Our Healthcare and Health Insurance System is broken. Healthcare costs continue to rise at the expense of employers and employees who often end up paying more each year for reduced levels of benefit and service. If you’ve had enough, then you’ve come to the right place. In this show, we explore what is wrong with the current system and examine what drives higher healthcare costs. We interview companies that are providing innovative services and solutions designed to not only disrupt the health insurance marketplace but deliver lower costs and better value for your employees.
Who is this show for? It’s for employers, CEO’s, CFO’s, HR Directors and Benefit Managers and anyone else who is tired of the same poor results that we continue to get from our Health Insurance and Healthcare System. It’s for those who are suspect of the same old answers for why healthcare costs go up and want actionable strategies to get better results.
Join us! Get educated and get ready to take action!
Nate Murray | Crossover Health
In this episode, Michael interviews Nate Murray, the Chief Business Development Officer at Crossover Health. Crossover Health is a national primary care medical group that connects employees with remarkable care options while helping employers take control of their healthcare spend.
Christin Deacon | Amino
In this episode, Michael moderates a webinar that highlights an employer who took action to help their employees find higher quality, more cost-effective care. The episode highlights two panelists, one with Christin Deacon, the Assistant Director of the New Jersey State Health Plans, and the second with David Vivero, the Co-Founder and CEO of Amino.
Omar Dawood | Calm
In this episode, Michael interviews Omar Dawood, the Chief Medical Officer and Head of Sales at Calm, the #1 app for sleep, meditation and relaxation. The app has over 100 million downloads and over 1.5M 5-star reviews.
Omar is a clinician and stage IV cancer survivor with over 25 years of senior management, medical research and clinical experience, innovating medical devices and digital health products as a senior executive. At Calm, he leads B2B employer and health plan sales and is passionate about helping people around the globe lead healthier, happier lives by building resilience through better sleep and improved mindfulness.
While 20% of Americans are dealing with a mental health illness of some sort, Omar believes that we shouldn’t forget about the other 80% of people who experience stress and anxiety without a mental health diagnosis. That’s where Calm comes in to act as a preventative measure to improve behavioral and mental health as well as resilience through mindfulness practices, meditation, and strategies for better sleep.
Calm started as a B2C app but is making strides in the B2B sector to support employers, employees, and organizations. And it’s working. The sign-up rate on employer accounts is 30% with 80% engagement, and the experiences it offers – like the “Daily Calm” and “Sleep Story” – are helping employees reduce stress, sleep better, respond better to life, communicate more effectively, and boost immunity around the world.
The benefits Calm offers to organizations and employees is clear. For organizations, they provide actionable insights and aggregate trends. For employees, they offer pathways to increased resilience and wellbeing and a “Calm Effect” that touches every area of their life.
Calm’s NPS is just over 70 and they do qualitative ratings and satisfaction measurements in a number of ways. The team at Calm is excited for more innovation in behavioral and mental health and encourage collaboration in the field in order to spread health and happiness to billions.
Here’s a glance at what we discuss in this episode:
00:50 - Introducing Omar and Calm.
02:30 – His cancer diagnosis changed his view on medicine and the industry’s lack of data; he didn’t appreciate the value of mental and behavioral health until 10 years ago.
04:45 – He saw a need to bring an engaging experience to behavioral health; this is how he came upon Calm and loves his role in bringing that to employers/employees.
06:30 – The 1 in 5 statistic: Omar believes we should consider the preventative health of the other 80% who also experience stress and anxiety but aren’t diagnosed.
08:50 – The pandemic opened up the dialogue that we’re all coping and should do something about it because we’re human, not because we’ve been diagnosed.
10:00 – Most employees experience stress and anxiety; digital health made help easier and more accessible, but still sat downstream in terms of treatment.
12:50 – What was missing was something more upstream and preventative.
13:00 – EAP services 0-3% engagement, Calm’s sign-up rate is 30% on employer accounts and average engagement of 80%; it’s not seen as behavioral health at all.
14:40 – Calm is an experience, not a product, and becomes a part of the user’s life to support better resilience through meditation, mindfulness, and better sleep.
16:30 – They started with B2C and are now working with employers and organizations to broaden their impact.
18:15 – The benefits of meditation: The “Daily Calm” content through the app helps people respond (not react) to life and communicate better.
21:30 – It impacts your immune system, your ability to support yourself through challenges, and shift your perspective.
23:20 – Narrated mindfulness topics: Gratitude, visualization, positive frameworks, communication.
27:00 – Using Cal
Justin Leader | Highlight Health
In this episode, Michael introduces Justin Leader, the CMO of Highlight Health and a self-funded benefits and risk advisor. Early in his career, Justin learned about the major shortcomings of the healthcare and health insurance industry and how it is built for profitability, not value. When he met Josh Spivak, the CEO of Highlight Health, they saw an opportunity to build a better solution for an underserved segment of the population.
Highlight Health’s mission is to deliver affordable and accessible healthcare to the nation’s underinsured populations. Their product is not a health insurance product, but rather a healthcare product where in exchange for a fee, an employer’s underinsured employees get access to healthcare, education, and an advocate. The populations they serve typically don’t work enough hours to qualify for full time benefits, can’t afford their traditional benefits, or may be offered limited MEC or Minimum Value plans that really don’t offer access to comprehensive healthcare.
Highlight Health’s goal is to systemically help people access 80-90% of their basic healthcare needs through their platform and mitigate risk for catastrophic events. Highlight Health differs from other vendors in the market by providing an advocacy service for members and negotiating with Hospitals to provide inpatient and outpatient care at zero or reduced cost through federally-funded programs. Highlight Health is busy collecting feedback and success stories from members and they look forward to a future full of collaborations and philosophically-aligned partnerships to better serve their members.
Here’s a glance at what we discuss in this episode:
01:00 - Introducing Justin and Highlight Health.
02:40 - How he got into benefits consulting.
05:45 - How he became a part of Highlight Health.
07:50 - The political approach to healthcare and the point that’s missed.
09:00 - There’s tremendous pain when trying to navigate the healthcare system.
11:45 - The collective problem in healthcare and the responsibility all must take.
12:40 - The working poor and healthcare illiteracy.
14:00 - The difference between health insurance and healthcare.
14:15 - The Highlight Health product; your friend in healthcare.
15:10 - They focus on accessibility and care; advocacy is a cornerstone.
16:45 - They provide education and value to empower people to make better decisions.
18:22 - They take regulations and laws and leverage them to access care across the country.
19:30 - This is not a health insurance product, it's a healthcare, capitated product.
21:10 - Thoughts on GAP funding.
21:40 - How the drug component of Highlight Health works.
24:30 - Highlight Health’s vision for the future.
25:20 - How community-based programs work and how Highlight Health would help a member get care in a selected hospital system.
28:40 - Their goal is to systemically help people access 80-90% of their basic needs through their platform and mitigate risk for catastrophic events.
29:25 - They can provide compliance components and supplemental products.
32:00 - The employer’s get a simple, consolidated bill from Highlight Health.
33:05 - Employee outreach: They communicate the programs appropriately and offer virtual support.
36:30 - They’re collecting feedback and success stories and are holding big institutions accountable for the community care they’re required to provide.
39:00 - He’s looking forward to getting people excited for something new, collaborations, philosophically-aligned partnerships, and to leave a legacy.
https://highlight.health/ (Highlight Health)
Doug Aldeen | ERISA Attorney
In this episode, Michael introduces Doug Aldeen, a healthcare and ERISA attorney. He has represented reference-based pricing organizations, PPO networks, medium to small self-funded plans, TPA’s and provider sponsored HMO’s in various capacities.
Doug started his career at an insurance defense firm, then worked at a local HMO for years. It was there that he learned the ins-and-outs of the healthcare industry and realized that “discounts” aren’t real, but the prevalence and unsustainability of cost-shifting very much are. He found that in many cases there’s no correlation between what hospitals charge and their cost, and “turbo-charging”—where hospitals raise billed charges at unreasonable rates—is common in commercial insurance yet illegal in the Medicare world. Doug has seen “turbo-charging” of 12-24x, and 30x pricing on prescriptions and implants.
Surprisingly, employers are often completely unaware of what’s going on under the hood of their healthcare plan. They’re left in the dark because of limited access to data, billing statements without itemized, line-item costs, and “Revenue Neutrality Agreements” that sometimes allow providers to be paid more than they bill. Doug believes commercial insurance plans serve as an ATM for hospitals at the employers and patients expense, all because no one is monitoring, auditing, and demanding to see what’s getting billed, what’s getting paid, and why. And with the employer fiduciary duty under ERISA, this could be a costly oversight for employers that may lead to lawsuits in the future.
Doug works primarily with employers who have self-funded plans and reference-based pricing plans. He develops direct contracts with Hospitals and Providers on behalf of employers and their employees. For Doug, a successful agreement with a provider should be simple; only clean claims are paid, all claims are auditable, price is reasonable and there is a benefit incentive for employees to receive care at the facility. More importantly, a safe harbor has been created where the employee can receive care without having to worry about balance bills which are not allowed under the contract. With his day to day work and advisory position at RIP Medical Debt, Doug is making a positive impact in the healthcare industry and we’re excited to see him keep up the good work.
Here’s a glance at what we discuss in this episode:
00:30 - Introducing Doug, a healthcare and ERISA attorney who helps employers and payers offer affordable healthcare to employees and dependents.
02:12 - He’s been a lawyer for 28 years; he worked in an insurance defense firm doing dram shop cases in 1997 and ended up at a local HMO for 7 years.
03:30 - The most fundamental flaw in the industry: discounts aren’t real, overpaying, and cost shifting in the commercial market are unsustainable.
05:45 - There’s no relation between what they are charging and their cost; we need honest conversations and common middle ground.
06:30 - Hospital “turbo-charging”: Hospitals charge X and insurance companies match it with the premium; it’s “chumminess” between providers and insurance carriers.
08:35 - Turbo-charging is expressly illegal in the Medicare-world but not the same in the commercial world; you can see this anywhere from 12-24x.
09:30 - He’s seen 30x pricing on Rx and implants; CFOs need preservation of PandL and need to get motivated to understand how this all works.
11:00 - Turbo-charging is illegal with Medicare; we can’t vilify healthcare providers, it’s not them.
12:40 - Data ownership: Cigna owns the data and allows you to access it on a limited basis; the data should be a part of the plan; you should be able to see bill charges.
14:10 - Anthem has a “Revenue Neutrality Agreement” executed on the side with the hospital system - they found 30% of claims were paid more
Mike Poelman | Apta Health
In this episode, Michael introduces Mike Poelman, the founder and president of Apta Health. Although Mike started his career as an accountant and controller, he quickly realized that he was a salesman at heart so he shifted into the TPA world working on self-funded health plans. This is where he realized that things needed to be done differently. Mike saw that lack of transparency and collusion were the biggest problems in the industry, and legacy solutions simply weren’t designed to provide employers what they needed, which is what inspired him to create a number of companies, including Apta Health.
Apta Health aggregates middle market employer groups under one umbrella so they can benefit from care coordination and cost containment solutions that are typically only available to Fortune 500 size companies. This member centric approach allows more effective customer service, higher member engagement by a team of experts/advocates to reduce provider gaps, contain costs, and improve the member journey. In fact, 88% of employees engage with a care coordinator even before a claim enters the system, which is unheard of in the industry.
The team at Apta Health has an NPS rating of over 70 for their members, employers, and providers because of their attention to the customer experience first and the TPA second. Apta Health has an exciting future ahead. They’ve recently won the 2020 Health Value Award from the Validation Institute and look forward to continuing their use of analytics and data to empower brokers and employer groups to make easy, cost-effective decisions.
Here’s a glance at what we discuss in this episode:
00:45 - Introducing Mike, the founder and president of Apta Health, who is passionate about providing self-insured solutions.
01:05 - Apta Health is a provider of care coordination and cost-containment solutions to optimize self-funded healthcare programs.
02:30 - He started as an accountant and controller but is a salesman at heart; when he first started in the industry, all he had was a phone book and phone.
04:05 - He didn’t intend to be a part of a TPA but he knew he wanted to change things by looking from an employer standpoint first.
04:40 - He started Novo Benefits, a platform where employers are empowered to get direct contacts and unbundle their programs.
05:30 - They’ve evolved into an aggregator with Apta Health; they are changing the industry and empowering employer groups.
06:50 - The key issues in the healthcare industry: transparency and collusion.
09:00 - What Apta Health does: They aggregate employer groups under one umbrella so they can benefit from large group level pricing, solutions, and engagement.
10:36 - They offer Fortune 500-level engagement to the underserved middle-market.
11:00 - The Quantum care coordination model and how it’s different: more effective disease management, better execution, and functionalities done by one pod.
12:30 - Apta is a conglomerate of solutions; they’re getting 200% better engagement
13:50 - The member journey, reduce provider gaps, drive the member experience, and get results and better engagement.
15:47 - A team of experts/nurses help guide and navigate patients through disease management to get them what they need, not just verify coverage.
17:25 - The pod team helps members find more cost-effective solutions they may not know about and create a trusting relationship with members.
21:15 - Stories of above-and-beyond service from the team that is fighting for the member.
22:35 - Deep analytics helps decide what’s best for groups, they use quality metrics, point solutions drive what needs to happen, and an easy number to reach support.
25:15 - Their PCP-centric model helped them avoid wasteful spending; the real-time intercept helps direct members and helps them avoid unnecessary tests.
28:00 - Mike shares his experience with his