This is where health insurance leadership comes together.
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together over 400 payer and health plan executives
and more than 100 speakers to Chicago April.
This year's event includes keynote conversations with the
industry's top leaders and former president George W.
Bush. For the full agenda and event details,
visit beckershospitalreview.com
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here in Chicago.
Hello, everyone, and welcome to the Becker's Healthcare
Podcast. I'm Scott King. Thrilled today to be
joined by a very special guest, doctor Dominique
Chauby, vice president,
clinical affairs with Clover Health. Doctor Chauby, how
are you doing today? Thanks so much for
joining us. Oh, thank you so much, Scott,
and, thank you for giving me this opportunity
to share my perspectives.
Oh, no. It's wonderful to have you, and,
you know, we're gonna we're gonna need your
perspective, but there's a lot going on in
health care right now. So, before we get
to, you know, some of the topics I
wanted to ask you about, I was wondering
if you could please just tell us a
little bit about your your background in health
care and your your journey there.
Sure.
So as you mentioned, I'm Damanjeet Chabe. I'm
the vice president of clinical affairs
at Clover Health.
Been with Clover since November
2021.
But prior to that,
you know, I've been in the health care
industry for more than twenty five years on
the health care system side as a physician
leader
in a variety of,
you know, roles.
And,
and, actually, I think one of my passion
really is
how do we deliver the best,
quality care to our Medicare beneficiaries.
And that's really, I think, all my experience
is kind of coming together,
you know, in my position here at Yover.
Thanks for sharing that info. You know, definitely
paints a picture on why your perspective is
unique here. And the first thing I wanted
to ask you about is,
you know, how are your relationships with providers
changing
as both sides face cost pressure and, you
know, workforce shortages specifically?
Yeah.
I think that's a great question. I would
say the short answer is that,
you know, the rising cost pressure and workforce
shortages,
I they are, and they will continue to
shift away.
My my sense really is that, you know,
we are gonna see a shift away from
a simple fee for service contracting
towards people thinking more deeply
about,
you know, either risk sharing
or operational partnerships,
whether those are kind of like joint ventures
or value based primary care or home based
care models.
And for us at Clover Health,
I think our unique and very differentiated
model,
which is an MA plan, but is leveraged
with a technology platform
and a very mature home based care model
are the foundational strengths, you know, that are
driving this value based relationship with our primary
care providers
and that support our home based care model.
And, really, I think to my mind, you
know, I actually would love to, even, give
more color to this
because first, our,
you know, our, Clover Assistant Technology,
right, that our platform
really is a physician enablement,
AI platform.
And it kind of unifies data from more
than 100,
you know, sources,
EHRs,
HIEs,
labs, pharmacy claims,
and really surfaces
very specific,
patient specific
guideline aligned insights at the point of care.
So you can well imagine
physicians, primary care physicians who are so busy
in their offices,
for them to get this meaningful data,
you know, is extremely valuable, and it helps
in this cost equation and this very resource
scarce
environment because how do they even know many
a times who got admitted,
who got discharged,
what was the discharge diagnosis,
which patient is at high risk,
which patient hasn't had their screening mammogram.
So I think that's a huge value add.
You know, we we help them find that
needle in the haystack
so that they can focus on the clinical
care. And secondly, I would say that our
Clover home care program
really is helping support this cost pressure and
work shortage issue Mhmm. Because we, you know,
we have a we have an MD, NP,
led longitudinal care, which is delivered at home
at no cost to the patient.
It's really tailored to the medical and social
needs of our members
and supports them across their health care journey,
meaning from an acute crisis
to a chronic disease management,
trans you know, from palliative care at home
to transitioning them to hospice.
So
imagine that the synergistic
model that we have, that primary care,
you know, in the office
supported
by, you know,
supported by, like, care at home for the
elderly, for the frail, for the ones who
are, like,
with advanced illness, limited life expectancy.
I mean, that really is a model that
combines,
you know, the best of both worlds so
that we can make a huge difference in
our patient population.
You know, I've I've spoken with a lot
of people on the payer side recently, and
they're kinda categorizing
that, you know, the the payer provider relationship
now is a lot
less transactional than it used to be. It's
a lot more kinda coming from an area
of of problem solving with you just you
know, some of the pressures we you just
talked about that Yeah. Kind of both sides
are facing. Is is that what you're seeing,
doctor Chabi? Is kind of Yes. Everyone's getting
together to problem solve more now? I think
so. I think I I I totally agree
with you. I think we see that.
You know, we need to problem solve together.
I think people realize that we have built
lots of silos.
Right? And, you know,
each one does their own thing within their
own silos,
and we are not able to do this
horizontal
connectivity,
as we really would like to do and
kind of reduce this fragmentation of care.
And, you know, so people are vying for
the same resources.
Right? And they're trying to solve the same
problems. So why don't we get, you know,
kind of combine our efforts,
for problem solving that?
Absolutely.
And the other thing I wanna ask you,
where do you see the biggest gap today
between payer strategy
and operational execution?
I, you know, I think I think plans
realize. Right? I think plans know that they
must manage utilization,
because
I what
and they cannot consistently intervene. Right? Early, in
person, and with clinical authority.
So what I'm seeing is that there is
this,
you know, that even though that most MA
plans, I would say, usually will have very
similar strategies, right, on paper.
But where peep where plans can fail
is when you do not translate those strategies
into kind of reliable, repeatable
execution,
so that you can kind of deliver the
right care to the right member at the
right time. So let's kind of, like you
know, I was thinking that,
like, when we think about this, you know,
what are some of kind of, like, illustrative
examples?
So let's just say that, you know, on
on paper, a strategy
may very well be that, right, we need
to manage utilization.
But
how do we reduce these avoidable admissions or
readmissions through a value based care or a
home based
services and better coordination.
Because
we find that even though that's the idea,
but in the execution,
the reality is that
we sometimes, the MA plan, don't even know,
you know, who those high risk members are.
And even if you identify them, then you
actually are identifying the event after it has
actually already happened. And then when you do
oppose discharge
kind of an outreach, it can be delayed.
And, really, it's telephonic.
Majority of the time, that's really what happens.
Right? And it's nonclinical.
Or if it is clinical, then it's a
kind of a low authority. It's an RN
based care management based phone calls,
who really don't have any prescribing power.
So I feel that the interventions then become
too late. They are too weak. And the
execution gap really becomes, I think, this decisive
clinical action, which I think is just so
important.
Because if we don't control
the clinical capacity and how that clinical capacity
actually acts,
that is really the gap which I see
because you really can't phone coach your way
out of, you know, like, this acute instability.
And having joint you know, like, having delegation,
working with vendors sometimes,
having value based contracts don't necessarily
guarantee execution.
So I think that's where the gap could
be because
everyone's busy. Health systems are inpatient
centric.
PCPs are overloaded.
You know, and there's home you know, and
home health has its own capacity constraints.
So I it all becomes like, you know,
what we think about the strategy as home
based care, for example, but the operation actually
becomes just a telephonic care. And we have
to kind of, like I think that be
that is kind of, like, the biggest,
observations that I've had.
And that is why I feel that
even having data, you can have risk models,
you can have predictive analytics, you can have
dashboards.
But if those insights don't actually reach your
frontline clinicians,
those alerts are really not actionable.
And they have to be in real time.
So, otherwise, analytics without this activation is just
kind of reporting. So what we do differently
at Clover, honestly, is we have our own
clinical teams,
and we act on within few days on
our ADT feed notifications.
And we really have, you know, clinicians
who are prescribing clinicians at the center of
these transitions,
so that we don't merely treat these post
discharge events,
you know, as care management task, but we
are actually
treating these post discharge,
you know, events as medical events. And then
our CA technology
really helps to surface those actionable information at
the point of care, which I think is
really, really, really important. Because
as you know, in the MA world,
you know, you can't
reprice midyear. You can't negotiate your way out.
I think coding has its own drawbacks.
So you have to change utilization.
So you say that we wanna manage utilization,
but do we truly have the wherewithal, or
do we have really the operational, you know,
I think the operational,
insights or the operational execution
in a way that it really matters? Because
utilization will only change when someone shows up
early and fixes the problem.
What's one investment or initiative you believe will
most reshape how health plans operate over the
next two to three years?
So, Scott, I think in my view,
MA winners,
over the next three years will invest
kind of, like, I think in maybe in
fewer bets, but execute it deeply because we
just talked about it. Right? What's the difference
between strategy and operations?
And so you have to execute deeply.
And while the traditional thought process,
centers around making choices
or selecting from an array of goals that
are always important, growth, profitability,
member experience,
retention,
or kind of like the heaters and stars,
you know,
or managing cost via
I think these are just traditional
foundational
principles.
However, I feel that if MA plans
can bet on executing a care delivery model
that leverages data and technology,
care that is anchored in primary care,
care that is rooted in a mastery of
chronic disease management,
and care that is delivered at home.
Because if we do that well and we
execute that well, I believe that's where quality,
cost, and member trust intersect.
So I I think if we can bet
on that, and it all comes to,
do we have a care delivery model that
meets those needs?
That's really how
powerful it can be to reshape and build
upon, you know, the traditional health plan models
because we know the population is aging. Right?
It's aging fast. We have, like, more than
fifteen percent of people above the age of
85.
There's a huge chronic disease burden.
We also know that chronic disease and multimorbidity
is a primary driver
of Medicare
utilization.
We know that if we don't manage it
well, if we don't manage chronic disease well,
it's directly linked to frequent ER visits,
preventable hospital admissions,
higher readmission rates, and just a very poor
patient experience.
I have seen the cycle of inpatient, outpatient,
you know, very
closely,
and I've always been
looking to see how can I impact and
make that better,
because
I you know,
this is this kind of, I think, is
that if if if the MA plans can
invest in this effective
care delivery system, I think we'll all reap
the benefits of managing the utilization
and actually,
member trust in us? Because the more trust
we have, if it's a trust driven relationship,
you know,
it it it really makes a difference.
If yeah. You know, I'm happy to actually
share a little, you know, a story to
illustrate what I'm talking about because I was
recently accompanying our clinical team during a home
visit.
And prior to the actual visit, our clinicians
had visibility into this meaningful information
about our patient. So our technology platform had
surfaced, what her existing conditions were, that they
you know, the patient was discharged recently from
the hospital after a surgical procedure.
The patient had some, a colon surgery,
and really had a colostomy, which is, like,
let's just say, you know, it creates a
stoma and an opening in the abdomen,
which is connecting the intestine from the inside
to the outside.
And she was not a happy camper at
all.
You know, this person was,
you know, when we reached in you know,
when we were in the home, we found
her despondent. We found her overwhelmed,
unable to walk, not taking care of her
colostomy,
for her surgical instructions, not picking up the
phone from her doctor's office, not taking her
medications.
And and the family was just urging her
to go back to the emergency room.
And this team, you know, like our home
care team, they assessed and they managed all
those medical concerns,
whether it was a colostomy bag, provided education,
or the DM me, connected to her to
our behavioral health team, called the primary care
physician, who, by the way, was not even
aware that the patient had surgery,
called the surgeon's office, arranged transportation,
called the daughter. So you can just, you
know, if you just sense
all the things that are happening when you're
actually in the member's home and you are
problem solving and you are actually resolving those
issues,
this cannot be done if you don't have,
you know, a clinical team exercising
not only good clinical judgment,
but actually executing on the clinical care.
While these are everyday stories, by the way,
let's not forget that these are powerful examples
of the right care at the right time
because they do contribute to good outcomes.
And, really, my thesis is that,
you know, our kind of, like, our CLOVER
advantage
is that it's PCP centric care.
And that's why, you know, we are supporting
how to identify, how to manage.
And this this kind of strategy that we
were talking about, like bridge the silos
between the providers, patients, and the systems
is probably
is probably key. So I think that any
plans
that will, you know, kind of,
plans that will
invest
in an effective care delivery system
will surely reap the benefits,
you know, in the years to come for
managing their population.
I appreciate you sharing that story. That's such
a good example of of your team just,
you know, willing to go above and beyond,
for a member. I I think that says
a lot about about, Clover's operations and what
they're willing to do for members. So thank
you for sharing that. And
the next question I have for you, doctor
Shabi,
is if you could change one regulatory or
industry practice tomorrow to improve affordability and access,
what would it be and why?
Yeah. I think there are lots. But, like,
maybe the one thing that I think, Scott,
I feel that is really important. I think
if the industry and CMS,
even though that we have made progress, let's
just say, if if we can make the
ability to exchange data,
you know, via via the FHIR,
and based APIs
among providers and peers, like, really make it
a ground reality,
you know, it'll be a huge opportunity to
improve care and cut cost.
You know, while there is progress,
I still don't think that we,
you know,
we are where we need to be because
I I think day to day, we don't
realize
how this interoperability
allows us to bring the most sophisticated
care coordination,
to any provider, right, anywhere. And even if
that provider is not part of an integrated
health system.
So I think if we could just, you
know, get health care industry and CMS to
support that,
because smaller plans and independent clinicians,
you know, they cannot compete if vertically
integrated,
you know,
with their I mean, they cannot compete with
this vertical integration,
programs,
because they have proprietary data advantages.
And I think all the examples that I
gave you, like,
to just know what is happening with our
members, when, where, so that we can intervene
at the right time is just critical to,
you know, providing the best care. So I
I think that, to my mind, is really
very important. And, of course, you know, like,
can we revise our,
you know, STAR measures to be more meaningful?
You know? I think that's another opportunity.
I mean, if you look at medication adherence
measure, which I've been delving very deeply,
have been involved very deeply in managing some
of those measures,
and understanding them.
You know, there's so much duplication.
There is there's so much at odds with
each other, although they are well intended.
But I I don't think that we actually
measure actual adherence.
Maybe we are just measuring dispensing.
Having said that,
I think claims data analysis
is never,
you know, the best,
way forward to understand
why
why people are being treated the way they
are being treated and why they are not
being treated with certain drugs if they are
not being treated. So, I I mean, I
think there's always room to improve,
you know, how you know, measurements.
But,
I would think that the most important thing
to my mind is
shared data.
Share the data in a visible way
because it would impact so much in terms
of access, in terms of cost, and in
terms of driving quality.
And the last question I have for you,
doctor Chawbi,
what issue is putting the most pressure
on health plan margins right now,
and how are you responding differently in in
2026?
Well, I I think everyone is probably, you
know, facing rising medical cost, right, including including
prescription drug cost.
And, of course, for every, I I think,
for every plan that kind of predicts and,
you know,
plans
for growth and managing cost,
I don't know whether,
does utilization
outpace the premium growth,
and then the headwinds for all payers,
which, you know,
some are known and some are potentially unknown.
But, you know, I do think prescription drug
cost,
are playing,
they're a major structural pressure point.
You know, we know that
the Inflation Reduction Act, I think it has
put, more,
responsibility.
So plans need to bear a much larger
share of the drug cost. And I think
the other thing is as we innovate, as,
you know, science and technology,
you know,
give us more options.
The high cost specialty drugs,
you know, oncology, obesity, or the GLP ones
are, you know, growing rapidly
and can
influence the increase in spend per member.
But at the same time, that is why
I think that,
you know, it's really important that we have
a better relationship with our providers.
We think about cost management
outside
just, you know,
standard
rate negotiations because we have to focus on,
are we delivering the right care?
And, yes, you have to have good data
and analytics. You know, you have to invest,
so that you can identify who are the
high drivers of the utilization and really tailor
the interventions
according to that.
So while,
many plans are tightening their portfolios,
you know, to focus on more profitable markets
and population,
given these constraints that we are just talking
about, utilization,
you know, and revenue,
we at Clover
are taking a strategic approach of measured growth,
because we have a strong conviction in our
model of care.
We've seen about 53%
growth this year,
but we also have had 95
retention.
We've had favorable, you know, impact of our
four stars.
And we also see a very strong and
improved cohort economics,
to say.
So I think that
and the reason we see that is because
we have this differentiated layering of our Clover
Assistant technology
and the clinical services that are in house.
Right? It you know, it's our teams
who manage.
So while our Clover Assistant technology is an
AI leader in MA,
it supports the physicians in improved, you know,
better quality care. We see outcomes
for we see better outcomes. If our physicians
use our Clover Assistant technology,
we see better outcomes for diabetes, chronic kidney
disease,
for example. So I think that's a great
differential.
And then we have a very strong and
mature home based MDNP driven clinical program
that uses our technology and cost effectively manages
care,
for a rising risk and the highest risk
patient population. So
I think to I would say that we
are responding,
therefore,
very purposefully
and with intention,
understanding our strengths,
while also being very
cognizant of all these potential headwinds,
you know, for sure.
Well, I think it's the right way to
to move forward right now. And and, doctor
Chawbi, thank you so much for joining the
podcast and for your time and and all
your great insights. Really looking forward to having
you speak at our spring payer issues roundtable
in April.
Likewise. Thank you for giving me this opportunity,
Scott.