Recently on Relentless Health Value, we’ve been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days.
In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis.
Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes. She also shares strategies for plan sponsors to effectively manage high cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving, while underlining the importance of patient engagement and satisfaction.
Don't miss next week's episode with Dr. Eric Bricker for a deeper dive into these topics.
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05:22 What is a high-cost claimant, and how is the definition changing?
07:42 Why buy-and-bill pharmaceuticals can be so costly for plan sponsors.
10:19 What are plan sponsors getting wrong about this situation?
11:28 What do you need as an employer to understand your plan data fully?
13:41 EP462 with Scott Conard, MD.
17:35 What are plan sponsors currently doing that they should not being doing?
19:54 Why starting small is important.
23:02 EP468 with Matt McQuide.
25:37 What are the steps employers should take to improve their high-cost claimant spend?
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Episode 471.
"High Cost Claimants in 2025 andBeyond. What Is Really Expensive Not
to Know?" I'm gonna call this part one.
Today I speak with Dr. Christine Hale.
(00:23):
American Healthcare Entrepreneurs andExecutives, You Want to know, Talking.
Relentlessly Seeking Value.
Recently on Relentless Health Value,we've been tinkering around with
a few recurring themes recurringthrough lines that are just true
about American healthcare these days.
One of the things Matt McQuide and Italked about from a few weeks ago that
(00:46):
if a plan sponsor isn't navigatingor steering members, someone else is.
Furthermore and wrapped up in all ofthis is the vital importance of trust and
patients trusting who they are talking to.
The Encore with Kenny Cole coming upis gonna hammer on this point even more
than Matt McQuide did, and Dr. ScottConard did in those earlier episodes.
(01:07):
If you want to steer or navigate amember, they need to have an existing,
trusted relationship with somebody,a case manager, a primary care
team, maybe even an onsite clinic.
You know, they all know Monica, andwhen she calls, they pick up the
call because they already know her.
And that is a huge part of theconversation today with Dr. Christine
Hale when it comes to high cost claimants.
(01:29):
Because it's often not some randomaccident when a patient slash member
winds up in whatever care settingthey find themselves, and that is
especially true when that patient,again, is a high cost claimant.
Let's never forget that one person'scost is someone else's profit and
high cost claimants are not alwaysbut often exceptionally profitable.
(01:52):
So your members aregetting steered, all right.
And if it's not you doing the steering,it's someone else who has a huge financial
incentive to figure out where thathigh cost claimant is gonna wind up.
This is part of the story Idiscuss in great depth, by the way,
next week with Dr. Eric Bricker.
So as you listen to this show, keepwho is steering my members slash the
(02:13):
patients in the back of your mind.
Also, keep in mind the undeniable,almost biblical level commandment
that comes up in almost everyRelentless Health Value episode.
The importance of not only havingdata, timely data, but also having
the wherewithal to analyze it.
But what I also realized during thisconversation is the absolute growing
importance of recognizing a pointthat Dr. Scott Conard made in his
(02:36):
show about Whole Person Health andrecognizing that we are all one whole
person, not a bunch of little parts.
So yeah, we really need to have pharmacyand medical claims, data co-mingled
altogether and at the member level.
People in the know have been sayingto get one data set, not two or 12
for years, but at this point, givenscientific advancements that are
(02:59):
really expensive such as cell andgene therapy and infusions that may
or may not be billed under the medicalbenefit or the pharmacy benefit.
Not having one data set to rule them allis going to have increasingly expensive
consequences, which Dr. Christine Halequantifies during the show that follows.
So I am not gonna get into it here.
(03:20):
One other recurring theme that comes upin the show today is the importance, the
vital importance as Dr. Steve Schutzerunderscored about the Betsy Seal's
episode recently of keeping track of thevalue that is accruing to the patient or
member, not forgetting the human beingwhile we are looking at the spreadsheets.
Turns out in this high cost claimantzone, you forget about the human being
(03:44):
at your own financial peril, whilepossibly also subjecting the member to
potentially avoidable clinical suboptimalness or even harm at the same time.
These are a few humans that first ofall, desperately need help, but also
failing to align with their actual needsis going to wind up as a real world fail.
(04:05):
Dr. Christine Hale says quite crisplyactually that high cost claimants don't
get cheaper a lot of times if our approachis mostly some kind of across the board
trying to take things away from these highcost claimants, is definitely one of those
sounds good on paper, doesn't actuallywork out great kinds of approaches.
Dr. Christine Hale, my guest todayis a pediatrician by training.
(04:28):
She got an MBA because she wanted to workon changing the healthcare system and
spend a bunch of years as a consultantand also working at primarily academic
medical centers and children's hospitals.
Past eight years, she has workedfor an employee benefits consultant.
And as I mentioned earlier, do tune innext week for the show with Dr. Eric
Bricker, where we go hard on how providerorganizations can very strategically
(04:52):
and profitably take advantage ofeverything you learned on this show when
plan sponsors and probably payers anddefinitely consultants are unaware or
maybe getting paid to look the other way.
Not everything is gonna show up ina 5500 disclosure form by the way.
Don't forget that plan sponsors.
But that is a conversationfor another day.
My name is Stacey Richter.
(05:12):
This podcast is sponsoredby Aventria Health Group.
And here's my conversationwith Dr. Christine Hale.
Dr. Christine Hale, welcometo Relentless Health Value.
Thanks so much, Stacey.
Glad to be here.
Jumping right in.
What is a high cost claimant?
That definition we areseeing is changing over time.
Historically and classically,it was $50,000 for one
(05:33):
individual in a 12 month period.
Increasingly, as costs continue torise, especially in the upper echelon
of these cases, more and more employersare saying, honestly, we can't deep
dive into every $50,000, we're startingto set the bar at a hundred thousand
dollars or even higher than that.
Generally, that a hundred thousanddollars and up in the employer
(05:56):
sponsored world represents half to 1%,so 0.5 to 1% of all of the claimants
on an employer sponsored plan.
Interestingly, the definition of ahigh cost claimant has now doubled.
Who do these individuals tend to be?
There is so much diversityin this population.
We're gonna see, particularly in anemployer that has an older population,
(06:17):
we'll see things you might expect,chronic heart disease, chronic kidney
disease, cancer, but also there'sa very large proportion of these
individuals, particularly the higherthe cost that are under the age
of 20 or even under the age of two.
So it ends up being a reallydiverse set of diagnoses.
Everything from chronic illness but alsobig hospital stays, babies, sepsis, really
(06:41):
intensive outpatient procedures like ABAtherapy, dialysis, specialty pharmacy.
This is something that is really impactingplans because when we set up our insurance
model in this country decades ago, itwas designed for those unknown risks.
Those out of the blue, didn'tsee it coming, big claims.
(07:03):
Now so much of what we do,even in conditions like cancer,
are ongoing large claims.
And that presents a reallyunique challenge for plans.
Yeah, because they get lasered.
That's right.
You were talking about theobvious pharmacy claims.
And I'm assuming you're talking about notonly pharmacy claims that come through
the pharmacy, I'm assuming also you'retalking about infusions and things which
(07:24):
turn up on the medical side of the house.
That's correct.
And in fact, especially the, wecall it medical pharmacy, right?
So these tend to be IV infusions.
They're administered in a healthcaresetting, hospital-based clinic, a provider
office, particularly when those infusionsare happening in a hospital-based setting.
What a lot of employers don'trealize is that there's three
(07:46):
components to that bill.
There's the cost of the drug itself,which of course can be quite costly.
The second piece, which tends tobe pretty modest and reasonable,
is the cost to give the drug.
But then because the drug was procuredthrough the hospital pharmacy,
hospitals are allowed to mark up thecost of the drug as much as they want.
We call that buy and bill.
And that multiple can be two timesthe cost of the drug, five times,
(08:09):
even 10 times the cost of the drug.
And when you're talking a drugthat's a hundred, 200, $300,000 a
year, and they mark it up 10x, youstart to do the math, and that's
really impactful for a single member.
I'm gonna assume that was a littleforeshadowing that just happened there.
Call me, Nancy Drew, girl, detective, butlike I'm thinking that last part there.
(08:30):
So we were just talking about medicalpharmacy and the three costs of that bill.
One of them was the cost of the drug.
The second one is the administrationfee to infuse the drug or you know,
some kind of service level fee.
And then the third one is the markupbecause the hospital is in fact
procuring the drug and then reselling it.
I mean, there's a reselloperation that's going on there.
(08:50):
But let me ask you one morequestion before we dig in on that.
Given who these people are, their 0.05% upto 1% maybe of, total claimants, does this
have, I guess this is a two part question.
First part is, what's theimpact on total plan costs here?
It is so dramatic, much moredramatic than I expected when
(09:11):
I came from the provider side.
We see consistently across ouremployer groups, regardless of
geography by its size industry anda multitude of factors, that half a
percent to 1% makes up anywhere froma third to 40% of overall plan costs.
Whoa.
Hold up there.
So we've got less than 1% to 1%by number of plan members who
(09:36):
are, what'd you say up to 40%
That's correct.
You also said that you didn't realizethis before you got over on the plan side.
Do most plan sponsors realize this,or is it somehow or another vague?
It's so funny.
You should ask.
It really depends on how muchthey're looking at their data.
The employers that are demandingtheir data and really diving
(09:58):
into it, they're seeing this.
They know there's a handful ofpeople that are disproportionately
driving their expense.
Unfortunately, many of our employergroups, either had problems getting their
data or they don't themselves, or havea partner that can analyze that data.
Or they're just being told,sorry for your luck, there's
nothing you can do about this.
(10:18):
Yeah.
Sorry for your luck.
My next question was gonna be what do plansponsors tend to get wrong about this?
And it sounds like we've got one ofthem right out of the gate, which
is, unless there's data to be had.
And there's analytics.
You're gonna get plan sponsors, sorryfor your luck, but your plan costs
are gonna go up whatever next year.
(10:39):
And they're not quite understandingthat that was a result of
somebody's in the 0.05 to 1%.
Like they might just thinkacross the board plans costs are
going up or something like that.
So it sounds like that's kind of likenumber one thing that can go wrong.
That's right.
And the level of specificity to buildon that, of that data is so critical.
In so many cases, employers aregetting maybe an annual report from
(11:03):
their administrator and their PBM,and that report might say something
like chemotherapy for $500,000.
It doesn't even say whatbody part the cancer's in.
So there's really no way in thatsituation to know, is this appropriate?
Is it clinically supportedwith evidence base?
Is the member getting good careand is it being billed properly?
(11:23):
Because you don't even knowwhat drugs we're given.
You don't know what the diagnosis is.
It sounds like the data has to includethe member level, but then also the DRGs.
Like, what, if I'm a plan,what do I need to get there?
You need your medical and your pharmacyat a line item, detail level, and
you need them integrated by member.
(11:45):
This is particularly important if youhave a carved out pharmacy plan or you
have two separate partners, one that'sadministering medical and one pharmacy.
That's important because we seethings, for example, where someone
goes in and gets a gene therapy, whichmight cost $2 million, $3 million,
where the clinician never slowed downor stopped the maintenance therapy
(12:08):
to see if the gene therapy worked.
Gene therapy isn't intended to be acure, at least for a period of time,
but there's no way to know if you'vegot a cure if you don't actually slow
down or stop the maintenance therapy.
And if you have two separate plans andone's getting one piece of that and the
other's getting the other, and you'renot integrating at a member level,
then you're never gonna know that.
Okay, so I'm, I'm pickingup a couple of things.
(12:30):
So, one has to be at the memberlevel, but number two, it has to
be aggregated at the member level,both medical as well as pharmacy.
As more of these therapies come intoexistence because go science, the more
it becomes a really false dichotomy.
You know what I mean?
Like we're just very artificiallysplitting things into
(12:53):
categories to our own detriment.
That's right.
Especially human beingsare all one human being.
And a lot of the nuance in how youmanage these things is the interplay
between multiple factors and thinkingabout why is it, for example, that
someone can't be successful, they'renot improving on this therapy.
Do they have something else going on?
(13:14):
Do they have the wrong diagnosis?
Do they have some geneticthing that prevents them from
responding to that therapy?
It's very nuanced and trying to forcefit people and populations into buckets,
while certainly that helps when you'redoing broader population initiatives,
this half to 1%, I call purple zebraunicorns because each member needs a look
(13:36):
at them specifically rather than trying toforce fit them into some generic bucket.
We just did a pod with Dr. ScottConard, who talked about whole person
health and the dangers of splittingpeople into pharmacy and medical.
We're splitting people into mental health.
There's just so many ways that thehuman body can be sectioned into
(13:57):
parts and so many stories abouthow that goes horribly wrong.
Not only from a clinical perspective,things can go horribly wrong, but
if we're talking about hundreds ofthousands, maybe millions of dollars,
I mean, if the floor here is a hundredthousand dollars, there's lots of
zeros here and lots of problems.
And you just brought up one of them,which is, okay, so you're paying however
(14:20):
many zeros here for a gene therapy,while at the same time continuing to
subject the patient to the baselinemaintenance therapy, which also most
people would agree is expensive.
I mean, first of all, the poor patient,like their body's getting pounded by
two treatments at the exact same time.
And it's maybe not twiceas it's really expensive.
(14:42):
And I think you hit a really importantpoint here, which is we have to keep
in mind the impact on the member.
The impact of their clinical outcomes.
Their convenience of receivingtheir care, access to care.
The good news is you don't have todiminish those things to get savings.
And in fact, in this population, manytimes, we're improving the clinical
(15:04):
outcome by getting them to the rightcare by making sure that they have
innovative therapies if they needthem, but that they're not on therapies
that aren't delivering clinical value.
So this can be a win-win situationfor employers because they can deliver
amazing service to their members andsave a lot of money at the same time.
I'm liking where this conversation isheaded because it definitely sounds like
(15:27):
there are things that can be done here.
Obviously, like the prices are whatthe prices are and the, the member
demand is what the member demand is.
And for good reasons and maybenot so good reasons, right?
If there is science behind, this is acurative, you know, if you're a parent.
And your kid is dying and your kid couldpotentially have access to a lifesaving
(15:49):
pick something, you know, calling thatmember demand in kind of an insulting way.
And I hear that, which is kindof why I'm saying that, right?
Like I think we have tobe really careful here.
And the, these prices are really high,but there's definitely things it sounds
like that can be done to mitigate.
The worst thing would be to pay awhole lot of money for something
that actually doesn't work.
(16:10):
What we should be striving for is let'stry to get the best possible price
and the best possible outcome if we'regonna be spending the money to do this.
And again, another insight coming over tothe employer side that I was very pleased
about was that the overwhelming majorityof our clients really genuinely care
about their employees and their families.
(16:31):
And they want to be able to providethese life changing, life altering
quality of life, improving therapeutics.
But they also have to be a plannedfiduciary, and we're hearing more and
more about that in the press, and thatbalance can be very tricky when you
have people that are marking up thecost of their drugs, for example, 10
times what they're actually acquired at.
(16:52):
There's that foreshadowing again.
What we should do right now isspecify what plan sponsors need to be
doing here at a foundational level.
And there's a lot that sounds dataheavy, getting the data at the member
level both the pharmacy side ofthe house as well as the medical.
Like find these individuals, the 0.05to 1%, which is a very small number.
(17:14):
So figure out for that limitednumber of individuals exactly
and specifically what's going on.
Like that sounds like just rightoutta the gate, number one thing.
So let's just say, now we knowwho these people are, what's wrong
with them, and where they are.
So maybe let me just ask you thisquestion in a backwards kind of way.
(17:36):
What should plan sponsors not bedoing that maybe they tend to wind up
doing accidentally or Ill advisedly.
Couple of things to keep in mind.
The first and foremost is a big mistakefolks make is trying to boil the ocean.
Thinking they have to address all thecases or even address a much larger
population outside of this half to 1%.
(17:59):
There's certainly a place for that, butif you're trying to get ahead of your high
cost claims, starting small is an option.
The next piece is, ofcourse, we mentioned this.
We alluded to this, is looking at optionsthat take things away from members.
Sometimes a plan is in such dire needof immediate cost savings, that that is
the option, but overwhelmingly, this canbe done in a quality can convenience,
(18:23):
cost neutral or better fashion?
And then I think the last thing wouldbe not tying your data to your strategy.
So falling victim to, oh, the latestvendor that walked in my office and
said, I need a certain solution.
That must be right when you haven'tactually verified that that's relevant
(18:44):
for your population specifically.
This is what I'm hearing,do not boil the ocean.
There's no need.
There's 20 individuals.
So this is definitely something that youraverage human brain and plan sponsors
tend to be very smart people, right?
So like we can look through that listof individuals and pick somebody and
these are patients that are costinghundreds of thousands of dollars.
(19:07):
So just impacting something probablyrelatively minor here, and we're
gonna get to this in a sec so, wecan have a huge financial impact.
And just drawing on the thread that youbrought up before about convenience,
I'm looking forward to asking youhow we can both save money as well
as make it better for the patient.
Which leads me to the second thing thatyou said is kind of a, don't do this.
(19:27):
Taking things away from patientsmight not actually result in the
cost savings that one might expect.
You remove something and that mightbe the thing that's keeping the
lid on a whole lot of other things.
That's number two.
And then number three is to make surethat we're looking at our data and
keeping our eye on our own strategy.
(19:48):
What should we be doing instead?
I'll try to go in the order relatedto the, don'ts that you just outlined.
I'll start with starting small.
That's very helpful.
It's almost like a SWOT approachwhere you're literally going case
by case by case to develop anindividual member level strategy.
Now over time, as you start tosee patterns emerge amongst these
(20:12):
individuals, and you start to see.
Oh, I intervened in this manner.
In this situation, you can then lookand say, this is a more pervasive issue,
and either I need to be taking that sameapproach across multiple individuals,
or the things that I tried didn'twork and I need a broader solution.
(20:32):
A third party vendor solution ora plan design change, but start
first with that SWOT approach.
It's also really helpful to do that,to build organizational support.
So a lot of times I'm hearing fromemployers, I'd love to tackle this,
but we have way too many competingpriorities, or I have to get approval
through 15 committees to do something big.
(20:53):
The nice thing about starting with ahandful of cases is most time you don't
have to go through 15 layers of approval.
And you can garner savings thatcan then be reinvested in bigger
initiatives and you can build thecase that this is an appropriate and
effective area to focus your time.
Start small.
Probably already in any given HRand I'm gonna get laughed at, 'cause
(21:16):
this is what HR does all day is helpindividual members and you don't have to
go ask for permission to be doing that.
That's the day job here.
Right?
So this is basically an extension ofwhat somebody's doing all day anyway.
So a follow on to that, which may beyour next point anyway, is alright,
so is the HR person then engaging withthese people, because we've all heard how
(21:36):
difficult it is to engage and da da da.
So how does that work?
That's a very important topic, andagain, a concern I hear about addressing
these cases for many employers.
The first point I'll make on this is,the good news by starting small, taking
a SWOT approach, is you don't have toengage a huge number of individuals.
You need to engage a small population,and frankly, first off, many of the
(21:59):
things you'll do, particularly lookingfor claim errors, looking for fraud, the
member doesn't even know are happening.
These are all happening behind the scenes.
But certainly on the clinical front,getting people to better care, changing
where that care is rendered so it'smore convenient, lower cost, that
does require member engagement, buton a handful of people, and these
(22:19):
members very often are desperate.
They're looking for help.
They're swirling in the healthcare system.
They're frustrated because theyfeel like their doctors aren't
coordinating or nobody knows what'sgoing on, or it's really inconvenient
and burdensome to have to go in andget an infusion in the hospital.
So they are much more open thanyour average employee to engagement.
(22:43):
Yeah, and just pausing on thisengagement thing for one sec,
because I think sometimes when theemployees members, they don't engage,
and we say that as a broad stroke.
We're talking about everybody all at once.
Making a very sweeping judgmentthere and a couple of things and we
did have a show with Matt McQuidewhere we dug into that, but it kind
(23:07):
of goes back to the whole solutionlooking around for a problem, right?
Like if you have somebodywho's largely healthy.
They don't think they have an issue.
This is adult learning 101 by the way.
If anyone took any of thoseclasses, everybody is super busy.
Everybody has a lot of priorities.
So if you're running around with asolution and somebody doesn't think
they have a problem, then the levelof engagement, it's just like you
(23:30):
don't have anything that they'regonna prioritize in their life.
This is not that situation.
They have a problem.
They recognize they have a problem,if they are in the middle of a crisis
and there is help proffered, it willbe accepted mostly, most of the time.
And to take that one step further,frankly, a lot of these members are
already engaging because they'reat a point where they're asking
(23:52):
about FMLA or short-term disability.
I'm constantly educating ouremployers, that is a trigger to say,
Hey, is there something we might beable to intervene on this member's
behalf even before their high cost?
They're about to become high cost, andso let's actually get ahead of that.
The other piece is in the situationwhere imagine an employer, their HR
(24:15):
benefits team is looking at the dataand they see something going on with a
member, but they haven't had interactionswith that member, relying on a trusted
partner, one who would be a familiarname to the member is a great strategy.
So often that's case management or anavigator, but we've even engaged groups
like onsite clinic providers if they'retreating the member for other things.
(24:39):
Or the member's, primary care orspecialist to say, the member will receive
the offer for care from you, well, becausethey trust you, they respect your opinion,
and so engaging those members or thosesources that can actually be that trusted
voice to deliver the offer for help.
Definitely go back and listen to theshow with Matt McQuide from a couple
(25:01):
of weeks ago, a huge part of thatconversation is wildly relevant here.
Another piece that's important isparticularly again, when we require
member engagement for something likemoving the site of administration for
a drug that should not be mandated.
It's an offer of help, as you said.
Now, a lot of members will be reallyexcited about that because most people
would rather sit at home and watch Netflixin their jammies than go to a hospital.
(25:25):
But not everyone will.
Sometimes people have a reason thatthey prefer to stick with their
current plan, and that's their choice.
That's their purview, but at least youhave done everything you can to help them.
If I'm putting this kind of intoa stepwise here, the first step
obviously is to be able to identifythese individuals with enough
time to impact what's happening.
(25:47):
Like it's one thing to be able to dothis retrospectively, I guess, but it's
quite a another thing and this is whyyou said at the very beginning, like,
if you're only getting your data once ayear, like that's probably not helpful.
So now I'm kind of putting thepieces together, why that mattered.
So step one is identify individuals.
And that might happen through, I guess,regular data feeds, but the other
bit, you said there may be other waysthat are kind of leading indicators.
(26:10):
Like if somebody's calling in withan FMLA asking lots of questions
about that, probably we shouldanswer with one question of our
own, which is what's going on.
And that kills two birds with onestone because if they all of a sudden
bring up some major medical issue,then consider them engaged, which
is kind of our second step here.
(26:31):
Figure out how we're gonna reachout in a way that is going to be
deemed as helpful, not invasive.
And that could be, it could be HRthemselves, depending on many factors.
But it also could be engagingthe onsite clinic or engaging in
navigator, like if those individualsalready have a relationship with
(26:51):
these particular patients, thenenabling those patients to continue
to work with their trusted partners.
And then the third thing isthis should be an offer to help.
Not anything mandated, because again,this is a very small number of people,
so appealing to their particular sort ofwhat they want, that there's two things.
(27:16):
Number one, they're gonna be morereceptive to what you're offering if you
try to figure out what they actually want.
You have alluded several times, anddon't forget, we started out talking
about how some sites of care are reallymore expensive than other sites of care.
I am inferring that that is part oftrying to figure out what the win-win is.
Do you wanna just digin on that for a moment?
(27:37):
I like to think of this ina couple of big buckets.
The first is making sure, firstand foremost, as you just stated,
that the member is gettingthe appropriate evidence-based
and effective for them care.
Because we know that not everymember's gonna respond to
every therapy the same way.
Unfortunately, as was my own casefor my 15 months of disability.
(28:01):
Many of these members are going aroundwith incomplete or incorrect diagnoses,
and it's very hard to impact that ifyou are, for example, as we had a case
giving a $300,000 a year medication forthe wrong diagnosis, that not only is
not fixing the member's problem, it'sexposing them to potential complications
(28:22):
and bad outcomes, and prohibiting themfrom actually getting the lifesaving
or life altering care they need.
The second bucket is exactlywhat you say, which is, okay.
Now we've identifiedwhat the diagnoses are.
What care is likely towork for this member?
How do we deliver that care inthe most convenient and cost
effective manner possible?
(28:44):
And certainly site of care on infuseddrugs is a huge opportunity for that.
But also we're seeing some innovations,and again, yay for medical advancement
uh, for things like doing dialysis ina member's home, this is great because
members have to, traditionally, if they'reon hemodialysis, they have to leave work
three times a week to go sit in a center.
(29:06):
Now it can be set up to be run in theirhome overnight, and they're avoiding that
missed work and disruption to their life.
And then don't forget on thebackend, it's not a win-win.
It's more of a neutral win.
But all of those things you can do on thebackend by just simply making sure that
there aren't fat finger errors on a bill.
We had a $400,000 error on ainpatient bill for a COVID claim.
(29:30):
That just somebody fat fingered thedose of steroids that they billed for.
And you know, sadly, like every industrymedicine has its share or bad actors
that are gaming the system at best orat worst, actually committing fraud.
Uncovering those things andgoing to that to write that
situation is hugely important.
You said three things there.
(29:51):
Once we have identified theseindividuals and engaged them.
Number one, ensure the treatment isappropriate evidence-based care.
And earlier we talked aboutsomeone getting double treated.
You know, they're getting gene therapywhile they're still getting the same.
Like, that is obviously notevidence-based nor appropriate.
And then you just broughtup another example where the
(30:12):
patient may be misdiagnosed.
There's just that inflammatory newsarticle the other day about a patient
who didn't actually have cancer who wasgetting cancer therapy for nine years.
So let's hope that is an outlier.
But it is definitely true that ifsomebody goes for a second opinion,
70% of the time the treatment changes.
So, you know, like this is certainly athing to make sure that the treatment
is appropriate and evidence-based.
(30:33):
Then the second thing is, okay, once we'vedetermined that, then let's make sure
that this treatment is being deliveredin the most cost effective way possible.
That could involve doing something,and you've said this also several
times that might actually be moreconvenient for the patient, right?
So like this is not send them to theplace nobody agrees is the right place.
(30:53):
Like the patient couldbe happy about this.
But that site of care is notonly more convenient, but it also
could be wildly less expensive.
And by the way, Autumn Yongchu and EricDavis really dig in on this in a pod from,
I don't know, maybe it was a year ago.
And they also touched on the third thing,which is just the number of errors here.
Our system is obviously rifewith errors and fat fingered, or
(31:17):
just all kinds of stuff going on.
But because the numbers are so highhere, really looking, scrutinizing
these things incredibly carefullyis also something that we should
not forget to put on our list.
We've talked a lot about a lot ofthings today, Dr. Christine Hale.
Is there anything I neglected toask you that you wanna talk about?
There's one more point just to buildon everything else we've talked about.
(31:39):
Don't be afraid to get creative.
A lot of times these situations,by definition are complex and there
are member factors involved, andyou have to try to figure it out.
Don't stop with the surface solution.
A great example, we talked a lot aboutthe impact of redirecting site of care.
In fact, our largest win we've everhad was $3 million for one person
(32:02):
simply by moving their infusion outof a hospital and into their home.
But we also had a case where a casemanager reached out on our behalf to
ask a member if they wanted to do this,we're accustomed to members loving this.
This person literally would notanswer the phone after they called.
And our team said, you know,that just doesn't make sense.
(32:22):
And so we did some researchall about board, I promise
you, but publicly available.
But we found a blog thatthe member is a hoarder.
She was writing about that experienceand we said, ah, she likely doesn't
want someone coming to her home.
So we sent her to a hotel andsent home healthcare there and
saved the company $800,000 a year.
So don't be afraid tothink outside the box.
Get a little creative within thebounds, of course, of reasonableness,
(32:45):
but it's not a one size fits all.
It sounds like something whichis eminently possible given the
very small numbers of patientsthat we're talking about here.
And this is also, dare I say, right upHR. Most the, let's just say the good
ones are listening to this podcast,so those who are listening to this.
There's so much creativity to be hadwith HR and I've seen just relative
(33:08):
to all kinds of crazy situations withemployees in the workplace, and it
just sounds like this is another areawhere those muscles can be flexed.
And the other nice thing about focusingon the member first and meeting them when
they are is those members can become yourabsolute best champions with respect to
communicating the value you're delivering.
(33:28):
We've had members that have sentthank you letters to their employers
who've written newsletter articlesto their entire company saying
how much this changed their life.
So you can really make a differencefor individuals, and then they will
help you build enthusiasm around whatyou're trying to do in your plan.
And let me just remind everybody, therewas a solo show that I did several
(33:50):
weeks ago where I rant, I'm justgonna say it out loud, why it's so
important to be focusing on the member.
And had I done this recording beforethat show, I would've added this,
that by focusing on the member, thisis just another place where actually
doing the right thing, turns out notonly to be the right thing clinically,
(34:11):
but it also will wind up saving money.
Dr. Christine Hale, if someone isinterested in learning more about your
work, where would you direct them?
Stacey, everyone can look forme on LinkedIn, follow my feed
and see what we're up to there.
Dr. Christine Hale, thank you so much forbeing on Relentless Health by you today.
Thanks Stacey.
Hey guys, it's Marty Makary.
I wanna let you know that I love.
(34:34):
Relentless Health Value.
I follow it and get thenewsletter and it's great stuff.
Episode 471.
"High Cost Claimants in 2025 andBeyond. What Is Really Expensive Not
to Know?" I'm gonna call this part one.
Today I speak with Dr. Christine Hale.
(00:23):
American Healthcare Entrepreneurs andExecutives, You Want to know, Talking.
Relentlessly Seeking Value.
Recently on Relentless Health Value,we've been tinkering around with
a few recurring themes recurringthrough lines that are just true
about American healthcare these days.
One of the things Matt McQuide and Italked about from a few weeks ago that
(00:46):
if a plan sponsor isn't navigatingor steering members, someone else is.
Furthermore and wrapped up in all ofthis is the vital importance of trust and
patients trusting who they are talking to.
The Encore with Kenny Cole coming upis gonna hammer on this point even more
than Matt McQuide did, and Dr. ScottConard did in those earlier episodes.
(01:07):
If you want to steer or navigate amember, they need to have an existing,
trusted relationship with somebody,a case manager, a primary care
team, maybe even an onsite clinic.
You know, they all know Monica, andwhen she calls, they pick up the
call because they already know her.
And that is a huge part of theconversation today with Dr. Christine
Hale when it comes to high cost claimants.
(01:29):
Because it's often not some randomaccident when a patient slash member
winds up in whatever care settingthey find themselves, and that is
especially true when that patient,again, is a high cost claimant.
Let's never forget that one person'scost is someone else's profit and
high cost claimants are not alwaysbut often exceptionally profitable.
(01:52):
So your members aregetting steered, all right.
And if it's not you doing the steering,it's someone else who has a huge financial
incentive to figure out where thathigh cost claimant is gonna wind up.
This is part of the story Idiscuss in great depth, by the way,
next week with Dr. Eric Bricker.
So as you listen to this show, keepwho is steering my members slash the
(02:13):
patients in the back of your mind.
Also, keep in mind the undeniable,almost biblical level commandment
that comes up in almost everyRelentless Health Value episode.
The importance of not only havingdata, timely data, but also having
the wherewithal to analyze it.
But what I also realized during thisconversation is the absolute growing
importance of recognizing a pointthat Dr. Scott Conard made in his
(02:36):
show about Whole Person Health andrecognizing that we are all one whole
person, not a bunch of little parts.
So yeah, we really need to have pharmacyand medical claims, data co-mingled
altogether and at the member level.
People in the know have been sayingto get one data set, not two or 12
for years, but at this point, givenscientific advancements that are
(02:59):
really expensive such as cell andgene therapy and infusions that may
or may not be billed under the medicalbenefit or the pharmacy benefit.
Not having one data set to rule them allis going to have increasingly expensive
consequences, which Dr. Christine Halequantifies during the show that follows.
So I am not gonna get into it here.
(03:20):
One other recurring theme that comes upin the show today is the importance, the
vital importance as Dr. Steve Schutzerunderscored about the Betsy Seal's
episode recently of keeping track of thevalue that is accruing to the patient or
member, not forgetting the human beingwhile we are looking at the spreadsheets.
Turns out in this high cost claimantzone, you forget about the human being
(03:44):
at your own financial peril, whilepossibly also subjecting the member to
potentially avoidable clinical suboptimalness or even harm at the same time.
These are a few humans that first ofall, desperately need help, but also
failing to align with their actual needsis going to wind up as a real world fail.
(04:05):
Dr. Christine Hale says quite crisplyactually that high cost claimants don't
get cheaper a lot of times if our approachis mostly some kind of across the board
trying to take things away from these highcost claimants, is definitely one of those
sounds good on paper, doesn't actuallywork out great kinds of approaches.
Dr. Christine Hale, my guest todayis a pediatrician by training.
(04:28):
She got an MBA because she wanted to workon changing the healthcare system and
spend a bunch of years as a consultantand also working at primarily academic
medical centers and children's hospitals.
Past eight years, she has workedfor an employee benefits consultant.
And as I mentioned earlier, do tune innext week for the show with Dr. Eric
Bricker, where we go hard on how providerorganizations can very strategically
(04:52):
and profitably take advantage ofeverything you learned on this show when
plan sponsors and probably payers anddefinitely consultants are unaware or
maybe getting paid to look the other way.
Not everything is gonna show up ina 5500 disclosure form by the way.
Don't forget that plan sponsors.
But that is a conversationfor another day.
My name is Stacey Richter.
(05:12):
This podcast is sponsoredby Aventria Health Group.
And here's my conversationwith Dr. Christine Hale.
Dr. Christine Hale, welcometo Relentless Health Value.
Thanks so much, Stacey.
Glad to be here.
Jumping right in.
What is a high cost claimant?
That definition we areseeing is changing over time.
Historically and classically,it was $50,000 for one
(05:33):
individual in a 12 month period.
Increasingly, as costs continue torise, especially in the upper echelon
of these cases, more and more employersare saying, honestly, we can't deep
dive into every $50,000, we're startingto set the bar at a hundred thousand
dollars or even higher than that.
Generally, that a hundred thousanddollars and up in the employer
(05:56):
sponsored world represents half to 1%,so 0.5 to 1% of all of the claimants
on an employer sponsored plan.
Interestingly, the definition of ahigh cost claimant has now doubled.
Who do these individuals tend to be?
There is so much diversityin this population.
We're gonna see, particularly in anemployer that has an older population,
(06:17):
we'll see things you might expect,chronic heart disease, chronic kidney
disease, cancer, but also there'sa very large proportion of these
individuals, particularly the higherthe cost that are under the age
of 20 or even under the age of two.
So it ends up being a reallydiverse set of diagnoses.
Everything from chronic illness but alsobig hospital stays, babies, sepsis, really
(06:41):
intensive outpatient procedures like ABAtherapy, dialysis, specialty pharmacy.
This is something that is really impactingplans because when we set up our insurance
model in this country decades ago, itwas designed for those unknown risks.
Those out of the blue, didn'tsee it coming, big claims.
(07:03):
Now so much of what we do,even in conditions like cancer,
are ongoing large claims.
And that presents a reallyunique challenge for plans.
Yeah, because they get lasered.
That's right.
You were talking about theobvious pharmacy claims.
And I'm assuming you're talking about notonly pharmacy claims that come through
the pharmacy, I'm assuming also you'retalking about infusions and things which
(07:24):
turn up on the medical side of the house.
That's correct.
And in fact, especially the, wecall it medical pharmacy, right?
So these tend to be IV infusions.
They're administered in a healthcaresetting, hospital-based clinic, a provider
office, particularly when those infusionsare happening in a hospital-based setting.
What a lot of employers don'trealize is that there's three
(07:46):
components to that bill.
There's the cost of the drug itself,which of course can be quite costly.
The second piece, which tends tobe pretty modest and reasonable,
is the cost to give the drug.
But then because the drug was procuredthrough the hospital pharmacy,
hospitals are allowed to mark up thecost of the drug as much as they want.
We call that buy and bill.
And that multiple can be two timesthe cost of the drug, five times,
(08:09):
even 10 times the cost of the drug.
And when you're talking a drugthat's a hundred, 200, $300,000 a
year, and they mark it up 10x, youstart to do the math, and that's
really impactful for a single member.
I'm gonna assume that was a littleforeshadowing that just happened there.
Call me, Nancy Drew, girl, detective, butlike I'm thinking that last part there.
(08:30):
So we were just talking about medicalpharmacy and the three costs of that bill.
One of them was the cost of the drug.
The second one is the administrationfee to infuse the drug or you know,
some kind of service level fee.
And then the third one is the markupbecause the hospital is in fact
procuring the drug and then reselling it.
I mean, there's a reselloperation that's going on there.
(08:50):
But let me ask you one morequestion before we dig in on that.
Given who these people are, their 0.05% upto 1% maybe of, total claimants, does this
have, I guess this is a two part question.
First part is, what's theimpact on total plan costs here?
It is so dramatic, much moredramatic than I expected when
(09:11):
I came from the provider side.
We see consistently across ouremployer groups, regardless of
geography by its size industry anda multitude of factors, that half a
percent to 1% makes up anywhere froma third to 40% of overall plan costs.
Whoa.
Hold up there.
So we've got less than 1% to 1%by number of plan members who
(09:36):
are, what'd you say up to 40%
That's correct.
You also said that you didn't realizethis before you got over on the plan side.
Do most plan sponsors realize this,or is it somehow or another vague?
It's so funny.
You should ask.
It really depends on how muchthey're looking at their data.
The employers that are demandingtheir data and really diving
(09:58):
into it, they're seeing this.
They know there's a handful ofpeople that are disproportionately
driving their expense.
Unfortunately, many of our employergroups, either had problems getting their
data or they don't themselves, or havea partner that can analyze that data.
Or they're just being told,sorry for your luck, there's
nothing you can do about this.
(10:18):
Yeah.
Sorry for your luck.
My next question was gonna be what do plansponsors tend to get wrong about this?
And it sounds like we've got one ofthem right out of the gate, which
is, unless there's data to be had.
And there's analytics.
You're gonna get plan sponsors, sorryfor your luck, but your plan costs
are gonna go up whatever next year.
(10:39):
And they're not quite understandingthat that was a result of
somebody's in the 0.05 to 1%.
Like they might just thinkacross the board plans costs are
going up or something like that.
So it sounds like that's kind of likenumber one thing that can go wrong.
That's right.
And the level of specificity to buildon that, of that data is so critical.
In so many cases, employers aregetting maybe an annual report from
(11:03):
their administrator and their PBM,and that report might say something
like chemotherapy for $500,000.
It doesn't even say whatbody part the cancer's in.
So there's really no way in thatsituation to know, is this appropriate?
Is it clinically supportedwith evidence base?
Is the member getting good careand is it being billed properly?
(11:23):
Because you don't even knowwhat drugs we're given.
You don't know what the diagnosis is.
It sounds like the data has to includethe member level, but then also the DRGs.
Like, what, if I'm a plan,what do I need to get there?
You need your medical and your pharmacyat a line item, detail level, and
you need them integrated by member.
(11:45):
This is particularly important if youhave a carved out pharmacy plan or you
have two separate partners, one that'sadministering medical and one pharmacy.
That's important because we seethings, for example, where someone
goes in and gets a gene therapy, whichmight cost $2 million, $3 million,
where the clinician never slowed downor stopped the maintenance therapy
(12:08):
to see if the gene therapy worked.
Gene therapy isn't intended to be acure, at least for a period of time,
but there's no way to know if you'vegot a cure if you don't actually slow
down or stop the maintenance therapy.
And if you have two separate plans andone's getting one piece of that and the
other's getting the other, and you'renot integrating at a member level,
then you're never gonna know that.
Okay, so I'm, I'm pickingup a couple of things.
(12:30):
So, one has to be at the memberlevel, but number two, it has to
be aggregated at the member level,both medical as well as pharmacy.
As more of these therapies come intoexistence because go science, the more
it becomes a really false dichotomy.
You know what I mean?
Like we're just very artificiallysplitting things into
(12:53):
categories to our own detriment.
That's right.
Especially human beingsare all one human being.
And a lot of the nuance in how youmanage these things is the interplay
between multiple factors and thinkingabout why is it, for example, that
someone can't be successful, they'renot improving on this therapy.
Do they have something else going on?
(13:14):
Do they have the wrong diagnosis?
Do they have some geneticthing that prevents them from
responding to that therapy?
It's very nuanced and trying to forcefit people and populations into buckets,
while certainly that helps when you'redoing broader population initiatives,
this half to 1%, I call purple zebraunicorns because each member needs a look
(13:36):
at them specifically rather than trying toforce fit them into some generic bucket.
We just did a pod with Dr. ScottConard, who talked about whole person
health and the dangers of splittingpeople into pharmacy and medical.
We're splitting people into mental health.
There's just so many ways that thehuman body can be sectioned into
(13:57):
parts and so many stories abouthow that goes horribly wrong.
Not only from a clinical perspective,things can go horribly wrong, but
if we're talking about hundreds ofthousands, maybe millions of dollars,
I mean, if the floor here is a hundredthousand dollars, there's lots of
zeros here and lots of problems.
And you just brought up one of them,which is, okay, so you're paying however
(14:20):
many zeros here for a gene therapy,while at the same time continuing to
subject the patient to the baselinemaintenance therapy, which also most
people would agree is expensive.
I mean, first of all, the poor patient,like their body's getting pounded by
two treatments at the exact same time.
And it's maybe not twiceas it's really expensive.
(14:42):
And I think you hit a really importantpoint here, which is we have to keep
in mind the impact on the member.
The impact of their clinical outcomes.
Their convenience of receivingtheir care, access to care.
The good news is you don't have todiminish those things to get savings.
And in fact, in this population, manytimes, we're improving the clinical
(15:04):
outcome by getting them to the rightcare by making sure that they have
innovative therapies if they needthem, but that they're not on therapies
that aren't delivering clinical value.
So this can be a win-win situationfor employers because they can deliver
amazing service to their members andsave a lot of money at the same time.
I'm liking where this conversation isheaded because it definitely sounds like
(15:27):
there are things that can be done here.
Obviously, like the prices are whatthe prices are and the, the member
demand is what the member demand is.
And for good reasons and maybenot so good reasons, right?
If there is science behind, this is acurative, you know, if you're a parent.
And your kid is dying and your kid couldpotentially have access to a lifesaving
(15:49):
pick something, you know, calling thatmember demand in kind of an insulting way.
And I hear that, which is kindof why I'm saying that, right?
Like I think we have tobe really careful here.
And the, these prices are really high,but there's definitely things it sounds
like that can be done to mitigate.
The worst thing would be to pay awhole lot of money for something
that actually doesn't work.
(16:10):
What we should be striving for is let'stry to get the best possible price
and the best possible outcome if we'regonna be spending the money to do this.
And again, another insight coming over tothe employer side that I was very pleased
about was that the overwhelming majorityof our clients really genuinely care
about their employees and their families.
(16:31):
And they want to be able to providethese life changing, life altering
quality of life, improving therapeutics.
But they also have to be a plannedfiduciary, and we're hearing more and
more about that in the press, and thatbalance can be very tricky when you
have people that are marking up thecost of their drugs, for example, 10
times what they're actually acquired at.
(16:52):
There's that foreshadowing again.
What we should do right now isspecify what plan sponsors need to be
doing here at a foundational level.
And there's a lot that sounds dataheavy, getting the data at the member
level both the pharmacy side ofthe house as well as the medical.
Like find these individuals, the 0.05to 1%, which is a very small number.
(17:14):
So figure out for that limitednumber of individuals exactly
and specifically what's going on.
Like that sounds like just rightoutta the gate, number one thing.
So let's just say, now we knowwho these people are, what's wrong
with them, and where they are.
So maybe let me just ask you thisquestion in a backwards kind of way.
(17:36):
What should plan sponsors not bedoing that maybe they tend to wind up
doing accidentally or Ill advisedly.
Couple of things to keep in mind.
The first and foremost is a big mistakefolks make is trying to boil the ocean.
Thinking they have to address all thecases or even address a much larger
population outside of this half to 1%.
(17:59):
There's certainly a place for that, butif you're trying to get ahead of your high
cost claims, starting small is an option.
The next piece is, ofcourse, we mentioned this.
We alluded to this, is looking at optionsthat take things away from members.
Sometimes a plan is in such dire needof immediate cost savings, that that is
the option, but overwhelmingly, this canbe done in a quality can convenience,
(18:23):
cost neutral or better fashion?
And then I think the last thing wouldbe not tying your data to your strategy.
So falling victim to, oh, the latestvendor that walked in my office and
said, I need a certain solution.
That must be right when you haven'tactually verified that that's relevant
(18:44):
for your population specifically.
This is what I'm hearing,do not boil the ocean.
There's no need.
There's 20 individuals.
So this is definitely something that youraverage human brain and plan sponsors
tend to be very smart people, right?
So like we can look through that listof individuals and pick somebody and
these are patients that are costinghundreds of thousands of dollars.
(19:07):
So just impacting something probablyrelatively minor here, and we're
gonna get to this in a sec so, wecan have a huge financial impact.
And just drawing on the thread that youbrought up before about convenience,
I'm looking forward to asking youhow we can both save money as well
as make it better for the patient.
Which leads me to the second thing thatyou said is kind of a, don't do this.
(19:27):
Taking things away from patientsmight not actually result in the
cost savings that one might expect.
You remove something and that mightbe the thing that's keeping the
lid on a whole lot of other things.
That's number two.
And then number three is to make surethat we're looking at our data and
keeping our eye on our own strategy.
(19:48):
What should we be doing instead?
I'll try to go in the order relatedto the, don'ts that you just outlined.
I'll start with starting small.
That's very helpful.
It's almost like a SWOT approachwhere you're literally going case
by case by case to develop anindividual member level strategy.
Now over time, as you start tosee patterns emerge amongst these
(20:12):
individuals, and you start to see.
Oh, I intervened in this manner.
In this situation, you can then lookand say, this is a more pervasive issue,
and either I need to be taking that sameapproach across multiple individuals,
or the things that I tried didn'twork and I need a broader solution.
(20:32):
A third party vendor solution ora plan design change, but start
first with that SWOT approach.
It's also really helpful to do that,to build organizational support.
So a lot of times I'm hearing fromemployers, I'd love to tackle this,
but we have way too many competingpriorities, or I have to get approval
through 15 committees to do something big.
(20:53):
The nice thing about starting with ahandful of cases is most time you don't
have to go through 15 layers of approval.
And you can garner savings thatcan then be reinvested in bigger
initiatives and you can build thecase that this is an appropriate and
effective area to focus your time.
Start small.
Probably already in any given HRand I'm gonna get laughed at, 'cause
(21:16):
this is what HR does all day is helpindividual members and you don't have to
go ask for permission to be doing that.
That's the day job here.
Right?
So this is basically an extension ofwhat somebody's doing all day anyway.
So a follow on to that, which may beyour next point anyway, is alright,
so is the HR person then engaging withthese people, because we've all heard how
(21:36):
difficult it is to engage and da da da.
So how does that work?
That's a very important topic, andagain, a concern I hear about addressing
these cases for many employers.
The first point I'll make on this is,the good news by starting small, taking
a SWOT approach, is you don't have toengage a huge number of individuals.
You need to engage a small population,and frankly, first off, many of the
(21:59):
things you'll do, particularly lookingfor claim errors, looking for fraud, the
member doesn't even know are happening.
These are all happening behind the scenes.
But certainly on the clinical front,getting people to better care, changing
where that care is rendered so it'smore convenient, lower cost, that
does require member engagement, buton a handful of people, and these
(22:19):
members very often are desperate.
They're looking for help.
They're swirling in the healthcare system.
They're frustrated because theyfeel like their doctors aren't
coordinating or nobody knows what'sgoing on, or it's really inconvenient
and burdensome to have to go in andget an infusion in the hospital.
So they are much more open thanyour average employee to engagement.
(22:43):
Yeah, and just pausing on thisengagement thing for one sec,
because I think sometimes when theemployees members, they don't engage,
and we say that as a broad stroke.
We're talking about everybody all at once.
Making a very sweeping judgmentthere and a couple of things and we
did have a show with Matt McQuidewhere we dug into that, but it kind
(23:07):
of goes back to the whole solutionlooking around for a problem, right?
Like if you have somebodywho's largely healthy.
They don't think they have an issue.
This is adult learning 101 by the way.
If anyone took any of thoseclasses, everybody is super busy.
Everybody has a lot of priorities.
So if you're running around with asolution and somebody doesn't think
they have a problem, then the levelof engagement, it's just like you
(23:30):
don't have anything that they'regonna prioritize in their life.
This is not that situation.
They have a problem.
They recognize they have a problem,if they are in the middle of a crisis
and there is help proffered, it willbe accepted mostly, most of the time.
And to take that one step further,frankly, a lot of these members are
already engaging because they'reat a point where they're asking
(23:52):
about FMLA or short-term disability.
I'm constantly educating ouremployers, that is a trigger to say,
Hey, is there something we might beable to intervene on this member's
behalf even before their high cost?
They're about to become high cost, andso let's actually get ahead of that.
The other piece is in the situationwhere imagine an employer, their HR
(24:15):
benefits team is looking at the dataand they see something going on with a
member, but they haven't had interactionswith that member, relying on a trusted
partner, one who would be a familiarname to the member is a great strategy.
So often that's case management or anavigator, but we've even engaged groups
like onsite clinic providers if they'retreating the member for other things.
(24:39):
Or the member's, primary care orspecialist to say, the member will receive
the offer for care from you, well, becausethey trust you, they respect your opinion,
and so engaging those members or thosesources that can actually be that trusted
voice to deliver the offer for help.
Definitely go back and listen to theshow with Matt McQuide from a couple
(25:01):
of weeks ago, a huge part of thatconversation is wildly relevant here.
Another piece that's important isparticularly again, when we require
member engagement for something likemoving the site of administration for
a drug that should not be mandated.
It's an offer of help, as you said.
Now, a lot of members will be reallyexcited about that because most people
would rather sit at home and watch Netflixin their jammies than go to a hospital.
(25:25):
But not everyone will.
Sometimes people have a reason thatthey prefer to stick with their
current plan, and that's their choice.
That's their purview, but at least youhave done everything you can to help them.
If I'm putting this kind of intoa stepwise here, the first step
obviously is to be able to identifythese individuals with enough
time to impact what's happening.
(25:47):
Like it's one thing to be able to dothis retrospectively, I guess, but it's
quite a another thing and this is whyyou said at the very beginning, like,
if you're only getting your data once ayear, like that's probably not helpful.
So now I'm kind of putting thepieces together, why that mattered.
So step one is identify individuals.
And that might happen through, I guess,regular data feeds, but the other
bit, you said there may be other waysthat are kind of leading indicators.
(26:10):
Like if somebody's calling in withan FMLA asking lots of questions
about that, probably we shouldanswer with one question of our
own, which is what's going on.
And that kills two birds with onestone because if they all of a sudden
bring up some major medical issue,then consider them engaged, which
is kind of our second step here.
(26:31):
Figure out how we're gonna reachout in a way that is going to be
deemed as helpful, not invasive.
And that could be, it could be HRthemselves, depending on many factors.
But it also could be engagingthe onsite clinic or engaging in
navigator, like if those individualsalready have a relationship with
(26:51):
these particular patients, thenenabling those patients to continue
to work with their trusted partners.
And then the third thing isthis should be an offer to help.
Not anything mandated, because again,this is a very small number of people,
so appealing to their particular sort ofwhat they want, that there's two things.
(27:16):
Number one, they're gonna be morereceptive to what you're offering if you
try to figure out what they actually want.
You have alluded several times, anddon't forget, we started out talking
about how some sites of care are reallymore expensive than other sites of care.
I am inferring that that is part oftrying to figure out what the win-win is.
Do you wanna just digin on that for a moment?
(27:37):
I like to think of this ina couple of big buckets.
The first is making sure, firstand foremost, as you just stated,
that the member is gettingthe appropriate evidence-based
and effective for them care.
Because we know that not everymember's gonna respond to
every therapy the same way.
Unfortunately, as was my own casefor my 15 months of disability.
(28:01):
Many of these members are going aroundwith incomplete or incorrect diagnoses,
and it's very hard to impact that ifyou are, for example, as we had a case
giving a $300,000 a year medication forthe wrong diagnosis, that not only is
not fixing the member's problem, it'sexposing them to potential complications
(28:22):
and bad outcomes, and prohibiting themfrom actually getting the lifesaving
or life altering care they need.
The second bucket is exactlywhat you say, which is, okay.
Now we've identifiedwhat the diagnoses are.
What care is likely towork for this member?
How do we deliver that care inthe most convenient and cost
effective manner possible?
(28:44):
And certainly site of care on infuseddrugs is a huge opportunity for that.
But also we're seeing some innovations,and again, yay for medical advancement
uh, for things like doing dialysis ina member's home, this is great because
members have to, traditionally, if they'reon hemodialysis, they have to leave work
three times a week to go sit in a center.
(29:06):
Now it can be set up to be run in theirhome overnight, and they're avoiding that
missed work and disruption to their life.
And then don't forget on thebackend, it's not a win-win.
It's more of a neutral win.
But all of those things you can do on thebackend by just simply making sure that
there aren't fat finger errors on a bill.
We had a $400,000 error on ainpatient bill for a COVID claim.
(29:30):
That just somebody fat fingered thedose of steroids that they billed for.
And you know, sadly, like every industrymedicine has its share or bad actors
that are gaming the system at best orat worst, actually committing fraud.
Uncovering those things andgoing to that to write that
situation is hugely important.
You said three things there.
(29:51):
Once we have identified theseindividuals and engaged them.
Number one, ensure the treatment isappropriate evidence-based care.
And earlier we talked aboutsomeone getting double treated.
You know, they're getting gene therapywhile they're still getting the same.
Like, that is obviously notevidence-based nor appropriate.
And then you just broughtup another example where the
(30:12):
patient may be misdiagnosed.
There's just that inflammatory newsarticle the other day about a patient
who didn't actually have cancer who wasgetting cancer therapy for nine years.
So let's hope that is an outlier.
But it is definitely true that ifsomebody goes for a second opinion,
70% of the time the treatment changes.
So, you know, like this is certainly athing to make sure that the treatment
is appropriate and evidence-based.
(30:33):
Then the second thing is, okay, once we'vedetermined that, then let's make sure
that this treatment is being deliveredin the most cost effective way possible.
That could involve doing something,and you've said this also several
times that might actually be moreconvenient for the patient, right?
So like this is not send them to theplace nobody agrees is the right place.
(30:53):
Like the patient couldbe happy about this.
But that site of care is notonly more convenient, but it also
could be wildly less expensive.
And by the way, Autumn Yongchu and EricDavis really dig in on this in a pod from,
I don't know, maybe it was a year ago.
And they also touched on the third thing,which is just the number of errors here.
Our system is obviously rifewith errors and fat fingered, or
(31:17):
just all kinds of stuff going on.
But because the numbers are so highhere, really looking, scrutinizing
these things incredibly carefullyis also something that we should
not forget to put on our list.
We've talked a lot about a lot ofthings today, Dr. Christine Hale.
Is there anything I neglected toask you that you wanna talk about?
There's one more point just to buildon everything else we've talked about.
(31:39):
Don't be afraid to get creative.
A lot of times these situations,by definition are complex and there
are member factors involved, andyou have to try to figure it out.
Don't stop with the surface solution.
A great example, we talked a lot aboutthe impact of redirecting site of care.
In fact, our largest win we've everhad was $3 million for one person
(32:02):
simply by moving their infusion outof a hospital and into their home.
But we also had a case where a casemanager reached out on our behalf to
ask a member if they wanted to do this,we're accustomed to members loving this.
This person literally would notanswer the phone after they called.
And our team said, you know,that just doesn't make sense.
(32:22):
And so we did some researchall about board, I promise
you, but publicly available.
But we found a blog thatthe member is a hoarder.
She was writing about that experienceand we said, ah, she likely doesn't
want someone coming to her home.
So we sent her to a hotel andsent home healthcare there and
saved the company $800,000 a year.
So don't be afraid tothink outside the box.
Get a little creative within thebounds, of course, of reasonableness,
(32:45):
but it's not a one size fits all.
It sounds like something whichis eminently possible given the
very small numbers of patientsthat we're talking about here.
And this is also, dare I say, right upHR. Most the, let's just say the good
ones are listening to this podcast,so those who are listening to this.
There's so much creativity to be hadwith HR and I've seen just relative
(33:08):
to all kinds of crazy situations withemployees in the workplace, and it
just sounds like this is another areawhere those muscles can be flexed.
And the other nice thing about focusingon the member first and meeting them when
they are is those members can become yourabsolute best champions with respect to
communicating the value you're delivering.
(33:28):
We've had members that have sentthank you letters to their employers
who've written newsletter articlesto their entire company saying
how much this changed their life.
So you can really make a differencefor individuals, and then they will
help you build enthusiasm around whatyou're trying to do in your plan.
And let me just remind everybody, therewas a solo show that I did several
(33:50):
weeks ago where I rant, I'm justgonna say it out loud, why it's so
important to be focusing on the member.
And had I done this recording beforethat show, I would've added this,
that by focusing on the member, thisis just another place where actually
doing the right thing, turns out notonly to be the right thing clinically,
(34:11):
but it also will wind up saving money.
Dr. Christine Hale, if someone isinterested in learning more about your
work, where would you direct them?
Stacey, everyone can look forme on LinkedIn, follow my feed
and see what we're up to there.
Dr. Christine Hale, thank you so much forbeing on Relentless Health by you today.
Thanks Stacey.
Hey guys, it's Marty Makary.
I wanna let you know that I love.
(34:34):
Relentless Health Value.
I follow it and get thenewsletter and it's great stuff.
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