Reborn vs. Reform

Sponsored by Hint Health Join us for an insightful session that uncovers the ONE thing truly controlling the healthcare system. Learn how to distinguish viable solutions from wasteful efforts and move beyond temporary fixes to address core issues. We'll explore the evolution of effective solutions and how collaborative efforts can enhance them further. This session highlights the critical role of consulting with clinicians to achieve maximum healthcare delivery efficiency and delves into the components of an average health plan in our reimagined healthcare system. Expect a candid discussion on the impracticality of reforming the current system and the barriers that impede meaningful change. Instead, we'll shift focus to the rebirth of a patient-centered healthcare system designed to promote health and wellness. Discover how empowering doctors, engaging patients, and appealing to congressional leaders can drive substantive change in a parallel healthcare system already being shaped by a growing group of benefits catalysts.

Transcription:

Eric Silverman (00:09):

All right. Where's my ugly picture? There you go. Oh, there we go. Okay. Anybody love panels where we spend 10 minutes talking about ourselves? I don't either. So we're going to hop right into it. If you want to know their bios, if you're not sure, check LinkedIn, connect with them. I'm sure you guys would be happy to connect. Yes, yes. Alright, let's get rolling. Emma, lemme start with you.

(00:31):

This Session is intended to shed light on where this session is intended to shed light on where the current healthcare system lacks the ability to reform. Talk us through some of the incentives you've listed up here that are contributing factors.

Emma Fox (00:49):

Okay. My name is Emma. I'm the CEO of E Powered Benefits. And at our agency, we're very fortunate to work solely in the self-funded market. And if you follow me on social media, I'm known as the anti BUCA activist, which means I build all of my health plans without the help of carriers and insurers. And the reason I do that is for really the three things that you see on the screen today. One of the biggest problems was the Affordable Care Act came out with a lot of really good intention and I think it meant really well. And there's a lot of provisions in there that do a lot of really good things. But I think a lot of people in the room would agree that there are some faults and it's certainly not perfect. Not much that comes out of the government is one of the things was the medical loss ratio, which really intended to make the profits available to carriers or available to insurers smaller so that it could be a little fairer and that the system wasn't as profit driven.

(01:47):

But unfortunately, as with most things, you figure out how to inflate something in order to squeeze a little more out of it. And that's essentially what the MLR or the medical loss ratio has done, which has really meant the opposite of what was intended. It was intended to reduce claims. And what is actually done is help inflate claims so that those profit margins can increase along with it. Another example of these incentives are how brokers are paid. And I'll go on record to say right now, a lot of brokers don't have a choice. A lot of us grew up in fully insured markets and mid markets where we don't have a choice but to take our compensation as a portion of premium or something very similar. But that does mean that if your compensation is tied to premiums and premiums go up, your compensation also goes up regardless of the job that you do.

(02:31):

So if you don't do a very good job for your clients or you're just kind of coasting, you're still going to make more money, which is sort of a backwards incentive. And the one that really revealed a lot to me about the system was the way that doctors are paid, which is probably the one that's least well known. And without boring all of you, the way that doctors are paid are based on a production. An RVU is a measurement, but it's a financial attachment to a procedure or a referral or some kind of service that helps the doctor up and at the end of the day helps them sustain their own salary for their families. And so when you look at how the system is working, it works really well for a lot of people. It just doesn't work very well for patients and doctors. And so those are some of the problems that we're looking at at our agency and trying to reverse them when we're building health plans.

Eric Silverman (03:21):

So Tiffany, to keep it moving from your clinical standpoint, how does this impact patient care when we consider the statistics here?

Tiffany Ryder (03:30):

Yeah, there, well, I'm so excited to talk about the next slide, but this is fine. I am an emergency medicine PA by training, and that's sort of how I got into this room was seeing patients insured uninsured. I always thought it was only a patients who were unlucky enough to not have health insurance. But what I found in the emergency department is that that's not at all true. And what I also found was that people were getting huge bills from seeing me when they could have been getting care, better care, more specialized care, more appropriate care in other venues. When I look at this and I see this 67% of bankruptcies due to medical debt, I know that a large percentage of that is from patients who carry health insurance. So what is the answer? And that's how I met Emma, and that's how I landed on the stage here. Because what I found is that when patients are getting care that's appropriate for their complaint, for their problems, that this is less of an issue and that there are ways that we can arrange things to where I'm not checking all of the boxes so that my department head, my medical director, is happy that my bill could be coded at a five if that were appropriate. But don't worry about that. We'll take care of it. You hear things like this and you see these numbers and it's very clear that something needs to be done.

Eric Silverman (05:14):

So Zak, what do you think about all this man?

Zak Holdsworth (05:17):

Yeah, so Zak Holdsworth, I'm the Co-Founder of Hint Health and I'm from New Zealand, not Australia, just get it out there. So I think my company, we support direct primary care. So that's one of the reasons I've been invited in here today. So the, I guess end result of a lot of these perverse incentives, lack of price transparency, what it has done is it's led to both physical health and mental health problems in the us. And a lot of these things are to a certain extent, probably preaching to the converted, or at least I hope I am in terms of the US healthcare system is pretty broken. And it's basically, it's impacting outcomes. It's impacting the way people get care. Some of the statistics here, and some of these are shocking to me, but it's the highest comorbidity and chronic conditions in the world. It's got the highest, one of the highest ity rates of infants and mothers at childbirth in the world.

(06:16):

I think that's in advanced economies, but it's still a shocking statistics. The mental health of our, actually go back, we just jumped through a couple more of these. The mental health of the population is just sort of spiraling out. And actually this is something that impacts both patients as well as clinicians. The clinicians have, I think one of the, if not the greatest, the highest suicide rate of any profession in the US, which is obviously not a good thing and the double the obesity rate of the average globally. And so the next slide here, what this leads to is when you look at how this is impacting the healthcare system is ranked globally from a public health perspective, it's ranked 23rd out of 23rd out of modern economies. This chart on the right I think is pretty good at analysis, showing the system performance on the left versus cost.

(07:25):

And you'll see us is in the bottom right hand corner. So we are spending on average about double what some of these other OECD countries are spending while getting actually basically a worse deal. It's more expensive as well as outcomes and health measures and life expectancies, all these key metrics that matter, trending in the wrong direction and the spending is shocking. There's a sort of statistic that I just found just incredibly shocking, which is there's about 500,000 bankruptcies in the US every year that can be attributed to a medical. And so if you just sort think that the idea of going bankrupt yourself, it's almost inconceivable what was happening half a million people per year as a result of this. I find another way of articulating the scale of the problem is when you look at the total preventable costs in the US healthcare system, it's close to a trillion or maybe even at this point exceeding a trillion dollars a year in terms of preventable costs.

(08:32):

The total system is, it's about 4 trillion, but about a quarter of that it's preventable, which is NASA's combined budgets since inception. And that's what we're wasting in US healthcare. And I think the key point I wanted to leave you with on this slide is that these problems will, if we continue just to take the status quo, traditional options that are easy to pick off the shelf, which happen to be compounding in costs in the eight to 12% per year range, if we just take the status quo options, there's no way we're going to be able to dent the magnitude of this problem. And so, and this is the point of this topic reform versus reborn, which is I think those of us on this panel think what we really need is fundamentally transformative ideas that are doing things in a very, very different way that address the lack of price transparency and address the perverse incentives address the administrative overhead, all these things that we heard about in the price slides. So that's what I think.

Eric Silverman (09:35):

So I have a specific question I want to ask you, Emma, but before I even get to that and a few more slides, would you add anything to anything that Zak just talked about?

Emma Fox (09:43):

Only to point out that I think New Zealand is doing the best on that chart. Did you notice that

Zak Holdsworth (09:48):

New Zealand is doing okay, but yeah,

Emma Fox (09:49):

Look at that.

Zak Holdsworth (09:50):

Yeah, it's back up. New Zealand is New Zealand fast following America over 30 years will be more similar to America, I think.

Tiffany Ryder (09:58):

Yeah, I have things to add on this slide. So it just struck me two minutes ago while you were talking that the three of us have all spent a considerable amount of time utilizing healthcare in other countries.

(10:15):

And when I see this map, this graph, it's not surprising to me whatsoever. So I lived many years in Germany and had children there and used healthcare like everyone else. I was just telling a story over lunch. I had my appendix out while I was there and I went to my primary care doctor because my tummy hurt and I said, Hey, I'm having this problem. And he said, I think that your appendix is getting ready to burst and you might die and you should go to the emergency department. And I argued with him for a requisite amount of time and then I listened. So I ride my bike over to, because I didn't have a car, ride my bike over to the emergency department and I walked in and there's no one in the waiting room. There's no one there. Literally zero patients in the emergency room.

(11:03):

So that was strange. So I walk over, I've got my little insurance card, my American insurance card that I never use because I pay $23 or 23 euros in cash to see my primary care, who will see me day night at my house, whatever it is. And I go in and the surgeon is waiting there. I go to hand my insurance card to this woman and she's like, oh, actually I'm your surgeon, come with me. And I'm like, why are you here? Am I already dead? But it's just there's this whole other way that different places in the world, I would guess most of these.

Zak Holdsworth (11:40):

Yeah.

Tiffany Ryder (11:40):

Think about primary care and it's a question that I get asked regularly as an emergency room provider. They say, why are you always on LinkedIn and you won't shut up about direct primary care? Do you work in direct primary care? Do you own a direct primary care clinic? And for me, it is so clearly one of those out of the box solutions that puts the patient back in the room with a doctor who has time to actually spend time with them and solve their problems and keep them out of the emergency room.

Zak Holdsworth (12:16):

And if we're on origin stories, I mean my equivalent of that is like 20, 30 years ago I 6:00 PM on a Friday night, I lived in a rural community on a farm and my mom could call the family practice up. Our GP in New Zealand call a GP, you call a GP, and they say, yeah, come around. Come around right now. So drive over there. So we had telemedicine same day, next to day appointments, direct personal connection to the sort of one person that's going to help you navigate the healthcare system. That kind of became, to a certain extent, part of the origin story for why we started our company, hint Health, which

Tiffany Ryder (12:56):

Sure, that makes sense.

Eric Silverman (12:57):

And I don't get out much because my health challenges are US-based. So there's that.

(13:02):

Emma, let's revisit the initial discussion of incentives. Okay. How are these driving some of the statistics that we just saw?

Emma Fox (13:10):

I mean actually I think all of them do. When you have a system that's set up for profitability and not for health or wellbeing and not for addressing some of the most basic needs, Tiffany just mentioned in other countries, I grew up in the UK healthcare system, that system gets a lot of flack. There are a lot of misconceptions about healthcare and the national healthcare system in the UK. I also had my appendix removed in the UK and none of these incentives exist there. And I've never, until I moved to the US I have never had to worry about paying medical bill. I've never had to worry about going into bankruptcy. I've never had to worry about whether or not I could get access to care or how long it was going to take me to get into a primary care office or how long it's going to take for me to have my appendix out when they're on the verge of bursting.

(13:57):

And I think that's because none of these things exist. And much like the model that we're going to talk about, the direct primary care model, when you connect physicians or clinicians with what they were intended to do in the first place, the thing that they went to school for, I don't think physicians go to school for fun. I think they genuinely have a heart for helping people. And as soon as we put them into the system, we take that away from them. If you think about how they're compensated, a relative value unit is worth 38 ish dollars one RVU, but each procedure can be assigned a number of RVs. And if you're a doctor who's just starting out and you're in a big healthcare system and you're trying to feed your own families and you see someone, maybe they need an MRI, maybe they don't, but if you refer them to an MRI and that has X amount of R vus, they're going to get a better paycheck at the end of the month. And a lot of people are pointing fingers, it's the brokers, it's the doctors, it's the health insurers, it's not, it's all of us and it's the employers who refuse to do anything about it is what it really comes down to. And it's not even their fault because they're being advised that there's this one option or there's these three equally crappy options to choose from.

Tiffany Ryder (15:05):

Yes.

Emma Fox (15:05):

Nobody's telling them that there's actually this whole entire system outside of the box that doesn't include any of this crap. So I think when you look at these incentives and you do the George Costanza, you reverse them and just do the opposite. You will find opposite outcomes. That's just how it works. It's literally that simple.

Eric Silverman (15:27):

I love that reference George Costanza. That's all I got out of that.

Emma Fox (15:30):

I don't even really know who he is. My husband talks about him all the time. It's like he's

Eric Silverman (15:32):

Seinfeld

Emma Fox (15:32):

Hero or something.

Eric Silverman (15:33):

They don't have Seinfeld in the UK.

Emma Fox (15:35):

Yeah, no.

Eric Silverman (15:36):

Am I the only one on the stage that has their appendix? Do you have your appendix?

Tiffany Ryder (15:40):

Did you get your appendix out in

Eric Silverman (15:42):

I haven't yet. Yes.

Tiffany Ryder (15:44):

All's still time.

(15:44):

There's still timeframe

Eric Silverman (15:45):

All time. Tiffany, all of this is particularly disturbing statistics as it really represents a pattern. So even with insurance, right? Those people with insurance, what do all these numbers mean to you?

Tiffany Ryder (16:02):

Well, I must say that I woke up to this slide this morning in my inbox and I said, oh, oh, I have to read this study. So I just read the study like an hour ago. And the reason that I had to read the study is because I saw 61.4% and I did not believe that number, not because it's too high, because I think it's way too low anecdotally, based on what I see when I go to the emergency department, this is a low number. It was correctly typed. And I did read the study and it was fine, but here's what I see. And when I see this unnecessary ER visits and I talk to people about unnecessary visits, they say, I don't know why Americans are so stupid and just keep going to the er, right? This is what my European friends say. And you talk to maybe an employer and they say, I don't know why all of my employees think they need to go to the er, but when I'm in the er, I ask every single patient, not because I mind anyone coming to the er, I don't care why you're there.

(17:09):

I would love to see you and help you. But I say, well, I'm not really, maybe I'm missing something here. I don't really understand why you're here because I'm not concerned about any of these things. They don't sound super scary. You don't look super scared. Why are you here? And the answers I get are ridiculous because they're all systems problems. They are. I can't haven't seen my primary care doctor in a year. And so they said, I'm actually not a patient anymore, even though I've been in that practice for 10 years, and in order to establish care, I have to wait at the end of the line and it's going to take me in Maryland, it's about three months, so six weeks to three months depending on where you are.

(17:57):

I called my kid's pediatrician, but they said that they're not seeing sick kids right now. And I know that my kid's not in danger of dying, but they really need care. Can you look at them, right? I mean, the reasons that people are in the emergency department are 100% avoidable. I need my blood pressure medication refilled. I haven't been to my doctor in three months and they said they can't refill it if I haven't been in, but I actually don't have money to pay the $30 copay. So these are the reasons. So that's just that box that you could look at, the ICD 10 codes, I don't know the diagnosis, the number that goes to it, and you can see what that means. Those are just the ear infection that you can say, okay, that person shouldn't be here. But also that isn't really in that data is the subset of people who are at risk of death because they didn't have access to primary care four days ago or 14 days ago. The person who has sepsis now from an infection that really could have been easily treated with a two day antibiotic two weeks ago. So I think that there's a much larger percentage of emergency room visits and hospitalizations and procedures that we're paying for that. I just don't understand how we're not investing more in the primary care space.

Eric Silverman (19:30):

It's certainly hard to comprehend. Emma, let's keep moving, but I want to translate this into cost, right? So let's talk about the incentives, the lack of healthcare literacy. We recognize the need for improvement, but at least we have price transparency now, right?

Emma Fox (19:48):

No,

Eric Silverman (19:49):

Damnit.

Emma Fox (19:49):

I mean, yeah, but no. I'll give you an example. So one of my heroes is a lady named Chris Deon. If you don't know her, please find her on LinkedIn. She's an incredible advocate. She's testified before Congress. She's a remarkable human being. And she posted this post, this is just a small portion of it, but really quickly, she was comparing Duke University Hospital and UnitedHealthcare contracted rates. And this is what we got out of the transparency ruling, right? We said hospitals have to post their prices from now on. Consumers are entitled to it. They should know what the price is ahead of time, which is completely reasonable. But what we found was now we know how badly we're getting screwed, like now it's public knowledge. So we can see now that your worst case scenario in almost all of those machine readable files is when you pull out your insurance ID card, almost always.

(20:44):

And so if you think about that, we're paying for the insurance, right? We're asking employees to put a contribution from their paycheck that pays their bills towards insurance, and then we're telling them to go use that insurance, which we now know is the worst financial deal that they are going to get. Then we're asking them to pay deductibles, co-insurances, copays. And that's inflating every year, five, seven, 10%. And when you look at these examples, you could just be a cash pay patient and save probably thousands upon thousands of dollars a year and not have these burdens. The price transparency thing was really enlightening because now we can see it, but no one's doing anything about it and no one's being held accountable, which again, I point back to the government, anything that comes out of the government doesn't generally come with any sense of accountability. And so who is responsible for holding all these hospitals accountable? Who's responsible for holding the insurers accountable for not being able to come up with contracted rates that are better than cash prices? Isn't that the point? That's why we go into these negotiations. So yeah, we have transparency, but it's showing us how badly of a deal we're getting.

Eric Silverman (21:57):

Who else needs a drink?

(21:59):

My goodness, I don't even drink and I need a drink. Coke Zero please.

Emma Fox (22:04):

I heard there was going to be a happy hour at town hall where we can all ask questions.

Eric Silverman (22:07):

There is. We're getting closer. We're getting closer, but we're not done this, Zak, let's talk for a second buddy before we, or as we continue to get going. Let's get to what you've identified as a solution. So direct primary care has become a popular point of discussion in the employer group market. What does it actually solve for you though?

Zak Holdsworth (22:27):

Yeah, I mean, I think maybe just start with a bit of definition for those of you who aren't familiar with DPC, and I think maybe also a broader point I'll make is a lot of the things Tiffany, Emma have mentioned around lack of transparency or perverse incentives. Direct primary care is a manifestation of how to solve some of those issues within primary care. But there are other kind of things that you can do in parallel to direct care that maybe we'll spend some time talking about. But just in terms of definitionally DPC, which is what our company is set up to support, you're taking instead of a traditional insurance fee for service relationship where these physicians are on the Hester wheel, they need to see as many patients as they can as quickly as they can. They're typically making referrals as quickly as they can.

(23:20):

They don't have enough time to really care for the patient in order to meet their financial goals. They need to shift those patients through high volume to downstream things or route them directly to the ERR if they don't have the ability to see them same day or next day. What DPC is, is independent dp actually, can you just click back? So it's independent clinician, they'll typically charge a fixed monthly fee across. We've got thousands of DPCs on our platform. Their average is around the 75 to $80 a month range. And with that, you're getting essentially unlimited access to primary care, telemedicine, urgent care. A lot of the ER examples you mentioned, they're not er, but maybe they are emergent or urgent. So you need to be seen right away for that, your sick child or if you broke your pinky or something like that, where your primary care physician is trained to and has the skills to actually address it.

(24:19):

And importantly, they're not dragging along with them. The administrative burden of the insurance fee for service chassis, they're not billing insurance. Your $80 a month includes unlimited access. It includes everything you need both across virtual as well as in person. And it really allows these clinicians to wrap their patients in amazing care. And actually this is one of my favorite examples of the extreme of this is we have a client that, and I sort of don't recommend this, but he sort of jokingly says, in case of emergency, call me. Because his point is, if you call the system, they're not going to know who you are. They're not going to know your back history, you're not going to get very personalized care. So what he's saying is, Hey, if you think you're having a heart attack, well probably you're not. Give me a call. I'm going to know you.

(25:13):

If you are, I'm going to call the hospital on your behalf and get them to come around. So again, we don't recommend that to our clients generally because obviously some risk there. But that story of how they're really fundamentally changing the paradigm is really important. And just to be clear, these doctors, you'll see them and they will spend 30, 40, 50 an hour with you, 50 minutes an hour with you depending on what your needs are. So maybe next slide here. So there's a few things that this does. First of all is this, I think this is maybe underappreciated, but clinicians go into care is a general going in because they want to help people. But what's actually happening is they've been put into a situation where there's called moral injury where you're actually not able to treat the patient. So this idea of a patient come in that if only you had the time to actually spend with them, you'd be able to address this issue, whether it's mental health or chronic disease or whatever it might be.

(26:15):

They know that they can't clinically do that in seven to 11 minutes, and they'll go bankrupt if they spend 45 minutes. So the only thing they're able to do is make a referral to a specialist, which is, and if you do that 35 times a day, that's really wears you down. And these doctors and clinicians, they're flipping that and they're actually restoring the love of medicine and the sort of sacred bond between patient and doctor. That's kind of one of the big things we see. The second piece here is, again, if you through the lens of an employer, you're shelling out the 75 bucks a month, what you're going to see is not only directly are you going to not have no longer primary care claims, but all those unnecessary referral to specialists, all of those additional people showing up to the ER that really, really don't need to be there.

(27:03):

The people that could have been a disease could have been prevented, and so they don't actually need to go to the ER at any way. All of those things as well as primary hair claims dropping or they're downstream unnecessary claims will drop off as well. And then importantly, what we are seeing is these clinicians are able to build really good businesses. If you just do the math, 75 bucks a month, let's say on average 500 to 600 patients per clinician, it's just for math, simple math, say 500, well, that's 450 K per year in recurring revenue. And it's generally a higher gross margin recurring revenue than a traditional fee for service models. So what we're able to see is these clinicians actually are building really strong businesses that don't, let's say fall over during covid. You heard the stories about all the bankruptcies of primary care.

(27:54):

You're like, what are you talking about? We need primary care right now there's a pandemic. So in DPC, we actually saw a growth of our customers grew more than they'd been growing previously during covid because of the underlying fundamentals of their business. So this is these new models that really flip the incentives and do so in such a way that can drive massive improvements in outcomes. And then this is just the way I tend to think about this is just sort of an axiom of almost, it's almost like an axiom of physics or it's a law of physics. It's like we know everyone knows, right? That if you invest in primary care, if you invest in preventative, it lowers healthcare costs. There's no functioning healthcare system in the world that doesn't have a highly functioning primary care system. And what's happened is the insurance fee for service infrastructure has essentially broken the back of the primary care system in the US healthcare system.

(28:51):

And we at Hint, I think a lot of the people here on this panel believe that if you are to transform one thing, right? That's the thing. If you're able to transform that one thing, it has this massive ripple on effect. Next slide, which can lead to much, much lower overall healthcare costs. So what you end up with is what we like to call quadruple aim, right? Instead of the triple aim cost quality outcomes, you're actually able to get cost quality outcomes as well as patient satisfaction and clinician satisfaction. And you're able to develop a deep trusted bond with your doctor who knows who you are, who knows how to care for you, can help you navigate, Hey, you need an X-ray, I see you're on a high deductible plan. It's going to cost you $300 because the imaging center down the road is going to get paid 70% of the time in 180 days.

(29:42):

If they don't say this, obviously, but the underlying mechanics are they're going to get paid 70% of the time in 180 days. If we bill this to insurance, the cash rate, I know the CEO of the imaging center, the cash rate's 75 bucks. If you pay it right now, what do you prefer? Right? So that's a very simple example of how these doctors will often help you navigate the system and help in conjunction with the types of advisors that on the stage for example, they're able to say, okay, we want to implement a DPC option. Here's how you can do that. And if you're interested, come and talk to the Hint Connect team in the booth. Pitch that.

Eric Silverman (30:23):

Zak, Zak, how seriously, and I'm curious, Emma, how does an employer even begin to start looking at this and developing a program like this? How do you even start really?

Emma Fox (30:34):

Well, I do want to back up what Zak said actually, which is that primary care in the US is bankrupt. If you look around, a lot of primary care offices in the fee for service model have been bought by larger health systems and they're using those practices as loss leaders. They're not using them for the purposes of reducing the referrals or the specialist referrals that Zak's talking about. And what happens is when somebody doesn't have access to primary care, and I am very, very fortunate that I run a nonprofit actually with this lady here down in Texas where we decided to test to the theory what happens if we give primary care to people and it doesn't cost 'em anything. They have unlimited access. It's remarkable. The mental health of people, the lack of need to see a specialist, the quality of care, the quality of life, just the productivity that they're able to bring into their lives and their families.

(31:29):

Just by having access to one doctor that cares about their baseline health will absolutely change the life of every individual who has access to it. So how do you do it? I talk to prospective clients all the time that tell me that their brokers have told them they're too big, they're too small, not in this area of the country that will never work here. I heard somebody in this crowd earlier today say that it sounds very chaotic and there's all these parts and pieces and how could it possibly work? The first thing is get your consultant right? If you're an employer in this room, you've never heard this strategy before in any meeting with your consultant, you have the wrong consultant. They do not know how to contain costs. They do not know what the problem is. And if they do not understand the problem, they will not be able to fix the problem. And I'm not saying that that's their fault. I'm saying that it's not their wheelhouse, that's not their expertise. Another big misconception is that if you're a really big employer, you need a really big broker house wrong. What you're going to get in a big broker house is a general contractor. What you need is a specialist.

(32:33):

You need clinical consultation. I worked for insurance carriers for 10 years and I finally threw my hands up. I felt like I had my own moral injury and I went out on my own. And I realized very quickly, I'm building these health plans to finance healthcare, but I don't know how healthcare gets delivered. So how can I possibly set up the financial backing for a health plan when I don't understand what it's actually paying for, how that works. So having clinical consultation while you're building out your health plan, even if it's a fully insured health plan, is a really crucial component to understanding what you're actually paying for and why that's important evidence-based medical management, we talk about this all the time. You have it in your fully insured plans. It's when Aetna uses a HHI think they use now for clinical appropriateness, like is this treatment appropriate for the condition that it's treating? Well, that's a really important part. You want evidence-based guidelines, Milliman guidelines. You don't want carrier based guidelines that are going to drop into that incentive pool that we talked about in the beginning. I firmly believe that everybody should have unlimited cost-free access to primary care. It is a complete life changer.

Tiffany Ryder (33:40):

Can I hop in there?

Emma Fox (33:41):

Yeah, go for it.

Tiffany Ryder (33:41):

One quick thing because all patients say this to me when no one's looking. They say, yeah, but primary care sucks. Well, it does. I just want to address this elephant in the room, which is primary care does suck, your doctor doesn't suck. But when you have five minutes to treat six conditions and change someone's life, that's a tall order, which is why we have all the moral injury and the increased suicide risk and all of that. But when you have that 45 minutes without these perverse incentives, without me having to do mental calculus on how many moles can I test in this appointment without it affecting my bottom line to where I should have a patient come back, A DPC doc is looking at that patient and they're saying, how can I help you in the best possible way that's best for your health? And we will keep you from having to come back. And I think that's just a really big distinction. I didn't want to run out of time and not have time to say it.

Zak Holdsworth (34:42):

I mean, just on that, the incentive there, it's like if you're a DPC, the incentive actually is to have 500 really healthy patients.

(34:50):

Because they're not going to be sick coming into the office every day. SO'S natural incentive alignment. But I wanted to hear you, Emma, finish your because I think there some let go.

Tiffany Ryder (34:58):

I'll let go now.

Emma Fox (35:01):

Well, now you've thrown me all off. So no, I really think, listen, the advice that you get is really important. Think about how you're selecting your accountant. Think about how you select your attorneys when you need legal representation, you should be making the same considerations when you're selecting a consultant that is advising you on one of your biggest line items that you're paying for. And if you're a broker in the room and you don't understand anything that I'm saying, there are so many programs certifications, there are mentoring programs out there that will help you understand this sort of different model. I think that being able to mitigate the waste and abuse in the system, if you think about how the opioid epidemic started, how do you think it started? Because doctors have five minutes to treat you. They're either going to refer you to somewhere or they're going to write you a prescription so that you'll be okay hopefully when you leave the office.

(35:49):

The system has sort of squeezed us all into the smallest space possible, and we're supposed to have some really big amazing outcomes from that. It's just never going to work. So what we need to really do and what it comes down to is really point number one and point number eight, which is get the proper representation, vet your people properly, make it the most important decision that you make this year, and then eliminate the perverse incentives everywhere that you go. My husband's favorite character is George Costanza. So I use it all the time, do everything opposite and see what happens. I promise you'll have opposite outcomes.

Eric Silverman (36:22):

As we start to wrap up. I mean, I could keep asking questions, but I'm curious what's on your mind. If we have some mics that go around the room, you got to have questions. This is still such a new innovative concept that is certainly not everywhere, certainly not yet. Not adopted by every broker, and certainly not adopted by every employer. Please don't be shy front row.

Audience Member 2 (36:50):

Zak hinted at this, but I'd like to hear more from some of the other panel. You see that you talked about how properly functioning primary care tends to reduce downstream steerage, and you talked about the savings, which are even greater among the chronically ill. Can you talk a little bit to the audience about why that is and what the mechanism is that actually gets these more chronically ill people, healthier for less money and reduces the steerage to the specialist, the inpatient and outpatient facilities?

Zak Holdsworth (37:18):

Was that question for me?

Audience Member 1 (37:20):

All three of you?

Zak Holdsworth (37:21):

Yeah. I mean, I think the short version I think is that if you have a primary care clinician that really understands you completely and sort of incentivized to spend as much time as they can with you such that they're able to develop a full picture, then when things start to happen or evolve as you go through life, they're going to be the first people that you connect with and they're actually going to help you navigate. Healthcare is complex. They're actually going to help you navigate. You're not going to need a, if you're an employer, a diabetes prevention program, your primary care clinicians, that's bread and butter for them. That's not hard for a primary care doc with the right amount of time. So that's one example. But if it's something simple or something complex, they're going to be there with you helping you interpret and also helping hold you accountable to actually going through on your side of the bargain.

(38:23):

In terms of improving outcomes, we've got one client that a really great, I thought analogy he gave was the patient came in and had some depression problems and that was leading to eating disorders and it was leading to pre-diabetic. It was a chain. And his diagnosis was is they're lonely. And so he actually spent time with them. They were new to town, teaching 'em how to make friends, which is kind not really a medical thing to a certain extent, but it's just a really interesting case study of how, if you know what the right levers are in healthcare, you can have really massive compounding impact downstream throughout the chain of events that happens in life.

Eric Silverman (39:11):

Question?

Audience Member 2 (39:12):

Yes,

Eric Silverman (39:13):

Go ahead.

Audience Member 2 (39:14):

I can't hear enough of this sharing. It's such an amazing conversation. You guys mentioned it's the first time actually heard you mention the European system, and I'm very familiar with the European system because Israel also has this same system, and Germany probably is the best in the world when citizens are paying such a high taxes on healthcare as well as in other state, in country. It seems like you support of single payer. Am I hearing you not having that question for me? I had to ask you guys because this is, she's looking right at you.

Tiffany Ryder (40:02):

I know you are looking at me.

Eric Silverman (40:03):

We don't have a lot of time. 30 seconds.

Tiffany Ryder (40:05):

I mean, here's really what I think. If healthcare were free in America, we would still have a disaster on our hands.

(40:14):

We have got to change the paradigm to focus on primary care because I think that that is what patients need. Really quick story. So when I had a mom of twin two year olds that came in with eye pain and I asked my emergency medicine questions, which are, so mostly I'm looking at this kid, I think the kid is fine, but this kid is not in the pediatrician's office. This kid is in the emergency department. So I asked the questions, go through the list of things that could be a corneal abrasion like a scratch to their eye. And I had to sit this kid down. I had to put chemicals in their eyes, I had to do these invasive procedures. I had to do all of these tests because I couldn't discharge this patient by saying, look, just come back tomorrow if everything's okay, right?

(41:01):

They're in the emergency department. They have to be treated at that standard of care. And what I think that we really need is more access to primary care so that we can sort these things out without having to do a ton of inappropriate, unnecessary testing because well, you're at the cardiologist, so this is the standard of care as we've defined it in cardiology or in emergency medicine or what have you. And so I don't really know where I sit on that question, but I do know that we will not thrive, we will not serve our patients if we are not supporting primary care and we are not supporting primary care.

Eric Silverman (41:41):

And shot Emma go.

Emma Fox (41:43):

Okay. I will say I'm very in favor of a universal healthcare system. I don't think it'll work in the US and I think it will not work in the US because until politicians know the difference between health insurance and healthcare and they stop running on health insurance expansion platforms, it's never going to work. Because the problem is in healthcare delivery and financing and those two things go together here. And so until the people who are making decisions in our government can differentiate those two pieces of information, I don't think it can work in a dream world. Yes, absolutely. Would I love primary care for all. I would vote for that.

Tiffany Ryder (42:18):

Yes, me too.

Zak Holdsworth (42:19):

For that. And I think just to reinforce the MS point, I agree with the thesis. It's like it's practically politically not practical. So then where my head goes to is what are the practical things that we can do now to affect change? And we know that employers spend close to a trillion dollars a year on healthcare, and so that's basically a third, right? If you're able to figure out how can we shift that spending into something that is much more cost effective and better for the patients and saves money for the employer, that's kind of like a big lever, I think, which is part of the reason I think we're here today.

Eric Silverman (42:55):

That's all we got. What do you think? Good stuff. Alright. Thank you everybody. Appreciate it. Thank you.