Hello, everyone. This is Jacob Amerson with the
Becker's Payer Issues podcast.
Thrilled today to be joined by Chris Gay,
who is the CEO of EveryHealth.
Chris, thanks you so much for taking the
time to be here with me once again
on the podcast.
Well, thank you, Jacob, for having me on
on the podcast.
Absolutely. And before we dive into everything we
wanna talk with you about today, Chris, for
our audience that might not be familiar, can
you tell them a little bit about yourself
and what it is that you do at
EveryHealth?
Sure.
Chris Gay. I'm the CEO and one of
the cofounders of EveryHealth. So I was a
software developer by training, and that's turned serial
entrepreneur.
And, inside of EveryHealth,
I mostly set the strategy
and, make sure that we have the resources
to fulfill that strategy. And, and that includes
a lot of talent and recruitment.
And in terms of our company,
we started eight years ago as a start
up
trying to address issues that we felt were
inequities in US health care around access and
quality and engagement and total cost.
And,
we started out in Silicon Valley with a
$120,000.
Now what you can best think of us
as a software company that owns a full
health insurer.
And,
we focus on the mid market commercial mid
market fully insured.
Most of our membership is in the state
of Texas.
Fantastic. So a bit of a unique structure
there,
in terms of the wider industry landscape, Chris.
And I wanted to start us off by
going back to the conversation that you and
I had had here on the podcast about
six months ago this summer.
You had mentioned that EveryHealth has achieved a
7%
prior authorization denial rate with 100% of those
denials upheld on appeal,
which as you know, far out outperforms
the industry average.
And and then you also offered to license
your technology that, has led you to achieve
that to competitors.
So I wonder, you know, broadly, if we're
looking out across the industry, this is a
topic that gets a lot of negative headlines,
a lot of bad press for a lot
of insurers.
So,
you know and this is all, of course
the the context here is, you know, this
summer, nearly 50 insurers committed to,
standardizing
electronic prior auth processes, including EveryHealth,
in collaboration
with the government. And so
broadly, across the industry, what what's the biggest
obstacle here, do you think,
that's preventing
larger insurers especially from
replicating what you've built at EveryHealth?
Is it fundamentally
a technology problem, like we heard doctor Oz
suggest this summer,
or is this a business model problem at
its core, or is it something else? What
do you think?
Oh,
I think it's
three things.
So I'll I'll, I'll answer the first one
as the technology, and you can come back
with the other two as follow-up questions.
It is a technology issue,
and it's a technology issue. And, again, I
I think it's the other two things as
well.
But it's a technology issue because of the
scale.
Prior authorizations are a shared frustration
by both the medical provider community
and health systems and physicians
and the health plan and
payer side of the industry.
But we have a job in population health
to look across health systems, look across employers
and state lines.
When we do that at at a at
a large data level,
you see a lot of variation in clinical
care.
And that impacts medical quality. That impacts patient
experience.
It also impacts the broader community.
When we waste resources, it means there's less
to be used for everyone else. It's not
a limitless ceiling. We can't continually
spend more,
and more and more as a society
without driving higher quality medical outcomes.
Happy to spend more
when
it's,
corresponds with higher outcomes.
But because it's a big data problem and
because it spans a lot of complexity, it's
perfect for technology. Let computers do
the boring,
challenging work of matching records,
doing eligibilities for patients, doing eligibilities for facilities,
doing eligibilities for providers,
doing the code checks.
Computers are great at that.
And that's why software is superb for the
solution and why we're happy to license what
we do for other peep.
It works. It works really well, and it
lets our staff work at the top of
their license, allows you to turn things around
in minutes instead of days back to the
patient.
It's the benefit of that, and it results
in higher medical quality.
So tech can really solve a lot of
problems here.
So, ultimately, this is a scale issue in
in your mind. And I I wonder you
know, I remember
like I I said in that original conversation
that we had this summer, you had offered
your your to license your technology to competitors.
Have any taken you up on that since
since our conversation?
Yes. I will tell you it's in pilot
with other companies.
It's pretty straightforward to do,
but, you know, large companies need time to
make decisions and evaluate things, and that's perfectly
understandable.
But we're pretty pleased that others want to
change what they're doing and
make it more patient focused
with faster turnaround times and lower cost and
higher quality. So that's what the software allows.
Certainly. So you mentioned this is also a
technology problem, Chris. And and like I said,
my original
question, you know, I posed to you that
this is a potentially a business model problem
too for the industry.
Do do you think that that's an accurate
assessment?
Absolutely.
I think you have
you've got organizations
on the payer provider side
on both sides
that,
to put it politely,
are trying to maximize margin.
And there are times to have margin. As
the Sisters of Charity used to say, if
you have no margin, you have no mission.
Right? So having margin isn't a crime. None
of us can
build even nonprofits without margin.
The challenge you have is you have very
sophisticated large organizations
and,
on both sides, and
there is a lot of optimization
going on.
And I would argue,
my opinion, there's a lot of artificial friction
created.
And and
there are parties on both sides that
really push the extremes.
And
the way the business models work,
you know,
either side can outdo it outdo the other.
And there's so for instance, on the the
payers payer side, you have,
organizations
that in response to a bunch of garbage
being submitted,
expanded the number of codes
that they put on the for qualification.
And, hey, said, look. Let's pump the brakes
a little bit. Let's take a little more
time to evaluate this because too many things
were getting pushed through
that didn't meet medical quality or standards.
And they erred on the side of too
many codes and too slow.
If you wanna be you know? And then
on the on the provider side, you've got
organizations that have contracted out their what they
call revenue cycle management.
They're not even directly talk talking to the
health plan. They put it to a third
party, and that third party is oftentimes
submitting
for anything they can think of,
and often resubmitting.
So they'll fire off the same claim nine
times
inside of forty five days.
And the payer has to respond to all
nine of those even though eight of them
are dupes duplicates.
This is just a couple of examples of
how both sides kinda weaponized against each other.
And,
it's fundamentally because the business models aren't aligned
around patient care. And that's why AHIP has
stepped forward and said enough of this nonsense.
50 of us has health plans, including EveryHealth.
We're gonna lead the industry. We're gonna say,
let's reduce the codes.
We're gonna say,
let's enforce more digital submissions so we
can clearly identify dupes faster.
We want patients to get an answer quickly,
and we're gonna do this all based upon
improving medical quality and patient experience.
And so I think it's a great example
of how a political organization can step in
and say,
everyone put the knives and forks down.
Let's have a real conversation, and we'll we'll
we'll be the first to start. Yeah. Absolutely.
So AHIP has stepped in. A lot of
this, I think, behind the scenes has been
very much pushed by CMS, of course.
And you say that it's a lot of
the this issue that it's artificial,
that it maybe could have been been fixed
sooner.
And on and on top of that that
context of what's going on federally
and and with AHIP and and all the
groups that they represent,
We we're seeing around the country. It's been
happening for years, but it's really ramped up,
I would say, the last year or two
where we've seen a lot of the states
take on this issue themselves.
California, pretty notably
this year, passed and and then, enacted two
prior authorization reform bills,
one mandating,
quicker response times for these requests,
another allowing the states or regulators to to
waive,
these requirements entirely for for certain services or
certain approval rates that are achieved.
And so
I wonder, you know, from where you said,
I know you're you're operating solely within Texas,
but how effective do you think state level
reforms are at actually reducing friction,
you know, this this patchwork of state mandates
versus what we're seeing now with with this
pledge at the federal level with the private
sector?
I yeah. And I'll I'll be clear. I'm
speaking personally here for myself.
I'm not a fan of Patrick state regulation.
Again, because as as health plans on the
population population health side, we're spanning states, and
it just creates system complexity.
I'm more a fan of the voluntary,
initiatives that we we're part of at AHIP
that are looking nationally.
Let's talk about some of the things in
there. Effectively, what they're looking for is faster
turnaround times and gold parting.
And,
I I don't
I don't think you need more legislation to
get there.
Like, we we've proven you can
you can do this at every help with,
you know, 100%
upheld upon appeal and only a 7% medical
denial rate. And, oh, by the way, this
year, we're driving even lower. I think we're
on track this year to be somewhere around
four to 5%.
Again, always upheld on appeal. So you can
use technology,
and you can use voluntary commitments
to improve the patient experience
and to work with providers,
and to improve medical quality and lower costs.
It's it's all doable.
Now having said that,
I would say, you know, my goal and
my organization's goal is, hey. Let's go further.
What if we could eliminate PAs?
What if we could gold card everything?
And, Jacob, that requires partnership with providers.
That requires partnership with the American Medical Association
and the American Hospital Association.
But we could get there as an industry,
but I would put some backstory on it.
Right?
There has to be accountability. Hey. If you
want us to gold card everything, that's like
saying there's gonna be a blank check.
We'll prove to us that you've got the
clinical
you you follow the your own clinical guidelines.
Just follow your own guidelines. And the trouble
is still a lot of large organizations
and and provider groups don't follow their own
care guidelines.
And yet, we as a society gave $30,000,000,000
of taxpayer money for EHR upgrades
and systems upgrades across the industry.
And yet we're still getting
45%
of our submissions that we receive are fax
and paper.
And and even then, we gotta dig through
it all. So, like,
my organization, I'd be willing to gold card
everything if providers came to us and said,
hey.
We're following our own Garrett guidelines. It's all
here in the EHR.
We'll have a digital connection.
And, hey, if we ever want a variance
on something, like, hey, there's a good reason
we're varying from the clinical guidelines. Here's all
of our documentation.
Great. Let's go. Let's do this.
And we have the technology to do this
at a national level, Jacob. There's no reason
we couldn't take the best care guidelines of
the whole world
and
every major system in The United States and
put it in a single system of record
or open source it and say hook that
up to your EHR. And every point in
time, for any given patient, you would know
the next step in their journey of care
based upon the evidence.
And so I I think there's a way
we could all do this nationally,
but the patchwork approach of state by state
legislations misses the forest for the trees.
Sure. No. I I totally get that. And
I think it's you know, when you look
into some of these state bills even more
into detail, you realize they don't necessarily,
they don't affect or they don't,
yeah, they don't affect
the plans that most people are on. A
lot of self insured plans,
they really only affect the plans that states
themselves can can regulate.
And then, of course, you got the issue
where a lot of health plans most health
plans are operating
in different states with, you know, employees that
recover all over the country. You bring up
a great point about what they actually regulate.
A lot of states are regulating less than
20% of the market. Yeah.
Yeah. Because the rest of it's federally regulated,
Medicare or
ACA or self insured to your point under
ERISA. Yeah. And,
it's stopped making fully insured health plans,
carry all the water for everyone else like
Gangadine.
Mhmm. If you're gonna regulate the market, regulate
the entire market,
not just 20% of it because that creates
adverse selection.
Yeah. And it's fascinating when you see the
headlines as if it is affecting the whole
market,
because I think there is just not an
understanding
in the media of of the complexities of
that.
But before
before we run out of time today, I
do wanna make sure to ask you about,
the the traditional Medicare prior auth pilot, which
is set to go into effect in just
a few weeks.
We know who, the vendors are gonna be
that are gonna administer this.
A a good chunk of them are connected
to insurers in some way. Either they they
work with them already on prior auth or
they've been funded
by them.
And and then if this for our listeners
who might not be familiar, this is the
wasteful and inappropriate service reduction pilot, w I
s e r, initiative,
starting in January, introducing prior auth requirements for
17 services to traditional
Medicare for the first time.
There's been a lot of criticism this year.
There's been legislation introduced in the house by
Democrats to stop this entirely. The hospital association
has been,
critical of the legislation,
specifically around the AI use that this is
gonna introduce to the program,
in terms of decision making, it sounds like.
So,
you know, what do you think about this,
Chris, in terms of
is adding prior auth requirements to traditional Medicare
a step forward or backwards?
And what should what does CMS need to
get right here to avoid some of these
problems that, we just lightly touched on in
terms of the commercial market?
Boom.
There's a lot in there, Jacob.
You know, first, it's a clever bill acronym
there, WISER.
And,
you know, the challenge being,
Medicare wasn't supposed to stay. I think what
people forget is that Medicare wasn't supposed to
stay the way it currently is. That originally
Medicare Advantage
was launched a long time ago
and was meant to be kind of rolled
back into.
And so we wouldn't have Part a and
Part b anymore in their current forms,
that we're supposed to learn from Medicare Advantage.
But the people that launched that and the
leadership and the policies have now changed, and
we have independent programs in the country of,
in effect, Medicare and Medicare Advantage, two very
different programs.
And what I what I think the administration
because I don't speak for the industry. What
I think they're trying to do is trying
to take some of the lessons learned from
Medicare Advantage and pull it over.
And one of those is that sometimes, again,
you've got a lot of clinical variation.
And it's
too much
too much clinical variation, and it has a
big impact, particularly for a large federal program.
And they're trying to reel that in a
bit.
The trick is it's very early. It's too
soon to tell. We can't grade them on
their performance. All they did was issue a
request for
proposals,
and they've chosen some vendors. But they haven't
done any work yet, so we have no
way to judge their performance.
I think it can be done very well,
though, Jacob.
I personally don't have a problem with using
AI to do all the
the boring work that no nurse and doctor
wants to do. No nurse or doctor wants
to scan through
faxes and emails and go through 50 pages
of notes to find the one thing that's
the indication necessary to support
the clinical guideline.
But software
and AI is just
software, software does all that really well.
So it can be a decision support tool
presented to the nurses and doctors. Say, hey.
Look. We found three indications of breast cancer.
This supports,
you know, further treatment. Let's go. And let
the nurse or doctor go straight to the
point in the notes that have the indications.
They got directed straight to the the guidelines.
And so
they're able to work at the top of
the license and do more patient care, and
they get a turnaround time back to the
patient. It's quick.
Everybody wins.
So as much as people are frustrated by
Medicare all of a sudden having a potential
new process to it, it may not be
a bad thing.
That's just my opinion.
It'll be interesting
to watch it as as we
go into next year. I know from our
from where we sit, you know, we hear
a variety of opinions on this, from it
being
the end of Medicare according to some to
some saying it's the modernization and, like you've
said, bringing over some of those lessons learned
from Medicare Advantage. So definitely something we're gonna
be keeping our eye on as well.
And their concern is a federal program is
also cost.
Right? Sure. One of the biggest things in
The United States is just affordability, affordability, affordability
right now,
in terms of political messaging.
And HHS's
budget
is huge now. Yeah. Right? And it's growing,
at a faster rate than the economy.
At this rate, it's if it continues at
this rate, it may have already eclipsed it,
but I think it's probably on track to
equal the entire budget of DOD.
Yeah. And, I mean, they wouldn't
the government has to look at some things
and say, hey. At what point is this
too expensive?
Yeah. Maybe we could manage this better.
This may not be the correct way to
manage it, but
at least they're looking at some pros and
cons and trade offs, and they're willing to
try something and experiment. Definitely. To be said,
I would say look at it in the
bigger picture of Medicare Advantage
was
long term originally meant to become or pull
all the lessons from MA into Medicare.
So if you think of it on that
long arc of fifteen years of policy and
planning, this is really just coming back to
where we started.
It's not so radical.
Well, Chris, before we go,
anything that we're missing? Anything you wanna share
with the wider industry while you have their
years or or any reflections,
of of the year that just occurred?
Well, every time I go into a room
now,
and it's not a room of friends and
family,
as soon as they learn
what industry I work in or who I
work for,
it's like the tension automatically increases.
And I think many of my peers in
the industry have the same issue.
And so what I would encourage people to
do is
engage.
When they engage with us and they have
real, honest conversations,
the temperature drops.
People went, oh, you've got a reason for
that. Oh, that makes sense.
People want a real and honest dialogue in
this country right now, and I think we
as leaders in industry have an obligation to
provide that. And we do that.
We find commonality.
And in that commonality,
we can move
entire industries forward,
and we can shift communities
to better population health. And so I just
encourage everyone over the holidays here, don't be
afraid of the hard conversations.
Have common ones. Have candid ones, and, enjoy
the holidays.
That's really great advice. Humanize
your industry.
Chris Gay, I really appreciate you taking the
time to chat with me, before year's end
and
really appreciate you sharing your expertise and your
thoughts with our audience. Thank you. Thank you,
Jacob.
And to our audience, if you'd like to
listen to more podcasts from Becker's, you can
visit beckershospitalreview.com.