1 00:00:00,160 --> 00:00:02,240 Hello, everyone. This is Jacob Emerson with the 2 00:00:02,240 --> 00:00:05,200 Becker's Payer Issues podcast. Thrilled today to be 3 00:00:05,200 --> 00:00:07,919 joined by Chris Gay, who's the CEO of 4 00:00:07,919 --> 00:00:08,419 EveryHealth. 5 00:00:08,800 --> 00:00:10,880 Chris, thanks so much for taking the time 6 00:00:10,880 --> 00:00:12,660 to be with me on the podcast today. 7 00:00:12,904 --> 00:00:14,824 Well, thank you, Jacob. Thanks for having me. 8 00:00:14,824 --> 00:00:16,904 Yeah. Absolutely. And before we dive into everything 9 00:00:16,904 --> 00:00:18,265 we wanna talk to you about, Chris, can 10 00:00:18,265 --> 00:00:19,785 you tell us a little bit more about 11 00:00:19,785 --> 00:00:22,605 yourself, your background in terms of your career, 12 00:00:22,744 --> 00:00:24,425 and what it is that you're doing today 13 00:00:24,425 --> 00:00:25,164 at EveryHealth? 14 00:00:26,449 --> 00:00:27,109 Oh, goodness. 15 00:00:27,570 --> 00:00:29,410 Well, what I'm doing today at Every Health, 16 00:00:29,410 --> 00:00:30,309 I'm the CEO. 17 00:00:31,570 --> 00:00:33,409 I used to have beautiful long flowing hair 18 00:00:33,409 --> 00:00:35,729 in a ponytail. Now I'm bald, which tells 19 00:00:35,729 --> 00:00:37,909 you what responsibility does to a man. 20 00:00:38,774 --> 00:00:41,015 I enjoy my role, and most of my 21 00:00:41,015 --> 00:00:42,475 time though is really spent, 22 00:00:43,255 --> 00:00:43,755 overseeing, 23 00:00:44,534 --> 00:00:46,695 community and just kinda pushing us forward in 24 00:00:46,695 --> 00:00:47,674 population health. 25 00:00:49,015 --> 00:00:50,234 I'm a serial entrepreneur, 26 00:00:50,929 --> 00:00:51,429 and 27 00:00:51,890 --> 00:00:53,810 I I came to health care by way 28 00:00:53,810 --> 00:00:55,429 of personal experience. 29 00:00:57,649 --> 00:00:59,190 You know, I had friends and family 30 00:01:00,450 --> 00:01:02,549 that had some pretty horrible health care experiences. 31 00:01:03,854 --> 00:01:06,194 And my cofounders and I started this because 32 00:01:06,334 --> 00:01:08,174 we feel that in hindsight, when we looked 33 00:01:08,174 --> 00:01:10,495 at those shared experiences that a little bit 34 00:01:10,495 --> 00:01:11,474 of human attention 35 00:01:12,495 --> 00:01:13,875 or a little bit of money 36 00:01:14,734 --> 00:01:16,495 at the right point in time can change 37 00:01:16,495 --> 00:01:16,995 lives. 38 00:01:18,729 --> 00:01:20,890 The challenge is, Jacob, when you step back 39 00:01:20,890 --> 00:01:22,009 at it all, how do you do that 40 00:01:22,009 --> 00:01:24,090 systemically across the whole nation to be in 41 00:01:24,090 --> 00:01:26,269 the right place at the right time 42 00:01:26,729 --> 00:01:29,129 with a level of trust with someone that 43 00:01:29,129 --> 00:01:30,989 they'll trust you enough to share? 44 00:01:32,444 --> 00:01:35,185 They'll trust you enough to accept help. 45 00:01:35,724 --> 00:01:36,864 That's the hard part. 46 00:01:38,125 --> 00:01:40,204 And it turns out insurers are ideally suited 47 00:01:40,204 --> 00:01:43,084 to affect large population health change because insurers 48 00:01:43,084 --> 00:01:46,289 control the data. They control the technology. They 49 00:01:46,289 --> 00:01:48,930 control a huge portion of the, patient member 50 00:01:48,930 --> 00:01:49,430 experience. 51 00:01:50,369 --> 00:01:52,869 And, they're ideally positioned to work with, 52 00:01:53,489 --> 00:01:54,950 physicians and medical providers, 53 00:01:55,250 --> 00:01:57,734 that want to improve population health. So you 54 00:01:57,895 --> 00:01:59,415 can think of us as a software company 55 00:01:59,415 --> 00:02:00,875 that owns an insurance company. 56 00:02:02,534 --> 00:02:05,254 Understood. Understood. And, you know, we're gonna talk 57 00:02:05,254 --> 00:02:06,795 about something today that is, 58 00:02:07,174 --> 00:02:09,754 gonna going to affect, in theory, a majority 59 00:02:09,974 --> 00:02:11,435 of the American population. 60 00:02:11,949 --> 00:02:13,150 And I'll get into that in just a 61 00:02:13,150 --> 00:02:15,310 second. But just so we set some context 62 00:02:15,310 --> 00:02:16,449 for our audience, Chris, 63 00:02:16,909 --> 00:02:19,069 every health, how many members do you serve 64 00:02:19,069 --> 00:02:21,250 and and what markets are you in today? 65 00:02:21,870 --> 00:02:23,650 Sure. We are a commercial 66 00:02:24,455 --> 00:02:26,715 insurer, so we do large group fully insured. 67 00:02:28,215 --> 00:02:29,894 We only underwrite right now in the state 68 00:02:29,894 --> 00:02:32,134 of Texas. So we're a small insurer with 69 00:02:32,134 --> 00:02:34,155 about 5,000 lives. Okay. 70 00:02:34,534 --> 00:02:36,634 And, we also own our own medical network. 71 00:02:37,329 --> 00:02:38,849 Fantastic. 10,000 72 00:02:38,849 --> 00:02:39,909 provider locations 73 00:02:40,289 --> 00:02:43,169 are directly contracted by us. Fantastic. No. I 74 00:02:43,169 --> 00:02:44,469 appreciate the context there. 75 00:02:45,329 --> 00:02:47,750 So so let's dive into a big announcement 76 00:02:47,969 --> 00:02:50,549 from from the wider insurance industry. 77 00:02:50,965 --> 00:02:53,305 This earlier this week. It was June 23. 78 00:02:54,324 --> 00:02:55,465 Insurers announcing 79 00:02:55,764 --> 00:02:58,084 a series of commitments to what they call 80 00:02:58,084 --> 00:02:59,144 it what they're calling, 81 00:02:59,685 --> 00:03:01,944 streamlining, simplifying, and reducing 82 00:03:02,644 --> 00:03:06,539 prior authorization requirements across commercial Medicare Advantage and 83 00:03:06,539 --> 00:03:09,739 managed Medicaid plans. I just mentioned that's expected 84 00:03:09,739 --> 00:03:12,780 to affect over 250,000,000 85 00:03:12,780 --> 00:03:13,280 Americans, 86 00:03:14,620 --> 00:03:17,020 and and nearly 50 insurers have committed to 87 00:03:17,020 --> 00:03:18,479 this, and that includes EveryHealth. 88 00:03:19,814 --> 00:03:23,094 That includes things like standardized submission processes for 89 00:03:23,094 --> 00:03:23,594 electronic 90 00:03:23,974 --> 00:03:24,715 prior authorizations, 91 00:03:25,414 --> 00:03:28,455 reductions to the overall amount of requirements that 92 00:03:28,455 --> 00:03:30,694 that providers and and, of course, members have 93 00:03:30,694 --> 00:03:33,199 to face, and an easier appeals process among 94 00:03:33,199 --> 00:03:34,659 a few a few other things. 95 00:03:36,159 --> 00:03:38,080 So we are hearing from stakeholders all across 96 00:03:38,080 --> 00:03:39,280 the industry about this. 97 00:03:39,919 --> 00:03:41,860 Some some positive, some negative, 98 00:03:42,400 --> 00:03:44,560 and some, you know, I think just laying 99 00:03:44,560 --> 00:03:46,375 in wait just lying in wait to see 100 00:03:46,375 --> 00:03:48,855 what's gonna come ultimately from this over over 101 00:03:48,855 --> 00:03:50,555 the next few years or so. 102 00:03:51,415 --> 00:03:53,415 But but ultimately, it is being hailed as 103 00:03:53,415 --> 00:03:55,814 a significant step forward for the health care 104 00:03:55,814 --> 00:03:59,094 system. So from your perspective, Chris, what was 105 00:03:59,094 --> 00:04:01,949 the driving force behind the industry's decision 106 00:04:02,409 --> 00:04:05,930 to to coalesce around these major changes? And 107 00:04:05,930 --> 00:04:07,449 how do you think that health plans and 108 00:04:07,449 --> 00:04:08,669 and policy makers 109 00:04:09,210 --> 00:04:11,069 all align to make these reforms, 110 00:04:11,930 --> 00:04:12,590 a reality? 111 00:04:15,275 --> 00:04:16,975 Put me on the hot seat. The 112 00:04:17,514 --> 00:04:19,514 well, I can't speak for some of my 113 00:04:19,514 --> 00:04:20,654 peers in the industry 114 00:04:21,194 --> 00:04:23,354 or AHIP itself. I mean, we're a member 115 00:04:23,354 --> 00:04:24,574 of AHIP. We're signatory 116 00:04:25,035 --> 00:04:26,254 to this announcement. 117 00:04:27,910 --> 00:04:30,230 No. We believe at every that this prior 118 00:04:30,230 --> 00:04:30,730 authorization, 119 00:04:31,270 --> 00:04:32,490 a voluntary commitment 120 00:04:33,430 --> 00:04:34,949 set of standards, it's a step in the 121 00:04:34,949 --> 00:04:35,610 right direction. 122 00:04:37,189 --> 00:04:38,250 Why did it happen? 123 00:04:38,949 --> 00:04:41,270 You know, I think, you know, I'm speaking 124 00:04:41,270 --> 00:04:42,250 personally here. 125 00:04:43,165 --> 00:04:44,384 I think there is 126 00:04:44,764 --> 00:04:46,764 a a large amount of modernization that still 127 00:04:46,764 --> 00:04:48,925 is yet to occur in our industry, broader 128 00:04:48,925 --> 00:04:51,824 industry of healthcare. And there's still opportunities 129 00:04:52,285 --> 00:04:54,145 to improve customer service 130 00:04:54,605 --> 00:04:57,560 and reduce any points of friction or latency. 131 00:04:58,660 --> 00:05:00,279 And I believe the population 132 00:05:00,660 --> 00:05:02,180 has just gotten to the point where their 133 00:05:02,180 --> 00:05:03,480 voices are being heard, 134 00:05:04,500 --> 00:05:05,000 inside, 135 00:05:06,500 --> 00:05:07,000 organizations 136 00:05:07,300 --> 00:05:10,259 and outside as the consuming public, and they 137 00:05:10,259 --> 00:05:11,495 want better 138 00:05:12,035 --> 00:05:14,535 service. And I think that's perfectly understandable. 139 00:05:16,754 --> 00:05:18,595 Yeah. No. Absolutely. And I, you know, I 140 00:05:18,675 --> 00:05:21,154 well, from our perspective, when when we look 141 00:05:21,154 --> 00:05:24,229 at industries being ranked by customer service, 142 00:05:24,930 --> 00:05:26,629 quality right now and expectations, 143 00:05:27,089 --> 00:05:29,569 it is generally the insurance industry that that 144 00:05:29,569 --> 00:05:30,389 falls behind, 145 00:05:31,169 --> 00:05:33,189 you know, like I said, in national rankings. 146 00:05:33,329 --> 00:05:35,115 So it's interesting you say that. This is 147 00:05:35,115 --> 00:05:37,562 a lot of this is coming from that 148 00:05:37,562 --> 00:05:40,009 that customer service expectation from from the wider 149 00:05:40,009 --> 00:05:42,457 public. Call a thing a thing. You know? 150 00:05:42,457 --> 00:05:44,904 It's like, talk about the problem in the 151 00:05:44,904 --> 00:05:47,352 middle of the room. Sure. Reason it is 152 00:05:47,352 --> 00:05:49,870 so challenging for you know, legacy insurers is 153 00:05:49,870 --> 00:05:52,449 they are responsible for a massive amount. 154 00:05:52,829 --> 00:05:53,329 Yeah. 155 00:05:53,709 --> 00:05:55,490 Compliant, medical quality, 156 00:05:55,870 --> 00:05:57,490 and they provide a vital service, 157 00:05:57,949 --> 00:05:59,409 but it's hugely complex. 158 00:05:59,789 --> 00:06:01,069 And they get pulled and, you know, the 159 00:06:01,069 --> 00:06:03,069 big legacy insurers are pulled in 50 different 160 00:06:03,069 --> 00:06:06,264 directions by 50 different state legislators. Sure. Legislatures. 161 00:06:08,485 --> 00:06:10,564 So it is challenging. They're they're not subject 162 00:06:10,564 --> 00:06:11,384 to the same 163 00:06:11,925 --> 00:06:14,245 customer service standards that someone is that checks 164 00:06:14,245 --> 00:06:16,404 into a hotel. Yeah. Very fair. Give them 165 00:06:16,404 --> 00:06:18,644 give them a measure of flexibility. I mean, 166 00:06:18,644 --> 00:06:20,709 they're dealing with life and death stuff, huge 167 00:06:20,709 --> 00:06:22,409 amounts of evidence based literature, 168 00:06:23,189 --> 00:06:25,829 and a lot of complexity that would crush 169 00:06:25,829 --> 00:06:26,649 most businesses. 170 00:06:27,509 --> 00:06:28,009 But 171 00:06:29,349 --> 00:06:31,829 on the flip side, the consuming public doesn't 172 00:06:31,829 --> 00:06:34,175 understand that. Yeah. No. That's a great point. 173 00:06:34,175 --> 00:06:35,115 It just goes, 174 00:06:36,294 --> 00:06:38,475 hey. From my my small point of view, 175 00:06:38,935 --> 00:06:40,475 I feel this wasn't good enough. 176 00:06:40,854 --> 00:06:41,354 And, 177 00:06:42,055 --> 00:06:44,055 you know, the industry has not done a 178 00:06:44,055 --> 00:06:46,375 good job over the past thirty, forty years 179 00:06:46,375 --> 00:06:47,035 of explaining 180 00:06:47,759 --> 00:06:49,459 why population health is necessary, 181 00:06:50,240 --> 00:06:51,939 why what we do is vital, 182 00:06:52,560 --> 00:06:54,099 and that without us, 183 00:06:54,399 --> 00:06:56,339 and the population health, things would be 184 00:06:57,199 --> 00:06:59,539 radically different and not in a positive way. 185 00:06:59,599 --> 00:07:00,099 Sure. 186 00:07:00,404 --> 00:07:02,725 And but the Well You know, there's a 187 00:07:02,725 --> 00:07:03,704 gap there between 188 00:07:04,084 --> 00:07:06,805 reality and what people believe, and that's causing 189 00:07:06,805 --> 00:07:07,704 a lot of frustration. 190 00:07:08,004 --> 00:07:09,685 Yeah. No. Certainly. And I mean, you know, 191 00:07:09,685 --> 00:07:11,444 when people do interact with a company like 192 00:07:11,444 --> 00:07:13,044 yours and and some of the companies on 193 00:07:13,044 --> 00:07:14,345 this list, it is, of course, 194 00:07:14,769 --> 00:07:16,930 some of the most emotional situations of that 195 00:07:16,930 --> 00:07:19,169 they've encountered in their lives. So, of course, 196 00:07:19,169 --> 00:07:21,649 you know, there's there's a lot of emotions 197 00:07:21,649 --> 00:07:23,110 evolved and often misunderstandings. 198 00:07:23,649 --> 00:07:25,029 So your point is well heard. 199 00:07:25,729 --> 00:07:27,169 And let's talk a little bit about that 200 00:07:27,169 --> 00:07:28,310 complexity because 201 00:07:29,194 --> 00:07:31,354 now, let's say over the next eighteen to 202 00:07:31,354 --> 00:07:33,914 twenty four months, you and and the wider 203 00:07:33,914 --> 00:07:37,134 industry are being tasked with making these reforms 204 00:07:37,194 --> 00:07:38,334 or these these promises 205 00:07:39,034 --> 00:07:41,399 actual tangible reality for your members. 206 00:07:42,279 --> 00:07:44,620 So so from every perspective specifically, 207 00:07:45,000 --> 00:07:46,680 what does that actually look like? What are 208 00:07:46,680 --> 00:07:49,160 some of the conversations you're having internally? What 209 00:07:49,160 --> 00:07:51,240 are what's the technical changes that have to 210 00:07:51,240 --> 00:07:52,699 occur for you to meet 211 00:07:53,000 --> 00:07:53,819 these commitments? 212 00:07:54,845 --> 00:07:55,345 Yeah. 213 00:07:56,285 --> 00:07:57,404 You need to take, 214 00:07:58,044 --> 00:08:00,044 you need to get to the point that 215 00:08:00,044 --> 00:08:02,144 doctors or physicians and their patients 216 00:08:02,764 --> 00:08:03,584 get answers 217 00:08:03,964 --> 00:08:05,745 the majority of the time in minutes 218 00:08:06,204 --> 00:08:08,285 while the patient's still in the room with 219 00:08:08,285 --> 00:08:08,944 the physician 220 00:08:09,900 --> 00:08:10,879 rather than days. 221 00:08:11,580 --> 00:08:13,100 That's the goal. You know, my we're like 222 00:08:13,180 --> 00:08:14,939 My goal at Every Health is we wanna 223 00:08:14,939 --> 00:08:17,520 drive prior authorization denials to zero. 224 00:08:18,540 --> 00:08:19,040 Period. 225 00:08:20,220 --> 00:08:22,639 And we're we're really close to achieving that. 226 00:08:22,884 --> 00:08:25,705 The broader industry, the challenge that they're fighting, 227 00:08:26,805 --> 00:08:28,245 and a lot of my peers are dealing 228 00:08:28,245 --> 00:08:29,064 with is 229 00:08:29,605 --> 00:08:32,565 the medical provider industry overwhelmingly still run like 230 00:08:32,565 --> 00:08:33,705 it's 1980. 231 00:08:34,325 --> 00:08:36,664 It's forty percent of the inbound 232 00:08:37,230 --> 00:08:39,409 prior authorization requests are still fax. 233 00:08:40,669 --> 00:08:42,750 And they're not even good faxes, Jacob. They 234 00:08:42,750 --> 00:08:45,230 send them over. It'll be like everything between 235 00:08:45,230 --> 00:08:47,149 both sides of a of a Manila jacket 236 00:08:47,149 --> 00:08:47,649 folder, 237 00:08:48,269 --> 00:08:50,414 a huge stack of paperwork. It'll be skewed 238 00:08:50,414 --> 00:08:52,654 30 degrees. It'll have two different person's handwriting 239 00:08:52,654 --> 00:08:54,195 on it, stamps on it. 240 00:08:55,615 --> 00:08:57,455 And each each state's different with its own 241 00:08:57,455 --> 00:08:58,514 regulated form. 242 00:08:59,134 --> 00:09:01,955 So Yeah. It's quite a challenge. Technolog 243 00:09:02,495 --> 00:09:04,754 you've, you've got to do a lot of 244 00:09:05,350 --> 00:09:05,850 inbound 245 00:09:06,389 --> 00:09:07,690 document cleanup. 246 00:09:09,350 --> 00:09:12,250 It's not just OCR work. You've got to 247 00:09:12,950 --> 00:09:15,529 verify eligibility of the member and the provider, 248 00:09:15,590 --> 00:09:17,350 check the medical codes against the 249 00:09:18,070 --> 00:09:18,970 are those legitimate? 250 00:09:19,429 --> 00:09:21,754 Are those are they submitting for the right 251 00:09:21,754 --> 00:09:23,754 thing? You know, is the billing code match 252 00:09:23,754 --> 00:09:25,214 the procedure code request? 253 00:09:25,514 --> 00:09:27,514 Then you gotta compare it to all the 254 00:09:27,514 --> 00:09:28,014 evidences, 255 00:09:28,475 --> 00:09:30,394 and the if it's not a if it 256 00:09:30,394 --> 00:09:32,714 moves on to a medical evaluation, you've got 257 00:09:32,714 --> 00:09:34,735 to take a look and see if the 258 00:09:35,500 --> 00:09:37,600 the medical information submitted, 259 00:09:38,779 --> 00:09:40,779 matches up with the request and the care 260 00:09:40,779 --> 00:09:43,019 guidelines, which is all evidence based. It is 261 00:09:43,019 --> 00:09:45,019 not a small challenge. And then you gotta 262 00:09:45,019 --> 00:09:46,240 get that back to someone 263 00:09:47,420 --> 00:09:48,639 Yeah. In minutes. 264 00:09:50,254 --> 00:09:51,634 It's a huge lift. 265 00:09:52,334 --> 00:09:54,274 Very doable, but it's a huge lift. 266 00:09:55,615 --> 00:09:57,615 I can't imagine. I can't imagine. And how 267 00:09:57,615 --> 00:09:59,294 are you feeling about the timeline of all 268 00:09:59,294 --> 00:10:01,774 of this? Even just, again, from your company's 269 00:10:01,774 --> 00:10:04,334 perspective, do you feel prepared to to meet 270 00:10:04,334 --> 00:10:04,995 this timeline? 271 00:10:05,970 --> 00:10:07,190 Yes. I mean, 272 00:10:07,730 --> 00:10:09,029 we've built the technology. 273 00:10:10,370 --> 00:10:12,289 We've built software systems that allow us to 274 00:10:12,289 --> 00:10:14,470 do this already. We're already compliant, 275 00:10:15,649 --> 00:10:17,490 with the things that the company can be 276 00:10:17,490 --> 00:10:19,664 compliant with and on these voluntary commitments. We 277 00:10:19,664 --> 00:10:21,664 already do this electronically. We already do it 278 00:10:21,664 --> 00:10:22,485 in real time, 279 00:10:23,664 --> 00:10:25,504 and we're happy to license that software to 280 00:10:25,504 --> 00:10:26,084 our competitors. 281 00:10:27,105 --> 00:10:29,205 You know, we want population health to increase. 282 00:10:29,664 --> 00:10:30,945 Mhmm. And to give you an idea how 283 00:10:30,945 --> 00:10:33,504 well that's working behind the scenes, the industry 284 00:10:33,504 --> 00:10:35,399 average for prior authorization denials 285 00:10:35,960 --> 00:10:37,820 is 25 to 35. 286 00:10:38,360 --> 00:10:41,399 Okay. Every health, our prior authorization denials in 287 00:10:41,399 --> 00:10:43,420 the past calendar year were only 7%. 288 00:10:43,800 --> 00:10:46,920 Wow. And 100% of those were upheld upon 289 00:10:46,920 --> 00:10:49,399 appeal, which means we are following the science. 290 00:10:49,399 --> 00:10:50,620 It's evidence based. 291 00:10:50,995 --> 00:10:53,095 Whereas the industry average for 292 00:10:53,475 --> 00:10:55,875 denials being upheld on appeal is probably closer 293 00:10:55,875 --> 00:10:56,695 to the mid-50s 294 00:10:57,554 --> 00:11:00,115 in terms of percentage like 56% or so, 295 00:11:00,355 --> 00:11:01,495 based upon Kaiser 296 00:11:01,875 --> 00:11:03,634 or, healthcare.gov. 297 00:11:03,634 --> 00:11:04,134 Sure. 298 00:11:04,620 --> 00:11:07,179 So it can be done. Okay. It's just 299 00:11:07,340 --> 00:11:09,500 it's a hard lift. Yeah. Well, and, you 300 00:11:09,500 --> 00:11:11,899 know, it's I I I wanna go back 301 00:11:11,899 --> 00:11:13,580 to what you just mentioned that often on 302 00:11:13,580 --> 00:11:15,179 the provider side of things, and I I 303 00:11:15,179 --> 00:11:16,620 suppose on the insurance side of things as 304 00:11:16,620 --> 00:11:17,120 well, 305 00:11:17,500 --> 00:11:19,259 often the system is operating like it's the 306 00:11:19,259 --> 00:11:21,554 nineteen eighties. But we're, you know, we're obviously 307 00:11:21,554 --> 00:11:23,154 not in the eighties anymore. There's so much 308 00:11:23,154 --> 00:11:24,534 more technology available, 309 00:11:25,235 --> 00:11:28,034 to companies like yours to hopefully make this 310 00:11:28,034 --> 00:11:29,654 a little bit of an easier process. 311 00:11:30,034 --> 00:11:31,074 You know, I know it's a bit of 312 00:11:31,074 --> 00:11:33,714 a simplified question to a very complicated problem. 313 00:11:33,714 --> 00:11:33,875 But, 314 00:11:35,389 --> 00:11:37,330 do you think that new technology 315 00:11:37,710 --> 00:11:39,389 I hate to use the AI buzzword, but 316 00:11:39,389 --> 00:11:40,990 can AI make this, 317 00:11:41,389 --> 00:11:44,690 a much easier lift compared to the past? 318 00:11:45,389 --> 00:11:45,889 Absolutely. 319 00:11:46,910 --> 00:11:48,529 We use AI powered tools 320 00:11:48,995 --> 00:11:49,595 to do, 321 00:11:50,034 --> 00:11:52,855 administrative approvals and administrative denials 322 00:11:53,394 --> 00:11:55,315 and to prepare all the case work to 323 00:11:55,315 --> 00:11:57,815 summarize things for our nurses and doctors. 324 00:11:58,195 --> 00:12:00,754 We never use AI to make a medical 325 00:12:00,754 --> 00:12:03,014 denial or a final medical determination, 326 00:12:04,340 --> 00:12:05,960 about a denial. Sure. 327 00:12:06,740 --> 00:12:08,259 It is really useful. You gotta keep in 328 00:12:08,259 --> 00:12:09,940 mind sometimes we get a stack of paperwork, 329 00:12:09,940 --> 00:12:11,960 sometimes a 130 pages 330 00:12:12,580 --> 00:12:13,720 of medical notes 331 00:12:14,259 --> 00:12:15,160 that can span 332 00:12:16,100 --> 00:12:17,480 entire patient's history. 333 00:12:17,945 --> 00:12:19,464 Sure. They just send us the whole thing 334 00:12:19,464 --> 00:12:20,924 over as a fax. And 335 00:12:21,945 --> 00:12:24,024 nurses and doctors don't wanna spend their time 336 00:12:24,024 --> 00:12:26,825 digging through 130 pages trying to figure out, 337 00:12:26,825 --> 00:12:28,904 hey, what is relevant for this PET scan 338 00:12:28,904 --> 00:12:30,904 request or what's relevant for this knee surgery 339 00:12:30,904 --> 00:12:31,404 request? 340 00:12:33,459 --> 00:12:36,019 AI powered tools do a great job of 341 00:12:36,019 --> 00:12:37,079 quickly summarizing 342 00:12:37,620 --> 00:12:39,779 and tagging what is relevant in in the 343 00:12:39,779 --> 00:12:42,019 medical case so that the nurses and doctors 344 00:12:42,019 --> 00:12:43,720 can work at the top of their license 345 00:12:45,315 --> 00:12:47,235 and get a speedy response back to that 346 00:12:47,235 --> 00:12:48,214 doctor and patient. 347 00:12:48,674 --> 00:12:51,095 And sometimes we found the AI 348 00:12:51,714 --> 00:12:54,054 powered clinical summaries and guideline 349 00:12:54,674 --> 00:12:56,695 checks, evidence based guidelines, 350 00:12:57,299 --> 00:12:59,700 find things that even our nurses and doctors 351 00:12:59,700 --> 00:13:02,820 didn't didn't find. Mhmm. It's a great decision 352 00:13:02,820 --> 00:13:04,340 support tool, and I think we as an 353 00:13:04,340 --> 00:13:07,480 industry should be adopting every technology we can 354 00:13:07,940 --> 00:13:11,534 that improves medical quality and population health. Absolutely. 355 00:13:11,595 --> 00:13:13,754 Point earlier, customer service. Like, let's get this 356 00:13:13,754 --> 00:13:15,294 down to minutes instead of days. 357 00:13:16,554 --> 00:13:18,575 Absolutely. And I can't imagine, you know, 358 00:13:19,034 --> 00:13:20,715 you you were talking earlier about the complexity 359 00:13:20,715 --> 00:13:22,715 of some of these larger organizations that are 360 00:13:22,715 --> 00:13:25,620 signed on to these commitments. I can't imagine 361 00:13:25,620 --> 00:13:27,460 what they're trying to sort through in terms 362 00:13:27,460 --> 00:13:29,720 of, you know, meeting meeting these deadlines. 363 00:13:31,460 --> 00:13:33,860 But I also wanna ask you about some 364 00:13:33,860 --> 00:13:36,920 of the criticism. We've already been hearing from 365 00:13:37,225 --> 00:13:39,384 from providers, from from the trade groups that 366 00:13:39,384 --> 00:13:40,205 represent them, 367 00:13:41,625 --> 00:13:44,745 basically laying out concerns about this, saying that, 368 00:13:44,745 --> 00:13:46,825 you know, we've heard these types of promises 369 00:13:46,825 --> 00:13:49,065 in the past from the industry that really 370 00:13:49,065 --> 00:13:50,125 never came to fruition, 371 00:13:51,279 --> 00:13:52,799 or that, you know, a lot of the 372 00:13:52,799 --> 00:13:53,299 companies 373 00:13:53,600 --> 00:13:55,920 are are publicly traded and that they still 374 00:13:55,920 --> 00:13:57,779 have to meet their commitment to investors, 375 00:13:58,799 --> 00:14:01,220 and and that this will just shift administrative 376 00:14:01,279 --> 00:14:02,740 burdens to other areas. 377 00:14:04,304 --> 00:14:06,065 How would you respond to that? I mean, 378 00:14:06,065 --> 00:14:07,684 how do you think that the success 379 00:14:08,065 --> 00:14:10,804 of these reforms will ultimately be measured? 380 00:14:11,825 --> 00:14:13,665 I think ultimately they can be measured at 381 00:14:13,665 --> 00:14:14,725 the denial rates. 382 00:14:16,110 --> 00:14:18,509 Ultimately, that for me, that's the KPI I 383 00:14:18,509 --> 00:14:20,669 would focus on over the long term, that 384 00:14:20,669 --> 00:14:23,149 a prior authorization denial rate should decline over 385 00:14:23,149 --> 00:14:25,470 time if you're working in partnership with physicians, 386 00:14:25,470 --> 00:14:27,889 providers, making sure that they're submitting it, 387 00:14:28,269 --> 00:14:29,715 the best way the first time, 388 00:14:30,115 --> 00:14:31,955 the quickest way so you can get them 389 00:14:31,955 --> 00:14:34,035 an answer. The the goal is we all 390 00:14:34,035 --> 00:14:35,014 serve the patient. 391 00:14:36,754 --> 00:14:38,375 But I but I understand the criticism. 392 00:14:39,235 --> 00:14:41,335 Some of that, in my opinion, is 393 00:14:41,875 --> 00:14:42,375 misinformation 394 00:14:43,555 --> 00:14:44,295 that people 395 00:14:45,839 --> 00:14:47,779 don't understand that prior auths, 396 00:14:48,159 --> 00:14:49,539 it's not about billing. 397 00:14:50,480 --> 00:14:52,959 You don't make money. At least at EveryHealth, 398 00:14:52,959 --> 00:14:54,740 we don't make money by denying, 399 00:14:55,679 --> 00:14:58,399 prior auths. Prior auths are purely driven about 400 00:14:58,399 --> 00:15:01,574 evidence based care. What is best for a 401 00:15:01,574 --> 00:15:05,115 patient given the scientific medical literature? That's it. 402 00:15:05,654 --> 00:15:08,054 That's the only goal. That's the only criteria. 403 00:15:08,054 --> 00:15:10,134 And then we're independently as industry, all of 404 00:15:10,134 --> 00:15:12,375 us in industry that are part of medical 405 00:15:12,375 --> 00:15:14,394 quality standards like URAC or NCQA, 406 00:15:14,929 --> 00:15:16,629 whichever is is a part of, 407 00:15:18,289 --> 00:15:19,669 we're independently accountable 408 00:15:20,209 --> 00:15:22,870 on our medical quality, and our prior authorizations 409 00:15:23,009 --> 00:15:25,569 are reviewed. And you even have, something called 410 00:15:25,569 --> 00:15:26,709 inter rater reliability. 411 00:15:27,804 --> 00:15:28,545 So anytime 412 00:15:29,165 --> 00:15:31,184 you have a a medical quality review, 413 00:15:32,845 --> 00:15:35,725 independent committee comes in, pulls a statistically random 414 00:15:35,725 --> 00:15:37,565 sample of your your prior auths and your 415 00:15:37,565 --> 00:15:39,504 medical decisions and reviews them. 416 00:15:40,230 --> 00:15:42,549 And, like, the industry standard on that is 417 00:15:42,549 --> 00:15:44,549 anywhere from you you really wanna be above 418 00:15:44,549 --> 00:15:45,370 90% 419 00:15:45,990 --> 00:15:46,970 inter rate of reliability. 420 00:15:48,309 --> 00:15:51,350 In the industry, you can float between 7294% 421 00:15:51,350 --> 00:15:51,850 ballpark. 422 00:15:52,309 --> 00:15:53,990 Okay. We at every health are at a 423 00:15:53,990 --> 00:15:54,730 100%. 424 00:15:55,214 --> 00:15:56,735 And that's our target. I hope we can 425 00:15:56,735 --> 00:15:57,634 maintain it. 426 00:15:58,975 --> 00:16:00,834 But all this to say, I think the 427 00:16:01,134 --> 00:16:02,355 a lot of the pushback 428 00:16:02,894 --> 00:16:03,954 is just misinformation 429 00:16:04,575 --> 00:16:06,674 about what a prior authorization is 430 00:16:07,529 --> 00:16:10,009 and what it's meant to do. Yeah. No. 431 00:16:10,009 --> 00:16:11,549 It's fair. I mean, it's great insight. 432 00:16:12,649 --> 00:16:13,549 It's really interesting. 433 00:16:15,049 --> 00:16:17,209 What else were we missing on this, Chris? 434 00:16:17,209 --> 00:16:19,209 I mean, what have you been hearing the 435 00:16:19,209 --> 00:16:20,829 last few days since this announcement, 436 00:16:22,009 --> 00:16:23,070 that that you 437 00:16:23,504 --> 00:16:26,245 wanna talk about, that you wanna address? 438 00:16:26,705 --> 00:16:28,065 You've you've got the ears of a lot 439 00:16:28,065 --> 00:16:29,825 of other health care leaders, a lot of 440 00:16:29,825 --> 00:16:30,804 other health plan, 441 00:16:31,424 --> 00:16:34,065 leaders out there, listening in. What do you 442 00:16:34,065 --> 00:16:35,585 wanna say to them about, 443 00:16:36,590 --> 00:16:38,669 the next few months and and couple years 444 00:16:38,669 --> 00:16:39,970 to come around this? 445 00:16:41,309 --> 00:16:43,809 I think we have a fantastic opportunity 446 00:16:45,070 --> 00:16:46,769 to address a nationwide 447 00:16:49,414 --> 00:16:49,914 concern. 448 00:16:51,495 --> 00:16:52,714 And our industry 449 00:16:53,495 --> 00:16:54,794 needs to move quickly. 450 00:16:55,654 --> 00:16:57,495 And if we move quickly and it's an 451 00:16:57,495 --> 00:16:59,735 opportunity to address that gap again that we 452 00:16:59,735 --> 00:17:02,554 talked about at the beginning between public perception 453 00:17:02,695 --> 00:17:05,000 and reality, and that our industry just hasn't 454 00:17:05,000 --> 00:17:07,240 done a good job of educating the public 455 00:17:07,240 --> 00:17:09,480 about the necessity and value of what we 456 00:17:09,480 --> 00:17:09,980 do. 457 00:17:11,799 --> 00:17:13,400 If we do this as an industry and 458 00:17:13,400 --> 00:17:14,140 move quickly, 459 00:17:14,919 --> 00:17:15,980 we have more credibility. 460 00:17:17,025 --> 00:17:19,105 Our opportunity to educate the public will be 461 00:17:19,105 --> 00:17:19,605 extended, 462 00:17:20,705 --> 00:17:22,085 and that can 463 00:17:22,545 --> 00:17:25,684 reap huge benefits across the industry and society 464 00:17:25,904 --> 00:17:27,924 if we're seen to be working with providers 465 00:17:27,984 --> 00:17:29,445 to solve real, tangible 466 00:17:30,160 --> 00:17:30,980 human problems 467 00:17:31,519 --> 00:17:33,279 that all of our friends experience around the 468 00:17:33,279 --> 00:17:34,099 dining table. 469 00:17:34,559 --> 00:17:36,000 So, I mean, big picture, that's how I 470 00:17:36,000 --> 00:17:37,619 think of it, Jacob. Sure. 471 00:17:38,319 --> 00:17:38,819 Smaller 472 00:17:39,200 --> 00:17:41,839 picture, you know, the smaller stuff, we have 473 00:17:41,839 --> 00:17:42,500 the technology. 474 00:17:43,275 --> 00:17:44,955 We can do this. It's it it is 475 00:17:45,195 --> 00:17:47,275 the beautiful thing about technology is it scales 476 00:17:47,275 --> 00:17:48,894 to big problems really quickly. 477 00:17:49,434 --> 00:17:49,934 And, 478 00:17:50,555 --> 00:17:51,994 you know, we're already doing it here at 479 00:17:51,994 --> 00:17:53,695 Every Health, and we're happy to 480 00:17:54,075 --> 00:17:55,914 help power all of our peers to do 481 00:17:55,914 --> 00:17:56,494 it themselves. 482 00:17:59,170 --> 00:18:01,970 Fantastic. Well, Chris, I wanna thank you for 483 00:18:01,970 --> 00:18:04,150 taking the time to chat with me 484 00:18:04,529 --> 00:18:07,009 and for sharing your your insights and your 485 00:18:07,009 --> 00:18:09,750 expertise with our audience. We really appreciate it. 486 00:18:10,369 --> 00:18:10,849 Sure. 487 00:18:11,410 --> 00:18:12,585 Thank you very much. 488 00:18:13,304 --> 00:18:15,304 And to our listeners, if you'd like to 489 00:18:15,304 --> 00:18:17,784 listen to more podcasts from Becker's HealthCare, you 490 00:18:17,784 --> 00:18:20,605 can visit beckershospitalreview.com.