1 00:00:00,080 --> 00:00:02,000 Hello, everyone. This is Jacob Amerson with the 2 00:00:02,000 --> 00:00:03,699 Becker's Payer Issues podcast. 3 00:00:04,080 --> 00:00:06,559 Thrilled today to be joined by Chris Gay, 4 00:00:06,559 --> 00:00:08,500 who is the CEO of EveryHealth. 5 00:00:08,880 --> 00:00:11,199 Chris, thanks you so much for taking the 6 00:00:11,199 --> 00:00:13,359 time to be here with me once again 7 00:00:13,359 --> 00:00:14,339 on the podcast. 8 00:00:15,115 --> 00:00:16,554 Well, thank you, Jacob, for having me on 9 00:00:16,554 --> 00:00:17,375 on the podcast. 10 00:00:17,754 --> 00:00:19,754 Absolutely. And before we dive into everything we 11 00:00:19,754 --> 00:00:21,835 wanna talk with you about today, Chris, for 12 00:00:21,835 --> 00:00:23,434 our audience that might not be familiar, can 13 00:00:23,434 --> 00:00:25,535 you tell them a little bit about yourself 14 00:00:25,594 --> 00:00:26,875 and what it is that you do at 15 00:00:26,875 --> 00:00:27,375 EveryHealth? 16 00:00:28,379 --> 00:00:28,879 Sure. 17 00:00:29,420 --> 00:00:31,660 Chris Gay. I'm the CEO and one of 18 00:00:31,660 --> 00:00:33,659 the cofounders of EveryHealth. So I was a 19 00:00:33,659 --> 00:00:36,780 software developer by training, and that's turned serial 20 00:00:36,780 --> 00:00:37,280 entrepreneur. 21 00:00:38,379 --> 00:00:40,159 And, inside of EveryHealth, 22 00:00:40,954 --> 00:00:42,655 I mostly set the strategy 23 00:00:43,435 --> 00:00:45,454 and, make sure that we have the resources 24 00:00:45,755 --> 00:00:48,715 to fulfill that strategy. And, and that includes 25 00:00:48,715 --> 00:00:50,015 a lot of talent and recruitment. 26 00:00:51,434 --> 00:00:52,734 And in terms of our company, 27 00:00:53,674 --> 00:00:55,914 we started eight years ago as a start 28 00:00:55,914 --> 00:00:56,414 up 29 00:00:56,789 --> 00:00:58,869 trying to address issues that we felt were 30 00:00:58,869 --> 00:01:02,309 inequities in US health care around access and 31 00:01:02,309 --> 00:01:04,890 quality and engagement and total cost. 32 00:01:05,909 --> 00:01:06,310 And, 33 00:01:07,109 --> 00:01:08,549 we started out in Silicon Valley with a 34 00:01:08,549 --> 00:01:09,734 $120,000. 35 00:01:09,895 --> 00:01:11,334 Now what you can best think of us 36 00:01:11,334 --> 00:01:13,435 as a software company that owns a full 37 00:01:13,814 --> 00:01:14,555 health insurer. 38 00:01:15,495 --> 00:01:15,895 And, 39 00:01:17,094 --> 00:01:19,814 we focus on the mid market commercial mid 40 00:01:19,814 --> 00:01:20,954 market fully insured. 41 00:01:21,415 --> 00:01:23,015 Most of our membership is in the state 42 00:01:23,015 --> 00:01:23,674 of Texas. 43 00:01:24,930 --> 00:01:26,850 Fantastic. So a bit of a unique structure 44 00:01:26,850 --> 00:01:27,350 there, 45 00:01:27,890 --> 00:01:30,609 in terms of the wider industry landscape, Chris. 46 00:01:30,609 --> 00:01:33,409 And I wanted to start us off by 47 00:01:33,409 --> 00:01:35,409 going back to the conversation that you and 48 00:01:35,409 --> 00:01:37,569 I had had here on the podcast about 49 00:01:37,569 --> 00:01:39,109 six months ago this summer. 50 00:01:40,075 --> 00:01:42,555 You had mentioned that EveryHealth has achieved a 51 00:01:42,555 --> 00:01:43,375 7% 52 00:01:43,754 --> 00:01:47,034 prior authorization denial rate with 100% of those 53 00:01:47,034 --> 00:01:48,894 denials upheld on appeal, 54 00:01:49,194 --> 00:01:51,454 which as you know, far out outperforms 55 00:01:51,915 --> 00:01:53,215 the industry average. 56 00:01:53,739 --> 00:01:56,299 And and then you also offered to license 57 00:01:56,299 --> 00:01:58,780 your technology that, has led you to achieve 58 00:01:58,780 --> 00:02:00,000 that to competitors. 59 00:02:01,019 --> 00:02:03,179 So I wonder, you know, broadly, if we're 60 00:02:03,179 --> 00:02:05,179 looking out across the industry, this is a 61 00:02:05,179 --> 00:02:07,840 topic that gets a lot of negative headlines, 62 00:02:07,899 --> 00:02:09,444 a lot of bad press for a lot 63 00:02:09,444 --> 00:02:10,104 of insurers. 64 00:02:10,724 --> 00:02:11,224 So, 65 00:02:11,525 --> 00:02:12,724 you know and this is all, of course 66 00:02:12,805 --> 00:02:14,245 the the context here is, you know, this 67 00:02:14,245 --> 00:02:16,584 summer, nearly 50 insurers committed to, 68 00:02:17,125 --> 00:02:17,625 standardizing 69 00:02:18,324 --> 00:02:21,224 electronic prior auth processes, including EveryHealth, 70 00:02:21,764 --> 00:02:22,504 in collaboration 71 00:02:22,805 --> 00:02:24,344 with the government. And so 72 00:02:25,659 --> 00:02:28,219 broadly, across the industry, what what's the biggest 73 00:02:28,219 --> 00:02:29,419 obstacle here, do you think, 74 00:02:29,900 --> 00:02:30,639 that's preventing 75 00:02:31,180 --> 00:02:33,199 larger insurers especially from 76 00:02:33,659 --> 00:02:35,520 replicating what you've built at EveryHealth? 77 00:02:35,900 --> 00:02:36,719 Is it fundamentally 78 00:02:37,259 --> 00:02:39,854 a technology problem, like we heard doctor Oz 79 00:02:40,094 --> 00:02:41,314 suggest this summer, 80 00:02:41,694 --> 00:02:44,094 or is this a business model problem at 81 00:02:44,094 --> 00:02:45,935 its core, or is it something else? What 82 00:02:45,935 --> 00:02:46,594 do you think? 83 00:02:47,614 --> 00:02:48,114 Oh, 84 00:02:50,014 --> 00:02:50,914 I think it's 85 00:02:51,215 --> 00:02:51,955 three things. 86 00:02:52,334 --> 00:02:54,655 So I'll I'll, I'll answer the first one 87 00:02:54,655 --> 00:02:56,019 as the technology, and you can come back 88 00:02:56,019 --> 00:02:57,879 with the other two as follow-up questions. 89 00:02:59,780 --> 00:03:01,560 It is a technology issue, 90 00:03:02,900 --> 00:03:05,219 and it's a technology issue. And, again, I 91 00:03:05,219 --> 00:03:06,659 I think it's the other two things as 92 00:03:06,659 --> 00:03:07,159 well. 93 00:03:07,459 --> 00:03:09,299 But it's a technology issue because of the 94 00:03:09,299 --> 00:03:09,799 scale. 95 00:03:10,665 --> 00:03:12,844 Prior authorizations are a shared frustration 96 00:03:13,145 --> 00:03:15,324 by both the medical provider community 97 00:03:15,784 --> 00:03:17,245 and health systems and physicians 98 00:03:18,025 --> 00:03:20,044 and the health plan and 99 00:03:20,425 --> 00:03:21,885 payer side of the industry. 100 00:03:22,949 --> 00:03:25,189 But we have a job in population health 101 00:03:25,189 --> 00:03:28,790 to look across health systems, look across employers 102 00:03:28,790 --> 00:03:30,009 and state lines. 103 00:03:30,870 --> 00:03:32,790 When we do that at at a at 104 00:03:32,790 --> 00:03:34,090 a large data level, 105 00:03:34,469 --> 00:03:36,710 you see a lot of variation in clinical 106 00:03:36,710 --> 00:03:37,210 care. 107 00:03:38,444 --> 00:03:41,004 And that impacts medical quality. That impacts patient 108 00:03:41,004 --> 00:03:41,504 experience. 109 00:03:42,444 --> 00:03:44,544 It also impacts the broader community. 110 00:03:45,645 --> 00:03:48,125 When we waste resources, it means there's less 111 00:03:48,125 --> 00:03:49,645 to be used for everyone else. It's not 112 00:03:49,645 --> 00:03:51,344 a limitless ceiling. We can't continually 113 00:03:51,645 --> 00:03:52,705 spend more, 114 00:03:53,460 --> 00:03:55,159 and more and more as a society 115 00:03:55,620 --> 00:03:58,360 without driving higher quality medical outcomes. 116 00:03:58,819 --> 00:04:00,120 Happy to spend more 117 00:04:00,659 --> 00:04:01,159 when 118 00:04:01,540 --> 00:04:02,040 it's, 119 00:04:03,379 --> 00:04:04,840 corresponds with higher outcomes. 120 00:04:05,735 --> 00:04:07,735 But because it's a big data problem and 121 00:04:07,735 --> 00:04:09,655 because it spans a lot of complexity, it's 122 00:04:09,655 --> 00:04:12,235 perfect for technology. Let computers do 123 00:04:12,534 --> 00:04:13,275 the boring, 124 00:04:14,455 --> 00:04:17,035 challenging work of matching records, 125 00:04:17,415 --> 00:04:20,555 doing eligibilities for patients, doing eligibilities for facilities, 126 00:04:21,110 --> 00:04:22,889 doing eligibilities for providers, 127 00:04:24,310 --> 00:04:25,610 doing the code checks. 128 00:04:26,149 --> 00:04:27,610 Computers are great at that. 129 00:04:27,990 --> 00:04:31,029 And that's why software is superb for the 130 00:04:31,029 --> 00:04:33,189 solution and why we're happy to license what 131 00:04:33,189 --> 00:04:34,329 we do for other peep. 132 00:04:35,514 --> 00:04:37,435 It works. It works really well, and it 133 00:04:37,435 --> 00:04:39,115 lets our staff work at the top of 134 00:04:39,115 --> 00:04:41,194 their license, allows you to turn things around 135 00:04:41,194 --> 00:04:43,194 in minutes instead of days back to the 136 00:04:43,194 --> 00:04:43,694 patient. 137 00:04:44,074 --> 00:04:45,995 It's the benefit of that, and it results 138 00:04:45,995 --> 00:04:47,214 in higher medical quality. 139 00:04:47,819 --> 00:04:49,579 So tech can really solve a lot of 140 00:04:49,579 --> 00:04:50,399 problems here. 141 00:04:51,099 --> 00:04:53,419 So, ultimately, this is a scale issue in 142 00:04:53,419 --> 00:04:55,339 in your mind. And I I wonder you 143 00:04:55,339 --> 00:04:56,159 know, I remember 144 00:04:56,459 --> 00:04:58,459 like I I said in that original conversation 145 00:04:58,459 --> 00:05:00,319 that we had this summer, you had offered 146 00:05:00,904 --> 00:05:03,884 your your to license your technology to competitors. 147 00:05:05,064 --> 00:05:06,745 Have any taken you up on that since 148 00:05:06,745 --> 00:05:07,644 since our conversation? 149 00:05:08,745 --> 00:05:10,845 Yes. I will tell you it's in pilot 150 00:05:11,064 --> 00:05:12,204 with other companies. 151 00:05:14,069 --> 00:05:15,689 It's pretty straightforward to do, 152 00:05:16,069 --> 00:05:17,990 but, you know, large companies need time to 153 00:05:17,990 --> 00:05:20,490 make decisions and evaluate things, and that's perfectly 154 00:05:20,629 --> 00:05:21,129 understandable. 155 00:05:22,069 --> 00:05:24,889 But we're pretty pleased that others want to 156 00:05:25,509 --> 00:05:27,449 change what they're doing and 157 00:05:28,435 --> 00:05:30,055 make it more patient focused 158 00:05:30,595 --> 00:05:33,714 with faster turnaround times and lower cost and 159 00:05:33,714 --> 00:05:35,894 higher quality. So that's what the software allows. 160 00:05:36,115 --> 00:05:38,115 Certainly. So you mentioned this is also a 161 00:05:38,115 --> 00:05:40,914 technology problem, Chris. And and like I said, 162 00:05:40,914 --> 00:05:41,574 my original 163 00:05:42,000 --> 00:05:43,759 question, you know, I posed to you that 164 00:05:43,759 --> 00:05:46,660 this is a potentially a business model problem 165 00:05:46,800 --> 00:05:48,100 too for the industry. 166 00:05:48,560 --> 00:05:50,180 Do do you think that that's an accurate 167 00:05:50,400 --> 00:05:50,900 assessment? 168 00:05:51,759 --> 00:05:52,259 Absolutely. 169 00:05:53,360 --> 00:05:54,319 I think you have 170 00:05:55,435 --> 00:05:56,735 you've got organizations 171 00:05:57,115 --> 00:05:58,735 on the payer provider side 172 00:05:59,115 --> 00:06:00,095 on both sides 173 00:06:01,274 --> 00:06:01,774 that, 174 00:06:02,954 --> 00:06:04,014 to put it politely, 175 00:06:05,035 --> 00:06:07,694 are trying to maximize margin. 176 00:06:09,060 --> 00:06:11,300 And there are times to have margin. As 177 00:06:11,300 --> 00:06:12,819 the Sisters of Charity used to say, if 178 00:06:12,819 --> 00:06:14,439 you have no margin, you have no mission. 179 00:06:14,819 --> 00:06:17,139 Right? So having margin isn't a crime. None 180 00:06:17,139 --> 00:06:17,879 of us can 181 00:06:18,259 --> 00:06:20,680 build even nonprofits without margin. 182 00:06:21,735 --> 00:06:23,415 The challenge you have is you have very 183 00:06:23,415 --> 00:06:25,035 sophisticated large organizations 184 00:06:25,654 --> 00:06:26,154 and, 185 00:06:27,814 --> 00:06:29,514 on both sides, and 186 00:06:30,454 --> 00:06:31,915 there is a lot of optimization 187 00:06:32,294 --> 00:06:33,035 going on. 188 00:06:33,415 --> 00:06:34,555 And I would argue, 189 00:06:35,189 --> 00:06:37,430 my opinion, there's a lot of artificial friction 190 00:06:37,430 --> 00:06:37,930 created. 191 00:06:38,790 --> 00:06:39,529 And and 192 00:06:39,830 --> 00:06:41,930 there are parties on both sides that 193 00:06:42,310 --> 00:06:43,529 really push the extremes. 194 00:06:44,790 --> 00:06:45,290 And 195 00:06:45,990 --> 00:06:47,770 the way the business models work, 196 00:06:49,225 --> 00:06:49,805 you know, 197 00:06:50,105 --> 00:06:52,845 either side can outdo it outdo the other. 198 00:06:53,305 --> 00:06:55,865 And there's so for instance, on the the 199 00:06:55,865 --> 00:06:58,264 payers payer side, you have, 200 00:06:59,064 --> 00:06:59,564 organizations 201 00:07:00,024 --> 00:07:02,504 that in response to a bunch of garbage 202 00:07:02,504 --> 00:07:03,324 being submitted, 203 00:07:05,439 --> 00:07:06,980 expanded the number of codes 204 00:07:07,759 --> 00:07:09,620 that they put on the for qualification. 205 00:07:10,720 --> 00:07:12,879 And, hey, said, look. Let's pump the brakes 206 00:07:12,879 --> 00:07:14,000 a little bit. Let's take a little more 207 00:07:14,000 --> 00:07:16,160 time to evaluate this because too many things 208 00:07:16,160 --> 00:07:17,460 were getting pushed through 209 00:07:17,839 --> 00:07:19,939 that didn't meet medical quality or standards. 210 00:07:21,254 --> 00:07:22,775 And they erred on the side of too 211 00:07:22,775 --> 00:07:24,074 many codes and too slow. 212 00:07:24,775 --> 00:07:26,775 If you wanna be you know? And then 213 00:07:26,775 --> 00:07:28,775 on the on the provider side, you've got 214 00:07:28,775 --> 00:07:31,254 organizations that have contracted out their what they 215 00:07:31,254 --> 00:07:32,715 call revenue cycle management. 216 00:07:33,060 --> 00:07:34,899 They're not even directly talk talking to the 217 00:07:34,899 --> 00:07:36,259 health plan. They put it to a third 218 00:07:36,259 --> 00:07:38,199 party, and that third party is oftentimes 219 00:07:39,139 --> 00:07:39,639 submitting 220 00:07:40,579 --> 00:07:42,120 for anything they can think of, 221 00:07:42,980 --> 00:07:44,199 and often resubmitting. 222 00:07:44,899 --> 00:07:47,779 So they'll fire off the same claim nine 223 00:07:47,779 --> 00:07:48,279 times 224 00:07:48,814 --> 00:07:50,354 inside of forty five days. 225 00:07:51,134 --> 00:07:53,055 And the payer has to respond to all 226 00:07:53,055 --> 00:07:54,495 nine of those even though eight of them 227 00:07:54,495 --> 00:07:55,954 are dupes duplicates. 228 00:07:56,735 --> 00:07:58,574 This is just a couple of examples of 229 00:07:58,574 --> 00:08:01,555 how both sides kinda weaponized against each other. 230 00:08:02,175 --> 00:08:02,654 And, 231 00:08:03,919 --> 00:08:06,899 it's fundamentally because the business models aren't aligned 232 00:08:07,439 --> 00:08:10,160 around patient care. And that's why AHIP has 233 00:08:10,160 --> 00:08:12,180 stepped forward and said enough of this nonsense. 234 00:08:12,560 --> 00:08:14,899 50 of us has health plans, including EveryHealth. 235 00:08:16,415 --> 00:08:18,654 We're gonna lead the industry. We're gonna say, 236 00:08:18,654 --> 00:08:19,875 let's reduce the codes. 237 00:08:20,175 --> 00:08:21,074 We're gonna say, 238 00:08:21,615 --> 00:08:24,595 let's enforce more digital submissions so we 239 00:08:25,055 --> 00:08:26,995 can clearly identify dupes faster. 240 00:08:27,375 --> 00:08:29,314 We want patients to get an answer quickly, 241 00:08:29,615 --> 00:08:31,439 and we're gonna do this all based upon 242 00:08:31,439 --> 00:08:33,700 improving medical quality and patient experience. 243 00:08:34,480 --> 00:08:35,840 And so I think it's a great example 244 00:08:35,840 --> 00:08:37,600 of how a political organization can step in 245 00:08:37,600 --> 00:08:38,179 and say, 246 00:08:38,960 --> 00:08:40,740 everyone put the knives and forks down. 247 00:08:42,175 --> 00:08:44,014 Let's have a real conversation, and we'll we'll 248 00:08:44,014 --> 00:08:46,274 we'll be the first to start. Yeah. Absolutely. 249 00:08:46,495 --> 00:08:48,815 So AHIP has stepped in. A lot of 250 00:08:48,815 --> 00:08:50,575 this, I think, behind the scenes has been 251 00:08:50,575 --> 00:08:53,634 very much pushed by CMS, of course. 252 00:08:54,575 --> 00:08:56,250 And you say that it's a lot of 253 00:08:56,250 --> 00:08:57,950 the this issue that it's artificial, 254 00:08:58,570 --> 00:09:01,550 that it maybe could have been been fixed 255 00:09:01,929 --> 00:09:02,429 sooner. 256 00:09:03,769 --> 00:09:05,690 And on and on top of that that 257 00:09:05,690 --> 00:09:07,309 context of what's going on federally 258 00:09:07,769 --> 00:09:09,529 and and with AHIP and and all the 259 00:09:09,529 --> 00:09:10,670 groups that they represent, 260 00:09:10,995 --> 00:09:12,835 We we're seeing around the country. It's been 261 00:09:12,835 --> 00:09:14,835 happening for years, but it's really ramped up, 262 00:09:14,835 --> 00:09:16,754 I would say, the last year or two 263 00:09:16,754 --> 00:09:18,835 where we've seen a lot of the states 264 00:09:18,835 --> 00:09:20,215 take on this issue themselves. 265 00:09:21,235 --> 00:09:22,615 California, pretty notably 266 00:09:23,154 --> 00:09:26,120 this year, passed and and then, enacted two 267 00:09:26,120 --> 00:09:27,980 prior authorization reform bills, 268 00:09:28,759 --> 00:09:29,740 one mandating, 269 00:09:30,200 --> 00:09:32,620 quicker response times for these requests, 270 00:09:33,000 --> 00:09:36,120 another allowing the states or regulators to to 271 00:09:36,120 --> 00:09:36,620 waive, 272 00:09:37,574 --> 00:09:40,615 these requirements entirely for for certain services or 273 00:09:40,615 --> 00:09:42,315 certain approval rates that are achieved. 274 00:09:42,695 --> 00:09:43,514 And so 275 00:09:44,134 --> 00:09:45,815 I wonder, you know, from where you said, 276 00:09:45,815 --> 00:09:48,534 I know you're you're operating solely within Texas, 277 00:09:48,534 --> 00:09:51,190 but how effective do you think state level 278 00:09:51,190 --> 00:09:53,769 reforms are at actually reducing friction, 279 00:09:54,710 --> 00:09:56,970 you know, this this patchwork of state mandates 280 00:09:57,029 --> 00:09:59,669 versus what we're seeing now with with this 281 00:09:59,669 --> 00:10:01,990 pledge at the federal level with the private 282 00:10:01,990 --> 00:10:02,490 sector? 283 00:10:03,535 --> 00:10:05,535 I yeah. And I'll I'll be clear. I'm 284 00:10:05,535 --> 00:10:07,235 speaking personally here for myself. 285 00:10:07,935 --> 00:10:10,355 I'm not a fan of Patrick state regulation. 286 00:10:11,774 --> 00:10:14,175 Again, because as as health plans on the 287 00:10:14,175 --> 00:10:17,160 population population health side, we're spanning states, and 288 00:10:17,160 --> 00:10:18,779 it just creates system complexity. 289 00:10:20,360 --> 00:10:22,139 I'm more a fan of the voluntary, 290 00:10:23,160 --> 00:10:25,879 initiatives that we we're part of at AHIP 291 00:10:25,879 --> 00:10:27,500 that are looking nationally. 292 00:10:28,384 --> 00:10:29,745 Let's talk about some of the things in 293 00:10:29,745 --> 00:10:31,985 there. Effectively, what they're looking for is faster 294 00:10:31,985 --> 00:10:33,845 turnaround times and gold parting. 295 00:10:34,705 --> 00:10:35,205 And, 296 00:10:36,625 --> 00:10:37,524 I I don't 297 00:10:38,544 --> 00:10:40,625 I don't think you need more legislation to 298 00:10:40,625 --> 00:10:41,365 get there. 299 00:10:42,179 --> 00:10:44,360 Like, we we've proven you can 300 00:10:45,139 --> 00:10:47,399 you can do this at every help with, 301 00:10:48,019 --> 00:10:49,399 you know, 100% 302 00:10:49,540 --> 00:10:51,779 upheld upon appeal and only a 7% medical 303 00:10:51,779 --> 00:10:53,139 denial rate. And, oh, by the way, this 304 00:10:53,139 --> 00:10:54,980 year, we're driving even lower. I think we're 305 00:10:54,980 --> 00:10:56,740 on track this year to be somewhere around 306 00:10:56,740 --> 00:10:57,674 four to 5%. 307 00:10:58,875 --> 00:11:01,195 Again, always upheld on appeal. So you can 308 00:11:01,195 --> 00:11:02,014 use technology, 309 00:11:02,475 --> 00:11:04,254 and you can use voluntary commitments 310 00:11:04,794 --> 00:11:06,334 to improve the patient experience 311 00:11:06,634 --> 00:11:07,855 and to work with providers, 312 00:11:08,875 --> 00:11:11,115 and to improve medical quality and lower costs. 313 00:11:11,115 --> 00:11:12,254 It's it's all doable. 314 00:11:13,399 --> 00:11:14,620 Now having said that, 315 00:11:15,079 --> 00:11:17,079 I would say, you know, my goal and 316 00:11:17,079 --> 00:11:19,819 my organization's goal is, hey. Let's go further. 317 00:11:21,000 --> 00:11:22,940 What if we could eliminate PAs? 318 00:11:24,279 --> 00:11:25,899 What if we could gold card everything? 319 00:11:27,855 --> 00:11:31,394 And, Jacob, that requires partnership with providers. 320 00:11:32,014 --> 00:11:34,415 That requires partnership with the American Medical Association 321 00:11:34,415 --> 00:11:35,955 and the American Hospital Association. 322 00:11:36,575 --> 00:11:38,915 But we could get there as an industry, 323 00:11:39,830 --> 00:11:41,509 but I would put some backstory on it. 324 00:11:41,509 --> 00:11:42,009 Right? 325 00:11:42,389 --> 00:11:43,990 There has to be accountability. Hey. If you 326 00:11:43,990 --> 00:11:45,429 want us to gold card everything, that's like 327 00:11:45,429 --> 00:11:46,970 saying there's gonna be a blank check. 328 00:11:47,590 --> 00:11:49,029 We'll prove to us that you've got the 329 00:11:49,029 --> 00:11:49,529 clinical 330 00:11:49,990 --> 00:11:52,330 you you follow the your own clinical guidelines. 331 00:11:53,534 --> 00:11:55,855 Just follow your own guidelines. And the trouble 332 00:11:55,855 --> 00:11:58,115 is still a lot of large organizations 333 00:11:58,654 --> 00:12:00,975 and and provider groups don't follow their own 334 00:12:00,975 --> 00:12:01,634 care guidelines. 335 00:12:02,815 --> 00:12:06,355 And yet, we as a society gave $30,000,000,000 336 00:12:07,389 --> 00:12:10,370 of taxpayer money for EHR upgrades 337 00:12:11,070 --> 00:12:13,089 and systems upgrades across the industry. 338 00:12:13,789 --> 00:12:15,330 And yet we're still getting 339 00:12:16,029 --> 00:12:17,230 45% 340 00:12:17,230 --> 00:12:19,230 of our submissions that we receive are fax 341 00:12:19,230 --> 00:12:19,970 and paper. 342 00:12:21,375 --> 00:12:22,975 And and even then, we gotta dig through 343 00:12:22,975 --> 00:12:23,954 it all. So, like, 344 00:12:24,654 --> 00:12:26,574 my organization, I'd be willing to gold card 345 00:12:26,574 --> 00:12:29,134 everything if providers came to us and said, 346 00:12:29,134 --> 00:12:29,634 hey. 347 00:12:30,574 --> 00:12:32,975 We're following our own Garrett guidelines. It's all 348 00:12:32,975 --> 00:12:34,610 here in the EHR. 349 00:12:34,910 --> 00:12:36,370 We'll have a digital connection. 350 00:12:36,910 --> 00:12:38,590 And, hey, if we ever want a variance 351 00:12:38,590 --> 00:12:40,110 on something, like, hey, there's a good reason 352 00:12:40,110 --> 00:12:42,110 we're varying from the clinical guidelines. Here's all 353 00:12:42,110 --> 00:12:42,850 of our documentation. 354 00:12:43,389 --> 00:12:45,809 Great. Let's go. Let's do this. 355 00:12:46,345 --> 00:12:47,865 And we have the technology to do this 356 00:12:47,865 --> 00:12:49,544 at a national level, Jacob. There's no reason 357 00:12:49,544 --> 00:12:51,304 we couldn't take the best care guidelines of 358 00:12:51,304 --> 00:12:52,205 the whole world 359 00:12:52,745 --> 00:12:53,245 and 360 00:12:53,705 --> 00:12:55,304 every major system in The United States and 361 00:12:55,304 --> 00:12:57,085 put it in a single system of record 362 00:12:57,625 --> 00:12:59,789 or open source it and say hook that 363 00:12:59,789 --> 00:13:01,389 up to your EHR. And every point in 364 00:13:01,389 --> 00:13:03,549 time, for any given patient, you would know 365 00:13:03,549 --> 00:13:05,389 the next step in their journey of care 366 00:13:05,389 --> 00:13:06,450 based upon the evidence. 367 00:13:06,990 --> 00:13:09,070 And so I I think there's a way 368 00:13:09,070 --> 00:13:10,610 we could all do this nationally, 369 00:13:10,910 --> 00:13:13,454 but the patchwork approach of state by state 370 00:13:13,454 --> 00:13:16,034 legislations misses the forest for the trees. 371 00:13:16,495 --> 00:13:18,654 Sure. No. I I totally get that. And 372 00:13:18,654 --> 00:13:20,014 I think it's you know, when you look 373 00:13:20,014 --> 00:13:22,495 into some of these state bills even more 374 00:13:22,495 --> 00:13:24,674 into detail, you realize they don't necessarily, 375 00:13:25,855 --> 00:13:27,394 they don't affect or they don't, 376 00:13:27,990 --> 00:13:29,049 yeah, they don't affect 377 00:13:29,669 --> 00:13:31,429 the plans that most people are on. A 378 00:13:31,429 --> 00:13:32,970 lot of self insured plans, 379 00:13:33,509 --> 00:13:35,350 they really only affect the plans that states 380 00:13:35,350 --> 00:13:36,809 themselves can can regulate. 381 00:13:37,269 --> 00:13:38,470 And then, of course, you got the issue 382 00:13:38,470 --> 00:13:39,990 where a lot of health plans most health 383 00:13:39,990 --> 00:13:41,049 plans are operating 384 00:13:41,365 --> 00:13:43,445 in different states with, you know, employees that 385 00:13:43,445 --> 00:13:45,205 recover all over the country. You bring up 386 00:13:45,205 --> 00:13:47,285 a great point about what they actually regulate. 387 00:13:47,285 --> 00:13:49,205 A lot of states are regulating less than 388 00:13:49,205 --> 00:13:51,065 20% of the market. Yeah. 389 00:13:51,524 --> 00:13:53,705 Yeah. Because the rest of it's federally regulated, 390 00:13:53,845 --> 00:13:54,985 Medicare or 391 00:13:55,559 --> 00:13:57,960 ACA or self insured to your point under 392 00:13:57,960 --> 00:13:59,559 ERISA. Yeah. And, 393 00:14:00,440 --> 00:14:03,500 it's stopped making fully insured health plans, 394 00:14:04,679 --> 00:14:06,440 carry all the water for everyone else like 395 00:14:06,440 --> 00:14:06,940 Gangadine. 396 00:14:07,320 --> 00:14:09,660 Mhmm. If you're gonna regulate the market, regulate 397 00:14:09,720 --> 00:14:11,019 the entire market, 398 00:14:11,365 --> 00:14:13,524 not just 20% of it because that creates 399 00:14:13,524 --> 00:14:14,424 adverse selection. 400 00:14:14,725 --> 00:14:16,404 Yeah. And it's fascinating when you see the 401 00:14:16,404 --> 00:14:18,404 headlines as if it is affecting the whole 402 00:14:18,404 --> 00:14:18,904 market, 403 00:14:19,365 --> 00:14:20,884 because I think there is just not an 404 00:14:20,884 --> 00:14:21,384 understanding 405 00:14:21,845 --> 00:14:23,845 in the media of of the complexities of 406 00:14:23,845 --> 00:14:24,090 that. 407 00:14:25,290 --> 00:14:26,269 But before 408 00:14:26,730 --> 00:14:28,009 before we run out of time today, I 409 00:14:28,009 --> 00:14:30,250 do wanna make sure to ask you about, 410 00:14:30,889 --> 00:14:33,769 the the traditional Medicare prior auth pilot, which 411 00:14:33,769 --> 00:14:35,290 is set to go into effect in just 412 00:14:35,290 --> 00:14:36,134 a few weeks. 413 00:14:36,535 --> 00:14:38,855 We know who, the vendors are gonna be 414 00:14:38,855 --> 00:14:40,475 that are gonna administer this. 415 00:14:41,014 --> 00:14:42,455 A a good chunk of them are connected 416 00:14:42,455 --> 00:14:44,934 to insurers in some way. Either they they 417 00:14:44,934 --> 00:14:47,174 work with them already on prior auth or 418 00:14:47,174 --> 00:14:48,075 they've been funded 419 00:14:48,535 --> 00:14:49,195 by them. 420 00:14:50,299 --> 00:14:52,059 And and then if this for our listeners 421 00:14:52,059 --> 00:14:53,179 who might not be familiar, this is the 422 00:14:53,179 --> 00:14:56,379 wasteful and inappropriate service reduction pilot, w I 423 00:14:56,379 --> 00:14:57,600 s e r, initiative, 424 00:14:58,379 --> 00:15:01,419 starting in January, introducing prior auth requirements for 425 00:15:01,419 --> 00:15:03,039 17 services to traditional 426 00:15:03,605 --> 00:15:05,144 Medicare for the first time. 427 00:15:05,924 --> 00:15:07,924 There's been a lot of criticism this year. 428 00:15:08,725 --> 00:15:10,804 There's been legislation introduced in the house by 429 00:15:10,804 --> 00:15:13,625 Democrats to stop this entirely. The hospital association 430 00:15:13,764 --> 00:15:14,504 has been, 431 00:15:14,964 --> 00:15:16,264 critical of the legislation, 432 00:15:17,620 --> 00:15:19,220 specifically around the AI use that this is 433 00:15:19,220 --> 00:15:20,919 gonna introduce to the program, 434 00:15:21,299 --> 00:15:23,399 in terms of decision making, it sounds like. 435 00:15:23,860 --> 00:15:24,360 So, 436 00:15:25,220 --> 00:15:26,899 you know, what do you think about this, 437 00:15:26,899 --> 00:15:27,779 Chris, in terms of 438 00:15:28,500 --> 00:15:31,424 is adding prior auth requirements to traditional Medicare 439 00:15:31,424 --> 00:15:32,884 a step forward or backwards? 440 00:15:33,264 --> 00:15:35,024 And what should what does CMS need to 441 00:15:35,024 --> 00:15:36,945 get right here to avoid some of these 442 00:15:36,945 --> 00:15:39,825 problems that, we just lightly touched on in 443 00:15:39,825 --> 00:15:41,285 terms of the commercial market? 444 00:15:42,029 --> 00:15:42,529 Boom. 445 00:15:43,629 --> 00:15:45,170 There's a lot in there, Jacob. 446 00:15:46,110 --> 00:15:48,129 You know, first, it's a clever bill acronym 447 00:15:48,190 --> 00:15:49,009 there, WISER. 448 00:15:50,029 --> 00:15:50,430 And, 449 00:15:51,870 --> 00:15:53,310 you know, the challenge being, 450 00:15:53,870 --> 00:15:56,184 Medicare wasn't supposed to stay. I think what 451 00:15:56,184 --> 00:15:58,345 people forget is that Medicare wasn't supposed to 452 00:15:58,345 --> 00:16:00,584 stay the way it currently is. That originally 453 00:16:00,584 --> 00:16:01,725 Medicare Advantage 454 00:16:02,504 --> 00:16:04,125 was launched a long time ago 455 00:16:04,745 --> 00:16:06,664 and was meant to be kind of rolled 456 00:16:06,664 --> 00:16:07,404 back into. 457 00:16:08,090 --> 00:16:09,690 And so we wouldn't have Part a and 458 00:16:09,690 --> 00:16:12,029 Part b anymore in their current forms, 459 00:16:12,889 --> 00:16:15,470 that we're supposed to learn from Medicare Advantage. 460 00:16:15,769 --> 00:16:18,009 But the people that launched that and the 461 00:16:18,009 --> 00:16:20,570 leadership and the policies have now changed, and 462 00:16:20,570 --> 00:16:22,725 we have independent programs in the country of, 463 00:16:22,725 --> 00:16:25,365 in effect, Medicare and Medicare Advantage, two very 464 00:16:25,365 --> 00:16:26,184 different programs. 465 00:16:26,725 --> 00:16:28,485 And what I what I think the administration 466 00:16:28,565 --> 00:16:29,684 because I don't speak for the industry. What 467 00:16:29,684 --> 00:16:30,804 I think they're trying to do is trying 468 00:16:30,804 --> 00:16:32,085 to take some of the lessons learned from 469 00:16:32,085 --> 00:16:33,705 Medicare Advantage and pull it over. 470 00:16:34,649 --> 00:16:37,129 And one of those is that sometimes, again, 471 00:16:37,129 --> 00:16:38,909 you've got a lot of clinical variation. 472 00:16:39,610 --> 00:16:40,350 And it's 473 00:16:40,889 --> 00:16:41,629 too much 474 00:16:41,929 --> 00:16:44,569 too much clinical variation, and it has a 475 00:16:44,569 --> 00:16:47,629 big impact, particularly for a large federal program. 476 00:16:48,009 --> 00:16:49,370 And they're trying to reel that in a 477 00:16:49,370 --> 00:16:49,870 bit. 478 00:16:50,684 --> 00:16:52,924 The trick is it's very early. It's too 479 00:16:52,924 --> 00:16:55,085 soon to tell. We can't grade them on 480 00:16:55,085 --> 00:16:57,404 their performance. All they did was issue a 481 00:16:57,404 --> 00:16:58,304 request for 482 00:16:58,845 --> 00:16:59,345 proposals, 483 00:16:59,965 --> 00:17:02,125 and they've chosen some vendors. But they haven't 484 00:17:02,125 --> 00:17:03,404 done any work yet, so we have no 485 00:17:03,404 --> 00:17:04,625 way to judge their performance. 486 00:17:05,164 --> 00:17:06,640 I think it can be done very well, 487 00:17:06,640 --> 00:17:07,460 though, Jacob. 488 00:17:08,080 --> 00:17:10,259 I personally don't have a problem with using 489 00:17:11,519 --> 00:17:13,299 AI to do all the 490 00:17:13,680 --> 00:17:15,599 the boring work that no nurse and doctor 491 00:17:15,599 --> 00:17:17,599 wants to do. No nurse or doctor wants 492 00:17:17,599 --> 00:17:18,660 to scan through 493 00:17:18,964 --> 00:17:22,164 faxes and emails and go through 50 pages 494 00:17:22,164 --> 00:17:24,565 of notes to find the one thing that's 495 00:17:24,565 --> 00:17:26,664 the indication necessary to support 496 00:17:27,204 --> 00:17:28,265 the clinical guideline. 497 00:17:29,684 --> 00:17:30,505 But software 498 00:17:30,884 --> 00:17:32,099 and AI is just 499 00:17:32,419 --> 00:17:34,839 software, software does all that really well. 500 00:17:35,779 --> 00:17:37,539 So it can be a decision support tool 501 00:17:37,539 --> 00:17:39,220 presented to the nurses and doctors. Say, hey. 502 00:17:39,220 --> 00:17:42,599 Look. We found three indications of breast cancer. 503 00:17:43,619 --> 00:17:44,440 This supports, 504 00:17:45,085 --> 00:17:47,805 you know, further treatment. Let's go. And let 505 00:17:47,805 --> 00:17:49,485 the nurse or doctor go straight to the 506 00:17:49,485 --> 00:17:51,424 point in the notes that have the indications. 507 00:17:52,205 --> 00:17:54,625 They got directed straight to the the guidelines. 508 00:17:54,765 --> 00:17:55,505 And so 509 00:17:56,045 --> 00:17:57,299 they're able to work at the top of 510 00:17:57,299 --> 00:17:59,500 the license and do more patient care, and 511 00:17:59,500 --> 00:18:01,099 they get a turnaround time back to the 512 00:18:01,099 --> 00:18:02,319 patient. It's quick. 513 00:18:02,700 --> 00:18:03,759 Everybody wins. 514 00:18:04,700 --> 00:18:06,940 So as much as people are frustrated by 515 00:18:06,940 --> 00:18:09,359 Medicare all of a sudden having a potential 516 00:18:09,419 --> 00:18:11,819 new process to it, it may not be 517 00:18:11,819 --> 00:18:12,720 a bad thing. 518 00:18:13,315 --> 00:18:14,455 That's just my opinion. 519 00:18:15,394 --> 00:18:16,455 It'll be interesting 520 00:18:17,075 --> 00:18:18,775 to watch it as as we 521 00:18:19,075 --> 00:18:20,994 go into next year. I know from our 522 00:18:21,075 --> 00:18:22,835 from where we sit, you know, we hear 523 00:18:22,835 --> 00:18:24,914 a variety of opinions on this, from it 524 00:18:24,914 --> 00:18:25,414 being 525 00:18:25,970 --> 00:18:28,130 the end of Medicare according to some to 526 00:18:28,130 --> 00:18:30,210 some saying it's the modernization and, like you've 527 00:18:30,210 --> 00:18:32,369 said, bringing over some of those lessons learned 528 00:18:32,369 --> 00:18:35,570 from Medicare Advantage. So definitely something we're gonna 529 00:18:35,570 --> 00:18:37,029 be keeping our eye on as well. 530 00:18:37,490 --> 00:18:39,809 And their concern is a federal program is 531 00:18:39,809 --> 00:18:40,710 also cost. 532 00:18:41,054 --> 00:18:43,294 Right? Sure. One of the biggest things in 533 00:18:43,294 --> 00:18:46,194 The United States is just affordability, affordability, affordability 534 00:18:46,414 --> 00:18:47,154 right now, 535 00:18:47,534 --> 00:18:48,994 in terms of political messaging. 536 00:18:49,534 --> 00:18:50,355 And HHS's 537 00:18:50,894 --> 00:18:51,394 budget 538 00:18:51,774 --> 00:18:55,075 is huge now. Yeah. Right? And it's growing, 539 00:18:56,279 --> 00:18:58,140 at a faster rate than the economy. 540 00:18:59,080 --> 00:19:00,759 At this rate, it's if it continues at 541 00:19:00,759 --> 00:19:02,279 this rate, it may have already eclipsed it, 542 00:19:02,279 --> 00:19:03,960 but I think it's probably on track to 543 00:19:03,960 --> 00:19:05,740 equal the entire budget of DOD. 544 00:19:06,440 --> 00:19:08,840 Yeah. And, I mean, they wouldn't 545 00:19:09,855 --> 00:19:12,335 the government has to look at some things 546 00:19:12,335 --> 00:19:15,054 and say, hey. At what point is this 547 00:19:15,054 --> 00:19:15,795 too expensive? 548 00:19:16,255 --> 00:19:18,755 Yeah. Maybe we could manage this better. 549 00:19:19,375 --> 00:19:21,214 This may not be the correct way to 550 00:19:21,214 --> 00:19:22,355 manage it, but 551 00:19:22,960 --> 00:19:25,600 at least they're looking at some pros and 552 00:19:25,600 --> 00:19:27,119 cons and trade offs, and they're willing to 553 00:19:27,119 --> 00:19:30,160 try something and experiment. Definitely. To be said, 554 00:19:30,160 --> 00:19:31,360 I would say look at it in the 555 00:19:31,360 --> 00:19:33,059 bigger picture of Medicare Advantage 556 00:19:34,000 --> 00:19:34,500 was 557 00:19:35,585 --> 00:19:38,305 long term originally meant to become or pull 558 00:19:38,305 --> 00:19:40,404 all the lessons from MA into Medicare. 559 00:19:41,424 --> 00:19:42,785 So if you think of it on that 560 00:19:42,785 --> 00:19:44,865 long arc of fifteen years of policy and 561 00:19:44,865 --> 00:19:46,545 planning, this is really just coming back to 562 00:19:46,545 --> 00:19:47,445 where we started. 563 00:19:48,065 --> 00:19:49,445 It's not so radical. 564 00:19:50,619 --> 00:19:52,319 Well, Chris, before we go, 565 00:19:53,099 --> 00:19:56,079 anything that we're missing? Anything you wanna share 566 00:19:56,460 --> 00:19:58,619 with the wider industry while you have their 567 00:19:58,619 --> 00:20:00,559 years or or any reflections, 568 00:20:01,500 --> 00:20:03,919 of of the year that just occurred? 569 00:20:04,724 --> 00:20:06,644 Well, every time I go into a room 570 00:20:06,644 --> 00:20:07,144 now, 571 00:20:07,924 --> 00:20:09,684 and it's not a room of friends and 572 00:20:09,684 --> 00:20:10,184 family, 573 00:20:11,684 --> 00:20:12,984 as soon as they learn 574 00:20:13,365 --> 00:20:16,325 what industry I work in or who I 575 00:20:16,325 --> 00:20:17,304 work for, 576 00:20:17,684 --> 00:20:20,025 it's like the tension automatically increases. 577 00:20:21,019 --> 00:20:22,380 And I think many of my peers in 578 00:20:22,380 --> 00:20:23,919 the industry have the same issue. 579 00:20:24,460 --> 00:20:26,140 And so what I would encourage people to 580 00:20:26,140 --> 00:20:27,039 do is 581 00:20:27,500 --> 00:20:28,000 engage. 582 00:20:28,779 --> 00:20:30,380 When they engage with us and they have 583 00:20:30,380 --> 00:20:31,759 real, honest conversations, 584 00:20:32,779 --> 00:20:34,000 the temperature drops. 585 00:20:34,625 --> 00:20:36,225 People went, oh, you've got a reason for 586 00:20:36,225 --> 00:20:37,684 that. Oh, that makes sense. 587 00:20:38,384 --> 00:20:40,625 People want a real and honest dialogue in 588 00:20:40,625 --> 00:20:42,705 this country right now, and I think we 589 00:20:42,705 --> 00:20:44,945 as leaders in industry have an obligation to 590 00:20:44,945 --> 00:20:47,045 provide that. And we do that. 591 00:20:47,505 --> 00:20:48,805 We find commonality. 592 00:20:49,690 --> 00:20:50,990 And in that commonality, 593 00:20:51,529 --> 00:20:52,509 we can move 594 00:20:53,210 --> 00:20:54,509 entire industries forward, 595 00:20:54,890 --> 00:20:56,349 and we can shift communities 596 00:20:56,970 --> 00:20:59,369 to better population health. And so I just 597 00:20:59,369 --> 00:21:02,009 encourage everyone over the holidays here, don't be 598 00:21:02,009 --> 00:21:03,230 afraid of the hard conversations. 599 00:21:04,244 --> 00:21:07,365 Have common ones. Have candid ones, and, enjoy 600 00:21:07,365 --> 00:21:08,025 the holidays. 601 00:21:08,884 --> 00:21:10,505 That's really great advice. Humanize 602 00:21:10,805 --> 00:21:11,625 your industry. 603 00:21:12,085 --> 00:21:14,005 Chris Gay, I really appreciate you taking the 604 00:21:14,005 --> 00:21:16,484 time to chat with me, before year's end 605 00:21:16,484 --> 00:21:16,984 and 606 00:21:17,419 --> 00:21:20,220 really appreciate you sharing your expertise and your 607 00:21:20,220 --> 00:21:22,539 thoughts with our audience. Thank you. Thank you, 608 00:21:22,539 --> 00:21:23,039 Jacob. 609 00:21:23,419 --> 00:21:24,859 And to our audience, if you'd like to 610 00:21:24,859 --> 00:21:27,019 listen to more podcasts from Becker's, you can 611 00:21:27,019 --> 00:21:29,599 visit beckershospitalreview.com.