72 episodes

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!

Reconstructing Healthcare: Innovative Solutions For Employers To Lower Their Healthcare Cost‪s‬ Reconstructing Healthcare: Innovative Solutions For Employers To Lower Their Healthcare Costs

    • Business

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!

    Justin Leader | Highlight Health

    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.
    Resources
    https://highlight.health/ (Highlight Health)
    https://www.linkedin.com/in/justindonaldleader/ (LinkedIn)

    • 42 min
    Doug Aldeen | ERISA Attorney

    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

    • 46 min
    Mike Poelman | Apta Health

    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

    • 51 min
    Dr. Simon Mathews | Vivante Health

    Dr. Simon Mathews | Vivante Health

    In this episode, Michael introduces Dr. Simon Mathews, a distinguished researcher, clinician, author, and Chief Medical Officer at Vivante Health. He is also a practicing gastroenterologist at the John Hopkins School of Medicine and the Head of Clinical Innovation at John Hopkin’s Armstrong Institute of Patient Safety and Quality.
    Simon’s research centers around understanding and improving the quality of digital health for patients. Unfortunately, he finds that the key issues in healthcare revolve around inefficiency, fragmentation, and a lack of a team-based approach that is centered around the patient’s best interest. This inspired him to work with Vivante Health, so patients with digestive issues could get the personalized, tech-forward support they need to heal. And with digestive disorders—everything from reflux to IBS to autoimmune disorders—making up a burden of $136 billion dollars on an annual basis, it’s clear that there’s a serious need.
    Vivante Health serves the large, underappreciated, and sometimes stigmatized realm of digestive disorders with a comprehensive and personalized digital platform. Patients are provided with a care team, including a licensed dietician and health coach, and their progress is supported with app reminders, appointment support, check-ins, and progress reports. Although tech is leveraged to best support the patient and their results, it’s the care team outreach and their personal touch that bridges the gap for truly positive user experience and improved outcomes.
    The care team at Vivante Health has an NPS rating of nearly 80. They work primarily with employers and are flexible in the way they integrate with new and existing systems. Although excited for everything currently underway, Simon looks forward to more clinical pathways and screenings in the future to continue to help patients quietly or outwardly suffering from digestive disorders.
    Here’s a glance at what we discuss in this episode:
    01:00 - Introducing Simon, his accolades, and how he came to work with Vivante Health.
    03:00 - He studies the space of digital health, it’s gaps, and it’s solutions, which was a perfect fit for Vivante Health.
    04:20 - Key issues in healthcare: Inefficiency, fragmentation, and a lack of a team-based approach.
    06:45 - On digestive disorders: Nobody has digestive disease in general, they have something specific like reflux, IBS, a type of liver disease, pancreatitis, etc.
    08:25 - Digestive disorders make up a burden of $136 billion annually; they come with a stigma and people don’t always feel comfortable with it.
    09:38 - How digestive disorders are being treated today and the cost implications vary widely, as the types of disorders vary.
    12:30 - The link between gut health and overall health, including immune and emotional health; there’s a connection.
    15:05 - The Vivante Health product and service; the space they serve is large and underappreciated.
    15:40 - It’s a comprehensive digital platform that addresses the management of the digestive disease and is integrated with common tech and a care team.
    16:15 - With a health coach and licensed dietician, patients get a personalized program based on their history, gaps in care, best practices, and evidence.
    19:05 - How they improve the customer experience: App reminders, appointment navigation, health coach support, check-ins, assessment tools, and progress reports.
    21:30 - The microbiome assessment: Certain diets/lifestyles have certain bacterial compositions and we can manipulate that bacteria, our microbiome.
    25:00 - The clinical rigor and evidence are of utmost importance for Simon and Vivante.
    27:30 - How progress is tracked with Vivante Health: Assessments, trend anticipation, self-management improvement, and care team outreach.
    30:45 - Their care team NPS rating is almost 80 and people appreciate a personal to

    • 47 min
    Dawn Cornelis | ClaimInformatics

    Dawn Cornelis | ClaimInformatics

    In this episode, Michael introduces Dawn Cornelis, the co-founder and Chief Transparency Officer of ClaimInformatics. ClaimInformatics is a payment integrity solution that helps its clients identify improper healthcare claim payments and recoup the money for the employer.
    When Dawn entered the world of claim processing 30 years ago, it didn’t take long for her to see that money was being wasted on a massive scale via unnecessary procedures, upcoding, bad systems, and egregious contracts. Unfortunately, there’s more abuse now than ever. With 3-7% of healthcare claims being inaccurately paid, it’s grown to be a problem that is worth over a trillion dollars. This inspired her to co-found ClaimInformatics to catch errors, fraud and contain costs for members. She emphasizes that these costs aren’t savings, it’s money that shouldn't have been paid in the first place.
    ClaimInformatics has a process where they are able to identify six levels of errors that lead to overpayments, including upcoding, miscoding and outright fraud. They review ASO/TPA network agreements, acquire and review all data, re-adjudicate claims, then share the results with clients to illustrate the level of overpayment in their plan. From there, they initiate the recovery process where they typically recover 80% of improper payments on behalf of the employer. In addition to recouping money for the employer, they put providers on notice who are engaging in egregious billing practices that they are now being watched and will be reported to the Network and Medical Board if behavior continues.
    ClaimInformatics works primarily with clients who are self-funded and under ERISA guidelines. They have flexible fee structures with aligned incentives to generate results for their clients. Dawn recommends everyone take a hard look at their reports, review their ASO agreement, and become acquainted with their performance audit terms. ClaimInformatics stands for integrity and member-centric service, and we’re excited to see how they continue on this trajectory into the future.
    Here’s a glance at what we discuss in this episode:
    00:30 - Introducing Dawn, the co-founder and Chief Transparency Officer of ClaimInformatics.
    02:30 - 30 years ago, she got into the claim processing and became a System Configuration Specialist; she then became a plan administrator for a Fortune500 commercial group.
    05:35 - They read the story in the data, and the data isn’t good in terms of waste via unnecessary procedures, expensive services, bad systems, and egregious contracts.
    07:45 - ClaimInformatics is all about integrity; they ensure payments are accurate and in accordance with agreements made.
    08:30 - They catch errors and fraud to contain cost; it’s not savings, it’s money that shouldn't have been paid in the first place.
    10:55 - Why are we still seeing 2-3% leakage when that waste is 100% preventable?
    11:15 - Most of their clients are self-funded and under ERISA guidelines.
    11:30 - The ClaimInformatics process: They review ASO, ascertain and review all data, re-adjudicate claims, then take the results to show clients what they’ve captured.
    12:50 - They follow the same guidelines as a claim’s office, make deposits on behalf of clients, and are member-centric in terms of protecting their overpayments, too.
    14:05 - They ensure member liability is made whole; they go back three years and see lots of coding and billing errors that are non-compliant of the rule sets.
    17:15 - Historical claims review results: Incorrect codes and upcoding make groups and members pay more.
    19:30 - Medical records either support or don’t support the coding choice; they have seen upcoding happen frequently across the board with outside billing companies.
    21:10 - There’s more abuse today than ever; there are six levels of errors that they’ve identified.
    25:22 - Providers are pa

    • 48 min
    Jim Wachtel |Renalogic

    Jim Wachtel |Renalogic

    In this episode, Michael introduces Jim Wachtel, the Executive Vice President of Sales and Marketing for Renalogic. Renalogic is dedicated to helping employers manage kidney disease in their employee population and reducing dialysis costs with preventive programs and pricing solutions.
    Jim was inspired to enter the healthcare industry because he recognized the cultural issues around healthcare. He wanted to support a company that not only helps make treatment accessible to those who need it but also takes measures to prevent chronic illness in the first place.
    With this mission in mind, Jim found Renalogic. Renalogic works to reduce the costs associated with dialysis — a treatment for End-Stage Renal Disease (ESRD) — and offers a Kidney Dialysis Avoidance Program for at-risk members. Kidney disease is known as “the silent killer” for a reason: It is estimated that 40% of people with kidney disease don’t know it. And if it progresses from Stage 5 to ESRD and dialysis begins, treatment is expensive — up to $1.3 million per year, per member.
    Renalogic started with cost-containment solutions, but their goal is to actually put their cost containment business out of business and focus on prevention instead. They have had a 99.3% success rate of keeping people off dialysis and have, in many cases, helped members reverse their kidney disease. They do this with personalized coaching that empowers participating at-risk members to take charge of their health. This, in turn, creates a ripple effect in their families that inspires cultural change one household at a time.
    As far as payment goes, Renalogic imposes payment on the dialysis provider and works to ensure Medicare is maximized for those who qualify, even before the age of 65. They have a proprietary way to re-price claims in a way that is fair and defensible. For their Kidney Disease preventive program, they have a pay-for-performance structure and only bill for employees that have signed up to work with their nurse practitioners/coaches.
    Renalogic has an exciting future ahead that includes a data service that will allow better service for those at-risk for kidney disease. And with a big vision that includes a healthier culture through education, empowerment, and preventative support, we are excited to see how the trickle-down effects of Renalogic’s efforts play a role in the health of future generations.
    Here’s a glance at what we discuss in this episode:
    00:30 - Introducing Jim, Renalogic, and Jim’s background and education.
    02:00 - He knew we had cultural issues around healthcare and that “the American lifestyle is wreaking havoc on chronic disease”.
    03:30 - Jim became interested in working with companies that help combat chronic illness and disease.
    04:45 - The problem is that the expertise required for solutions is hard to find; for employers, it’s hard to keep costs down while still providing quality care.
    06:00 - A small percent of the population is a majority of the costs; this 5% needs to be addressed in a reactive and proactive way.
    07:05 - They empower members to take charge of their health and don’t see people as a line item cost.
    09:20 - A large percent of the population has some stage of chronic kidney disease and up to 40% of people who have it don’t know it.
    10:35 - After Stage 5 of chronic kidney disease, you go into ESRD which is when dialysis is started; it costs up to $1.3M/ year per member, the 3rd highest flagged stop-loss claim.
    11:45 - The dialysis marketplace is concentrated and the duopoly in the market doesn’t have an incentive to lower costs.
    13:15 - They started with cost-containment solutions and have a system to re-price claims in a way that is reasonable and fair.
    16:06 - ESRD makes you eligible for Medicare before age 65 so that becomes a second payer and becomes primary after the waiting period.
    17:30 - Th

    • 43 min

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