This is Laura D with the Becker health
care podcast.
I'm thrilled today to be joined by Doctor
Darren Weather, Chief Medical Officer at Atrial Health
plans. Doctor Weather is the pleasure to have
you on the podcast guest today?
Laura, thanks for the invitation. Happy to join
you.
Now I'm really excited for our discussion and
and learn more about when you're doing at
health plans and how you're thinking about growth
and development for the future. But before we
dive in, can you tell us a little
bit more about yourself and your background?
Sure. Happy to do so.
I've been in managed care for the past
13 years,
holding roles at Cove tree ae
Blue Cross Blue Shield, Arizona and for the
past 2 years as the Chief Medical Officer
are at Atrial Health plans,
for your listeners
As a Medicare Advantage plan that's headquartered in
Salem, Oregon,
we offer MAM
map pd and
dual slip coverage in Nevada and, Oregon.
Oh, that's, you know, fantastic to hear and
certainly it's such a an important role that
you play within the community. Now, you know,
when you're looking at,
ahead, what are some of the big trends
and headwind that you're following? How are you
thinking
about, you know, some of the different things
happening in the healthcare space and and how
you really can be part of that ecosystem.
You know, I think there are so many
regulatory,
things that have faced us in.
The Medicare Advantage world,
you know, the final rule for 20 24
required
that health plans, create medical management committees that
they didn't have them,
and those committees had to involve
community physicians as well as health plan,
physicians and medical directors. So that was something
new that we brought on this year,
there certainly are other changes coming.
I was reading earlier today about how
different states are adding rules regarding.
Prior
authorization. So there has to be more transparency
than we're used to,
there has to be posting of the criteria
that we're using to make
determinations of care.
And all of these are good and positive
changes that have come to the marketplace,
but they do require the health plans and
the medical directors and Cmos to adjust
the way in which they're operating and performing.
Each day seems to bring a new headline
about the Gl 1, drug class,
and there are expanded uses and
potentially expanded
indications.
But along with that comes a lot of
unplanned cost.
So with Medicare,
in addition to using Gl ones to treat
diabetes,
we now have the indication for
treating
major cardiovascular
events, and
there are a lot of people who will
qualify
for that, and and that certainly cost that
most of us in the Medicare Advantage world
didn't plan for.
That that's really fascinating me here and especially,
you know, looking at, as you mentioned, the
growth and the development of the Gl ones.
When you think about
the expense associated with them as well as
indications and and so forth,
how do you plan around that in really
being able to,
cover it appropriately for your members?
Do you see additional
I guess policies is coming down the pipe
or or how do you really manage that?
Yeah. I think we are
helped end handicapped away.
In the M space because we have to
follow Medicare rules.
And so in that regard, if Medicare says,
creates
coverage
determination or local coverage
determination, then those are things that we're obligated
to follow.
In areas where they haven't, then we have
more leeway.
Certainly, those commercial plans,
have the leeway that we don't for M
a.
So for the Gl ones, if the person
has type 2 diabetes,
then they're potentially eligible for for use of
the medication,
I've read where
the Acp and others have recommended that Gl
one's not be used as first line. And
indeed,
in some cases like sema,
it's
in the package labeling that it should not
be used first line for uncontrolled diabetes.
So we do try and make sure there's
just appropriate
utilization of the medication
as for the Mace
application then
we're going to look to see if the
member
meets the age requirement, which is easy over
18,
that they have established
cardiovascular
disease. So they must have already had a
heart attack or a stroke or have symptomatic
Pad.
In order to qualify,
obesity also,
a requirement,
and
then the soft criteria is that the medication
has be used along with diet and exercise.
That's sort of a given and not really
something we focus a lot of attention on.
What we do see are a lot of
requests for people who meet the age and
obesity criteria, but they don't have established cardiovascular
disease already.
Whether Medicare will
seek statutory
relief
from congress and get
approval to use this class of medications for
weight losses yet to be seen. But I
think that decision is gonna have to be
based also
upon what
compensatory
measures Medicare will take to try and balance
the budget.
That's great insight. Thank you so much, Doctor.
Weather for walking us through that. Now I'm
wondering, you know, as you look ahead, how
are you thinking about growth for a future
on the health plan side. What really will
growth hinge on and how do you, you
know,
put yourself in the best position for success?
Atrial is a small plan and regionally based
there in the Pacific Northwest. And so
we've grown through establish
relationships with the providers with brokers with the
members
and
tend to establish
local care centers and the communities where we
offer coverage.
It's not unusual for our members to walk
into those service centers and
have questions
answered, they could pay premium if such as
required,
but really be just a part of our
world.
We hold classes in some of the community
centers and try and make it a place
where where folks feel comfortable and feel valued.
And that's worked for us,
in the last annual enrollment period we grew
by a, just about 30 percent year over
year.
And I think that speaks to the value
that members are finding in that type of
relationship.
I think the other factor that we would
look at is A number of larger multi
state plans,
united,
being 1,
are starting to pull out of communities where
they find it more difficult to
compete and where their margins may be smaller.
So what's challenging for them? I think creates
an opportunity for us.
That... That's really helpful to know and understand
it impressive growth. 30 sent here year over
year.
I remember is really something significant.
You know, when you have that kind of
place in the market where, you know, your
you're
smaller but growing.
How do you navigate some of that expansion?
How do you really make sure that you're
set up to accommodate for that additional membership
and and then looking, you know, do you
anticipate there'll be continued rate of growth along
those clients or how do you see the
next 2 5 years going?
Oh, part of our strategy has been to
grow
in partnership with delegated
entities.
So,
p 3 health partners, which is based in
Nevada,
is 1 of our largest partners.
We have additional partnerships in Nevada with Saint.
Mary's and Prime care.
And with Cascade,
community care, for Ccc
in Climate falls in in Oregon,
And these are entities which take risk on,
large segments of our population.
So,
as we grow, we grow in in
coordination with them,
plan alongside them for what additional resources will
be needed.
And and that that's been a big part
of
the work that we've done here in the
past 2 years and I anticipate that continuing
as we go forward.
Right now, the plan holds risk really on
just a small portion of the membership, you
know, perhaps just
fewer than 10 percent of the members are,
does the plan hold risk in So the
rest of it is really just delegated to
those
partners that we work with.
But as we look to grow then the
same opportunity comes forward, who wants to grow
with us and are those same partners
going to be part of that expansion or
do we need to
look to new partners in different areas?
This was the first year that Atrial moved
into the Portland marketplace.
And
and that's 1 of the areas where the
plan continues to hold risk.
We don't have a risk sharing partner there
yet, but that's something we're exploring.
Got it. That's helpful to know and, you
know, just really a fascinating to think about
how the evolution of the healthcare space
is really driving
where,
health care delivery is headed. Now before we
wrap up here, could you tell me a
little bit more about a project or initiative
from the last year that really yielded great
results?
Definitely.
Like many plans we're
dipping a tool to the world of Ai
informed tools
and we had a pilot project last year
with the company called health at scale,
which
brought in a fraud waste and abuse
Ai informed tool that we implemented
in this segment of the patient
population
this was new for them because they'd had
commercial clients, but not M A clients before,
and it took adjusting the algorithm that they
use so that it was in alignment with,
Medicare rules
such as
national coverage
determinations and local coverage
determinations.
And less reliant on their own internal algorithms,
but working in concert, we found that we
were able to identify an additional 2 percent
and total medical expense, which was modi quantifiable
or actionable.
Most of that was
over
utilization that hadn't been identified by our usual
tools that we were,
employing
in some cases, un instant,
diagnoses
or services,
not supported by the medical record.
And I think this is important because most
health plans hours included
have
remarkably slim margins
And
if you're able to find an extra 2
or 3 percent in medical expense, which you're
able to reduce, it can be quite substantial.
And impactful for the health plan.
So we're excited about what we've learned from
there
looking at how we can expand
those services across the rest of our
member
population
and also look at other new tools which
are coming to market, which might have
similar advantages.
Got it. That's really helpful to know and
and really great results again here. I I
think it's it's definitely
makes a lot of sense to really focus
in on the areas where, you know, you
can make the biggest impact, and
I I really appreciate you calling that to
attention here. Doctor Weather. Thank you so much
for joining us on the podcast today. This
has been a really fantastic interview, and I
look forward to connecting to you again soon.
Laura, Thanks very much.