Hello, everyone. This is Jacob Emerson with the
Becker's Payer Issues podcast. Thrilled today to be
joined by Chris Gay, who's the CEO of
EveryHealth.
Chris, thanks so much for taking the time
to be with me on the podcast today.
Well, thank you, Jacob. Thanks for having me.
Yeah. Absolutely. And before we dive into everything
we wanna talk to you about, Chris, can
you tell us a little bit more about
yourself, your background in terms of your career,
and what it is that you're doing today
at EveryHealth?
Oh, goodness.
Well, what I'm doing today at Every Health,
I'm the CEO.
I used to have beautiful long flowing hair
in a ponytail. Now I'm bald, which tells
you what responsibility does to a man.
I enjoy my role, and most of my
time though is really spent,
overseeing,
community and just kinda pushing us forward in
population health.
I'm a serial entrepreneur,
and
I I came to health care by way
of personal experience.
You know, I had friends and family
that had some pretty horrible health care experiences.
And my cofounders and I started this because
we feel that in hindsight, when we looked
at those shared experiences that a little bit
of human attention
or a little bit of money
at the right point in time can change
lives.
The challenge is, Jacob, when you step back
at it all, how do you do that
systemically across the whole nation to be in
the right place at the right time
with a level of trust with someone that
they'll trust you enough to share?
They'll trust you enough to accept help.
That's the hard part.
And it turns out insurers are ideally suited
to affect large population health change because insurers
control the data. They control the technology. They
control a huge portion of the, patient member
experience.
And, they're ideally positioned to work with,
physicians and medical providers,
that want to improve population health. So you
can think of us as a software company
that owns an insurance company.
Understood. Understood. And, you know, we're gonna talk
about something today that is,
gonna going to affect, in theory, a majority
of the American population.
And I'll get into that in just a
second. But just so we set some context
for our audience, Chris,
every health, how many members do you serve
and and what markets are you in today?
Sure. We are a commercial
insurer, so we do large group fully insured.
We only underwrite right now in the state
of Texas. So we're a small insurer with
about 5,000 lives. Okay.
And, we also own our own medical network.
Fantastic. 10,000
provider locations
are directly contracted by us. Fantastic. No. I
appreciate the context there.
So so let's dive into a big announcement
from from the wider insurance industry.
This earlier this week. It was June 23.
Insurers announcing
a series of commitments to what they call
it what they're calling,
streamlining, simplifying, and reducing
prior authorization requirements across commercial Medicare Advantage and
managed Medicaid plans. I just mentioned that's expected
to affect over 250,000,000
Americans,
and and nearly 50 insurers have committed to
this, and that includes EveryHealth.
That includes things like standardized submission processes for
electronic
prior authorizations,
reductions to the overall amount of requirements that
that providers and and, of course, members have
to face, and an easier appeals process among
a few a few other things.
So we are hearing from stakeholders all across
the industry about this.
Some some positive, some negative,
and some, you know, I think just laying
in wait just lying in wait to see
what's gonna come ultimately from this over over
the next few years or so.
But but ultimately, it is being hailed as
a significant step forward for the health care
system. So from your perspective, Chris, what was
the driving force behind the industry's decision
to to coalesce around these major changes? And
how do you think that health plans and
and policy makers
all align to make these reforms,
a reality?
Put me on the hot seat. The
well, I can't speak for some of my
peers in the industry
or AHIP itself. I mean, we're a member
of AHIP. We're signatory
to this announcement.
No. We believe at every that this prior
authorization,
a voluntary commitment
set of standards, it's a step in the
right direction.
Why did it happen?
You know, I think, you know, I'm speaking
personally here.
I think there is
a a large amount of modernization that still
is yet to occur in our industry, broader
industry of healthcare. And there's still opportunities
to improve customer service
and reduce any points of friction or latency.
And I believe the population
has just gotten to the point where their
voices are being heard,
inside,
organizations
and outside as the consuming public, and they
want better
service. And I think that's perfectly understandable.
Yeah. No. Absolutely. And I, you know, I
well, from our perspective, when when we look
at industries being ranked by customer service,
quality right now and expectations,
it is generally the insurance industry that that
falls behind,
you know, like I said, in national rankings.
So it's interesting you say that. This is
a lot of this is coming from that
that customer service expectation from from the wider
public. Call a thing a thing. You know?
It's like, talk about the problem in the
middle of the room. Sure. Reason it is
so challenging for you know, legacy insurers is
they are responsible for a massive amount.
Yeah.
Compliant, medical quality,
and they provide a vital service,
but it's hugely complex.
And they get pulled and, you know, the
big legacy insurers are pulled in 50 different
directions by 50 different state legislators. Sure. Legislatures.
So it is challenging. They're they're not subject
to the same
customer service standards that someone is that checks
into a hotel. Yeah. Very fair. Give them
give them a measure of flexibility. I mean,
they're dealing with life and death stuff, huge
amounts of evidence based literature,
and a lot of complexity that would crush
most businesses.
But
on the flip side, the consuming public doesn't
understand that. Yeah. No. That's a great point.
It just goes,
hey. From my my small point of view,
I feel this wasn't good enough.
And,
you know, the industry has not done a
good job over the past thirty, forty years
of explaining
why population health is necessary,
why what we do is vital,
and that without us,
and the population health, things would be
radically different and not in a positive way.
Sure.
And but the Well You know, there's a
gap there between
reality and what people believe, and that's causing
a lot of frustration.
Yeah. No. Certainly. And I mean, you know,
when people do interact with a company like
yours and and some of the companies on
this list, it is, of course,
some of the most emotional situations of that
they've encountered in their lives. So, of course,
you know, there's there's a lot of emotions
evolved and often misunderstandings.
So your point is well heard.
And let's talk a little bit about that
complexity because
now, let's say over the next eighteen to
twenty four months, you and and the wider
industry are being tasked with making these reforms
or these these promises
actual tangible reality for your members.
So so from every perspective specifically,
what does that actually look like? What are
some of the conversations you're having internally? What
are what's the technical changes that have to
occur for you to meet
these commitments?
Yeah.
You need to take,
you need to get to the point that
doctors or physicians and their patients
get answers
the majority of the time in minutes
while the patient's still in the room with
the physician
rather than days.
That's the goal. You know, my we're like
My goal at Every Health is we wanna
drive prior authorization denials to zero.
Period.
And we're we're really close to achieving that.
The broader industry, the challenge that they're fighting,
and a lot of my peers are dealing
with is
the medical provider industry overwhelmingly still run like
it's 1980.
It's forty percent of the inbound
prior authorization requests are still fax.
And they're not even good faxes, Jacob. They
send them over. It'll be like everything between
both sides of a of a Manila jacket
folder,
a huge stack of paperwork. It'll be skewed
30 degrees. It'll have two different person's handwriting
on it, stamps on it.
And each each state's different with its own
regulated form.
So Yeah. It's quite a challenge. Technolog
you've, you've got to do a lot of
inbound
document cleanup.
It's not just OCR work. You've got to
verify eligibility of the member and the provider,
check the medical codes against the
are those legitimate?
Are those are they submitting for the right
thing? You know, is the billing code match
the procedure code request?
Then you gotta compare it to all the
evidences,
and the if it's not a if it
moves on to a medical evaluation, you've got
to take a look and see if the
the medical information submitted,
matches up with the request and the care
guidelines, which is all evidence based. It is
not a small challenge. And then you gotta
get that back to someone
Yeah. In minutes.
It's a huge lift.
Very doable, but it's a huge lift.
I can't imagine. I can't imagine. And how
are you feeling about the timeline of all
of this? Even just, again, from your company's
perspective, do you feel prepared to to meet
this timeline?
Yes. I mean,
we've built the technology.
We've built software systems that allow us to
do this already. We're already compliant,
with the things that the company can be
compliant with and on these voluntary commitments. We
already do this electronically. We already do it
in real time,
and we're happy to license that software to
our competitors.
You know, we want population health to increase.
Mhmm. And to give you an idea how
well that's working behind the scenes, the industry
average for prior authorization denials
is 25 to 35.
Okay. Every health, our prior authorization denials in
the past calendar year were only 7%.
Wow. And 100% of those were upheld upon
appeal, which means we are following the science.
It's evidence based.
Whereas the industry average for
denials being upheld on appeal is probably closer
to the mid-50s
in terms of percentage like 56% or so,
based upon Kaiser
or, healthcare.gov.
Sure.
So it can be done. Okay. It's just
it's a hard lift. Yeah. Well, and, you
know, it's I I I wanna go back
to what you just mentioned that often on
the provider side of things, and I I
suppose on the insurance side of things as
well,
often the system is operating like it's the
nineteen eighties. But we're, you know, we're obviously
not in the eighties anymore. There's so much
more technology available,
to companies like yours to hopefully make this
a little bit of an easier process.
You know, I know it's a bit of
a simplified question to a very complicated problem.
But,
do you think that new technology
I hate to use the AI buzzword, but
can AI make this,
a much easier lift compared to the past?
Absolutely.
We use AI powered tools
to do,
administrative approvals and administrative denials
and to prepare all the case work to
summarize things for our nurses and doctors.
We never use AI to make a medical
denial or a final medical determination,
about a denial. Sure.
It is really useful. You gotta keep in
mind sometimes we get a stack of paperwork,
sometimes a 130 pages
of medical notes
that can span
entire patient's history.
Sure. They just send us the whole thing
over as a fax. And
nurses and doctors don't wanna spend their time
digging through 130 pages trying to figure out,
hey, what is relevant for this PET scan
request or what's relevant for this knee surgery
request?
AI powered tools do a great job of
quickly summarizing
and tagging what is relevant in in the
medical case so that the nurses and doctors
can work at the top of their license
and get a speedy response back to that
doctor and patient.
And sometimes we found the AI
powered clinical summaries and guideline
checks, evidence based guidelines,
find things that even our nurses and doctors
didn't didn't find. Mhmm. It's a great decision
support tool, and I think we as an
industry should be adopting every technology we can
that improves medical quality and population health. Absolutely.
Point earlier, customer service. Like, let's get this
down to minutes instead of days.
Absolutely. And I can't imagine, you know,
you you were talking earlier about the complexity
of some of these larger organizations that are
signed on to these commitments. I can't imagine
what they're trying to sort through in terms
of, you know, meeting meeting these deadlines.
But I also wanna ask you about some
of the criticism. We've already been hearing from
from providers, from from the trade groups that
represent them,
basically laying out concerns about this, saying that,
you know, we've heard these types of promises
in the past from the industry that really
never came to fruition,
or that, you know, a lot of the
companies
are are publicly traded and that they still
have to meet their commitment to investors,
and and that this will just shift administrative
burdens to other areas.
How would you respond to that? I mean,
how do you think that the success
of these reforms will ultimately be measured?
I think ultimately they can be measured at
the denial rates.
Ultimately, that for me, that's the KPI I
would focus on over the long term, that
a prior authorization denial rate should decline over
time if you're working in partnership with physicians,
providers, making sure that they're submitting it,
the best way the first time,
the quickest way so you can get them
an answer. The the goal is we all
serve the patient.
But I but I understand the criticism.
Some of that, in my opinion, is
misinformation
that people
don't understand that prior auths,
it's not about billing.
You don't make money. At least at EveryHealth,
we don't make money by denying,
prior auths. Prior auths are purely driven about
evidence based care. What is best for a
patient given the scientific medical literature? That's it.
That's the only goal. That's the only criteria.
And then we're independently as industry, all of
us in industry that are part of medical
quality standards like URAC or NCQA,
whichever is is a part of,
we're independently accountable
on our medical quality, and our prior authorizations
are reviewed. And you even have, something called
inter rater reliability.
So anytime
you have a a medical quality review,
independent committee comes in, pulls a statistically random
sample of your your prior auths and your
medical decisions and reviews them.
And, like, the industry standard on that is
anywhere from you you really wanna be above
90%
inter rate of reliability.
In the industry, you can float between 7294%
ballpark.
Okay. We at every health are at a
100%.
And that's our target. I hope we can
maintain it.
But all this to say, I think the
a lot of the pushback
is just misinformation
about what a prior authorization is
and what it's meant to do. Yeah. No.
It's fair. I mean, it's great insight.
It's really interesting.
What else were we missing on this, Chris?
I mean, what have you been hearing the
last few days since this announcement,
that that you
wanna talk about, that you wanna address?
You've you've got the ears of a lot
of other health care leaders, a lot of
other health plan,
leaders out there, listening in. What do you
wanna say to them about,
the next few months and and couple years
to come around this?
I think we have a fantastic opportunity
to address a nationwide
concern.
And our industry
needs to move quickly.
And if we move quickly and it's an
opportunity to address that gap again that we
talked about at the beginning between public perception
and reality, and that our industry just hasn't
done a good job of educating the public
about the necessity and value of what we
do.
If we do this as an industry and
move quickly,
we have more credibility.
Our opportunity to educate the public will be
extended,
and that can
reap huge benefits across the industry and society
if we're seen to be working with providers
to solve real, tangible
human problems
that all of our friends experience around the
dining table.
So, I mean, big picture, that's how I
think of it, Jacob. Sure.
Smaller
picture, you know, the smaller stuff, we have
the technology.
We can do this. It's it it is
the beautiful thing about technology is it scales
to big problems really quickly.
And,
you know, we're already doing it here at
Every Health, and we're happy to
help power all of our peers to do
it themselves.
Fantastic. Well, Chris, I wanna thank you for
taking the time to chat with me
and for sharing your your insights and your
expertise with our audience. We really appreciate it.
Sure.
Thank you very much.
And to our listeners, if you'd like to
listen to more podcasts from Becker's HealthCare, you
can visit beckershospitalreview.com.