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

In this episode, Michael introduces Marek Ciolko, the CEO of Gravie, a unique health plan that offers employers a shared savings model and employees the opportunity to personalize their insurance to meet their needs. Gravie does this by helping employers control costs while still providing employee-selected coverage and a better experience throughout the process.

Marek has a long history of operations management for Deloitte and companies within the healthcare industry. It was on this journey that he realized that there are only so many ways to bend the curve and reduce healthcare costs for everyone with incentives alone. He realized that the core of health insurance needed to be tackled, which is why now, through Gravie, he strives to level the playing field between the group and individual marketplace of health insurance within their platform. 

The current state of the world with the COVID-19 outbreak makes it painfully obvious that the consumer is underserved in our current system. Gravie’s mission is to improve the way people purchase and access healthcare. They focus on an underserved area of the market, which is group sizes with between 100 and 1,000 lives. Gravie works with employers to establish a defined contribution and then provides a platform of plan design options for employees to select from that meets their individual needs. In essence, Gravie is a marketplace and a decision support system for employees.

In addition to offering a marketplace to employers, the Gravie product is a level-funded offering that helps small employers self-fund, manage risk and share in excess surplus when claims are less than expected; to date, 30% of customers are receiving refunds at the end of the year. As a startup with 3 years of experience, Gravie is already taking massive strides to control healthcare costs for middle-market employers and employees and we look forward to seeing them grow and expand their offering. 

Here’s a glance at what we discuss in this episode: 

• 01:00 - Introducing Marek, his background, and his motivation for launching Gravie. 
• 02:30 - He worked for Deloitte and RedBrick Health and learned the challenges with healthcare costs. 
• 04:00 - With Bloom Health, they worked to make insurance customizable so employees could shop and the market could provide what they need. 
• 05:05 - Gravie levels the playing field between group and individual insurance marketplace by granting true consumer involvement in the selection process. 
• 06:55 - Health insurance is very expensive - our current global climate is highlighting that issue. 
• 09:00 - Sometimes companies don’t have enough choices for their employee’s diverse needs; people end up getting more than they need or not having enough.
• 09:50 - Consultants and brokers oftentimes see the employer as their client, not the employee. 
• 10:30 - Customization and tailoring allow the consumer to pay for what they need and leave out what they don’t.
• 12:00 - Employees have to go through their employers for health insurance, which makes it expensive for employers to attract and retain employees year over year.  
• 15:20 - Employers need a way to cap (fix) their healthcare liability while keeping their employees happy - that’s where Gravie comes in. 
• 17:11 - Gravie offers cost predictability and management of the entire system, including insurance, the administrative process, savings benefits, and employee customer service. 
• 20:00 - It leverages stop-loss and helps small employers self-fund easily; Gravie gets a share of savings when claims are less than expected, so they’re incentivized to keep costs below the employer’s cap.
• 24:00 - They’ve been in business for 2-3 years and

In this episode, Michael introduces Steve Watson, a CFO/CHRO and founder of Trendbreakers, a community of finance, human resources, and benefit advisor professionals that are on a mission to break the trend of rising employee healthcare costs. Trendbreakers helps CFOs, CHRO’s and business owners make the best employee benefit decisions by offering support, education, and consulting. 

Steve is a unique guest because he’s on the payor side of business...i.e., he is working for an employer who ultimately pays for healthcare via their insurance. He recognizes that the current healthcare system is lucrative for organizations and certain people, but also sees the problem with employers and families paying heavily for benefits they may not even use. A few years ago, his employer had a million-dollar claim that was going to increase premiums by 30% - and his broker’s commission by 30%, too. Through deeper investigation and learning, he recognized the incentive imbalance and that the system was rigged against employers.  

He was able to slash his company’s benefits costs, save thousands, and allow employees to enjoy no increases and better benefits - all while drastically reducing the administrative burden of enrollments and changing plans. After doing it for his own company, Steve realized that others in his position needed the network, strategies, and best practices to do the same. So he built Trendbreakers, the educational platform that helps inform business owners, CFOs and CHROs make the best healthcare decisions for their company and its people. 

Steve believes that a lack of accountability across the board has been a detriment to the system as a whole. He believes brokers must be transparent, accountable and have a high level of expertise in the exact areas their clients need so they can offer the best solutions. He also recommends brokers be conscious of the way they communicate with employers and use words and comparisons they can understand. 

Brokers have an excellent opportunity to educate and be a fiduciary for the employers they serve. And it’s important that employers have a plan in place that they’re confident in and has room for continued growth and savings down the road. Trendbreakers has a promising road ahead bridging the gap between peers and colleagues to create a system where everyone benefits.

Here’s a glance at what we discuss in this episode: 

• 01:00 - Introducing Steve, the CFO, CHRO, and founder of Trendbreakers. 
• 05:30 - What Steve thinks about our healthcare system and when the reality sunk in. 
• 09:30 - He transitioned into a self-funded plan to address the issues. 
• 12:00 - Now, he can impact the results, get data, and benefit from no claims.
• 13:05 - Employees have benefited from no increases, better benefits, and they lifted the administrative burden of having to have an enrollment.
• 13:30 - Trendbreakers provides education to company leaders, executives, and HR leaders so they understand the industry and speak the same language. 
• 14:50 - Broker/Consultant must-haves: Transparency, accountability, expertise.
• 17:05 - Brokers don’t always share new solutions with their clients that could save them significant dollars. 
• 20:00 - Brokers must communicate concepts in a way that the CFO/CHRO/owner understands because in many cases, they’ll need someone else to sign off on it, too.
• 22:20 - CFOs want to know the internal risk and meet other people who are self-funding to feel confident about their decision. 
• 24:10 - It takes peers, stories, and a group for people to feel confident about

In this episode, Michael introduces two partners of ScoutRx, Robert LeCureaux, the VP of Client Development and Amy Bandy, the VP of Operations. ScoutRx helps employer groups and members maintain affordable prescription drug costs through the use of their three core cost containment strategies. 

When previously working in the pharmacy and PBM industry in very different roles, Rob and Amy both recognized that it was very profit-driven and not much thought was given to the consumer and the burden of cost. They didn’t like this status quo - and how members had no voice and too many roadblocks - which is what inspired them to team up with other partners to create Scout Rx.  

With a lack of marketplace options to address the rising price and utilization of specialty medications, ScoutRx has made it their mission to bring overall costs down and create a better member experience. To date, they have been able to drive an average savings of about 43% for their clients, a sign that they are succeeding in their mission thus far. To be clear, ScoutRx is not a pharmacy benefit manager or administrator. They’ve partnered with a PBM to administer their program while they use their own core strategies autonomously. 

ScoutRx operates using three core strategies: Their Specialty Pharmacy Program, Copay Optimization Program, and International Pharmacy Program. Through their Specialty Pharmacy Program, they help members pay little to no money out-of-pocket for specialty drugs by finding drug manufacturer foundations and financial programs that patients can qualify for to offset the entire cost of the drug. The Copay Optimization Program takes advantage of drug manufacturer coupon cards to reduce the cost of the drug and potentially eliminate the patient’s copay altogether. The International Pharmacy Program allows members in the U.S. to get their high-cost or specialty medications from Canada at a substantially lower cost with eliminated copays and reduced cost to the group. The amazing part about all of this is that most of the logistics are done behind-the-scenes at ScoutRx with little effort needed from the patient. 

And as far as savings go? Some groups that they’ve worked with had a 96% generic utilization rate and were still able to save over $100,000 in their first year. The savings range in the first year is vast - from 16% all the way up to over 70% - and these savings continue into future years which will lead to lower inflation than employers would see with typical PBM’s and insurance carriers in the industry. ScoutRx is paid a percentage of savings which they outline in regularly distributed, fully-transparent, line-by-line reports.

ScoutRx is a good fit for small-to-midsized self-funded companies with 2,000 employees or less. While ScoutRx is a new company, its leadership team is experienced and its methodologies are proven. ScoutRx has a bright future ahead disrupting our healthcare system by making high-cost prescriptions more easily accessible to patients. 

Here’s a glance at what we discuss in this episode: 

• 00:30 - Introducing Rob and Amy, two partners for ScoutRx.
• 03:00 - The inspiration for ScoutRx: Rob saw that the industry was profit-driven and that not much thought was given to the consumer. 
• 04:30 - Amy saw all the roadblocks between members and their prescriptions in the traditional setting and wanted members to have a better option. 
• 06:00 - The key issue with the drug delivery and payment system of today is that specialty medications are often inaccessible to groups and patients. 
• 10:30 - Their specialty pharmacy program addresses accessibility so that patients can get pharmaceuticals for little or no cost. 
• 11:50 - The Patient Assistance Program - It’s a financially-based...

In this episode, Michael introduces Matt McCambridge, the co-founder, and CEO of Eden Health, a virtual primary care and navigation platform centered around care teams. Eden Health helps employees navigate today’s complicated healthcare landscape across insurance, primary care, and mental healthcare so they can make smart, well-informed and cost-conscious decisions. 

Matt had a personal situation that influenced his decision to move out of the venture capital space to launching a start-up in healthcare. When Matt’s sister was sick as a kid, Matt and his family personally witnessed the broken components of the healthcare system. Now, Matt is seeing how the “coordinated care” offered by Eden Health has made a difference in the lives of patients like his sister.   

Eden Health is a certified Primary Care Medical Home - the top-of-the-line quality certification in the country for primary care; this model emphasizes team-based care, communication, and coordination, which has been shown to lead to better care and why Eden has integrated specialties like behavioral health and physical therapy. The reason for including behavioral health, Matt explains, is that many other health issues are rooted in mental health conditions and these must be addressed to make meaningful progress with the patient’s health conditions. 

Matt’s company is different than other in-person or virtual primary care solutions in that it is highly integrated with a core focus on eliminating the employee’s hassle as a patient. Typically, it’s very confusing for employees to figure out where to go and for what, which is why Matt believes you simply cannot separate navigation from primary care and delivery. For this reason, they have an app with the accessibility to virtually chat with a doctor 7/365, and this connection enhances the solutions offered. By leveraging technology, they’ve been able to provide their users with the appropriate instant and personalized care. 

Eden Health also offers physical locations across the country for those who need it, and will even send a provider from their pool on-site to the workplace. Matt understands that the key to helping patients is engagement - and that engagement is more likely to occur if patients are receiving high-quality care through an integrated platform that they can easily use. Eden Health tracks their patients’ satisfaction with star ratings, and they proudly report an average of 4.95 out of 5 stars with a 75% response rate. 

Employers can engage with Eden Health in two ways: They can either fully-cover Eden Health for unlimited access or fully-insured with a fee that is reduced when insurance is taken into account since they would be considered an in-network provider. Eden Health has an exciting road ahead as they expand into new geographies and continue to grow and serve. 

Here’s a glance at what we discuss in this episode: 

• 00:30 - Introducing Matt, the co-founder and CEO of Eden Health. 
• 03:00 - The insights Matt received about healthcare from doing venture capital.
• 04:50 - The problems with the current primary care model. 
• 10:00 - How Eden health is different from other primary care solutions. 
• 13:20 - The importance of engagement that’s backed up by quality. 
• 14:30 - Why behavioral health is integrated into the program.
• 17:00 - On their certification as a primary care medical home.
• 18:50 - Why it’s important that Eden Health makes 66% fewer referrals to specialists.
• 21:20 - The process behind their specialist “closed-loop referrals” and how they short-cut the patient journey. 
• 24:45 - Pop-up on-site visits, permanent brick and mortar clinics, and the experience they create in the workplace. 
• 27:30 - On the trusted patient-provider relationship, how it...

In this episode, Michael introduces Gabriel Mecklenburg, the co-founder and COO of Hinge Health, a musculoskeletal solution for employers and health plans. Hinge Health is pioneering the world's most patient-centered digital hospital, starting with musculoskeletal health. Gabriel brings a unique perspective to the company because of his background in clinical research and because he, too, has been a patient needing this type of care. 

When Gabriel sustained a ligament tear practicing Judo while in college, he became exposed to many musculoskeletal treatments. He realized that the whole field was very much “behind the times” - and decided to switch his area of study to pursue a better solution in the industry. Because he felt distant from the patient when doing clinical research, he and his partner decided to do something that could positively impact patients at scale. When they realized there was nothing out there for musculoskeletal health from a digital health perspective, they created Hinge Health. 

Musculoskeletal injuries may be minor (a twisted ankle), acute (an ACL tear) or chronic (persistent lower back pain). Gabriel explains that chronic injuries are the biggest driver of avoidable cost. At Hinge Health, they focus on chronic injuries because they are the ones that, with the right care, can be lessened and eliminated without medications or surgery - which is what our current healthcare system resorts to all too often. 

The solution to chronic pain is multi-faceted. It requires physical therapy, ongoing education, and strategic behavioral change - and our current healthcare system simply can’t deliver on these needs despite the supporting research. Not only that, but the frequency at which a patient would need in-person care to get real results is totally unrealistic. 

The Hinge Health model takes established best-practices and turns them into their three-pillar approach that addresses exercise therapy, behavioral health, and education. Their educational component dispels myths and educates clients on scientifically-proven best practices, the behavioral health pillar helps patients create behavioral change that lasts, and the exercise therapy consists of sensor-guided movements with live feedback. They can do the exercises whenever and wherever - not just at a therapist’s office - and their adherence is tracked digitally. 

In a recent 10,000-patient study, 3 in 4 of their patients completed the entire 3-month core program. This level of treatment adherence is unheard of with traditional physical therapy, and a testament to the effectiveness of their program and the accountability provided through digital monitoring. More importantly, they’ve helped people reduce pain by over 60% - which is twice the reduction of pain you see when you put someone on opioids. Hinge Health will soon be releasing their digital musculoskeletal treatment study, which is perhaps the largest ever conducted in the industry. They’ve got a bright future ahead eliminating chronic pain and improving lives through their mission. 

Here’s a glance at what we discuss in this episode: 

• 00:30 - Introducing Gabriel, his background, and his inspiration for founding Hinge Health.
• 05:45 - What falls within musculoskeletal disorders and injuries and which Hinge Health focuses on.
• 07:45 - The problems with how the system is currently dealing with chronic musculoskeletal pain.
• 09:50 - The Hinge Health model, their three-pronged approach, and how they engage patients with each approach. 
• 15:25 - The patient journey: What to expect and how they’ve dramatically improved their adherence rate.
• 21:45 - The quality of Hinge Health coaches and exercise therapists.
• 24:00 - Meaningful results, why Hinge Health patients are engaged and see results, and how Hinge Health...

In this episode, Michael introduces John Powers, the Executive Vice President of Sales and Marketing for Advanced Medical Pricing Solutions (AMPS). AMPS provides market-leading healthcare cost containment services for self-funded employers, public entities, municipalities, labor unions, brokers, consultants, TPAs, payers, reinsurers, and HMOs. John is widely known as one of the most successful fraud investigators in the industry having conducted investigations in all 50 states and over 120 countries internationally. 

John dove into the healthcare industry about 12 years ago when he saw problems arising within the system. He found that many people held a misconception about their healthcare plans by thinking their plan covers everything when, in fact, it likely doesn’t. John believes consumerism is the missing link in our healthcare model, and he predicts a future where more employers move to a model of defined benefits. This, he believes, will make the system more equitable and transparent. 

Among other services, AMPS conducts medical bill reviews. They focus on hospital and facility claims, both inpatient and outpatient, that are in or out of the network. This line-by-line itemized review by coding specialists ensures that the correct treatment was done at the right time and for the right price - and their turnaround is only an average of 3.3 days. 

The problem is that most claim payers (TPA’s, Insurance Carriers) don’t get itemized facility bills, so they never get the chance to review them for errors and see where they’re being incorrectly charged. To complicate matters further, some health plans aren’t even requiring itemized Hospital bills prior to paying them. John speculates that this is because healthcare companies see hospitals as their most valuable asset. 

Shockingly, errors on hospital bills are extremely common, and 95% of the time they go unnoticed. AMPS uncovers errors in virtually 100% of bills ranging from $2 to $200,000, and most of their clients see an average of 10% in savings. And since AMPS only gets paid from the savings they find, there’s no upfront cost to using their service. The errors are corrected before the client pays the bill, as it’s notoriously difficult to request a refund after payment has already been rendered. 

John insists that if employers want to get control of their medical spend, they must unbundle the health plan components and get away from the limitations imposed by traditional insurance carriers. That way, they can review and audit their claims just as they would any other facet of their company’s budget. 

To prove why medical bill review is so important, John suggests asking your carrier account manager these three fundamental questions: 

1. Are you conducting a prepayment facility medical bill review for us, and if so, at what threshold and what are the results? How many errors have you found?  
2. Are you a fiduciary to my plan? 
3. Please confirm what network discount I am getting and what does that equate to as a percentage of Medicare?

John is confident their response will surprise and disappoint you, as they likely aren’t conducting a prepayment medical bill review, aren’t a fiduciary, and aren’t giving you the savings you thought. 

AMPS provides other services, like a reference-based pricing program that they’ve offered for the past 8 years. There are two models: Prospective, which negotiates on the front end but costs more, and retrospective, where negotiation is after the service and there are greater savings. They also do direct contracting. This is where consumerism and competition come into play to benefit both the hospital and employer. 

AMPS is excited to offer more direct contracts so patients can save money, know their options, get great care, and make informed decisions. The medical bill review...

In this episode, Michael introduces Shane Foss, the founder and CEO of Hooray Health. Hooray Health leverages an Urgent Care and Retail Clinic National Provider Network built for Individual and Group limited medical insurance plans. Shane has over twenty years of tenure as an executive in the medical industry and it was through this work that he became frustrated with the healthcare options in America. 

When Shane injured his back and needed medical care, he experienced the shortcomings of the healthcare delivery system first-hand when he received a balance bill from an urgent care center. He was able to negotiate down his bill, but the experience left him wondering what other Americans do in similar scenarios. This led to his discovery that many Americans are “functionally uninsured” and there’s no standardization of cost or transparency in the healthcare system. 

Shane was thus inspired to create a new platform that filled a gap in the market: affordable basic healthcare. Through this inspiration, Hooray Heath was born. Hooray Heath offers a low-cost, practical healthcare plan that is supported by technology and a robust provider network of Urgent Care and Retail Clinics. It is unconventional - which is exactly what Shane wanted. In a country where 75% of the population makes less than $50,000 a year (and many work part-time), Hooray Health offers peace of mind, basic healthcare, no surprise bills, and a fixed price that starts at only $99.

The member experience through Hooray Health is simple and centralized through their mobile app, where they offer “telemedicine”, a 24/7 bilingual medical concierge, pharmacy discounts, and more. It’s a fixed indemnity plan but feels like a regular PPO for basic coverage - and is 30% less than other similar plans on average. 

They offer two plans: a basic plan and a “plus” plan. The basic plan covers a wellness visit, five annual visits to the retail clinic or urgent care, and a $5,000 accident policy. The “plus” option includes everything in the basic plan plus a hospital indemnity buy-up for an additional $60. Hooray Health is easy to deploy and makes joining a seamless experience for both individuals and large corporations. 

Hooray Health has an exciting road ahead. Next year’s version of the mobile app will be even more integrated and supportive, and they’re working on formulating supplemental alternatives for high-deductible health plans. Hooray Health focuses on a segment of the population that is often overlooked when it comes to healthcare - part-time employees and low-income earners - and makes it so basic coverage is accessible, affordable, and easy for employers and employees alike. 

Here’s a glance at what we discuss in this episode: 

• 00:30 - Introducing Shane and Hooray Health
• 02:00 - Shane’s previous work in the industry and what inspired Hooray Health
• 05:45 - Why Shane believes we’re “functionally uninsured” as a country
• 08:00 - Employers need to manage their healthcare expenses like any other expense
• 09:30 - How Hooray Health works and who they serve
• 14:30 - The difference between Hooray Health indemnity plans and regular benefit plans 
• 16:00 - The difference between the basic and “plus” plan
• 18:00 - How the Hooray Health concierge service works 
• 20:20 - Information about their medical bill negotiation platform