Healthcare Navigation Done RIGHT! [WEBINAR]

Alright guys, we're gonna get cranking here. Thank you again. If you are on this webinar, thank you for taking the time to attend. I know it's a very busy time of year for everybody, so we really appreciate it. My name is Andy Neary, I'm with a healthcare strategist with the Olson Group. I'm excited today that we're gonna have on Nurse Deb Alt, founder of Alt International Medical Management. And the biggest thing about these webinars, if you've been on them before, we like to keep them short and sweet to respect your time. So this will be no longer than 25, 30 minutes. Going to do today is go into a Q and A with Nurse Deb and to talk about a very, very important piece of the health insurance plan that often gets overlooked and that is medical management. And so if you're on this call right now, if you've been on my past webinars, you'll notice that my webinars have a theme. And it really comes down to this. If you want to control your health insurance cost, which I hope everybody on this call has a goal to do, you have to focus on your claims. At the end of the day it comes down to claims. And so our goal with these webinars is to help you become better consumers, help you become more aware of what's out there and truly help you know what strategies are out there today that you may have not seen before that can truly help you not only control health insurance costs, but truly the ultimate goal here is to help you build better health, plan for less money and put money back in your employees wallets and give them better access to the healthcare system. And so one quick housekeeping before we get cranking on this webinar. If you have a question as we go through this webinar, whether it's for me, it's for Nurse Deb, just go right into the chat box and type the question and we'll make sure to get that answered whether it's during the Q and A or during the interview with Deb or at the end when we'll do some short Q and A. So again, if you got a question, feel free to just type it in the chat box and we'll make sure that.

We can address it during the webinar. So all right, let's get started. Most of you on the webinar this morning, find yourselves within the human resource department of your organization. And when you think about health insurance, I think we can all agree that it's a challenge for most organizations right now. But as a human resource professional, I think you face even more challenges today. Number one, you're wearing a lot of hats.

Each and every day, right? Benefits is just one thing you do each and every day. You have so many other things that go on every day that it's very hard to dedicate the time, effort, in some cases needed to really reign in insurance costs and focus on what you can do to build a better health plan. Now, some of you on the call might be in a beneficial situation where you have a team of people behind you working on the benefits, but I'm willing to bet most of you are a little over manned, over womaned, and wearing a lot of hats every day. The second challenge you face right now is, is the workforce. We have four different generations in the workforce right now, right? And they're all motivated by different triggers. You've got the baby boomers, who are probably the most loyal employees we've ever had. Then we've got the Gen Xers, which I am one myself. And then we got those millennials we always talk about. And now the Gen Z, where they're motivated by different things, right? They're not maybe so motivated by money, they're motivated by purpose. They're motivated by doing something that's bigger than them. But here's the interesting thing that we're starting to learn, especially in the benefits space, hone in on that. The girl on the left side of the image here, the left side of the screen, she's using a smartphone. And we have come to learn, especially when it comes to benefits technology, benefits, communication. One thing that is locking in all four generations is that smartphone right there. Everybody is using it. You know, it's interesting. I'll talk to employers and when we want to talk about what kind of benefit technology, benefit app we want to bring to their employees. And it's common that the conversation comes up. Well, not all my employees have access to smartphones, which is true. But the more I think about it, the more I've come to realize when you say that what we're really talking about is probably three or four employees out of 100 or 200 you might have in your organization. Because Whether you're a 22 year old new hire or you're a 70 year old veteran, there's a good chance you're probably using a smartphone today. But keeping all four generations happy at the same time, especially when it comes to crafting a benefit package, is extremely difficult. Our third challenge is recruiting. Think about the landscape today. When it comes to going out and hiring the top talent. Top talent have leverage right now because unemployment's under what, 4% nationwide. It's very hard to go out and find good talent today. And when you find the top talent, let's face it, they do have the leverage because there's plenty of employers out there looking for them right now. So when you think about these three challenges you have wearing multiple hats every day, undermanned, trying to keep four generations happy in the workforce, trying to recruit effectively, often the health plan goes overlooked. It's not given the time it should be. And at the end of the day, what's happened in our industry over time is you have been taught that there's three ways to control your insurance cost. Number one, shop the carriers. Number two, just raise deductibles and out of pocket limits. Easy way to reduce your bottom line at the organization, but a quick way to increase the bottom line and your employees financial exposure. And the third is just ask employees to pay more. But here is the end result of these three strategies you see on the screen right now. They make all of your other jobs, all of your other things you do every day that I just mentioned, the multiple hats, the recruiting, the keeping everybody happy that much harder because. Because what's happening over time is the benefits are getting worse and we're paying more for worse benefits. And so at the end of the day, it's impacting morality of your organization, it's impacting your ability to recruit, and it's mostly impacting your ability to keep everybody happy within the organization. So today our goal, Deb and I, is to show you one strategy, one way that you can truly start building a better health plan for less money. Because at the end of the day, guys, this is what it's all about. It comes down to one simple formula. You need to focus on claims, you need to focus on the medical and the pharmacy claims inside your plan. And that comes down to this one formula. The number of units of health care purchased.

Multiplied by the price at which those health care services are purchased. Think about that again. I'm going to say that again. The number of units of health care that are consumed multiplied by the price at which they are consumed. It's that easy. That's what we're going to focus on today. Mainly not only the number of units, because sometimes there's overcharging over too many procedures going on in the health insurance industry, in the healthcare system, but we know that they're also coming at a significant cost to you. And to your employees. So the three risks we help our employees manage. And this is one thing I want you to walk away from. You've heard this on my previous webinars. If you haven't been on one before, you're going to hear this for the first time. The key in controlling your health insurance cost is focusing on your claims. But it's also focusing away from just buying insurance and focusing more attention on managing risk. It's no longer about buying insurance, it's now about managing risk. First area of risk you got to manage is the financing risk. We talk about this all the time. You have to look how you're financing your health plan. Are you fully insured today? Are you level funded? Are you in a captive arrangement? What are you? Or are you partially self funded? The closer you can get your organization to level funding a captive or self funding, the more control you are going to give yourself controlling your claims. Second area of risk is the catastrophic claims. And that's it. This is an area we're going to focus on a lot today. What am I talking about? I'm talking about the size and frequency of your claims. You have to focus on the cost at which health care services are being purchased today. And then the third area of risk is health care purchasing risk. You have to help your employees access the health care system more effectively. It's no longer about buying an insurance plan, expecting the insurance plan to keep your health and health care costs down. It's now about figuring out how your employees are navigating the healthcare system and then putting strategies in place so they can access high quality care at a low cost. And that is what this webinar is all about. So with that being said, I want to bring nurse Deb Alt on from ALT International Medical Management. Deb, thank you for being on. If you want to make a quick introduction of yourself, we'll get cranking with the interview.

Thanks, Andy. I appreciate the opportunity to be here and I don't know, 30 minutes. We don't have time for an introduction. Let's jump right into it.

Sounds good. Sounds good. Okay, so with that being said, let's get right to the point. We know that controlling medical and pharmacy claims is the number one thing an employer must do to control health insurance costs. And it comes down to effective healthcare navigation, which is what this webinar is all about. And I love the fact that your message is built around the five pillars of healthcare navigation. Right patient, right care, right time, right place, and right price. What do you mean by that?

Well, that's our oversimplified way of walking people through the effective navigation of the two most cumbersome ecosystems in the universe, the health delivery system. So what care am I going to get? When am I going to get it? Where am I going to get it? And the health plan system. In other words, is this covered under my health plan? Should it be covered under my health plan? Should I be getting it somewhere for free outside of the health plan, et cetera. So this is really what my team of nurses and doctors do every day telephonically with patients that are covered by health plans that we're servicing. It's all about coming alongside them and hand holding them through the decision making process, which is a little bit of a mind shift for most patients. Right. In the past, they probably had abdicated all responsibility from pre certification and making those decisions to a doctor. As we see more and more doctors, offices and practices kind of snatched up by large health systems, we're beginning to get glimpses of some of the things like the gag orders that were on pharmacists are now being placed on doctors. So if, for example, there's a particular type of equipment that their health system employer doesn't have available, they're not allowed to discuss that as a treatment option with a patient. Well, maybe that a patient could go across town and get a much higher quality of care, better outcome. So having an objective, independent third party who's clinically focused, so nurses and doctors handholding your people through their decisions from the point of sickness to recovery, really what it's all about. And these are the five steps that we walk them through as we're doing that.

Awesome. So if we go back to the formula that I talked about earlier, that it really comes down to the number of units of healthcare consumed multiplied by the price at which they are consumed.

Programs like AIM can help address both sides of that formula.

Absolutely. I mean, we've all seen the myriad of studies. About 30% of healthcare spending is fraud, waste and abuse. You can't mitigate that if you're not engaging patients and helping them walk through that. Lots of times a doctor will order something because it's medical malpractice, wants him to order it. Not necessarily because it's the evidence based, best clinical care. And we need to identify those things and walk patients through that decision making process. On number one, do I even really need this? Is this the right care? Is, is it the thing that I really should be getting? Is it gonna get me better or is it gonna do me more harm? Instead of Good, Good.

Awesome. Awesome. So a couple slides back, I had shown the image of. If you think about how insurance is purchased today, most employers are relying on that insurance company and the network for which they own to control healthcare costs when it comes to reducing medical and pharmacy claims. Why shouldn't we trust the network discounts that the insurance carriers tout?

Because you're getting a percent off of what. So, for example, chemotherapy. Hate to say it, but it's one of the most priced gouged procedures or services in medicine today. It is very common for us to look up the wholesale acquisition cost of a drug and find that a healthcare provider has marked that bill up 2,000%. And then they're sending it through the PPO and getting you a 50 or 60% discount. G. Thanks.

So there are games that get played. We see that with chemotherapy, we see it with some prosthetic devices, we see it with durable medical equipment. And it's simply a matter of them hyper inflating their chargemaster. And the other challenge is if they're not the highest quality provider, they're not doing that procedure or service in sufficient volume. In a high volume, they may not be able to get the best wholesale price. Right. If you're buying 5,000 cars, you get a way different discount than if you go on and buy five versus if you go in and you buy one. So getting people to the right providers. The little secret here, Andy, is if you do these first four rights, the vast majority of the time getting the patient the right care at the right time, at the right place is going to result in the right price. There are some exceptions to that, chemotherapy, those kinds of things, but for the most part, if you can engage the patient, get them into the right care, get it done at the right time, get them to the highest quality place to get it done, right price will be the natural consequence.

Yep, absolutely. Absolutely. And so if you think about what we're talking about today, we're talking about medical management, right? And many of the employee employers on this webinar right now have been told that, well, the insurance company handles medical management. They handle disease management, care coordination. Why isn't this an effective model, Deb? Why is it important to work with a third party advocate?

Yeah, the reason I left the carrier and third party administrator environment about 18 or so years ago is because I got tired of my division and our profit carrying the rest of the company. When you look at the carrier model, while the box is checked for medical management, if you really pop the hood and take the COVID off the engine and get down in there looking at the cylinders and the transmission. What you're going to find is that those models are staffed with one nurse servicing 60,000 employee lives. That's an astronomically huge number of patients to be responsible for. When you staff like that, about 1% of the population gets any kind of extra assistance or any care management. We know that that model generates a PEPY increase year over year of about 7% because the other 99% are spending money that's going unchecked.

Right.

If you step that down to a TPA model, you typically get about one nurse per 20,000 employee lives. They do a little better. They touch about 5% of the population. They don't do a good job of publishing their PEPY outcomes or their claims cost outcomes. The best that I've seen is flat or maybe a 2 or 3% increase. We believe that the right patient to get help is any patient who has any health or insurance related problem, question or concern. If you want to help that many people, if you want to help all of the people that are accessing your health benefits, you've got a staff at one nurse per 5,000 employee lives. And if you think about it, 80% of your claims are generated by about 20% of your population. So maybe you should be hand holding 20% or more of your population, Right?

Yep.

If you do that, if you help them navigate the system more efficiently and more effectively, what happens is you get a 3.8% decrease in spend year over year over year. So instead of your trend being flat or going up, up, up, up, up, it can be flat or go down, down, down, down, down.

Great question, great points there about uncovering some of the unknown truths in our industry that we often say employers just aren't told about today. So thank you for sharing that. Now, Deb, can you give us an example of where having the right care management model is critical in addressing a chronic illness? Maybe share why it's important to monitor chronic illness for a member, the impact that it can have on a member's health and an employer's bottom line.

I'm a big fan of telling people the worst case scenario straight out of the gate. Right. And so we all have been impacted in some way, shape or form by someone that we know and love getting that horrible diagnosis of cancer. The truth of the matter is it's not an extraordinarily prevalent condition. So about four out of a thousand belly buttons will be diagnosed with cancer. There are certainly way more prevalent, serious and catastrophic conditions out there. But we don't always hear about them or see them. The thing that bothers me the most about cancer is the rate of misdiagnosis. Almost 30% of cancer patients are misdiagnosed, meaning that they don't really have cancer or that the pathology report came back with the wrong type of, or the wrong stage or the wrong cell type of cancer. That's a major problem because we rely on those test results and those diagnoses to be accurate when they're not accurate. Of those who are misdiagnosed, about 60% experience some sort of harm and about 30% of those who are misdiagnosed die as a result of the misdiagnosis. That's a serious question. Quality issue in our country. I posted the other day to Dave Chase, who's very active in the opioid epidemic, that Dave, hey man, I love you, but did you know that the rate of deaths from opioids is 16.9 per thousand. I'm sorry, per hundred thousand. The rate of cancer Deaths is almost 40 per 100,000. More than double that. So I get it. The opioid epidemic and drug related deaths are horrible. But we've got a bigger problem over here with cancer. And by the way, 20% of chemotherapy orders that are written have an error in them. Who is looking out for these patients?

Yeah, and so you're hitting it on the head, Deb. Quality. Obviously opioids is a hot topic because I think prescription drugs are a hot topic right now. But when you talk about quality, I mean, you just hit it on the head when you think about. In the webinars that I give, you know, I often talk about how price and quality are not inherently in line with each other when it comes to healthcare. Today, we still see consumers doing just whatever the doctors tell them or they want to stay with their specific doctor because he or she has their information. Can you tell us why this isn't always a good idea and how AIM helps members navigate the healthcare system more effectively? Because behavior change is hard, right? I just want to see my doctor because that's what I'm used to. How does AIM help consumers overcome that?

It's a real challenge. And this slide that you're working on right now is a perfect example of this. So the best way I can answer that is to tell you a story. So I like to work call center. I try to do it at least a couple of days a month, despite my traveling and speaking and all that, just because I love helping patients and I love having these stories to Come back. So here's one that actually happened to me. I answered the phone and the patient says to me, I need to go get an ultrasound. Does that require pre cert? And of course, we all know no plan on the planet is going to require pre cert for ultrasound. Right? It's minimal risk. It's inexpensive, it's non invasive. It's done in a doctor's office. Who cares about an ultrasound, Right? My response to that, though, instead of just saying, no, no, pre cert is required, is, I'll be happy to look that up. Tell me a little bit about why you're getting an ultra ultrasound. She says, well, we're pretty sure I have gallstones. I say, okay, where are you going to go to get the ultrasound? And she says, I'm going to go to St. Joseph Hospital. Well, you see, they're next to the bottom down there, right? 320 to 700 bucks for an ultrasound. She's on a $5,000 deductible health plan. And I say to her, well, okay, you can go to St. Joseph, but were you aware in your same town there are two places that will do it for 110 bucks? Right. By the way, were you aware the quality of Care at St. Joseph Hospital only gets 65 out of 100 points on our quality scale? Where we're looking at readmission rates and medication errors and falls and mortality rates. And, you know, when we're objectively looking at the quality, probably not the place that I would pick to go. Flip on to the next one there, Andy. So this is that particular facility and their quality score. Right. We're looking at mortality, complications, readmissions. By the way, look at that bottom right hand corner as well. There's our cost comparison. So we're looking at this objectively going, okay, wait a minute. This may not be the health system we really want you to walk in the door of. So hit the next button, Andy, and we'll see that the physician that she chose. Oh, it went behind. Had a quality score of 11.33. So that particular physician, not the one that we wanted her to go to, where the better place for her to go was this facility, Campbell hospital, ideally with Dr. Mandel, who has a 99.5 quality score. So all because she called in to say, I see on my ID card that pre certs required, and I'm supposed to call the nurse, I'm headed down this path toward gallbladder surgery. I have picked this doctor. Now, interestingly with her, I said, how did you pick that doctor? Well, she picked him because he's the surgeon who had done both her grandmother and her mother's gallbladder. And so he may be a fabulous guy, he might be very friendly. Obviously her family has experience with him. But if she, my mother, sister, cousin, best friend, I'd be steering her here. So plans have to make a choice. Do you want to do this just voluntarily, just get the information out there, which by the way, is a huge step forward. Right, because right now nobody's giving this information to their members or do you want to start incentivizing or penalizing? So a lot of my clients say if you call the nurse first and you go where the nurse tells you to go and you do what the nurse tells you to do, we will waive your deductible and copay so your health care will be free. By the way, self funded plan, tremendously smart move because it lowers their costs. They're the best performing pepy plans that we have on our book of business. You more than make up for waiving the deductible and copay by getting that member to the highest quality, most cost effective provider from the outset. And they're much happier because it's done for free. Others are not as aggressive in their motivation. They just want to get the information into the hands and let people make that decision and have the chips kind of fall where they fall. But the most cutting edge groups are like, yes, if we can get them the highest quality care possible, get them back to work faster, have them be happy about it. Let's do that.

So I'm going to hit upon, I'm going to have you hit upon here with a few minutes we have left on those cutting edge companies. But I want to restate some things you said that I think are important and I don't want the audience to miss this. Number one, we battle this every day with employers. Just giving them access to a big network isn't always the best idea because now they can literally go wherever they want and almost spend whatever they want because the more choices they have, the more variance in price and quality. And they don't have access to tools like you're seeing right here, the charts that Deb's showing to literally tell people which doctors are the highest quality, which are charging fair prices. And so if you truly want to control your health insurance cost, it's important you give your members access to this kind of data, this kind of help. And Deb talked about incentivizing, why not incentivize them when they make Those good decisions by eliminating their deductibles and their out of pockets, very, very important strategy you can use to start controlling health insurance costs. So Deb, let's talk about.

Those cutting edge companies. Could you share some examples of the impact good medical management can have on helping employers reduce their medical and pharmacy claims? Maybe give us examples of what happens when there's no care management all the way to a well managed, well oiled medical management program with a third party.

Solution like a. Yep, absolutely. And before we do that, Andy, I do want to point out, remember those four generations you were talking about? Yep. The people that are spending the most money on your health plan are typically in the 40 plus age bracket. Just giving them a website to go to or a PPO network is not going to be effective for those people. Right. You've got to have somebody engage with them, preferably telephonically. The younger folks, they'll go to an app, they'll, you know, chat with somebody online. Those that are actually spending the money, not so much. So there are tons of tools out there, there are lots of good cost comparison tools, but getting the right people to use them is as much a generational thing as anything else. And we've seen plans all over the board. Right. So some of the worst performing plans that I've seen as we've been working with brokers across the country and doing different analyses are running in the 20 to 22. I've even recently seen one that's 25,000 Pepy. And remember, Pepy is your medical and pharmacy claims combined allowed amount. Always look at allowed, not paid because you want the member responsibility baked in. Because if you're headed the right direction to where you want the plan to cover everything, you want to know the total allowed amount. But some plans are performing horribly. Milliman For 2018, if you take their Milliman Medical Index and you adjust it down from a family of four to a Pepy equivalent is at about 16,900 Pepy. That's the national average. I don't have any clients in medical management that are performing that poorly. My worst performing groups at about 14,000 pepy. By the way, that's a hospital group and most of that payment is going from their right pocket into their left hand pocket. So there are reasons that healthcare providers want to pay themselves very generously so that they can reset usual and customary in their market and those kinds of things. But those groups are pretty few and far between. When you actually insert a nurse handholding patients through their decision making process, you're going to get somewhere to the 9,000 pepy with a pretty low lift. If you want to get really creative and you want to do things like eliminating networks and doing direct contracting and doing bundled surgical pricing and carve out EAP and you know, if you want to get really cutting edge and you want to incentivize members and offer them free health plans, free health care, you can get that very easily down to about 3,800 Pepy. I've even got one group that's performing just shy of 2,000 Pepy.

Wow, that is impressive. So with a minute or two we have left, we just have a couple questions, one coming from the audience. But I want to ask you this one. If somebody on the webinar today wanted to take the next step and learn to see, wanted to see how medical management could improve their health plan, what would they have to do to have an opportunity to save money? What do they have to do to take that next step?

Well, interestingly, we don't work with just about anybody across the country. We work through a limited distribution channel methodology. So they'd have to work with someone like the Olson group who has access to our services. Obviously, this model is very different. Your consultant, advisor, your broker has to understand where you're trying to go in all the moving pieces and parts that it takes to to get you there. We're just one small sliver of that, albeit the linchpin sliver. Right. To pull all those other things together and to help patients navigate. But we're just one small part of that. So you have to be working with the right broker, consultant or advisor first. Secondarily, you have to have the mindset that if we can get our members to the highest quality care possible, we want to do everything that we can to support that. You have to have the executive team's buy in and you have to kind of get your mindset headed this direction first. So those are kind of the key steps. Once you've got that in place, then it's really easy for your broker consultant to work with you on plan design issues and how are we going to incentivize and how aggressive do we want to be? And really what do we want our pepy to be and how do we want the patient experience to feel as we're accomplishing that? And then we build a medical management program for that group.

Great. So we had one question come in. Speaking of healthcare navigation, speaking of plan design, and there may not be an answer to this, but what if you are somebody's in the emergency room with a non life threatening illness like an appendix. And you don't get to pick who your surgeon is as you're sitting in the emergency room. Is there any way a program like AIM can assist in a matter like this?

Sure. So first and foremost, if you're not calling 911, you should be calling the nurse. If you do call 911, as soon as you're stable, you should call the nurse. So you might be in the emergency room and they might have a particular quack, I mean doctor, surgeon on call for that night. That does not mean that you have to accept him. Right. So even if you're in the emergency room and they're saying you have an appendectomy and you know, we're calling in the OR crew, they'll be here in an hour, we're going to take you up to the emergency, to the emergency. Or you can say who's the surgeon? And you can talk to the nurse and find out, is that the highest quality surgeon? Because you can say, I don't want that surgeon. Can you call in somebody else? That would be an unusual circumstance. Usually if it's an emergency, they're taking you straight to OR and you don't have a choice. But if there's an hour delay, that's plenty of time while they're calling in the OR crew for you to go, whoa, whoa, timeout. Maybe I don't want that. Maybe I don't want to be here. Can you transfer me to another facility? Can you have Dr. X instead of this guy? You have options there. If you're, you know, under cpr, your choices are pretty limited. You don't have a choice there. But short of blood dripping on the floor or heart attack or you know, life threatening things like that. Even though it may be emergent, it may not be life threatening. You may have some options there.

Great. Awesome. Awesome, Deb. Thank you for that. That's so impactful. All right, guys, we got seconds left here. I want to be respectful of your time. I want you to think about everything Deb just said today. You know, it used to be that. Well, you know, we don't want to bother our employees. We don't want to tell them where to go. We don't want to to inhibit the decisions they're making in the healthcare system. But I do wanna remind you guys these number one reason health insurance costs are out of control right now is because of the decisions that are being made inside the healthcare system. And your employees need help. So no, we're not thinking about. We're not sitting here and saying you have to force them to go somewhere. What we're saying is put the tools in place that give your employees the ability to have somebody hold their hand to make those decisions, to help them and navigate them the right place, at the right time, at the right price, at the right price or at the right price. If you do that, not only are your employees going to love you because they're going to get better care, they're going to have better outcomes, but your bottom line, your employees, paychecks, their wallets are going to benefit from it as well. So, Deb, want to thank you for your time. It's been awesome having you on here, guys who are on this gang who are on this webinar right now. I am recording it. So we will be providing the recording after the webinar. If you have any other follow up questions after we're done, feel free to shoot me an email. And please, if you know, any colleagues that you think could benefit from these webinars because we're going to be hosting them every month, please share. Please invite them to jump along because we want to make sure we're helping as many people as we can. So with that being said, Deb, thank you. Thank you and the rest of the folks on this webinar, have an awesome day. We'll talk soon.