1 00:00:00,160 --> 00:00:02,240 Hi, everyone. This is Lucas Voss with Becker's 2 00:00:02,240 --> 00:00:03,919 Healthcare. Thanks so much for tuning in to 3 00:00:03,919 --> 00:00:07,120 the Becker's Healthcare podcast series. Very excited to 4 00:00:07,120 --> 00:00:08,820 talk about today utilization 5 00:00:09,279 --> 00:00:09,779 management 6 00:00:10,240 --> 00:00:11,859 that works, story strategies, 7 00:00:12,160 --> 00:00:13,939 and what's next. 8 00:00:14,294 --> 00:00:17,414 And I'm also very excited to be joined 9 00:00:17,414 --> 00:00:19,835 by Chad Kersting, business development director, 10 00:00:20,135 --> 00:00:23,894 eviCore by Evernorth, and doctor Eric Gracious, national 11 00:00:23,894 --> 00:00:27,755 physician executive also of eviCore by Evernorth. 12 00:00:28,480 --> 00:00:30,719 And it's great to have you both on, 13 00:00:30,719 --> 00:00:32,500 and I wanna start with introductions, 14 00:00:33,200 --> 00:00:34,579 to get us started here. 15 00:00:34,960 --> 00:00:36,979 Doctor Gracious, why don't you kick us off? 16 00:00:37,359 --> 00:00:39,619 Thanks, Lucas, and I appreciate the warm welcome. 17 00:00:39,679 --> 00:00:41,539 As you said, I'm Eric Gracious. I'm 18 00:00:42,185 --> 00:00:44,984 currently national physician executive for medical benefit services 19 00:00:44,984 --> 00:00:47,804 at Epicor by Eber North. I'm a pediatric 20 00:00:47,945 --> 00:00:50,105 hematologist oncologist by background, as well as a 21 00:00:50,105 --> 00:00:51,565 general pediatrician, and 22 00:00:52,024 --> 00:00:53,785 practiced for a number of years before jumping 23 00:00:53,785 --> 00:00:56,344 into the utilization management business about twelve years 24 00:00:56,344 --> 00:00:58,250 ago. And I've worn a number of different 25 00:00:58,250 --> 00:01:00,570 hats over time from patient care to research 26 00:01:00,570 --> 00:01:01,309 to teaching, 27 00:01:01,850 --> 00:01:03,710 and, again, most recently in 28 00:01:04,090 --> 00:01:05,229 utilization management. 29 00:01:05,609 --> 00:01:06,090 And, 30 00:01:06,890 --> 00:01:09,530 it's a complex issue, and I'm looking forward 31 00:01:09,530 --> 00:01:11,229 to digging into it with you today. 32 00:01:11,625 --> 00:01:13,944 Yeah. Absolutely. Excited to have you on. Chad, 33 00:01:13,944 --> 00:01:15,245 we'll kick it over to you. 34 00:01:15,865 --> 00:01:18,505 Thanks. Chad Kersting. I've been with eviCore by 35 00:01:18,505 --> 00:01:19,645 Evernorth for, 36 00:01:20,185 --> 00:01:21,805 going on my tenth year now. 37 00:01:22,265 --> 00:01:24,045 My background is in consumer behavior, 38 00:01:24,600 --> 00:01:27,340 influencing consumer behavior, changing consumer behavior. 39 00:01:27,880 --> 00:01:30,280 And, that is the division I started with 40 00:01:30,280 --> 00:01:32,459 at eviCore and have been able to 41 00:01:33,079 --> 00:01:33,579 expand, 42 00:01:34,120 --> 00:01:36,219 that role and and really, 43 00:01:36,885 --> 00:01:39,144 how can we bring more of that consumerism 44 00:01:39,604 --> 00:01:40,504 and education 45 00:01:40,805 --> 00:01:43,045 and things that eviCore was doing on the 46 00:01:43,045 --> 00:01:43,545 side, 47 00:01:44,405 --> 00:01:46,564 years ago to be more of a focus 48 00:01:46,564 --> 00:01:48,504 and and how can we help people? So 49 00:01:48,724 --> 00:01:51,125 beyond utilization management. So looking forward to having 50 00:01:51,125 --> 00:01:52,265 a conversation today. 51 00:01:52,780 --> 00:01:55,019 Yeah. Absolutely. It's exciting to bring both of 52 00:01:55,019 --> 00:01:57,359 your expertise together for this conversation. 53 00:01:57,979 --> 00:01:59,680 It's it's very it's great opportunity. 54 00:02:00,379 --> 00:02:03,519 And I wanna start with doctor Gratias. Utilization 55 00:02:03,819 --> 00:02:06,305 management, we'll refer to as a as throughout 56 00:02:06,305 --> 00:02:07,745 the conversation just to make it a little 57 00:02:07,745 --> 00:02:10,544 bit shorter here, often gets boiled down to 58 00:02:10,544 --> 00:02:11,444 prior authorization. 59 00:02:12,305 --> 00:02:14,805 What do you see as the most misunderstood 60 00:02:14,944 --> 00:02:15,685 or underappreciated 61 00:02:16,145 --> 00:02:17,764 aspects of today? 62 00:02:19,000 --> 00:02:20,760 Well, Lucas, thanks for the question. You I 63 00:02:20,760 --> 00:02:22,840 mean, you you really nailed it with that 64 00:02:22,840 --> 00:02:24,760 with that lead in. A lot of people 65 00:02:24,760 --> 00:02:25,260 view 66 00:02:25,800 --> 00:02:28,060 utilization management and prior authorization 67 00:02:28,439 --> 00:02:31,020 as the same thing versus interchangeable terms. 68 00:02:31,639 --> 00:02:32,139 And 69 00:02:32,915 --> 00:02:36,354 really, prior authorization is one tool that's used 70 00:02:36,354 --> 00:02:38,055 to manage utilization. So 71 00:02:39,314 --> 00:02:41,415 utilization management is really 72 00:02:41,875 --> 00:02:43,655 simply making sure that 73 00:02:44,115 --> 00:02:45,955 a patient gets all of the health care 74 00:02:45,955 --> 00:02:47,555 that they need and none of the health 75 00:02:47,555 --> 00:02:48,569 care that they don't. 76 00:02:49,050 --> 00:02:51,310 Mhmm. So that includes multiple 77 00:02:52,010 --> 00:02:54,750 multiple different types of utilization management. 78 00:02:55,450 --> 00:02:57,290 The most common is addressing what we would 79 00:02:57,290 --> 00:02:58,430 call over utilization, 80 00:02:59,050 --> 00:03:01,230 which is when patients are receiving 81 00:03:01,855 --> 00:03:03,775 health care services that aren't going to benefit 82 00:03:03,775 --> 00:03:05,235 them in any way at all. 83 00:03:05,775 --> 00:03:06,275 And 84 00:03:06,814 --> 00:03:10,254 prior authorization has historically been used to address 85 00:03:10,254 --> 00:03:10,754 overutilization. 86 00:03:11,694 --> 00:03:12,435 And overutilization 87 00:03:12,895 --> 00:03:15,155 management has gotten the the biggest 88 00:03:15,710 --> 00:03:18,349 component of the attention, which is why the 89 00:03:18,349 --> 00:03:19,250 terms are interchangeable. 90 00:03:19,870 --> 00:03:21,169 But what people don't recognize 91 00:03:21,870 --> 00:03:25,729 is that effective utilization management also addresses misutilization, 92 00:03:26,110 --> 00:03:28,930 meaning that a person needs health care services, 93 00:03:29,069 --> 00:03:31,264 but the the health care services that are 94 00:03:31,264 --> 00:03:33,425 most likely to help them are maybe slightly 95 00:03:33,425 --> 00:03:33,925 different 96 00:03:34,305 --> 00:03:35,844 than the ones that are being proposed. 97 00:03:36,544 --> 00:03:38,944 And so a great example would be someone 98 00:03:38,944 --> 00:03:39,444 who 99 00:03:40,384 --> 00:03:42,164 their physician has ordered a CT 100 00:03:42,465 --> 00:03:44,164 of their head to evaluate, 101 00:03:45,379 --> 00:03:47,140 something like a headache. But when you look 102 00:03:47,140 --> 00:03:48,980 at evidence based medicine and apply it to 103 00:03:48,980 --> 00:03:50,520 that patient for the reasons 104 00:03:51,140 --> 00:03:52,200 that you're looking 105 00:03:52,980 --> 00:03:55,219 at their head and their age and their 106 00:03:55,219 --> 00:03:57,700 other symptoms and things, an MRI would be 107 00:03:57,700 --> 00:04:00,844 a better study. So utilization management will actually 108 00:04:00,905 --> 00:04:02,984 connect with that provider and talk through the 109 00:04:02,984 --> 00:04:05,465 evidence and often result in a change in 110 00:04:05,465 --> 00:04:07,305 plan to that alternate study, which is gonna 111 00:04:07,305 --> 00:04:08,685 be better for the patient. 112 00:04:09,305 --> 00:04:11,384 And then the a bigger component, and, 113 00:04:11,889 --> 00:04:13,169 you know, it's where Chad and I are 114 00:04:13,169 --> 00:04:15,030 gonna spend a little bit more focused today 115 00:04:15,090 --> 00:04:16,150 is on underutilization 116 00:04:17,089 --> 00:04:19,330 and which is also part of utilization management. 117 00:04:19,330 --> 00:04:22,290 And this is something that actually quite a 118 00:04:22,290 --> 00:04:23,589 lot of 119 00:04:24,205 --> 00:04:26,605 people in health care are engaged in, and 120 00:04:26,605 --> 00:04:29,404 that's addressing services that people aren't using as 121 00:04:29,404 --> 00:04:31,725 much as they should. So a really common 122 00:04:31,725 --> 00:04:32,705 example there 123 00:04:34,045 --> 00:04:35,745 would be routine vaccination 124 00:04:36,125 --> 00:04:37,425 or cancer screen 125 00:04:38,509 --> 00:04:39,889 or something that we know 126 00:04:40,269 --> 00:04:41,889 can drive benefits. 127 00:04:42,990 --> 00:04:45,089 But people, for a variety of reasons, 128 00:04:45,629 --> 00:04:47,490 don't use as often as is recommended. 129 00:04:48,189 --> 00:04:51,389 And so a lot of hospitals and physician 130 00:04:51,389 --> 00:04:51,889 groups 131 00:04:52,264 --> 00:04:54,204 are actually involved in this part of utilization 132 00:04:54,264 --> 00:04:57,144 management or the guys of names like gap 133 00:04:57,144 --> 00:04:58,044 and care closure 134 00:04:58,985 --> 00:05:00,125 or care coordination. 135 00:05:00,745 --> 00:05:02,824 And so when you think about utilization management 136 00:05:02,824 --> 00:05:03,564 more holistically, 137 00:05:05,189 --> 00:05:08,089 it really encompasses addressing all of those facets 138 00:05:08,470 --> 00:05:09,850 of inappropriate utilization. 139 00:05:10,470 --> 00:05:12,550 And prior authorization is just one of many 140 00:05:12,550 --> 00:05:15,269 tools we have, which is a workflow processes, 141 00:05:15,269 --> 00:05:16,089 and it involves 142 00:05:16,764 --> 00:05:19,585 getting approval for to proceed with the services 143 00:05:19,884 --> 00:05:20,384 before 144 00:05:21,165 --> 00:05:23,425 leaping in, to the service delivery. 145 00:05:24,365 --> 00:05:26,125 Yeah. And you've touched on this a little 146 00:05:26,125 --> 00:05:27,245 bit, and I wanna come back to it. 147 00:05:27,245 --> 00:05:28,605 This is sort of a a a follow-up 148 00:05:28,605 --> 00:05:30,480 to this as well. So what do we 149 00:05:30,480 --> 00:05:31,759 need to do to shift this? What are 150 00:05:31,759 --> 00:05:33,759 the shifts that are needed to then improve 151 00:05:33,759 --> 00:05:36,339 this process to better serve clinicians and patients? 152 00:05:37,439 --> 00:05:39,600 That's a great that's a great question. So 153 00:05:39,600 --> 00:05:41,939 there's a number of kind of core principles 154 00:05:42,000 --> 00:05:43,600 that that you'll hear about out there in 155 00:05:43,600 --> 00:05:46,295 the world. So one is just broadening understanding. 156 00:05:46,915 --> 00:05:49,314 And when a kid will understand what utilization 157 00:05:49,314 --> 00:05:51,475 is supposed to be and that it is 158 00:05:51,475 --> 00:05:53,895 intended to be a collaborative effort. 159 00:05:54,595 --> 00:05:56,615 And this should be something where 160 00:05:57,279 --> 00:05:59,519 all the involved parties are are shooting for 161 00:05:59,519 --> 00:06:01,360 the same goal, which is the optimal health 162 00:06:01,360 --> 00:06:03,139 for the patient that's under discussion. 163 00:06:04,000 --> 00:06:05,379 I think we need more transparency 164 00:06:06,479 --> 00:06:06,979 around 165 00:06:07,439 --> 00:06:09,040 what the gaps in care are, what the 166 00:06:09,040 --> 00:06:11,360 utilization needs are for this person, and what 167 00:06:11,360 --> 00:06:12,740 are the sources of evidence, 168 00:06:13,814 --> 00:06:15,834 that are that are used and necessary 169 00:06:16,134 --> 00:06:18,074 to to help determine that. 170 00:06:18,535 --> 00:06:20,535 And you can only get there through through 171 00:06:20,535 --> 00:06:22,535 better information sharing. So there's a lot of 172 00:06:22,535 --> 00:06:23,514 efforts around 173 00:06:23,894 --> 00:06:25,115 you hear the word interoperability 174 00:06:25,814 --> 00:06:28,430 out there, which is essentially just a technical 175 00:06:28,430 --> 00:06:30,689 term for being able to more easily share 176 00:06:31,230 --> 00:06:34,509 clinical information or other important information about a 177 00:06:34,509 --> 00:06:35,569 particular patient 178 00:06:35,949 --> 00:06:38,350 through electronic means and more in real time. 179 00:06:38,350 --> 00:06:40,370 So there's not this back and forth of 180 00:06:40,685 --> 00:06:42,464 phone calls and faxes and 181 00:06:43,085 --> 00:06:44,685 and other things. And then, you know, the 182 00:06:44,685 --> 00:06:46,444 the most meaningful thing that we could do 183 00:06:46,444 --> 00:06:48,145 to really shift that focus 184 00:06:48,605 --> 00:06:50,064 would be to move the workflow 185 00:06:51,085 --> 00:06:51,985 further upstream 186 00:06:52,845 --> 00:06:53,165 so that 187 00:06:53,959 --> 00:06:55,480 you know, right now, a lot of utilization 188 00:06:55,480 --> 00:06:58,360 management processes come in after a physician and 189 00:06:58,360 --> 00:07:00,379 a patient have discussed a course of action 190 00:07:00,600 --> 00:07:02,439 and come to a decision on how they 191 00:07:02,439 --> 00:07:03,580 wanna move forward 192 00:07:04,199 --> 00:07:06,759 with sometimes without the the benefit of some 193 00:07:06,759 --> 00:07:08,060 of those evidence based 194 00:07:08,834 --> 00:07:11,154 guidelines being necessary at the point of care 195 00:07:11,154 --> 00:07:13,394 when that decision is being made. So when 196 00:07:13,394 --> 00:07:15,975 you start your workflow after that that thoughtful 197 00:07:16,035 --> 00:07:17,175 process has occurred, 198 00:07:17,714 --> 00:07:19,314 you've got an entity who's already a little 199 00:07:19,314 --> 00:07:20,995 bit on the defensive because they feel like 200 00:07:20,995 --> 00:07:22,834 they're defending a decision they've already come to 201 00:07:22,834 --> 00:07:23,654 in good faith. 202 00:07:24,079 --> 00:07:25,680 And if we could be further upstream and 203 00:07:25,680 --> 00:07:27,680 we were be a technical integration into the 204 00:07:27,680 --> 00:07:28,180 workflow, 205 00:07:29,519 --> 00:07:31,139 of that electronic health record, 206 00:07:31,680 --> 00:07:33,759 you know, and those decision aids around some 207 00:07:33,759 --> 00:07:35,759 of the evidence were there in EHR at 208 00:07:35,759 --> 00:07:37,680 the point of care, and we're enabling some 209 00:07:37,680 --> 00:07:38,500 of those discussions 210 00:07:39,545 --> 00:07:41,165 between the physician and the patient. 211 00:07:41,705 --> 00:07:43,865 The combination of that transparency and that technical 212 00:07:43,865 --> 00:07:45,485 integration of being further upstream. 213 00:07:45,865 --> 00:07:48,185 If we could somehow, you know, accomplish those 214 00:07:48,185 --> 00:07:50,685 at scale overnight, the whole discussion around utilization 215 00:07:50,904 --> 00:07:52,045 management would change. 216 00:07:52,470 --> 00:07:54,470 You know, we've certainly seen that in pockets 217 00:07:54,470 --> 00:07:56,490 where we've had, you know, one off opportunities 218 00:07:56,629 --> 00:07:58,009 to connect at that level, 219 00:07:58,550 --> 00:08:00,410 with folks that does change the conversation. 220 00:08:01,350 --> 00:08:03,269 And all of a sudden, this process is 221 00:08:03,269 --> 00:08:05,689 viewed as a support rather than a barrier. 222 00:08:06,504 --> 00:08:08,845 Yeah. It's a more active a more proactive 223 00:08:09,064 --> 00:08:11,704 approach really moving from reactive to proactive, which 224 00:08:11,704 --> 00:08:13,004 I think is so key. 225 00:08:13,384 --> 00:08:15,805 You've touched a little bit on underutilization 226 00:08:16,425 --> 00:08:18,024 as sort of one of the primary pieces, 227 00:08:18,024 --> 00:08:19,949 and you've mentioned an example there. And I 228 00:08:19,949 --> 00:08:21,470 wanted to come back to that. So this 229 00:08:21,470 --> 00:08:24,189 is, of course, talking about members not accessing 230 00:08:24,189 --> 00:08:25,329 the care they need. 231 00:08:25,870 --> 00:08:27,709 Can you walk us through an example where 232 00:08:27,709 --> 00:08:30,430 that was effectively addressed and changed and and 233 00:08:30,430 --> 00:08:31,169 what organizations 234 00:08:31,470 --> 00:08:32,529 should really take 235 00:08:32,830 --> 00:08:33,889 away from it? 236 00:08:34,634 --> 00:08:36,154 Well, sure. So I'll give you one where 237 00:08:36,154 --> 00:08:38,315 we we leveraged one of our own workflows. 238 00:08:38,315 --> 00:08:40,334 And and and again, Chad will go 239 00:08:40,794 --> 00:08:42,714 into some of this as well. But, you 240 00:08:42,714 --> 00:08:44,574 know, we have one of our underutilization 241 00:08:45,034 --> 00:08:48,254 programs involves closing gaps in cancer screening, 242 00:08:48,990 --> 00:08:50,029 where we have, 243 00:08:50,429 --> 00:08:52,450 patients that we know are overdue 244 00:08:53,470 --> 00:08:53,970 for 245 00:08:54,350 --> 00:08:56,529 their breast cancer screening like mammography. 246 00:08:57,470 --> 00:08:57,970 And 247 00:08:58,429 --> 00:09:00,429 we have, we have the ability to monitor, 248 00:09:01,634 --> 00:09:03,815 our overall systems. When we when we receive 249 00:09:04,435 --> 00:09:08,195 a prior authorization request, for example, or again, 250 00:09:08,195 --> 00:09:10,855 Louxter radiology is an example of radiology study, 251 00:09:11,315 --> 00:09:14,035 and that comes in as we're about to 252 00:09:14,035 --> 00:09:15,815 issue an approval for that study, 253 00:09:16,320 --> 00:09:18,559 the system will run a query and say, 254 00:09:18,559 --> 00:09:19,920 oh, this patient is on our list of 255 00:09:19,920 --> 00:09:22,080 people who are overdue for our mammography. And 256 00:09:22,080 --> 00:09:24,160 that outreach call will be transferred from our 257 00:09:24,160 --> 00:09:26,879 normal outreach unit to our preventive care team 258 00:09:26,879 --> 00:09:28,259 who will call that person 259 00:09:28,784 --> 00:09:31,184 and say, hey. We've just wanna let you 260 00:09:31,184 --> 00:09:33,024 know that your your MRI has been approved, 261 00:09:33,024 --> 00:09:34,625 and I hope your hope your shoulder feels 262 00:09:34,625 --> 00:09:37,024 better and everything goes well with that. But, 263 00:09:37,024 --> 00:09:38,304 hey. While while I got you on the 264 00:09:38,304 --> 00:09:40,704 phone, it looks like you're overdue for your 265 00:09:40,704 --> 00:09:41,204 mammography. 266 00:09:41,584 --> 00:09:42,660 You know? And I know you're in your 267 00:09:42,660 --> 00:09:44,820 shoulder taken care of right now, but certainly 268 00:09:44,820 --> 00:09:46,019 while we got you here, is there anything 269 00:09:46,019 --> 00:09:47,460 we can do to kinda help you get 270 00:09:47,460 --> 00:09:49,000 that closed? And 271 00:09:49,620 --> 00:09:51,860 and, you know, and then the person can 272 00:09:51,860 --> 00:09:53,059 say, well, you know, gosh. I have. I've 273 00:09:53,059 --> 00:09:54,519 just been so busy, and 274 00:09:54,875 --> 00:09:57,115 and we're able to leverage, the network of 275 00:09:57,115 --> 00:09:57,615 radiology 276 00:09:58,154 --> 00:10:00,235 facilities in their area. We can go ahead 277 00:10:00,235 --> 00:10:02,095 and get the study scheduled for them. 278 00:10:02,634 --> 00:10:03,995 Then we stay with them and follow-up to 279 00:10:03,995 --> 00:10:05,195 make sure that it was done and they 280 00:10:05,195 --> 00:10:06,954 got their results. If there was follow-up care, 281 00:10:06,954 --> 00:10:08,414 we help connect them to that. 282 00:10:08,720 --> 00:10:11,040 And just by kind of leveraging that existing 283 00:10:11,040 --> 00:10:11,540 connection, 284 00:10:12,160 --> 00:10:13,920 we already had where the the person was 285 00:10:13,920 --> 00:10:15,679 already expecting to hear from us and then 286 00:10:15,679 --> 00:10:18,240 taking advantage of that moment where we've got 287 00:10:18,240 --> 00:10:20,000 them engaged on the phone just to try 288 00:10:20,000 --> 00:10:21,279 to see what else we can do to 289 00:10:21,279 --> 00:10:24,179 help help them, you know, navigate their care 290 00:10:24,514 --> 00:10:26,274 and taking the time to actually solve it 291 00:10:26,274 --> 00:10:27,735 for them in the first call. 292 00:10:28,355 --> 00:10:30,514 That's an example that we we were helped 293 00:10:30,514 --> 00:10:32,034 to close a gap in care for that 294 00:10:32,034 --> 00:10:33,014 for that woman, 295 00:10:33,554 --> 00:10:35,014 and that wouldn't have existed 296 00:10:35,475 --> 00:10:37,475 if there wasn't a prior authorization process in 297 00:10:37,475 --> 00:10:38,370 place for her. 298 00:10:39,089 --> 00:10:41,649 So the change that really made a difference 299 00:10:41,649 --> 00:10:43,809 here, you've touched on it before too, was 300 00:10:43,809 --> 00:10:46,950 the shift to that more proactive approach. Correct? 301 00:10:47,730 --> 00:10:49,830 Correct. It was the it was the combination 302 00:10:49,970 --> 00:10:51,029 of being proactive. 303 00:10:51,490 --> 00:10:53,284 It was just taking the time to stay 304 00:10:53,284 --> 00:10:54,485 on the call with her and take the 305 00:10:54,485 --> 00:10:57,125 extra time to, you know, check her, check 306 00:10:57,125 --> 00:10:58,804 where she lived and see who was available 307 00:10:58,804 --> 00:11:00,245 and talk to her about her calendar and 308 00:11:00,245 --> 00:11:01,225 get it all scheduled. 309 00:11:01,684 --> 00:11:03,544 But, also, I think piggybacking 310 00:11:03,924 --> 00:11:04,424 on 311 00:11:05,159 --> 00:11:08,279 a communication channel they were expecting to engage 312 00:11:08,279 --> 00:11:10,839 with, which is where we have more success 313 00:11:10,839 --> 00:11:12,759 than a historic approach of a more of 314 00:11:12,759 --> 00:11:13,659 a cold call. 315 00:11:14,039 --> 00:11:15,659 Because, you know, we we've all been, 316 00:11:16,200 --> 00:11:18,794 you know, bombarded by robocalls and spans and 317 00:11:18,794 --> 00:11:20,715 other things. So peep you know, you know, 318 00:11:20,715 --> 00:11:21,914 a lot of people just don't pick up 319 00:11:21,914 --> 00:11:23,434 the phone and answer when they get a 320 00:11:23,434 --> 00:11:25,534 call from a random number they're not expecting. 321 00:11:25,914 --> 00:11:27,774 So I think it's the hook of being 322 00:11:28,075 --> 00:11:30,955 leveraging that communication that we we already have 323 00:11:30,955 --> 00:11:32,639 in place with them and then taking the 324 00:11:32,639 --> 00:11:34,559 extra time while we've got them and using 325 00:11:34,559 --> 00:11:36,820 that moment to help move their care forward. 326 00:11:37,360 --> 00:11:38,179 Yeah. Absolutely. 327 00:11:38,559 --> 00:11:40,000 Chad, this is where I wanna bring you 328 00:11:40,000 --> 00:11:41,299 in and and your expertise 329 00:11:42,000 --> 00:11:43,940 specifically around the consumer, 330 00:11:44,320 --> 00:11:46,934 as well. We talked about the proactivity, and 331 00:11:47,014 --> 00:11:48,934 there is, you know, an increased focus on 332 00:11:48,934 --> 00:11:51,975 maintaining health through preventative and proactive care. We 333 00:11:51,975 --> 00:11:54,794 certainly know that as opposed to just treating. 334 00:11:55,414 --> 00:11:57,434 How is that shift playing out within 335 00:11:57,975 --> 00:12:00,040 and what's enabling it, and and what are 336 00:12:00,040 --> 00:12:02,440 you seeing in terms of scalability across US 337 00:12:02,440 --> 00:12:04,299 Health Care? What does it look like? 338 00:12:05,240 --> 00:12:05,740 So, 339 00:12:06,040 --> 00:12:08,040 you know, I think that doctor Graces brings 340 00:12:08,040 --> 00:12:10,279 up, you know, points out one thing that 341 00:12:10,279 --> 00:12:12,044 we do really well or and sort of 342 00:12:12,284 --> 00:12:14,704 changed that that thought process of 343 00:12:15,004 --> 00:12:17,164 is just being yes or no, but being 344 00:12:17,164 --> 00:12:18,225 a little more collaborative. 345 00:12:18,924 --> 00:12:21,105 But but really, it's it's bringing that patient 346 00:12:21,164 --> 00:12:22,784 into the conversation and 347 00:12:23,325 --> 00:12:25,440 and understanding what's going on with that person, 348 00:12:25,600 --> 00:12:27,840 having that conversation with that person to identify 349 00:12:27,840 --> 00:12:28,419 the barrier. 350 00:12:29,039 --> 00:12:31,840 And utilization management really allows us to do 351 00:12:31,840 --> 00:12:35,759 that at a much higher touch point or 352 00:12:35,759 --> 00:12:37,759 contact level than we would be able to 353 00:12:37,759 --> 00:12:39,120 do if we didn't have it and what 354 00:12:39,120 --> 00:12:41,455 most other vendors and health plans have the 355 00:12:41,455 --> 00:12:43,375 issues with, and that is the contact. You 356 00:12:43,375 --> 00:12:44,274 know, doctor Gracious 357 00:12:45,054 --> 00:12:47,315 touched on it, and that is if someone's 358 00:12:47,375 --> 00:12:49,294 expecting they go to the doctor, the doctor 359 00:12:49,294 --> 00:12:51,714 says you're gonna need to have an MRI 360 00:12:51,855 --> 00:12:53,875 or or a CT scan on your knee. 361 00:12:54,095 --> 00:12:55,855 They've told them they need an authorization. So 362 00:12:55,855 --> 00:12:57,529 now that person knows, 363 00:12:58,149 --> 00:12:59,829 that that's the next step. So when their 364 00:12:59,829 --> 00:13:02,070 health plan shows up on the caller ID 365 00:13:02,070 --> 00:13:02,970 an hour later, 366 00:13:03,350 --> 00:13:05,350 they answer the phone. Or when we text, 367 00:13:05,350 --> 00:13:06,629 let them know we have an update about 368 00:13:06,629 --> 00:13:08,870 that authorization that drives that inbound phone call. 369 00:13:08,870 --> 00:13:10,250 So that interaction, 370 00:13:10,884 --> 00:13:13,144 interaction with the patients and and 371 00:13:13,924 --> 00:13:16,664 really treating them like a like a person, 372 00:13:17,044 --> 00:13:19,044 I think is what what's what's a little 373 00:13:19,044 --> 00:13:21,225 different than what you when you think about 374 00:13:21,284 --> 00:13:23,125 in the past. And and having that under, 375 00:13:23,284 --> 00:13:24,419 that it's that 376 00:13:24,740 --> 00:13:27,320 conversation to understand what's going on with them 377 00:13:27,620 --> 00:13:28,659 allows us to, 378 00:13:29,220 --> 00:13:31,860 uncover what that barrier might be, how how 379 00:13:31,860 --> 00:13:32,839 they've been affected, 380 00:13:33,220 --> 00:13:35,299 whether it's they can't take time off work 381 00:13:35,299 --> 00:13:37,059 to get certain things done, to go to 382 00:13:37,059 --> 00:13:38,839 their wellness visit or get their mammogram, 383 00:13:39,544 --> 00:13:41,384 or they're waiting two months to see their 384 00:13:41,384 --> 00:13:42,524 PCP because, 385 00:13:43,144 --> 00:13:44,985 primary care physicians are in a shortage and 386 00:13:44,985 --> 00:13:47,245 they didn't know they had virtual benefits. So 387 00:13:47,464 --> 00:13:49,404 just overcoming that health care illiteracy. 388 00:13:50,184 --> 00:13:52,519 And where I see this playing out in 389 00:13:52,519 --> 00:13:54,759 health care is especially as we get more 390 00:13:54,759 --> 00:13:55,659 virtual offerings, 391 00:13:56,600 --> 00:13:59,639 as we make it easier to interact with 392 00:13:59,639 --> 00:14:01,019 patients and customers 393 00:14:01,559 --> 00:14:02,299 and members 394 00:14:02,679 --> 00:14:03,740 via either 395 00:14:04,074 --> 00:14:06,154 some of those apps that are out there 396 00:14:06,154 --> 00:14:07,595 where we're able to have those two way 397 00:14:07,595 --> 00:14:10,634 conversations or or two way text conversations that 398 00:14:10,634 --> 00:14:12,235 that we utilize. But I think you'll see 399 00:14:12,235 --> 00:14:15,134 it utilized more and more as, 400 00:14:16,394 --> 00:14:18,714 utilizing that that capability more and more of 401 00:14:18,714 --> 00:14:21,009 actually interacting with the person to understand what's 402 00:14:21,009 --> 00:14:23,330 going on in their lives more than just 403 00:14:23,330 --> 00:14:24,149 case management, 404 00:14:25,170 --> 00:14:26,769 I think is what's different and where where 405 00:14:26,769 --> 00:14:27,429 we're headed. 406 00:14:28,210 --> 00:14:29,730 Yeah. And I think it speaks to the 407 00:14:29,730 --> 00:14:32,230 fact that, again, we're looking for personalized experiences, 408 00:14:32,529 --> 00:14:34,485 right, in our day to day lives. We're 409 00:14:34,485 --> 00:14:36,424 looking for that support that's customized 410 00:14:36,804 --> 00:14:39,464 to us, more of that consumer experience. 411 00:14:40,325 --> 00:14:41,845 I'm really curious to see you've touched on 412 00:14:41,845 --> 00:14:43,445 this a little bit. How do you see 413 00:14:43,445 --> 00:14:45,684 this trend evolve over the next five year? 414 00:14:45,684 --> 00:14:47,764 What's going to happen here, especially when you're 415 00:14:47,764 --> 00:14:48,825 looking at at 416 00:14:50,019 --> 00:14:50,980 I mean, I think one of the things 417 00:14:50,980 --> 00:14:53,059 that we've already started to do, and, again, 418 00:14:53,059 --> 00:14:55,779 doctor Gracious touched on it, earlier, and that 419 00:14:55,779 --> 00:14:58,440 is, that that person comes in or enters 420 00:14:58,500 --> 00:14:59,720 a health care journey. 421 00:15:00,179 --> 00:15:02,179 Knowing what else that person is due for 422 00:15:02,179 --> 00:15:03,860 or what else is going on in that 423 00:15:03,860 --> 00:15:04,695 person's life 424 00:15:05,575 --> 00:15:07,975 as EMRs get more and more connected or 425 00:15:07,975 --> 00:15:08,475 as 426 00:15:09,014 --> 00:15:11,174 even, we're able to collect more of the 427 00:15:11,174 --> 00:15:13,115 results from the scams to know, 428 00:15:13,654 --> 00:15:15,414 what were the results. And then being able 429 00:15:15,414 --> 00:15:17,754 to pair that up with either other authorizations 430 00:15:18,134 --> 00:15:19,035 that we've done 431 00:15:19,379 --> 00:15:20,679 or if it's Evernorth 432 00:15:21,059 --> 00:15:23,460 and ESI, what drugs are they on? And 433 00:15:23,460 --> 00:15:24,440 we get a cardiovascular 434 00:15:24,820 --> 00:15:27,059 request come in, and we can see they're 435 00:15:27,059 --> 00:15:29,540 taking this drug, just this drug, this drug, 436 00:15:29,540 --> 00:15:31,540 and this drug. They've had this pre auth 437 00:15:31,540 --> 00:15:33,779 pre auth and pre auth. Now they're asking 438 00:15:33,779 --> 00:15:36,674 for this. Where is this person headed? What 439 00:15:36,674 --> 00:15:39,014 does this person look like five years ago? 440 00:15:39,154 --> 00:15:40,754 What do they look like now? And being 441 00:15:40,754 --> 00:15:43,975 able to predict that and address certain things 442 00:15:44,595 --> 00:15:46,595 ahead of time, or are they working with 443 00:15:46,595 --> 00:15:48,514 the right providers? Are they you know, what 444 00:15:48,514 --> 00:15:51,019 vendors are out there, either the services that 445 00:15:51,019 --> 00:15:51,759 we offer? 446 00:15:52,139 --> 00:15:54,379 By looking at the data and seeing what's 447 00:15:54,379 --> 00:15:56,539 going on with that patient, are they working 448 00:15:56,539 --> 00:15:58,940 with the the the right groups in the 449 00:15:59,259 --> 00:16:01,519 to to effectively treat their condition? 450 00:16:02,220 --> 00:16:04,799 And being able to provide clinical decision support 451 00:16:05,034 --> 00:16:07,514 to their providers and and looking at things 452 00:16:07,514 --> 00:16:08,014 holistically. 453 00:16:08,634 --> 00:16:11,534 Because you sort of pointed out earlier that 454 00:16:11,674 --> 00:16:13,375 we are in the business historically 455 00:16:14,235 --> 00:16:15,375 of treating illness. 456 00:16:16,154 --> 00:16:18,075 People enter the health care system when they're 457 00:16:18,075 --> 00:16:18,815 already sick. 458 00:16:19,259 --> 00:16:20,860 But if we have the data on that 459 00:16:20,860 --> 00:16:21,360 person, 460 00:16:21,820 --> 00:16:25,100 we can pretty accurately predict what's coming next 461 00:16:25,100 --> 00:16:27,259 for them. And being able to do that 462 00:16:27,259 --> 00:16:28,000 at scale 463 00:16:28,460 --> 00:16:29,840 across our book of business, 464 00:16:30,460 --> 00:16:32,559 that is something that isn't very far off. 465 00:16:33,184 --> 00:16:34,164 Yeah. Absolutely. 466 00:16:35,264 --> 00:16:37,345 Chad and doctor Gracious, I wanna thank you 467 00:16:37,345 --> 00:16:39,424 both for your insights and time today. This 468 00:16:39,424 --> 00:16:42,004 is a fantastic conversation. It sounds like proactivity 469 00:16:42,144 --> 00:16:44,404 is the name of the game, which is 470 00:16:44,465 --> 00:16:45,445 very, very important. 471 00:16:45,819 --> 00:16:47,980 We also want to thank our podcast sponsor, 472 00:16:47,980 --> 00:16:50,299 eviCore by Evanorth, and you could tune in 473 00:16:50,299 --> 00:16:52,220 to more podcasts from Becker's Health Care by 474 00:16:52,220 --> 00:16:56,480 visiting our podcast page at beckershospitalreview.com.