02:30 aforementioned, that your average big status quo network has grown into.
00:02:31 --> 00:02:37 These networks are, lest we forget, built on a fee-for-service model that
00:02:37 --> 00:02:42 structurally aligns incentives in ways that are a lot of times misaligned
00:02:42 --> 00:02:45 with members and plan sponsors.
00:02:45 --> 00:02:52 The three heads of the aforementioned many-headed monster are the
00:02:52 --> 00:02:56 contractual illusion of discounts, that's the first head we discuss.
00:02:56 --> 00:03:00 Second, payment integrity, meaning even if you can figure out what the
00:03:01 --> 00:03:07 contracted price should be, you can't usually see what was actually billed
00:03:07 --> 00:03:10 that aligns with that what it should be.
00:03:10 --> 00:03:14 So there's almost no way to confirm that you are getting what you signed
00:03:14 --> 00:03:17 up for, at least without a lot of work.
00:03:18 --> 00:03:22 What complicates matters are old mainframe-based adjudication
00:03:23 --> 00:03:27 systems and high billing error rates that compound the problem.
00:03:28 --> 00:03:33 The third head of the monster that we discuss are wild variations in site
00:03:33 --> 00:03:38 of care costs for the exact same drugs and/or services, like one site of
00:03:38 --> 00:03:44 care can cost literally hundreds of thousands or a million dollars more than
00:03:44 --> 00:03:45 somewhere else that you could walk into.
00:03:45 --> 00:03:48 Both may be in the same exact network.
00:03:48 --> 00:03:53 After describing our monster, then we get into what are the solutions here.
00:03:54 --> 00:03:56 The discussed solutions are, first of all, change networks.
00:03:57 --> 00:04:01 And a little bit good luck with that working extremely well for
00:04:01 --> 00:04:04 a bunch of reasons that Evan Anderson and I talk about later on.
00:04:05 --> 00:04:09 Second possible way forward here is direct contract.
00:04:10 --> 00:04:13 And there's a couple of different flavors of direct contracting, which
00:04:13 --> 00:04:15 comes up in every single show lately.
00:04:15 --> 00:04:18 Primary care is one of them, direct contracting for primary care.
00:04:18 --> 00:04:22 And then also Center of Excellence type specialty care.
00:04:22 --> 00:04:25 Listen for a bunch of nuances.
00:04:26 --> 00:04:30 Third, steer and tier to the optimal site of care.
00:04:30 --> 00:04:35 And for reasons aforementioned, this is starting to exceed just, this is our
00:04:35 --> 00:04:42 preferred institution, and become site of care optimization for stuff like infusions
00:04:42 --> 00:04:46 where a member might go one place for the right diagnosis and treatment plan and
00:04:46 --> 00:04:49 maybe the first two infusions or something like this, but then go somewhere else
00:04:50 --> 00:04:53 for the continuing series of infusions.
00:04:53 --> 00:04:56 And number four, last thing we talk about, is bundling.
00:04:56 --> 00:05:01 But more than that, it's the aggregation of bundles into alternative health
00:05:01 --> 00:05:06 plans basically, and the pushing of the market toward a care episode
00:05:06 --> 00:05:10 where the quality can be measured or the outcomes can be measured,
00:05:10 --> 00:05:11 the appropriateness can be measured.
00:05:12 --> 00:05:16 Listen to the show with Dr. Ahilan Sivaganesan for a lot more on this.
00:05:16 --> 00:05:17 Link in the show notes.
00:05:17 --> 00:05:21 Or actually you could go back if you want kind of the primer on bundles and listen
00:05:21 --> 00:05:24 to episode 434 with Dr. Ben Schwartz
00:05:26 --> 00:05:30 So yeah, how was all that for, like, the spoiler of the century?
00:05:30 --> 00:05:32 Sorry, not sorry.
00:05:32 --> 00:05:34 My guest today is Evan Anderson.
00:05:34 --> 00:05:39 Evan has spent a career in the healthcare industry, and today he works
00:05:39 --> 00:05:43 on product strategy, general strategy, and operations for Handl Health.
00:05:44 --> 00:05:48 Speaking of Handl Health, big thanks and much appreciation for sponsoring
00:05:48 --> 00:05:53 today's episode and helping to offer up some of the financial assistance
00:05:53 --> 00:05:54 to keep the show on the air.
00:05:55 --> 00:05:58 Also, thanks to our founding sponsor, Aventria Health Group, and the team
00:05:59 --> 00:06:05 that tirelessly, week after week for the past 12 years, does all that needs
00:06:05 --> 00:06:10 to be done for each episode to get recorded, scheduled, edited, produced,
00:06:10 --> 00:06:13 the graphics made, proofreading, links created, posts written, newsletter sent.
00:06:14 --> 00:06:18 It's a lot, which is also why I appreciate the folks who have left a tip in the Tip
00:06:18 --> 00:06:21 Jar or do any kind of recurring donation.
00:06:21 --> 00:06:25 I see your names, and it is very restorative when my
00:06:25 --> 00:06:27 motivation starts to flag.
00:06:27 --> 00:06:28 You lot rock.
00:06:28 --> 00:06:29 Thank you, all.
00:06:29 --> 00:06:34 My name is Stacey Richter, and here is my conversation with Evan Anderson.
00:06:36 --> 00:06:38 Evan Anderson, welcome to Relentless Health Value.
00:06:38 --> 00:06:39 Thanks for having me, Stacey.
00:06:40 --> 00:06:45 So if we are talking about networks, maybe we just start at the very, very beginning.
00:06:46 --> 00:06:48 What is a network?
00:06:48 --> 00:06:53 And I'm gonna kick us off here, because I did just read a article
00:06:53 --> 00:06:57 written by Katie Talento entitled "I Dream of… a Post-Network
00:06:57 --> 00:06:59 World", where she defined a network.
00:06:59 --> 00:07:03 She says, "At its simplest level, a network is simply a set of contracts
00:07:03 --> 00:07:04 between carriers and providers."
00:07:05 --> 00:07:09 Yeah, so in summary, I think a network is a set of contracts, and
00:07:09 --> 00:07:12 there is a mechanism for making sure that those contracts are fulfilled
00:07:12 --> 00:07:17 between the owner of those networks as well as who's buying them.
00:07:17 --> 00:07:22 And I'm sure we're gonna dig into what those words mean because I
00:07:22 --> 00:07:26 think depending on who you ask, they may have a different definition.
00:07:26 --> 00:07:32 Just talked to Kimberly Carleson about the vast number of times where the,
00:07:32 --> 00:07:36 what is written on the contract is a little unclear, and therefore it is
00:07:36 --> 00:07:40 quite unclear whether the price that is being billed, like the number that
00:07:40 --> 00:07:44 is being billed, actually does in fact match whatever the contractual
00:07:44 --> 00:07:47 obligation or contractual agreement is, which is kind of unclear, but that's
00:07:47 --> 00:07:50 probably way too much foreshadowing.
00:07:51 --> 00:07:57 So if we talk about then what is the network myth, which is a term that,
00:07:57 --> 00:08:03 that you have used, if you were gonna just kind of like summarize what people
00:08:03 --> 00:08:10 believe about what we just said that may technically, accurately, IRL, in
00:08:10 --> 00:08:12 reality, not actually be the case.
00:08:14 --> 00:08:14 Yeah.
00:08:14 --> 00:08:20 I mean, I, I think that we have these contracts, and generally speaking, a
00:08:20 --> 00:08:24 contract can be fairly simple, but the reality is much different than that.
00:08:25 --> 00:08:29 The way that things have been going, we have these extremely complicated
00:08:29 --> 00:08:36 contracts, and there is a certain level of value that the plan
00:08:36 --> 00:08:39 administrators place on these, on these, on these carrier networks.
00:08:39 --> 00:08:42 And I think that, you know, over the years, there's been a lot of work to
00:08:42 --> 00:08:47 make those as powerful as possible, and it's not clear to me that they
00:08:47 --> 00:08:49 have to be as complex as they are.
00:08:50 --> 00:08:53 Several people have pushed back that there might be some standardizations
00:08:53 --> 00:08:54 possible, including Mark Cuban.
00:08:55 --> 00:09:05 And I think that, the main thing that these networks are doing is they're trying
00:09:05 --> 00:09:08 to obfuscate the actual costs of care.
00:09:09 --> 00:09:13 And then also trying to make it a little more complex to figure out if
00:09:14 --> 00:09:18 what those costs, if they actually been paid the way they should be.
00:09:18 --> 00:09:22 The winners in these cases are the administrators who, you know, have
00:09:22 --> 00:09:28 these carrier networks because they're able to drive costs and increases and
00:09:28 --> 00:09:34 be able to market their products as significant benefit to their clients.
00:09:34 --> 00:09:38 So, like, the marketing copy, there's, there's something like,
00:09:38 --> 00:09:41 you know, marketing is theater.
00:09:42 --> 00:09:44 The data is the source of truth.
00:09:44 --> 00:09:51 And unless you have… You can subtract X from Y to get Z. It's
00:09:51 --> 00:09:54 exactly like you just said, like, how much are we actually saving here?
00:09:54 --> 00:09:57 Are we paying what was, what was contracted?
00:09:57 --> 00:10:01 But then also, I think, kinda underlying a point that you just made
00:10:01 --> 00:10:06 is that it would be one thing if it was just I, carrier, have a contract
00:10:06 --> 00:10:08 with this one provider organization.
00:10:08 --> 00:10:10 But that's not what's happening now.
00:10:10 --> 00:10:15 There's all these dependencies where the contract depends on
00:10:15 --> 00:10:17 somebody else's contract, right?
00:10:17 --> 00:10:20 So then you wind up with weird cross-plan offsetting.
00:10:20 --> 00:10:23 You wind up with anti-competitive stuff.
00:10:23 --> 00:10:28 You wind up with weird shared savings stuff that is a
00:10:28 --> 00:10:29 giant question mark, right?
00:10:29 --> 00:10:34 Like, there's just so much in that complexity is buried so many
00:10:34 --> 00:10:39 money traps, so many honeypots, and not for the plan sponsor.
00:10:39 --> 00:10:40 Let's just be clear.
00:10:41 --> 00:10:43 To cut through the chaff here, I mean, if you only know the discounts,
00:10:44 --> 00:10:46 your looking at an optical illusion.
00:10:46 --> 00:10:49 You're negotiating, you know, a discount off a price that
00:10:50 --> 00:10:51 basically nobody can defend.
00:10:52 --> 00:10:53 It's off of a chargemaster.
00:10:54 --> 00:11:00 And that's sort of the way that the industry has built their marketing.
00:11:00 --> 00:11:06 And it's really not an effective way to understand whether or not you're getting
00:11:06 --> 00:11:08 value for the money that you're spending.
00:11:08 --> 00:11:15 At the same time, though, you try to get rid of a network and because
00:11:15 --> 00:11:20 having a network is the status quo, it's not like you can just
00:11:20 --> 00:11:22 be like, Okay, be gone, network.
00:11:22 --> 00:11:25 I see what you're doing there.
00:11:25 --> 00:11:29 I see how it may have started out as a good idea, for sure," right?
00:11:29 --> 00:11:34 And then has kind of morphed into this other thing, with
00:11:34 --> 00:11:37 perverse incentives and et cetera.
00:11:37 --> 00:11:42 But if you get rid of it, Hello, disruption.
00:11:43 --> 00:11:43 Yeah.
00:11:43 --> 00:11:47 We need networks, we need coverage, we need to minimize disruption.
00:11:47 --> 00:11:53 And I think that the, in the short term, we are stuck with networks, but
00:11:53 --> 00:11:57 I do think there's a number of things that we can do around the edges to push
00:11:57 --> 00:12:03 towards improving what services are provided at what price, and allowing
00:12:03 --> 00:12:08 for employers to one, understand that, and then make decisions based off of
00:12:08 --> 00:12:15 real data as we move towards different types of plans and different types of
00:12:15 --> 00:12:17 contracts that build these networks.
00:12:18 --> 00:12:23 For some nuances on this, read posts by Craig Gottwals.
00:12:24 --> 00:12:29 I will link to one of them where he says that for the right plan sponsor,
00:12:29 --> 00:12:35 not all, but for some, not having a network, even today, will work, and it
00:12:35 --> 00:12:37 can make care more affordable for members.
00:12:37 --> 00:12:42 But it does depend, again, on the plan and the demographics of the members that
00:12:42 --> 00:12:46 the plan has and their willingness to not have a logo on their members' cards.
00:12:46 --> 00:12:51 It also will require a plan who is on board with the level of engagement
00:12:51 --> 00:12:55 and communication that is required and be willing and have the staff or
00:12:55 --> 00:13:00 the outsourced vendors to deal with definitely some inevitable disruption.
00:13:00 --> 00:13:03 Again, we'll link to a post by Craig Gotwals on this topic.
00:13:04 --> 00:13:07 So if we're just gonna… and I'm, I'm on the edge of my seat.
00:13:07 --> 00:13:09 Maybe I'm creating suspense right now.
00:13:09 --> 00:13:14 Before we get to your recommendations relative to what you can do around
00:13:14 --> 00:13:18 the edges, I do just wanna make sure that we're kind of clarifying,
00:13:19 --> 00:13:23 I'm gonna call it the, three-headed monster of, of status quo networks.
00:13:23 --> 00:13:27 One of the things that you mentioned is the contractual
00:13:27 --> 00:13:29 illusion of discounts, right?
00:13:29 --> 00:13:29 Yeah.
00:13:30 --> 00:13:30 Yeah.
00:13:30 --> 00:13:34 And I think there was a Health Affairs article by Jiang in 2023
00:13:34 --> 00:13:37 that, that spoke about, you know, at roughly half the hospitals, the
00:13:37 --> 00:13:41 discounted cash rate is lower than the insurer ne- negotiated rate.
00:13:42 --> 00:13:45 I think that's a really powerful statement right there if you look at what, what
00:13:45 --> 00:13:50 are we actually buying if it's not a better price than what you could pay by
00:13:50 --> 00:13:52 just walking into a clinic or a hospital.
00:13:53 --> 00:13:57 And I think that there's a strong incentive for these care networks
00:13:57 --> 00:14:02 to, to keep the prices higher, and that there is an option to be able
00:14:02 --> 00:14:04 to see, you know, what that data is.
00:14:04 --> 00:14:08 But if we're just looking at what the discount is and we don't know what
00:14:08 --> 00:14:13 the denominator is, then we're walking in blind in terms of negotiating and
00:14:13 --> 00:14:14 understanding how we can save money.
00:14:15 --> 00:14:16 Yeah, absolutely.
00:14:16 --> 00:14:19 And you said there, there is kind of a structural incentive
00:14:19 --> 00:14:20 for prices to be high.
00:14:20 --> 00:14:23 There's been a number of shows where this has come up, I think most
00:14:23 --> 00:14:25 recently with Preston Alexander.
00:14:25 --> 00:14:29 If you're making a percentage of the premiums, now you make more
00:14:29 --> 00:14:36 money the higher the costs are in this kind of weird, perverse way.
00:14:36 --> 00:14:36 Correct.
00:14:36 --> 00:14:37 Yeah.
00:14:37 --> 00:14:41 And I think that, you know, a lot of these systems for adjudication are
00:14:41 --> 00:14:47 built off of really old mainframes that have a… There's… We've
00:14:47 --> 00:14:51 experienced it ourself that it's difficult to get these things updated.
00:14:51 --> 00:14:56 And so there's certain, like, rigidity in how these claims are adjudicated
00:14:57 --> 00:15:00 and the contracts are complicated and over years these things have
00:15:00 --> 00:15:02 gotten to be basically obtuse.
00:15:02 --> 00:15:05 It's almost impossible to go through them and understand it.
00:15:06 --> 00:15:09 The reality though is that, you know, it doesn't have to be that way.
00:15:09 --> 00:15:17 The logic is bad and right now it's grown over 25 years, and it's a problem.
00:15:17 --> 00:15:21 So, you know, nobody with skin in the game is, allowed to check the
00:15:21 --> 00:15:23 output, and that's a business model.
00:15:24 --> 00:15:28 Where there's mystery, there's margin, as I've said 900 times.
00:15:29 --> 00:15:35 It's also absolutely crazy when you start looking at the number of bills that have,
00:15:35 --> 00:15:37 the percentage of bills that have errors.
00:15:38 --> 00:15:41 Going back to the, the Kimberly Carleson episode where she just goes
00:15:41 --> 00:15:45 through, it's some crazy double-digit percentage of bills where if you
00:15:45 --> 00:15:48 actually look at them, there, there is… there's a, a billing problem.
00:15:49 --> 00:15:53 Yeah, I was gonna say, I think, is it episode 521 with Tsang.
00:15:53 --> 00:15:58 It's a $200 billion industry playing hot potato with the, these dollars, right?
00:15:58 --> 00:16:02 So the, the, the weakest party, patients, independent practices, or
00:16:02 --> 00:16:05 employers, the, those are the ones who are absorbing the cost when
00:16:05 --> 00:16:06 accuracy isn't determined upfront.
00:16:08 --> 00:16:10 Definitely go back and listen to that episode with Andrew Tsang about
00:16:10 --> 00:16:13 revenue cycle management if anyone hasn't, because a lot of these
00:16:13 --> 00:16:16 things become crystal, crystal clear.
00:16:16 --> 00:16:19 The other issue, and I'm gonna call this the third head of our three-headed
00:16:19 --> 00:16:22 monster, and there's probably people listening who can think of six more
00:16:22 --> 00:16:24 heads, but we're gonna stop with three,
00:16:26 --> 00:16:30 is this idea of structural, like, site of care flaws.
00:16:31 --> 00:16:34 You know, for example, Jim Jusko wrote an article two or three years ago.
00:16:35 --> 00:16:39 I think the article was entitled Networks: An Idea That Has Come and Gone.
00:16:39 --> 00:16:42 Just about how crazy it is that you could have the same doctor in
00:16:42 --> 00:16:47 the same place doing the exact same service, and depending on what, which
00:16:47 --> 00:16:51 network contracted the service, you could pay wildly different prices,
00:16:52 --> 00:16:59 which is just the definition of a dysfunctional market honestly.
00:17:00 --> 00:17:00 Yeah.
00:17:00 --> 00:17:01 Yeah, exactly.
00:17:01 --> 00:17:07 I mean, we're looking at, you know, every time you go into a hospital as
00:17:07 --> 00:17:09 opposed to outpatient, it's a multiplier.
00:17:09 --> 00:17:11 You know, sometimes as high as 13X.
00:17:12 --> 00:17:17 So, there is a huge differential based upon where you're seeing a provider on
00:17:17 --> 00:17:19 what those costs are actually gonna be.
00:17:20 --> 00:17:25 Do go back from a couple of weeks ago and listen to episode 529 with Dr.
00:17:25 --> 00:17:32 Eric Bricker, where site un-neutral payments comes up, and just how
00:17:32 --> 00:17:37 high facility fees are in comparison with physician professional fees.
00:17:37 --> 00:17:41 And if you did not understand what I just said, no worries.
00:17:41 --> 00:17:42 Again, episode 529.
00:17:43 --> 00:17:45 I know a lot of episodes are getting name-dropped.
00:17:46 --> 00:17:48 All links, as always, are in the show notes.
00:17:48 --> 00:17:52 But as I said in the introduction, this conversation I would consider
00:17:52 --> 00:17:57 sort of a primer, kind of a survey, rolling up a bunch of specific examples
00:17:58 --> 00:18:01 where our industry has lost itself.
00:18:03 --> 00:18:06 I think a lot of people know about that, but there's a lot of lack of
00:18:06 --> 00:18:09 information about when you're booking an appointment, where you're actually
00:18:09 --> 00:18:12 gonna see a provider, and what those costs are gonna be at the end of the day.
00:18:13 --> 00:18:19 And I think that in episode 501 with Ivana Krajcinovic, this is the poster child for
00:18:19 --> 00:18:27 the, you know, on this show, $135 versus 13 for the exact same infusion drug.
00:18:27 --> 00:18:28 Same drip, different tax ID.
00:18:28 --> 00:18:31 Both of which were in-network, which was the crazy thing.
00:18:32 --> 00:18:34 Like, you had two in-network providers.
00:18:34 --> 00:18:37 One of them was charging $135, and the other one was charging
00:18:37 --> 00:18:39 13 for the exact same thing.
00:18:39 --> 00:18:40 I mean, like
00:18:42 --> 00:18:43 question mark?
00:18:44 --> 00:18:49 I do feel like there's this, the three-headed monster that exists now,
00:18:49 --> 00:19:00 but I also just wouldn't want anyone to overlook the downstream or the underlying
00:19:00 --> 00:19:05 kind of foundational consequences of us having these three-headed
00:19:05 --> 00:19:08 monster networks as our status quo.
00:19:09 --> 00:19:14 And those are, and Dr. Eric Bricker talked about this in, in one of his episodes
00:19:14 --> 00:19:17 that I thought was really interesting, that I had never really thought about.
00:19:17 --> 00:19:23 Because the networks exist, what that means is if you're trying to
00:19:23 --> 00:19:26 not have a network, it's really hard.
00:19:26 --> 00:19:28 Because, you know, one of the things that the networks do is
00:19:28 --> 00:19:31 they reprice and dah, dah, dah, and nobody knows what the cost is.
00:19:31 --> 00:19:36 It's like this mysterious sorting hat, like, that, that you throw
00:19:36 --> 00:19:41 charges and tells you like, what the cost is supposed to be.
00:19:41 --> 00:19:43 But then if you don't have a network, then no one knows what
00:19:43 --> 00:19:45 the cost is supposed to be, right?
00:19:45 --> 00:19:47 So it makes it really hard.
00:19:48 --> 00:19:50 You cut one head off and the body grows it back.
00:19:51 --> 00:19:53 The, the body is, you know, it's, it's two things.
00:19:53 --> 00:19:57 It's opacity, for decades, sponsors contractually couldn't
00:19:57 --> 00:19:58 see their claims or rates.
00:19:58 --> 00:20:02 Gag clauses were only banned by CAA in 2021.
00:20:03 --> 00:20:05 And then you have misaligned agents.
00:20:05 --> 00:20:09 Every intermediary between the sponsor and the price gets paid
00:20:09 --> 00:20:12 in a way, in ways indifferent or positively correlated to higher spend.
00:20:13 --> 00:20:14 There's this kinda like two things here.
00:20:14 --> 00:20:20 Number one, this is such a well-funded industry, that there's so much money
00:20:20 --> 00:20:22 that everyone has an incentive.
00:20:22 --> 00:20:26 Exactly, like, if you, if you, there's some policy or anything, you know,
00:20:26 --> 00:20:30 a plan manages to get creative and figure out how to cut one of
00:20:30 --> 00:20:31 those heads off, then you're right.
00:20:31 --> 00:20:32 Like, the industry's gonna regenerate.
00:20:32 --> 00:20:35 But then number two, there's a lot of barriers to entry that
00:20:35 --> 00:20:37 this creates, which I think is kinda the point that I'm making.
00:20:37 --> 00:20:40 Like, if you walk in trying to pay cash, they're like, "Well, then you just, uh,
00:20:40 --> 00:20:42 you can't get an appointment, I guess."
00:20:43 --> 00:20:48 So I think now, Evan, is probably the time, since we've disheartened
00:20:49 --> 00:20:54 all listeners, where we start talking about what we potentially can do.
00:20:54 --> 00:20:57 You said there's things that you can do around the edges even now.
00:20:58 --> 00:21:04 And I'm assuming that you're saying around the edges because you want to
00:21:04 --> 00:21:13 move forward in such a way that isn't so disruptive that patients wind up
00:21:13 --> 00:21:17 getting caught unable to get care, or they have to work really hard.
00:21:17 --> 00:21:21 How do you conceive of what a good solution looks like right now?
00:21:22 --> 00:21:23 Yeah, it, great question.
00:21:24 --> 00:21:29 So first to evaluate, you know, a network switching, I mean, you need actual prices.
00:21:29 --> 00:21:31 Let's, let's just start there, okay?
00:21:32 --> 00:21:35 We're four years into hospital and plan transparency regulation, and
00:21:35 --> 00:21:39 the data's still messy, and hard to interpret without significant cleanup.
00:21:39 --> 00:21:42 Even with the data, switching networks can be disruptive.
00:21:43 --> 00:21:47 So what you need to do is run an analysis with your own claims file.
00:21:47 --> 00:21:52 Like you know, you need to have actual data on what the, the networks
00:21:52 --> 00:21:55 cost, and you need to have your own claims files to start with.
00:21:56 --> 00:22:00 So how does each network stack up for your people, your provider, and
00:22:00 --> 00:22:02 your providers in your geography?
00:22:02 --> 00:22:07 So sometimes, you know, switching network then can be justified, but you need
00:22:07 --> 00:22:08 that data first to do that analysis.
00:22:09 --> 00:22:16 So we're seeing employers, you know, facing extreme, increases, and I
00:22:16 --> 00:22:21 think that that's causing them to evaluate whether network changes can
00:22:21 --> 00:22:25 make some improvements if they have the right data to do the analysis.
00:22:26 --> 00:22:28 So thing one, and kinda what you're saying, is just like,
00:22:28 --> 00:22:31 let's just say, table stakes or whatever the right terminology is.
00:22:32 --> 00:22:36 You get your claims data, but then once you get those claims files, what you're
00:22:36 --> 00:22:41 doing is you're running simulations and saying, "Okay, if we had this
00:22:41 --> 00:22:44 network, what it would be? If we had this network carrier, what would it be?"
00:22:44 --> 00:22:45 Right?
00:22:45 --> 00:22:47 Like you're doing that math.
00:22:47 --> 00:22:51 And you might actually find that for whatever reason, one of them is
00:22:51 --> 00:22:52 superior to your current network.
00:22:52 --> 00:22:54 So, like, you might as well just try.
00:22:54 --> 00:22:55 Yeah.
00:22:55 --> 00:22:56 It's possible.
00:22:56 --> 00:22:57 I think that's the starting point.
00:22:57 --> 00:23:02 I think over time what we're gonna see is that the, the transparency arms race
00:23:02 --> 00:23:04 is gonna regress prices towards a mean.
00:23:04 --> 00:23:07 And so I think we're already seeing some of that in the market right now.
00:23:07 --> 00:23:13 So that's not gonna be a long-term solution for decreasing these
00:23:13 --> 00:23:15 in-price increases year over year.
00:23:16 --> 00:23:20 Yeah, and Jacob Asher, Dr. Jacob Asher was on the podcast a year or two ago
00:23:20 --> 00:23:21 who basically said the same thing.
00:23:21 --> 00:23:26 And that was even before price transparency, that like changing,
00:23:26 --> 00:23:28 because it's the same providers.
00:23:29 --> 00:23:30 I mean, like most every network, it's not like they have all
00:23:30 --> 00:23:32 different provider organizations.
00:23:32 --> 00:23:33 Like, it's the same providers.
00:23:33 --> 00:23:36 So if you're trying to get much higher quality out of the same provider
00:23:36 --> 00:23:39 network or you're trying to get much lower prices out of the same provider
00:23:39 --> 00:23:40 network, like it's kinda rough.
00:23:42 --> 00:23:42 Yeah, yeah.
00:23:42 --> 00:23:47 I, I mean, I think that, you know, we need to keep pushing, but longer term, I think
00:23:47 --> 00:23:51 that there needs to be other solutions that we're investigating that will help,
00:23:51 --> 00:23:52 and I think there are options out there.
00:23:53 --> 00:23:57 You talked earlier about things you can do around the edges of
00:23:57 --> 00:24:00 that, and I'm extremely interested in what those things are.
00:24:01 --> 00:24:03 Yeah, I think some of them can be really powerful depending
00:24:03 --> 00:24:04 on the size of the employer.
00:24:04 --> 00:24:08 So direct contracting, talked about on the show many times.
00:24:08 --> 00:24:13 I think that that, especially for direct primary care or advanced primary care,
00:24:13 --> 00:24:18 especially if it's tied into value-based incentives, can be super powerful for
00:24:18 --> 00:24:20 organizations and there's, for employers.
00:24:20 --> 00:24:24 And there's a number of companies that are providing direct contracting.
00:24:24 --> 00:24:28 But there's nothing stopping an employer from directly contracting
00:24:28 --> 00:24:32 themselves with a primary care practice in their local geography.
00:24:32 --> 00:24:36 So I think that that alone can make a big difference because if you're
00:24:36 --> 00:24:40 incentivizing the primary care provider, maybe you have some kind of capitated
00:24:40 --> 00:24:45 model with value-based incentives, there's a lot that you can do to
00:24:45 --> 00:24:47 prevent people from getting more sick.
00:24:47 --> 00:24:50 And the providers are incentivized to do that.
00:24:50 --> 00:24:55 When you're working with a network, the primary care providers are not
00:24:55 --> 00:24:59 really incentivized to do a lot of that preventative care because
00:24:59 --> 00:25:03 large hospital systems do make a lot of money off of specialty care.
00:25:04 --> 00:25:10 I'm gonna link to a great post by Mike Hopkins in response to a recent
00:25:10 --> 00:25:13 show on private equity getting into primary care, which is the
00:25:13 --> 00:25:16 episode with Yashaswini Singh, PhD.
00:25:17 --> 00:25:23 I really think that this post summarizes so concisely the considerations here.
00:25:24 --> 00:25:28 And there were some great comments on that post by Laurie Smith Giuliano
00:25:28 --> 00:25:31 and also Patrick Nelli, who was a guest on an earlier show, so go
00:25:31 --> 00:25:32 back and listen to that one too.
00:25:33 --> 00:25:37 And yeah, all of these links are in the show notes to the earlier show
00:25:37 --> 00:25:41 and also the post by Mike Hopkins for further reading and listening on
00:25:41 --> 00:25:46 the topic of not buying primary care through a status quo carrier network.
00:25:47 --> 00:25:50 And I think that also, like, you know, contracting with Centers
00:25:50 --> 00:25:55 of Excellence for things like MSK can be a huge value savings.
00:25:55 --> 00:25:58 And I think there is options to do that also, you know, locally.
00:25:58 --> 00:26:01 It can be a little bit more challenging, but there's a lot of
00:26:01 --> 00:26:06 great solutions around, you know, GI, cancer, MSK for Centers of Excellence.
00:26:06 --> 00:26:07 And that's a proven model.
00:26:07 --> 00:26:08 It's been around for a while.
00:26:09 --> 00:26:13 Not all employers are taking advantage of it, but direct contracting around
00:26:13 --> 00:26:17 primary care and some specialty care can be a significant savings.
00:26:18 --> 00:26:20 So the ideas that came up so far, find a better network.
00:26:21 --> 00:26:25 This is increasingly not a great solution as prices regress to the mean across
00:26:25 --> 00:26:27 the board, but yeah, give it a go.
00:26:27 --> 00:26:31 Second, direct contract with primary care or with specialty care.
00:26:32 --> 00:26:36 You certainly have advanced primary care or direct primary care.
00:26:36 --> 00:26:38 Listen to the show with Patrick Nelli.
00:26:38 --> 00:26:42 Listen to the show again with Ryan Jacobs for kind of a deep dive into what's going
00:26:42 --> 00:26:44 on and the advantages and the importance.
00:26:44 --> 00:26:46 Then the second one is Center of Excellence contracting.
00:26:47 --> 00:26:51 And I think, you know, for specialty, for example, oncology care or for
00:26:51 --> 00:26:55 example, with, MSK, musculoskeletal care.
00:26:55 --> 00:26:58 Talk about then what else.
00:26:58 --> 00:27:02 Well, I think that, you know, steerage architectures have
00:27:02 --> 00:27:03 been around for a while.
00:27:03 --> 00:27:07 I do think that there are some newer ones, relatively new ones
00:27:07 --> 00:27:09 that are becoming more powerful.
00:27:09 --> 00:27:14 So I think that network tiering been around for a long time, but I think
00:27:14 --> 00:27:19 the thing that's really important and hard to get to is including site of
00:27:19 --> 00:27:22 care tiers, not just provider tiers.
00:27:22 --> 00:27:26 That's critical, like we talked about earlier, because depending on where
00:27:26 --> 00:27:29 you're seeing a provider, you could have a massive difference in what you're paying.
00:27:29 --> 00:27:31 So those, that tiering needs to include that, and you can see
00:27:31 --> 00:27:32 some real savings from that.
00:27:33 --> 00:27:35 Now, that does create some disruption.
00:27:35 --> 00:27:39 And so, you know, the members need to engage and look at those network tiers,
00:27:39 --> 00:27:41 and you need to have the actual data.
00:27:41 --> 00:27:45 You have to have a pipeline to get that data in to understand what those costs
00:27:45 --> 00:27:47 actually are based on the site of care.
00:27:48 --> 00:27:50 You know, the other thing that you could think about is, and I'm excited
00:27:50 --> 00:27:53 about is bundling episodes of care.
00:27:53 --> 00:27:57 I mean, you, you sort of, we've, we've talked about that with regard to Centers
00:27:57 --> 00:27:58 of Excellence for specialty care.
00:27:59 --> 00:28:02 You, you know, you're typically, you know, bundling a MSK
00:28:02 --> 00:28:04 solution for a certain price.
00:28:04 --> 00:28:09 But you can do much more than that through, you know, dynamic co-pay plans,
00:28:09 --> 00:28:13 as an example, like bundling up to a hundred and fifty different episodes
00:28:13 --> 00:28:15 of care that can be included in that.
00:28:16 --> 00:28:20 And paying a single price to see a provider or, or a health
00:28:20 --> 00:28:23 system for that whole episode.
00:28:23 --> 00:28:27 And if you look at the value that that's driven by, you know, with the quality
00:28:27 --> 00:28:32 as well as the cost, then you can start to tier based on episodes of care.
00:28:32 --> 00:28:33 Call it an alternative health plan.
00:28:33 --> 00:28:40 Something like a, Surest, but maybe, you know, not dependent on a specific network.
00:28:40 --> 00:28:42 So I, I heard you say two things there.
00:28:43 --> 00:28:45 One is steer and tier.
00:28:46 --> 00:28:51 Again, talking about the Ivana Krajcinovic show where there's
00:28:51 --> 00:28:53 just… It's not like it's 10 bucks.
00:28:53 --> 00:28:59 She gives one example in that episode about how two members went… Again,
00:28:59 --> 00:29:01 all on the same network, by the way.
00:29:02 --> 00:29:05 If two members had gone down the street to get an infusion, the exact same infusion.
00:29:05 --> 00:29:07 So we're talking about a drug now, right?
00:29:07 --> 00:29:09 So it's not like the quality is any- It's the same drug.
00:29:09 --> 00:29:11 It would've been a million dollars less.
00:29:11 --> 00:29:11 $1 million.
00:29:12 --> 00:29:14 Like, this is, this is big money here.
00:29:14 --> 00:29:19 So the making sure that you're steering to certain sites of care.
00:29:20 --> 00:29:24 And look, this is not as easy as just moving around, I don't know, Lego pieces.
00:29:24 --> 00:29:30 Listen to the episode from a week or so ago with Jake Velie and Keith Hartman,
00:29:30 --> 00:29:35 who emphasize the clinical expertise needed to figure out how to get the
00:29:35 --> 00:29:37 right patient to the right place.
00:29:37 --> 00:29:41 Also listen to the show with Dr. Suhas Gondi, who really emphasizes
00:29:41 --> 00:29:45 the importance of communication in these moments, because moving patients
00:29:45 --> 00:29:50 around also can mean patients not getting care in a timely fashion while
00:29:50 --> 00:29:54 multiple parties who aren't talking to each other blindly kind of play
00:29:54 --> 00:30:00 a very unwelcome high-stakes squid guessing game about where the patient
00:30:00 --> 00:30:04 needs to go and whose form or what form needs to be filled in and faxed where.
00:30:05 --> 00:30:09 I.e., there's fragmenting of an already fragmented system.
00:30:09 --> 00:30:14 The episode also with Adam Stavisky, Dr. Leo Spector, and Ryan Wells from
00:30:14 --> 00:30:18 Health Here is also enlightening if you are looking to learn more about
00:30:18 --> 00:30:22 just, like, how this whole thing works for musculoskeletal MSK bundles.
00:30:24 --> 00:30:26 So the steering and tiering is certainly there.
00:30:26 --> 00:30:28 And then you mentioned bundling.
00:30:28 --> 00:30:31 There are a number of companies that are, are trying to develop these
00:30:31 --> 00:30:35 bundles and package them in certain ways, providing infrastructure
00:30:35 --> 00:30:37 or providing plans themselves.
00:30:37 --> 00:30:42 What you're saying is there's growing aggregators of bundles right?
00:30:42 --> 00:30:44 The, they'll go around, they'll do all the negotiation.
00:30:45 --> 00:30:47 They'll figure out what the beginning and end of the bundle is or the episode.
00:30:48 --> 00:30:52 That's an idea that has been around for a while.
00:30:52 --> 00:30:55 There is certainly some best practices relative to paying for an episode with
00:30:55 --> 00:31:00 a certain quality and certain time parameters and guarantees, et cetera.
00:31:00 --> 00:31:04 But what you're saying is new, is that the entities that are going
00:31:04 --> 00:31:08 around doing all of the direct contracts with various provider
00:31:08 --> 00:31:14 organizations, you can leverage all of the contracts that they've negotiated.
00:31:14 --> 00:31:18 Yeah, you can, yeah, you can negotiate those contracts.
00:31:19 --> 00:31:23 And I think that one of the things that it does, which I don't think
00:31:23 --> 00:31:26 we should underestimate, is chipping away at that fee-for-service model
00:31:26 --> 00:31:28 that providers have gotten used to.
00:31:28 --> 00:31:32 If you are starting to push for more bundling, you'll see
00:31:32 --> 00:31:36 providers think about the care that they're providing differently.
00:31:36 --> 00:31:39 There's a lot of different ways to do this bundling.
00:31:39 --> 00:31:43 I think that, you know, doing the contracting can be slow and arduous, but
00:31:43 --> 00:31:49 if you're looking at just bundling claims and having a single copay, I mean, that
00:31:49 --> 00:31:54 in and of itself can change the dynamic of how members decide on what kind of care
00:31:54 --> 00:31:59 to get, and you can push people towards providers that are higher value within
00:31:59 --> 00:32:05 that, that either provide both higher quality outcomes and lower costs or some
00:32:05 --> 00:32:07 mix of the two that equal higher value.
00:32:07 --> 00:32:10 So there's, there's multiple ways to do it, and if you're, if you're
00:32:10 --> 00:32:14 pushing this in multiple levels, I think we can change some of the
00:32:14 --> 00:32:16 status quo around fee-for-service.
00:32:16 --> 00:32:20 You're also kind of implying people are gonna build what the market wants.
00:32:20 --> 00:32:25 So if enough people, enough plan sponsors, enough companies are going
00:32:25 --> 00:32:30 around saying, "Give me your bundle price for X," then provider organizations
00:32:30 --> 00:32:32 are gonna rise to the market.
00:32:33 --> 00:32:35 And maybe vice, and maybe vice versa.
00:32:35 --> 00:32:39 We had Steve Schutzer, Dr. Steve Schutzer, on the podcast many years ago
00:32:39 --> 00:32:41 who built a huge Center of Excellence.
00:32:41 --> 00:32:43 He had all these bundled prices, et cetera, and couldn't find
00:32:43 --> 00:32:47 anyone to purchase the bundle.
00:32:47 --> 00:32:52 So it's definitely a two-sided market here also.
00:32:52 --> 00:32:53 Yes.
00:32:53 --> 00:32:57 I think that, you know, none of this is exotic anymore, but the way that
00:32:57 --> 00:33:00 we're approaching it, there are some innovative solutions to making it happen
00:33:00 --> 00:33:02 and, again, chipping around the edges.
00:33:03 --> 00:33:05 I think that essentially, you know, if we're looking for a, at
00:33:05 --> 00:33:11 a fee-for-service model, it's very hard to measure the quality of a
00:33:11 --> 00:33:14 single procedure or single service.
00:33:15 --> 00:33:20 But if we're bundling it, those metrics become much more powerful around an
00:33:20 --> 00:33:22 episode of care that we can measure.
00:33:22 --> 00:33:27 And I think that there's not that much headwinds to prevent
00:33:27 --> 00:33:28 us from doing some of that.
00:33:29 --> 00:33:34 As we look at the contracting to pay certain rates for higher quality care
00:33:35 --> 00:33:40 and higher volumes to certain providers and systems, that can be done as well.
00:33:40 --> 00:33:42 But I'm saying that there's, you know, it's all of the above.
00:33:43 --> 00:33:48 Which also sort of negates some of the three-headed monster issues that we were
00:33:48 --> 00:33:52 talking about with the network, because if you're negotiating these contracts
00:33:52 --> 00:33:56 around the edges, you know the price, you know the quality that you're looking
00:33:56 --> 00:34:01 for and you know how much you were charged, so you can compare the two.
00:34:02 --> 00:34:05 You know, one of the things that's occurring to me as you're talking
00:34:05 --> 00:34:12 here, Evan, is the differing role that the benefit consultant or
00:34:12 --> 00:34:13 the broker plays in this model.
00:34:14 --> 00:34:18 Because in the past, maybe the main role of a broker was,
00:34:18 --> 00:34:19 like, being a good shopper.
00:34:19 --> 00:34:23 You know, like helping the, the, the employ- You know, like I'm
00:34:23 --> 00:34:27 gonna shop for a network, and I'm shopping for stop loss, right?
00:34:27 --> 00:34:28 Et cetera, right?
00:34:28 --> 00:34:30 Like, I'm minimizing here, I am aware.
00:34:30 --> 00:34:35 But if we're thinking about the role of the broker/EBC in this
00:34:35 --> 00:34:40 new world, it's very much like an orchestration type affair.
00:34:41 --> 00:34:42 The role is changing.
00:34:42 --> 00:34:46 You know, the brokers and benefit consultants need to know the actual costs
00:34:46 --> 00:34:51 of things, and they need to be able to analyze that data, understand what the
00:34:51 --> 00:34:56 priorities are for their employers, and find solutions for them that exist out in
00:34:56 --> 00:35:01 the marketplace, and play the consulted role in helping get those employers
00:35:01 --> 00:35:02 onto the solutions that they need.
00:35:03 --> 00:35:07 Like, coming in and saying, "Oh, this, this network, offers a bigger discount."
00:35:07 --> 00:35:11 Like, that ship is starting to sail.
00:35:11 --> 00:35:13 Like, maybe not for the top of the bell curve, but it's, that's
00:35:13 --> 00:35:14 where this, this world is headed.
00:35:15 --> 00:35:17 But then, you know, you can't, like, what's the broker
00:35:17 --> 00:35:18 gonna do at that juncture?
00:35:18 --> 00:35:19 Like, good luck.
00:35:20 --> 00:35:26 So the other kind of orchestration that's falling on the, on the EBC broker, or
00:35:26 --> 00:35:29 the ones that are leading the charge here, is, like, okay, how do I actually
00:35:29 --> 00:35:36 orchestrate a full plan here to address if I know that something is super
00:35:36 --> 00:35:42 high cost, overly expensive or lower quality, then how am I actually doing
00:35:42 --> 00:35:43 the steering and tiering, and to whom?
00:35:44 --> 00:35:48 I think that what we focus on here at Handl is not just
00:35:48 --> 00:35:49 presenting data for data's sake.
00:35:49 --> 00:35:51 The data has to be actionable.
00:35:51 --> 00:35:52 We talk about that all the time.
00:35:52 --> 00:35:56 We need to be able to connect the dots between what the data
00:35:56 --> 00:35:59 states that you should do and how you're actually gonna do it.
00:35:59 --> 00:36:00 Talk to me about Handl Health.
00:36:01 --> 00:36:05 Handl Health is essentially a data infrastructure company.
00:36:05 --> 00:36:09 We provide self-funded employers and brokers with the information
00:36:09 --> 00:36:12 that allows them to get insights into how they can save money.
00:36:12 --> 00:36:17 And what they can do then with those insights is actually take them to
00:36:17 --> 00:36:20 a TPA or an ASO, and we provide the infrastructure for those TPAs
00:36:20 --> 00:36:23 and ASOs to implement those plans.
00:36:23 --> 00:36:26 So your customers are EBCs, brokers, TPAs?
00:36:29 --> 00:36:31 Yes, that's right.
00:36:31 --> 00:36:34 Yeah, we have some employers with Payment Integrity that bought direct as well,
00:36:34 --> 00:36:39 but yeah, it depends on is it just data for analytics, or is it data to provide
00:36:39 --> 00:36:42 infrastructure to allow for new designs?
00:36:42 --> 00:36:49 So if I am an EBC, broker, a sophisticated employer, or a TPA, and I'm like, Hmm,
00:36:49 --> 00:36:52 I wanna put in place some of the things that we're talking about today, but
00:36:52 --> 00:36:57 I'm not exactly sure whether I have the technology and the data ingestion pipes,
00:36:57 --> 00:37:00 whatever you wanna call it, in order to do that, like, that's who should call you.
00:37:01 --> 00:37:02 Exactly.
00:37:02 --> 00:37:03 Got it.
00:37:03 --> 00:37:07 Where, if they are looking at calling you, Evan Anderson,
00:37:07 --> 00:37:08 should they get ahold of you?
00:37:08 --> 00:37:11 So, you can go to our LinkedIn website.
00:37:12 --> 00:37:14 It's Handl without an E, Handl Health.
00:37:15 --> 00:37:19 our website's the same, Handlhealth.com without an E. And then you can also email
00:37:19 --> 00:37:22 me, Evan, E-V-A-N, @Handlhealth.com.
00:37:22 --> 00:37:25 Evan Anderson, thank you so much for being on Relentless Health Value today.
00:37:26 --> 00:37:27 It was a pleasure.
00:37:29 --> 00:37:33 Hi, this is Tom Nash, editor and producer of the Relentless Health Value Podcast.
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