In this episode of Shift Shapers, Susan Thomas, Chief Commercial Officer at LucyRx, discusses how LucyRx is addressing the issues and conflicts within the traditional Pharmacy Benefit Manager (PBM) landscape. The conversation delves into the structural problems of traditional PBMs, the role of misaligned incentives, and how LucyRx aims to eliminate these conflicts to benefit plan sponsors and patients. Key topics include formulary management, specialty pharmacy networks, and the importance of transparency and true net cost evaluations.

This Episode is Sponsored by Benepower

BenePower is an AI-powered platform that helps advisors build high-impact, self-insured health plans quickly and seamlessly by integrating the best point solutions, eliminating inefficiencies, and improving collaboration. It streamlines plan creation, reduces costs, enhances member outcomes, and positions advisors as industry leaders. Learn more at Benepower.com.

Key Takeaways

**Misaligned Incentives in PBMs**: Traditional PBMs have misaligned incentives due to their vertical integration with large insurance companies and ownership of mail and specialty pharmacies. This drives up costs for plan sponsors.

**Transparent Formulary Management**: LucyRx offers a formulary marketplace that eliminates exclusive arrangements with Group Purchasing Organizations (GPOs), allowing plan sponsors broader access to formularies and more flexible utilization management.

**Independent Pharmacy Network**: LucyRx contracts with independent pharmacy networks, such as Amazon, to provide a more efficient and cost-effective mail delivery service, ensuring quicker access to medications.

**Educational Initiatives**: LucyRx is actively educating advisors and plan sponsors on the benefits of their new pharmacy care model through a robust roadshow and sharing real-world case studies.

 **Future of Pharma**: With advancements in AI and machine learning, precision medicine can help in developing more effective targeted treatments. However, skepticism remains about whether large PBMs and pharma companies want a smaller, more precise target population.

In This Episode

00:00 Introduction to PBM Issues

00:39 Meet Susan Thomas from LucyRx

00:50 Susan's Journey into Healthcare

02:06 Problems with Traditional PBMs

02:28 LucyRx's Approach to PBM Conflicts

06:23 Formulary Management Innovations

13:55 Network and Specialty Pharmacy Solutions

16:17 Educating Advisors and Plans

20:23 Future of Pharmacy Benefits and AI

22:07 The Story Behind LucyRx

23:25 Conclusion and Farewell

In this episode of Shift Shapers, David interviews Ross Bjella, founder and CEO of Alithias, Inc., to discuss the challenges of changing health care behavior and the inaccuracies in measuring those changes. They explore the complexities of helping patients understand their health care options and costs, and advocate for transparent, actionable data to aid in more informed decisions. 

This Episode is Sponsored by Benepower

BenePower is an AI-powered platform that helps advisors build high-impact, self-insured health plans quickly and seamlessly by integrating the best point solutions, eliminating inefficiencies, and improving collaboration. It streamlines plan creation, reduces costs, enhances member outcomes, and positions advisors as industry leaders. Learn more at Benepower.com.

Transforming Health Care Behavior: Insights from Ross Bjella, CEO of Alithias, Inc.

Ross shares his journey into the health care sector, the importance of data-driven strategies, and how incentives can help patients choose high-value care providers. He also delves into the impact of consumer-directed health plans and how different company cultures affect health care engagement.

Key Takeaways

**Carrots Over Sticks:** Positive incentives (carrots) work better than punitive measures (sticks) in driving desired behavioral changes in healthcare.

**Challenge of Accurate Data:** Current tools and survey methods for measuring behavior changes in healthcare are not as accurate as desired. Ensuring accurate data collection and utilization is critical.

**Impact of Cost on Patients:** High deductibles and out-of-pocket responsibilities can lead to patients being functionally uninsured, causing them to delay care and potentially leading to more severe health outcomes and increased costs.

**Importance of Actionable Data:** Access to clean, normalized data that is understandable and actionable for patients and their families is crucial for making informed healthcare decisions.

**Effective Communication and Incentives:** Effective communication strategies and financial incentives (like waiving deductibles or providing cash rewards) can significantly improve patient engagement and lead to cost savings for both providers and patients. Tailoring communication and benefits to the culture of the organization is essential for success.

In This Episode

00:00 Introduction to Healthcare Behavior Challenges

00:47 Meet Ross Bjella: Journey to Healthcare Solutions

01:03 Understanding the Problem: High Costs and Insurance Issues

04:43 The Role of Data in Healthcare Decisions

08:33 Actionable Data for Patients and Plans

16:02 Engaging Employees and Employers

21:20 Measuring Success and Future Outlook

27:15 Conclusion and Final Thoughts

In this episode of Shift Shapers, we explore strategies to enhance the growth and adoption of Direct Primary Care (DPC) with Dr. Bernard Bubanic, CEO and President at Integrated Source One. Dr. Bubanic shares his journey and insights into creating a multidisciplinary approach to healthcare, ensuring access to comprehensive care without the financial hurdles. We discuss the integration of various services such as telehealth, behavioral health, and musculoskeletal services, as well as the importance of building relationships with patients for better health outcomes. The episode also covers how this model can provide measurable savings for employers and improve plan designs.

Key Takeaways

• Multidisciplinary Approach:  Dr. Bernard Bubanic's practice, Integrated Source One, focuses on direct patient care rather than just direct primary care. This includes primary care, health coaching, musculoskeletal options, and behavioral and mental health services, all offered under one umbrella.
• Employee and Family Coverage: Integrated Source One covers not only the employees but also their dependents at no additional cost. This approach is helping with better engagement and substantial cost savings for employers over time.
• Brick-and-Mortar and Virtual Care Integration: The practice combines onsite, near-site, and mobile clinics with telehealth services. This ensures continuity of care and immediate attention, making sure patients get timely and efficient care without the traditional wait times.
• Savings and ROI for Employers: By integrating direct patient care services into employee benefit plans, employers witness reduced healthcare costs and premiums over time, with a higher engagement rate by the third year, leading to significant long-term savings.
• Future Expansion and Technology: Moving forward, the practice is looking to incorporate new technologies, including AI, to enhance patient care quality and efficiency. This will continue to lower costs while improving health outcomes for patients.

In This Episode

00:00 Introduction to Direct Primary Care

00:37 Guest Introduction: Dr. Bernard Bubanic

01:15 The Journey to Integrated Source One

02:59 Challenges in Traditional Healthcare

04:11 Direct Patient Care: A Multidisciplinary Approach

05:35 Innovations in Healthcare Delivery

06:11 Seamless Integration of Onsite and Virtual Care

09:11 Measuring Success and ROI

12:30 Plan Design and Employee Benefits

19:54 Future of Direct Primary Care

21:14 Conclusion and Final Thoughts

Join us on this episode of ShiftShapers as host David Saltzman sits down with former New Jersey Congressman Rob Andrews, one of the key authors of the Affordable Care Act (ACA). Fifteen years after the ACA's passage and ten years since its implementation, Rob shares his journey from aspiring sports writer to influential lawmaker, his role in drafting the ACA, and thoughtful reflections on its successes, shortcomings, and future prospects. We delve into topics such as healthcare coverage expansion, consumer protections, cost control, value-based healthcare, mental health parity, and the ongoing provider shortage. Currently serving as the CEO of the Health Transformation Alliance, Rob continues to advocate for value-based health arrangements. Don't miss this insightful conversation for a deep dive into the evolution and future of U.S. healthcare.

Key Takeaways:

• Journey to Congress and ACA Involvement: Rob Andrews initially aspired to be a sports writer but ended up in politics, driven by a mix of early professional exposure and personal family experiences. He was significantly involved in drafting portions of the Affordable Care Act (ACA).
• ACA Achievements: The ACA successfully expanded coverage to millions, with Medicaid expansion and subsidies being critical components. It improved patient rights, eliminating pre-existing condition exclusions, extending coverage for young adults, and removing lifetime and annual policy limits.
• Shortcomings and Future Goals: ACA did not sufficiently address healthcare costs. The prevailing issue is that the system rewards the number of procedures over the quality of outcomes. There's a need for more focus on preventive health measures, behavioral health services, and better alignment of payment to performance.
• Healthcare Provider Shortage: There is a significant shortage of primary care providers and behavioral health professionals. Proposed solutions include increased compensation and incentives such as debt relief programs for medical students who work in underserved areas.
• Value-Based Healthcare: Value-based healthcare is crucial for better outcomes, involving rewarding providers based on risk-adjusted, clinically sound outcomes Both quantitative metrics (e.g., reduced A1C levels in diabetics) and qualitative measures (e.g., patient self-evaluation) should be considered to assess quality effectively.
• Current Role: Rob Andrews is the CEO of the Health Transformation Alliance, focusing on pooling resources to buy healthcare more efficiently and promoting value-based arrangements among member companies.

In This Episode

00:00 Introduction and Guest Welcome

00:41 Rob Andrews' Journey to Congress

03:14 Involvement in ACA Drafting

04:53 ACA Successes and Shortcomings

07:03 Future Improvements and Value-Based Healthcare

10:07 Addressing Primary Care and Behavioral Health Shortages

16:13 Measuring Quality in Healthcare

17:47 Rob Andrews' Current Role and Conclusion

Are you struggling to navigate the complex world of gag clause attestation requirements? In this must-watch episode of Shift Shapers, Jennifer Berman, JD, CEO of MZQ Consulting, provides a comprehensive breakdown of everything plan sponsors and advisors need to know about these critical compliance requirements.

From the Consolidated Appropriations Act of 2021 to today's implementation challenges, discover how these regulations are reshaping healthcare plan transparency. Jennifer explains why many contracts still contain illegal gag clauses in 2024 and what this means for your organization. Learn about the crucial differences between fully-insured and self-funded plans, and how these differences impact your compliance obligations.

Key topics covered:

• Detailed explanation of gag clauses and their impact on healthcare plans
• Step-by-step guide to annual CMS attestation requirements
• Understanding potential penalties and enforcement mechanisms
• Navigation of the HIOS system reporting process
• Critical differences between fully-insured vs. self-funded plan requirements
• Practical strategies for verifying gag clause compliance
• Tips for accessing and utilizing plan data effectively
• Real-world challenges in contract review and compliance

This episode delivers essential insights for anyone involved in healthcare plan administration and compliance. Whether you're managing benefits for your organization, advising clients on their healthcare plans, or ensuring regulatory compliance, you'll gain valuable knowledge about navigating these complex requirements. Jennifer's expertise provides actionable guidance for insurance professionals, consultants, and organizational leaders who need to understand and implement these critical transparency regulations.

In This Episode
00:00 Introduction to Gag Clause Attestation

00:45 Understanding Gag Clauses

01:39 Legal Requirements and Compliance

03:00 Challenges and Real-World Implications

04:58 Access to Plan Data and Its Importance

07:11 Reporting and Documentation

07:33 Understanding Certification and Penalties

10:02 Annual Reporting Requirements

10:18 Advisor's Role in Compliance

10:40 Self-Funded vs Fully Insured Plans

13:03 Ensuring No Gag Clauses

13:20 Final Thoughts and Key Takeaways

14:39 Conclusion and Farewell

Unlocking Post Claim Adjudication: Insights with Jordan Hersh

In this episode of ShiftShapers, host David explores the complex world of post claim adjudication with Jordan Hersh, Vice President of Enterprise Solutions at Vālenz. They discuss the intricacies of self-funded plans, reference-based pricing, and the potential savings associated with renegotiating out-of-network claims. The conversation delves into high performance networks, the inverse relationship between cost and quality in healthcare, and methods for improving transparency and cost containment. Learn about the strategies that can lead to significant cost savings while maintaining high-quality care.

In This Episode:

00:00 Introduction to Post Claim Adjudication

00:34 Meet Jordan Hirsch from Vālenz

01:29 Understanding Post Claim Work

02:13 Reference Based Pricing: Pros and Cons

03:55 Narrow Networks vs High Performance Networks

08:14 Out of Network Claims and Cost Containment

15:23 Transparency in Medical Care Costs and Quality

17:18 Incentives for Care Coordination

18:28 Wrapping Up: Savings and Final Thoughts

Quotes:

“Readmission rates, complication rates, mortality rates, we’re taking that into account and making sure that when people do people stay in-network or go to the panel of those high-performance network partners, they’re getting top tier coverage.”

“Depending on the primary PPO network regardless of broad network or network of concise nature, there’s going to be out-of-network medical claims. And that can cost self-funded plans a lot of money if it’s not managed correctly.”

“Some plans we’ve seen pay out-of-network claims at full bill charges, some take a usual customary approach. Having a much more direct and aggressive approach can really be a game-changer for self-funded plans and materially impact the bottom line.”

“So being able to achieve a discount, that can also assure them that they’re going to be paid and have a little bit more clarity on how the member responsibly can be split up. Oftentimes we see self-funded plans offering some type of incentive.”

“So a plan with a medical spend with a million dollars, implementing these types of tools into the right education training to the members, could reduce their overall medical spend by about 25%.”

What if technology could bridge the gap in healthcare access for underserved communities? Join us on this episode of ShiftShapers as we explore the intersection of healthcare technology and underserved communities with Kornelius Bankston, Managing Partner at TechPlug. Discover how innovative solutions are being tailored to meet the unique challenges faced by marginalized populations. Learn about the role of economic factors, geographical disparities, and the historical context affecting these communities, and see how grassroots efforts and collaborations with local health departments are paving the way for better healthcare access. Dive into the specifics of projects like SensorMed, which offer remote patient monitoring and other tech-based health solutions, and understand the foundational work that TechPlug is doing to bridge gaps in healthcare through specialized tech incubation.

We'll explore the real-world challenges faced by marginalized populations, such as transportation hurdles, prescription adherence, and food security, and how innovative solutions like remote patient monitoring are making a difference. Using New Orleans as a case study,Kornelius reveals how TechPlug collaborates with local health departments to assess and meet community needs effectively.

As we journey through TechPlug's early initiatives, Kornelius shares insights from his diverse career path, from aspiring physician to biotech recruiter and beyond. Learn about the grassroots efforts crucial for educating communities on healthcare technology and the challenges of building trust around data security. Cornelius's unique perspective underscores the importance of continuous innovation tailored to diverse populations' needs. Don't miss this thought-provoking conversation on making healthcare accessible for everyone.


Key Moments In this Episode:
“We identify an ambassador in a city, and typically it’s the department of health, to partner with to bring these innovative solutions to the community.” 

“As opposed to developing solutions in a vacuum, we’re able to bring real data, real time, quantitative and qualitative information back to the companies within our portfolio so they can provide the best possible solution to these populations.”

“I really don’t think a lot of companies that have innovative health solutions are really conscientiously having their innovation addressing the population.”

“There’s a lot of distrust within the healthcare system.”

“In tech, there’s this whole idea around privacy and data security and a lot of populations of underserved and marginalized communities really don’t understand where the data is going and who’s keeping data and how they get empowered by the data.”

00:00 Introduction to Healthcare Technology for Underserved Populations

01:52 Understanding Underserved and Marginalized Communities

03:02 Challenges Faced by Underserved Populations

04:55 Innovative Solutions and Technology in Healthcare

05:48 Community Assessment and Partnerships

09:57 The Role of TechPlug in Healthcare Innovation

14:37 Building Trust and Overcoming Skepticism

16:11 Future Prospects and Challenges in Healthcare Technology

18:43 Addressing Privacy and Data Security Concerns

20:07 Conclusion and Acknowledgments

In this episode of the ShiftShapers Podcast, host David Saltzman chats with Marissa Rufo, JD, MBA, a subject matter expert from MZQ Consulting, to demystify the complexities surrounding Medicare Creditable Coverage. They discuss why it's significant for employers and employees alike, particularly in light of recent legislative changes and the growing number of older employees in the workforce. The conversation addresses compliance requirements, methods for determining creditable coverage, and practical steps employers need to take to avoid penalties and lawsuits.

Medicare creditable coverage is a requirement for group health plans to be comparable to an average Medicare Part D plan. The consternation and confusion around creditable coverage has increased due to recent changes in legislation and the growing number of Medicare-eligible individuals still working full-time. Employers have a fiduciary duty to ensure compliance with creditable coverage requirements, as failure to do so can result in lawsuits and penalties. While employers are not required to have actual creditable coverage, they must determine the creditability of their prescription drug plans, provide notices to Medicare-eligible employees, and report their credibility status to CMS annually. Failure to provide accurate notices can result in financial costs and penalties for employees. There are two methods for calculating creditable coverage: the simplified determination method and the actuarial analysis method. Brokers can help employers navigate the compliance requirements and ensure they are providing the necessary notices to all Medicare-eligible individuals. MZQ Consulting offers affordable testing services to help employers determine the creditability of their prescription drug plans.

Takeaways

• Medicare creditable coverage is a requirement for group health plans, comparable to an average Medicare Part D plan.
• Employers have a fiduciary duty to ensure compliance with creditable coverage requirements.
• Failure to provide accurate notices can result in financial costs and penalties for employees.
• Brokers can help employers navigate the compliance requirements and ensure they are providing the necessary notices to all Medicare-eligible individuals.
• MZQ Consulting offers affordable testing services to help employers determine the creditability of their prescription drug plans.

In this episode of Shift Shapers, host David Saltzman sits down with Alycia Riedl, the new National President of NABIP, to discuss the future of the healthcare advisory industry. Alycia  shares her personal journey from reluctance to passion in the industry, following the legacy of her innovative father. They explore key issues on NABIP's radar, such as transparency, technology, and advocacy against single-payer systems. Alycia emphasizes the importance of evolving the role of advisors and her vision for a consumer-centered healthcare system. Additionally, they address leadership values and the strategic goals of NABIP for the coming years. Tune in to learn about the upcoming developments and strategic initiatives aimed at supporting healthcare advisors and improving the overall healthcare landscape.

Key Takeaways From This interview:

Career Journey: Alycia Riedl’s unexpected path to the insurance industry fueled by a passion for helping others.

Innovation and Adaptability: The importance of continuous improvement and innovation in the insurance industry.

Consumer-Centered Healthcare: NABIP’s commitment to a transparent, consumer-focused healthcare system.

Advisor Challenges: Addressing the difficulties advisors face with restrictive laws and compensation issues.

Leadership and Empathy: Reidl's emphasis on empathetic, data-driven leadership that supports team well-being.

The focus of this week's episode is on how modern healthcare system innovations utilize throwback TPA. Bob McCollins, vice president of sales at Edison Health Solutions, explains what’s happening in the TPA industry today and how a throwback TPA can help combine all the fantastic solutions out there to provide top-notch services.

What You’ll Learn From This Episode:

2:34 What throwback TPA means and how it works with current healthcare systems.

4:35 Keeping all of the various solutions together for the benefit of clients and potential clients.

7:57 TPAs need to be adaptable or focused on a single path in order to provide best-in-class services.

11:10 Changes to offerings and support in reference-based pricing.

14:48 Tasks they outsource to third parties.

16:39 Factors affecting claims' automatic adjudication.

20:35 TPA in the coming years.

This episode originally aired September 26, 2022