mjamilkowski

There are a lot of opportunities to partner with other innovators / startups. We are always looking for ways to do things differently. For you, it translates into a different experience with greater access and more convenience. It should also mean lower cost because of the shift to virtual and at-home care.

As for who - its a big universe. There are innovations in primary care, gut biome / nutrition, biometrics, physical therapy / activity, sleep, mental health, fertility / family planning, cancer, community resources / counseling, and so on. We have a running list of over 300 companies we have reviewed and have considered in terms of how to include. The hard part is to sponsor a mix that does not overlap too much. We've done that work.

Oh yeah it can get crazy expensive. I was just asking to gauge your sense of risk aversion. One of the things I think is missing is being able to bring value to you even if you do not have claims. Kind of like how we have responded to others in this conversation, we are trying to get a membership card in your wallet that provides you with a sense of value even if you only go to the pharmacy for Slim Jims. We think theres an opportunity to engage with people in a way that encourages maintenance, or sustaining, your health, or if you think, improve your health. All too often we wait for someone to get sick before offering care - we want to get in front of that. Identify and manage emerging issues. and so on.

And for those of you willing to stick it out and help make change happen here, we are hopeful that our differentiated product, use of technology, and processes will stir dialog and stimulate change. There is a saying "eat the mammoth one bite at a time" or something like that - basically when a problem is so big the best you can do is take it in bite sizes pieces. We - by ourselves - cannot change how everyone gets access to healthcare. We can start small and build from there. Our objectives are achievable and objective in the near term, aspirational in the long term. Thanks for contributing your thoughts to the debate!

Now I am curious why you buy health insurance. Are you insuring against the risk of a high cost claim, like a heart attack or premature baby, cancer or transplant? Is it just something you think you should have (but from your comments, dont really use the healthcare system very often)?

Sounds like each one of those "integrated" components are actually separate things and each has an expense to you. And theres noone at the plan to help you navigate or coordinate what you access or why you should. All up to you. Our approach is to make these types of things to be inside the benefit plan (e.g. no copays, no deductibles for telemedicine solutions), and support you with care guides and incentives. I hear your pain though - its why we are trying to do this. Better access, easy as well as affordable.

Hi Mark here - Just to be clear we are not using ROI, but rather clinical impact. The expectation being that the expense of encouraging better care through facilitating coordination, clinical teaming, and incentives addresses issues of access, transparency, and engagement/compliance. We are looking to change the healthcare experience from being confusing, disjointed, costly, and wasteful.

As for employer-based insurance, it is the market that more than 50% of all people get their insurance from currently [1]. Is it the best way to make sure people get access to care? No, its just a convenient way to pool risk, and there are significant tax and regulatory support structures in place to prop it up. No private enterprise is going to change this and it is unreasonable to expect that outside of massive political and regulatory changes. And when that revolution happens, our technology and infrastructure will be able to continue delivering the same positive benefits to the disaggregated community because quite frankly we are agnostic to whether 50,000 people are insured by us through 250 employers or as individuals - we are still treating the issues being faced by the people in the community.

[1] KFF Data https://bit.ly/3IFQkoB

Hi - Mark here - I'm curious to know what you get for your $500 monthly premium. Do you get anything else of value, any incentive programs, knowledge support, coaching, etc. I am assuming you get free access to telehealth. I would like to know if you use any of these other things

I have a different take. Haven was an attempt to get 3 large, very different, groups to reach consensus on some very contentious issues. It was akin to asking everyone at the Thanksgiving dinner table to agree on a political issue.

Were they able to come to consensus on anything? There was going to be winners and losers if they changed benefit plans to be on a common platform across all 3 organizations. Maybe one organization had more losers than winners.

Then Haven made the Great Vaporware Mistake with a huge public relations and marketing campaign before they actually did the hard work.

Then reality set in.

Yes it would be possible - and I know of a couple of benefits consultants that have tried to do this, but bias and independence is a vexing issue. Keep the ideas coming!

Underwriting a whole group actually gives us protection from risk selection and creates a more population based risk which is more stable. Yes there will be individuals that have extreme expenses, which is why we have reinsurance. It is the principle of risk pooling and credibility.

We are embedding several programs into the benefit plan and still charging a lower price. We think its the best solution to the employer demanding positive ROI on the disease management and telehealth based solutions

Hi – Mark (Chief Actuary) here. Now we’re talking.... rolls up sleeves ...thanks for asking the fun question.

Medicare for All (MFA) is a proposal to provide the Medicare-based basic basket of medical services as a baseline for health coverage. The common assumption is the reference here is the scope of services covered by Medicare Part A and B (hospital and physician related services, respectively). This is a limited basket of services. For example, there are restrictions on how many nursing days or physical therapy sessions, and it does not cover drugs. There is no oversight in the form of quality in its current form. There are thousands of search results for the search terms “OIG” and “Medicare fraud”.

And cost - rolls eyes Funding is a political nightmare because of the need to increase taxes and likely a need to adjust physician fee schedules upwards (I.e. the inherent cost to CMS becomes higher). Most physicians look to charge commercial based business as much as 4 times what Medicare pays in order to offset what they believe to be as inadequate rates set by MedPac. That dynamic would not be sustainable in a system where Medicare was being used for everyone’s basic care needs.

We said MFA by itself may not be enough because it does not address clinical variation in care delivery or just quality of care in general, it does not address prevalence of fraud, and it does nothing to address the cost issue. We all would end up spending an extra $10,000 a year on taxes for what would likely be inadequate health benefits and still end up buying private insurance just like current seniors do with Medicare Supplemental Plans. BTW – the most popular MedSupp plans are Plan F, G and N, all of which cover the deductible of Part B and add pharmacy coverage.

Comparisons to other countries is tricky because most other countries work from an appropriations model, I.e. in United Kingdom the government sets the budget for the National Health System, and the NHS in turn sets the budget for each region, which in turn sets the budget for each hospital in that region. If you need a knee replacement inside the NHS, the hospital you live near may not have the budget to buy one or you do not meet the priority based guidelines, you will be put in queue to wait. Its not an approach we have patience for, but hopping (!?) on a plane to get one in another country is not covered. As you can see, comparing countries health systems is difficult at best, and even misleading.

Product: It is possible that in the future we would roll out a PPO based product to have a broader out of network option. Right now we do not have any plans to do so. Our target employer groups are focused geographically which fits nicely with our EPO approach. Sales to larger groups and greater, or prolonged work from home trends, may accelerate our consideration of PPO product development.

Pharmacy benefit: We integrate the pharmacy benefit into the overall benefit plan. We are selling a full package, and to fully insured groups. We work with a great, NCQA/URAC accredited national pharmacy benefits manager. I think we provide pretty good pharmacy benefits (broad network, comprehensive formulary, decent prices) but it has been an interesting process to standup. Still not a lot of price transparency (even for the insurer). There is broad opportunity in this space for other players.

Sales: We are using a combined approach of direct and brokered sales efforts. As Jay responded to another question, we have been expanding our broker relationships.

Network: I am not sure I understand what you mean by two-sided network. We are building our network from scratch, which enables us to establish relationships with physicians and collaborate with them on the outcomes-based approach we prefer to use in our contracting. We use a national network to wrap around the direct contracted network so there is national coverage for emergencies. We do not believe high deductible plans and pervasive use of high copays translates into effective consumer use of healthcare services because at these levels the cost to the individual has become punitive and encourages delaying care not accessing care. incidentally, we have had a couple of self-insured employers’ express interest in our approach because even with the high deductible plan, their stop loss expenses were so high that the combination of self-insured administration fees and stop loss protection was just as expensive as being fully insured (as we offer better benefits and more care support).

There are employers and physicians that don’t see eye to eye will not want to work with us on this basis. Regardless we have built a network that satisfies all regulatory requirements. Some things will always be more expensive because of the specialization. Neonatology, for example, will always be extremely expensive for us because of the limited number of medical providers.

Yes you are right - And we recognize this as part of our outreach and contract development efforts. Our collaboration seems to be working and we are getting great reaction from physicians. We believe in a simple approach to keep it understandable and easy to administer to build that relationship

I’m sorry to hear about the bad reaction you had to the vaccine and then the terrible experience you had with the care system. You are correct, individuals do need to have better understanding and connection to the cost of care, and the cost dialog is convoluted and lacking transparency for a long list of reasons. We are operating within the system but are looking to change it. What we can change is how you, as an individual, receive value from your insurance company. The most obvious way is to be protected against the super high cost of some catastrophic circumstance, like a massive heart attack or surgery. But another way to receive value is through incentives and rewards that support you in your pursuit of wellness, whatever that means to you, as well as making it easy for you to get access to things that are of interest to you that individuals or smaller employers do not typically get access to because there are no economies of scale to encourage these vendors to offer their products and services to the retail public. I understand and appreciate your pain as a self-employed or small group.

For B2B, it’s worth noting that most Americans still receive their health coverage through employers, and this is especially true for the 200-2,000 company size segment. Meeting the majority of people where they are seems to be a reasonably impactful way of starting change. We can make a considerable impact for companies with 100 employees. We can make a massive impact for companies with more than 400. We currently are not geared to do much for individuals, but we’ll get there. https://www.kff.org/other/state-indicator/total-population/

B2B is scalable for launch, giving us access to information and leverage that is not achievable in the individual space without significant expense and economic loss. Starting in this market segment gives us a profitable platform to expand into other coverage areas and consider adjacent market segments. That said, we believe our approach which is intensely focused on quality will drive cost savings that satisfy employers. The 3-year rate-lock option helps to demonstrate results and builds confidence in our approach without demanding changes to plan designs that may be injurious to the employee’s long-term health.

I’m not sure I completely follow your question about changing coverage to keep an employer to keep the company afloat. Our plans are approved by the state and we cannot change benefits during the year. We cannot slash benefits to reduce costs to keep a client. That would be detrimental to the employer’s business model too because it would severely impact their ability to attract and retain talent. Trying to reduce benefits would have the opposite effect and increase costs, like the delays caused by high deductibles.

Thanks for the great summary!

thallium205 does a great job of summarizing some of the common approaches insurers have used to try and get outcomes to be part of the payment of care delivery. We find that most physicians have not been asked what they consider to be critical outcomes related measurements and benchmarks. We are approaching the physicians we contract with on a basis of partnership rather than combatant, and as a result we have been able to achieve direct physician contracts with value-based metrics and payment components that they are comfortable with. We have the technology and analytics to support the timely and accurate reporting of the emerging experience to support them because quite frankly we are only successful if they are as well. To the point about chronic patients, we support the physicians with extensive care coordination capabilities and analytic support to identify gaps in care, opportunities for broadening the clinical team, and to leverage efficient solutions in telemedicine. We make sure all of the efforts are being communicated back to the primary care and/or specialists so they know what’s going on with their patient when their patient is not in their office.

There is a long way to go however because there is not a lot of trust and there are significant technology barriers. We believe our approach is a breath of fresh air.

There are several studies and analysis about waste in the US healthcare system. This one gives a great overview and summarizes several other studies as well.

https://pubmed.ncbi.nlm.nih.gov/31589283/

The waste usually comes down to (1) variation in clinical approaches, like a heart patient being treated differently by several different doctors, (2) administrative inefficiency, such as transposing from paper or using fax machines, and not working collaboratively, (3) abuse and fraud, like we saw in the news recently.

Here’s another one along the same lines about clinical variation

https://www.bcbs.com/the-health-of-america/reports/study-of-...