Lou and his guest, Dave Chase, discuss Health Rosetta, high-performance health plans, the Quadruple Aim, and the results when a shift in mindset takes place that takes the attention off the insurance costs and places it on the quality of health care.
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Benefits With Friends S2, E1 With Dave Chase, Co-founder Of Health Rosetta
Healthcare, sadly, has become the number one driver of poverty, homelessness and bankruptcy.
You’ve got people trying to make decisions between buying healthcare or groceries.
2 out of 3 American working people are denying themselves care because of the out-of-pocket costs. Farmers, truck drivers, manufacturers, distributors, county governments and school districts are the ones suffering the most. It’s shameful.
The people prescribing healthcare don’t understand what it costs and employers don’t think that there’s anything that they can do about it.
All the solutions to fix healthcare have already been invented, proven and replicated. Number one, the government needs to make sure that the law on hospital pricing transparency is enforced.
Transparent, better care, lower cost and more controlled health plan are what we’re doing.
Providers that are unafraid to be judged on quality and post fair reasonable price upfront. We’ve built health plans that incentivize members to go to those types of providers by waiving any out of pocket. We can get members to a $700 MRI instead of a $7,000 MRI and the employer pays 100% of $700 instead of 50% of $7,000.
We can get people as healthy as possible as quickly as possible by getting them to the highest quality healthcare providers and getting the best care. Cost reduction is the natural consequence. The high-quality doctors, the ones who do it very well, that have low infection rates and that have low readmission rates cost less.
I was recruited by the state of Montana to take over the state employee health plan with the sole goal of turning it around financially. It saved $121 million and how we did it was putting in the reference-based pricing contracts from the hospitals, changing the pharmacy benefit and enhancing primary care. We managed it. They got pay raises. We didn’t need any legislation to do what we did. We went out and contracted with the right parties. There’s nothing to stop any public employee health plan from doing this.
Asheville City Schools is the eighth poorest school district in the State of Ohio. Union leaders started to nod their heads and say, “Yes. We want better benefits like zero deductibles and zero co-insurance.” The plan got better. There’s a direct primary care doctor and a community pharmacy. We took back healthcare over $2.4 million in savings in the very first year.
Our first year in, we saved $780,000 in Barbourville, Kentucky. That’s the equivalent of another small town within the town.
We saved the district and its employees so 2021 was $2.5 million. Somebody in the audience said, “We closed a school. That $1.5 million would’ve kept that school in our district open.”
If we hadn’t done anything and stayed on the same projection, it would be about $21 million.
We have a large Taft-Hartley that we saved $31 million in 1 year.
The city of Milwaukee was able to save $37 million in 1 year. They were able to avoid layoffs as well as lower the deductibles and copays from $4,000 per family to $0 per family.
We reduced the cost of prescription drugs by over $10 million.
I’ve got the data and examples. Show me where I’m wrong.
Our direct contracts are so significantly lower than the status quo Bupa plans. It enables the plan to offer all of these benefits at zero out-of-pocket to working people. Generics, surgeries and imaging for zero out-of-pocket.
We are able to take that money and redeploy it within the company. Whether it’s more benefits, more 401(k), more wages, less money out of their paycheck and pockets, enhance mental health benefits or enhanced physical therapy benefits.
We’ve put more than $5,000 per employee back in their pocket that is reinvested into retirement or their take-home pay for the betterment and quality of life. That has resulted in extremely high retention rates.
This model works everywhere.
The union was phenomenal. We couldn’t have done it without them. They became the biggest advocates. They wrote opinion pieces in newspapers.
The unions love it because they can add real take-home value to their members. The community loves it because they’re not being asked to dig into their pocket one more time to pay more in taxes.
Every employer did what the employers were working with did, which would be a $500 billion recurring stimulus every year.
In the inflationary market that we’re in, I can’t think of a better way to offset that than taking any entity’s 2nd or 3rd biggest line item and cutting it in half.
Healthcare can be done affordably for the working middle class.
America already has the solution. We just need to scale it.
This system is fixable.
This is season 2 episode 1. We thank you for your patience. That was a five-minute intro but it’s a powerful video done in conjunction with the gentleman that I’m going to bring on to the show, Dave Chase from the Health Rosetta. It’s what people need to know and it needs to spread. We have a big problem in the United States. Part of my mission is to be part of the solution here from my desk in Woodbury, New York. I’m not going to make Dave wait on the sidelines. He’s too important to this community. Dave, welcome to the show.
Thanks for having me, Lou. I’m looking forward to the chat.
I appreciate it. The first time I saw that video, I got goosebumps. It was so well done. It brings so many different messages together. I’m a long-winded New Yorker so when I get into conversations with people, it can go hours sometimes. If you listen to the message, employers, the American Healthcare consumer, which I want to get into because we exchanged some emails and we’re involved in so many of the same types of things, maybe on a different side and level with all of those superstars in that video, it’s incredible. Your production team is a lot better than mine because you’re looking at them. If you want to introduce yourself, maybe a little bit of your background of who’s Dave Chase.
I’m the Cofounder of Health Rosetta. My background was in the health technology side. We officially launched Health Rosetta a couple of years ago. I started working on it in earnest several years ago. There’s a long personal story that I’m happy to get into if you want to about what fired me up to tackle this problem and ask a lot of questions but the bottom line was that the root because of so many areas of dysfunction in healthcare was in this area. I’m a curious guy. I asked lots of questions and that’s what drew me to this area.
Back in the day, I started my career in a big consulting firm called Accenture. I’m putting in health IT systems in hospitals. I then started Microsoft’s healthcare business. Fast forward, the last thing I did before Health Rosetta was I had a company called Avado that ultimately WebMD acquired. It was around patient engagement. An oversimplification would be like HIPAA-compliant Gmail in a way. I’ve been around the tech side of it but in the last several years, I got into where is the biggest lever in the entire industry, the employee health plans.
The numbers approximately 80% of all Americans that are insured in this country have it through their employer. It’s been that way for quite a long time. This is my 30th year in 2022 selling insurance. I did that for many years. I don’t feel like I sell insurance anymore. That’s something I’ll get into because the entire focus is on insurance and has been for way too long but the focus needs to be on healthcare. When you say patient engagement, that’s something easy to say but it’s lacking in so many ways.
Patients aren’t engaged because they can’t be engaged. There’s no useful information for them to make an informed engaged decision. That’s what Health Rosetta has become. I saw the video of yours as I was going through and I was like, “I want to introduce Dave properly.” I saw a video from November of 2016 and it was so funny because that’s when I decided to leave the GA world. I was a brokerage broker for 25 years.
Something was off or lacking. I didn’t know what it was at that time. On January 2017, I left to focus exclusively on my agency. I wasn’t sure what my prospect looked like. That’s what set me on this path. As I sat there, I was starting to question things like a medical trend. Is that Pat in the video, the slide that says Bupa?
Yes, Patrick Long.
If they’re so enormous and they have so much leverage, why are the prices going up 5% or 10% every year? It didn’t make any sense to me. That’s how I happened upon the Health Rosetta connecting through other advisors through LinkedIn. I said, “Wow. Other people are thinking like me.” When you started Health Rosetta, was it a world that brokers would be attracted to? What did you envision in the very beginning?
People call them benefit brokers, benefit consultants or benefit advisors. As I dug in, I wrote a piece a couple of years ago in Forbes titled This Job Could Save America, talking about that role. At its best, it can save the American dream. Lots of good people in the industry, even in the most vilified corners of the industry, candidly, went into it for the right reasons but there are a lot of perverse incentives. In the status quo, the cold hard reality is employee health plans for many years have become the number one driver of inflation, debt, poverty and bankruptcy. That’s a sad statement. It’s a very avoidable thing but you have to re-look at what’s going on.
The cold hard reality is that employee health plans for the last 20 to 30 years have become the number one driver of inflation, debt, poverty, and bankruptcy. Click To Tweet
Through this journey, I was finding dysfunction upon dysfunction and going, “Other than these great clinicians we have, there’s virtually nothing to save about this system. It has to do a reset. That’s always the way things work. What’s going to replace that?” Starting with the Avado experience, I found these organizations that were reinventing healthcare delivery and it was incredible. By comparison, it was a utopia.
I joked with my friends that this is a marketing problem. Everybody would want this and it turns out, there’s a better way, number one. It’s not easy but easier than you think. Now versus several years ago when we got started, we have successes in every corner of the country, every industry, large and small organizations and the public and private sectors.
The real gratifying thing is it’s doable. The TED Talk you were referring to was titled Healthcare Stole the American Dream – Here’s How We Take it Back. We can’t do that o on our own. We need a lot of people like you to make it happen on the ground. If that doesn’t happen, I’m some idiot yelling at the internet. I need to have people make it happen.
It’s funny because you think you have the next best thing and what the consumer is looking for. HR directors, Chief of People, CEOs and CFOs, I call them benefit decision-makers. The more people involved, the better the company. One of the things that I’ve come to realize throughout my career is at some point, the financial minds of businesses stepped out of the room. They no longer came to the benefit renewals. They were involved in everyone but whether it be deliberate or an accident, managed care hit all the numbers. There’s nothing to crunch. The entire focus was on insurance. The average person thinks, “We can’t do anything about it. It goes up every single year. The best that we can hope for is to mitigate the damage.”
You and I both know a lot more can be done with that because when you do have the numbers and the actionable data, you can see that the claims are not just the claims. There is so many artificial cost and hidden profits. It’s amazing what’s allowed to be done. We talked about consumers. You and I had an exchange of emails on this. For me, there are multiple consumers in this. The one that you focus on most when you think about it is the employer because they’re making the benefit decisions for their entire organization and all of the people there but they’re consuming insurance.
We have to take that focus and make them understand, “You’re not consuming insurance. You’re buying insurance but you’re consuming healthcare for your employees. You’re financing it with the insurance.” We have to make them think of themselves differently. If they were buying office supplies and realized that they were buying $100 desks and paying $1,000 for them, they would fire their supplier in a second or a heartbeat.
As David Contorno mentioned in the video, “Why are they paying $3,500 for a $600 MRI?” If they knew that, they’d be like, “What else am I paying?” We would get reengaged in the conversation. That’s a crucial part. You then have the employees that are consumers when they’re opting and making a decision on, “Which plan am I going to take?”
Most of our clients offer multiple plan options. Maybe not all of them but a lot of them do. That employee, unfortunately, is making an uninformed decision. Too often, they’re buying the least expensive plan and find out a couple of months later, “Is it going to cost me what to have a baby?” They’re a consumer when they enter the healthcare system. They’re at the mercy of what I call a very predatorial healthcare system.
Consumer for me is threefold. We need to get through to the HR people because that’s where that footprint expands. We can’t go to employees and ask them to change anything. We have to get to the employers and get them to think about that initial purchase differently. I don’t know if you have any thoughts about that.
What we’re doing is asking people to do what they do with everything else that they spend money on. They don’t shut off their brain when they’re buying desks or finding an office space and throw in the towel or raise the white flag. That’s the type of thing where one of the things people don’t recognize when it comes to paying money for healthcare coverage is 20% roughly of the spend sometimes less is actual insurance. That’s stop-loss insurance. These are the random events that are pretty unpredictable, though you can do some things about those.
Eighty percent over enough lives is pretty darn budgetable. There are going to be a certain number of MRIs and primary care visits. These things can be budgeted. You can be smart in your procurement, in that way and step into it. That’s one of the key things that we guide people towards in this five-step process. The first step is a mindset shift so that you can solve this problem. The five steps are invisible to the member or only clearly a huge positive.
The last step is the one that has the biggest payoff in the hands of a professional and isn’t disruptive but you have to be very thoughtful about it. Maybe don’t start there. The “good news” is the shenanigans are so extreme in things like PBM contracts that there are lots of opportunities to save before you even change where people pick up their medications or the formulary. The most common interface people have with the healthcare system is their pharmacy.
The problem we have found is that when you look at the mid-market, the 50 to 5,000-employee market, where we have our biggest focus, it would be charitable to say that 95% of them don’t look at the agreements. They look at them the way probably you or I look at terms of service on some consumer websites like, “Check I agree.” In actuality, probably more than 98% don’t look at them but let’s call it 95%.
Let’s pick a company in the middle of that size range to use round numbers. An employer of 1,000 employees is spending $10 million on health benefits but never in 1 million years would that company do a $10 million acquisition and never look at the M&A agreement. That would be unfathomable but that’s what they’re doing when it comes to their health plan.
The biggest single a-ha for us is that you have to sweat those contract details. You sometimes hear about the waste in healthcare like PwC and the National Academy of Medicine picked a midpoint of $1.5 trillion and is wasted every year in the US healthcare system. That would be the eleventh largest economy in the world, bigger than Russia is what we waste. That’s not an accident. That’s all codified in those agreements that most employers aren’t even looking at. That’s why that’s one of our biggest investments.
After our people, our biggest investment is these expensive but awesome attorneys. We have a whole community of folks so we can amortize that investment across that. That’s why the worst result that we’ve seen when we’re directly involved with a plan is a 20% absolute reduction in spending with benefits typically getting better, like removing cost-sharing, adding proper primary care and stuff like that. You got to sweat those details that most aren’t. That’s an important place to start.
When I started down this path, it became very clear that self-insuring with independent TPAs, Third-Party Administrators, essentially replaces the fundamental role of the insurance carriers. They’re paying the claims, issuing ID cards and pulling in all of the different pieces but you have the ability because of that new relationship to bring in the best of the best.
The case management companies like Nurse Deb from the video have a real alignment with the employer, not in alignment with the insurance carriers that are picking the partnerships that suit their best interest and that best interest is almost always a financial best interest. They package it and make it so easy to buy and then they hide all the details. It’s in the consumer’s best interest not to have access to the data.
That’s the thing that’s been gratifying here. If you do the right thing and say, “We’re going to focus on healthcare quality and get people to high-value surgeons, doctors, pharmacies and all that.” Unfortunately, going back to those contracts and the point you made, in those contracts, the carriers’ real customers in many ways are the big health systems that they work with. That’s a whole other longer discussion. Their primary concern is those organizations despite what you may think.
They prevent you in these contracts in standard plans from guiding a member. Somebody like Deb and her team in these status quo plans would be contractually prohibited from getting you to the best surgeon at the best facility that doesn’t overtreat and that matters. The nice thing is if you focus on that quality, you get the cost savings for free. That is powerful. That’s a nice win.
We put everything we do in a big picture through this filter of what’s called the quadruple aim. Improve the caregiver experience that naturally leads to a better patient experience. That’s when the magic happens whereas that partnership, that patient engagement we’re talking about. When that happens, that naturally leads to the best health outcomes. If you’re in a good model, that leads to lower costs. Better caregiver experience, better patient experience, better outcomes, lower costs, that’s the quadruple aim. That’s a good filter.
Improving the caregiver experience naturally leads to a better patient experience. That's when the magic happens. Click To Tweet
The interesting thing is we try to focus on the positive. “Here is this much better world you can move into.” Some people will ask me about this or that big incumbent organization from the status quo. What I’ll say is, “They’re weirdly irrelevant if you’re focused on the quadruple aim. They have years of evidence of missing that target if you’re supposed to aim at the quadruple aim. We’re not about bashing them, they’re just not useful for us. Fortunately, we have the best clinicians in the world and they’re passionate. We need to let doctors be doctors and nurses be nurses and not turn them into glorified billing clerks.
One of the stats I saw is that the US is in last place in 8 of the 10 important factors of healthcare. Our system is behind first-world countries or developed countries. It’s not because we don’t have the capability. It’s because of the system. Their hands are being tied. Doctors are not bad people. We have some of the best doctors in the world. My wife was a NICU nurse for many years. They can do unbelievable things. It’s the system that ties their hands and takes control out of their hands. That’s not acceptable.
If this was a sports team, we’re paying ten times more to underperform. It’s the people in charge. I’m writing my first book. You’re on your 5th, 6th or 7th? It’s not easy. I got to hand it to you. It’s a big undertaking. As I’m writing it, I was getting things out. It became so abundantly clear to me that the healthcare systems, not the providers of healthcare but the people in the boardrooms make the big decisions that impact the financial goals of that organization.
The same thing on the health insurance side. In my years in the business, I know a lot of insurance carrier reps. They have no idea what’s going on. That’s purposeful because a lot of them could not go back to work tomorrow if they understood that the Bupa company that they’re working for, how they’re contributing to this unbelievably immoral stealing of the American dream.
We have amazing clinicians. Hospitals don’t save lives. Nurses and doctors with the help sometimes of medical devices or medications save lives. That’s important to remember. There are two things that we’re the undisputed world leaders in healthcare. We are the undisputed world leaders in preventable medical mistakes, death and serious complications as well. There are 10,000 serious preventable medical complications a day. Not because we have bad clinicians but because we have bad systems and bad cultures and understaffing.
The second thing that we’re the undisputed world leaders in, even while we’re spending twice what the next closest country is spending is medical bill-driven bankruptcy. We’re number one in those things but we’re near or at the bottom of the heap of the developed countries on most quality things. That’s an incredible waste of talent. People like your wife. The smartest most passionate gratification-delaying people that I grew up with often became nurses and doctors.
In many ways, they’re the biggest victims because they live it every day. Most of us don’t have to live in the healthcare system. Even before COVID, there were record levels of burnout and suicide. The term that is being used to replace burnout is moral injury. Burnout blames the victim, whereas moral injury is when somebody is in an organization and they’re being forced to do something that is at odds with their morals. That is what leads to depression worsening in some cases. It’s a tragic situation but entirely fixable.
The production company that shot the video we had at the start did one of a union in your area that covers the people involved in operating a building, the doormen, custodians and so on. I’ll give you a couple of data points. They removed one of these price-gouging and low-value hospitals that are not pulling their fair share. They’ve even got these massive tax breaks. Removing that one health system, for 1 year, they saved $32 million for their members. That allowed them to do a one-time unprecedented bonus to these working-class individuals of $3,000 and the largest raise in memory. It was good for the building owners too. They had the lowest premium increase they’d had ever.
To give you an idea or an example of what that means for a member, let’s say you’re pregnant. That is a joyous event in most situations but for a lot of people, that’s a real financial hardship. For these folks, they’re all in cost for all the prenatal care, labor, delivery, you name it for $40. That’s what’s possible when you have high-value plans. What a difference-maker for these people. They can focus on the joy of having a new child rather than worrying about a $20,000 bill.
In New York, we have a community rating. For small employers, which aren’t very small, employers with 100 or fewer full-time equivalent employees fall into the near community-rated market. Those are all fully insured plans. You’re not allowed to do stop-loss and self-insurance. The most comprehensive solution is self-insurance with an independent TPA, independent PBM, case management, direct contracting and direct primary care. There’s one in Long Island. My daughter who’s on the other side of that door works with me is signed up for her. It’s amazing.
Some of the solutions differ. Health Rosetta is not a stamp, “This is what we do. This is how we do it. These are the companies.” As I was going on this journey and this show, this is how to awaken the American healthcare consumer. That’s what I want to do. 2 to 5-person companies are still people. That’s what they have in common with the 1,000 groups. It’s just people. I love helping people.
Fundamentally, I can’t change where they’re shopping for insurance. We can do things like PEOs and things like that but for me, it starts with it being inexcusable that in this country with the technology that we have that someone has to do a Google search to find a doctor. Seventy percent of all Google searches are looking for a medical practitioner. It’s something insane like that.
What you’re going to get is, “Very clean office and friendly staff. Doctor had great bedside manner,” but you’re not getting the important details on how good this doctor is and how well they perform the particular surgery. “Are they orthopedist that specializes in elbows, knees, shoulders or backs? Are they good cardiologists? What type of cases do they take? Do they overprescribe opioids? Do they pull people out of the parking lot? Do they have 2,000 surgeries and is that appropriate?”
To me, that is what’s fundamentally lacking. The way to do the insurance is a little bit of a puzzle because it’s different for every single one of our clients. You don’t have to self-insure to make an impact and save, even a fully insured group at the heart of it. A lot of HR people and benefit decision-makers don’t understand this. Your premium is based on the amount of healthcare and prescriptions your employees consume. If we can lower the expected cost of ensuring those people, whether you’re fully insured or self-insured, your insurance costs are going to go down. You’re going to be a more attractive potential client and have a lot more options.
We talked about that a lot and you hit it right on the head. When we broke it down and we’re working with all these different companies to try to figure identity like, “What is the big problem,” the biggest problem is the mindset. I realized the American healthcare consumer, both patient, employee and employer has been groomed by managed care for many years. They have been groomed to get to the point we are and we raised the white flag. That’s the biggest obstacle.
If there’s a will, there’s a way. A lot of people and employers don’t have the will anymore. They’re defeated. 20 years of paying more and getting less have taken people from a $5 co-pay in the early ’90s on an HMO contract to a $17,000 plus family out-of-pocket and in some cases deductible. You have no coverage until you’ve spent $17,000 out of your pocket. “Thank you very much and send us $2,000 a month in premium.” If that doesn’t sum up the problem that we have from an insurance standpoint, I don’t know what else does.
If people are not reading now, hopefully, they’ll read this in the future. For people who aren’t familiar with Health Rosetta, to me, it is an ecosystem of people whom one day saw something like myself and could not go back to doing business the same way. It’s a lot easier. I’m sure you hear this from advisors and consultants, “I’m the BOO,” which stands for Benefit Optimization Officer. I don’t want to be a broker. Brokers sell insurance products.
Businesses need someone internally because HR simply does not have the time to spend on this. Unless we can reengage the C-Suite, we can’t expect them to get back into the game. That’s what they need to do. It needs to be a team approach. You need to either elevate the HR into that senior role, give them a seat at the table or someone from the table’s got to come down to HR and be at that level and say, “What is going on here?” It’s what GE did many years ago. I forget the gentleman’s name but I met him in New York City when he famously said, “GE spent more money on healthcare than on steel.”
It’s amazing. There are two things that I enjoy more than anything else in what you spoke about. Some of what you’re talking about spoke to this, which is once you see this, you can’t unsee it but here’s the cool thing. It’s people like you, Tina Wilt and Bryce Heinbaugh that are in our program where good people were trying to do the right thing. It was tough. Every year even if you’re making decent money, it sucks to have to go out and deliver, “Great news guys. Pay more, get less,” and then obfuscate the increases through cost shifting onto the backs of people least able to afford it.
When they go from that to this world, the light comes back in their eyes and they make that transition that I talk about sometimes generally as an adult, it’s better to have a job than not have a job. Once you have some competence, it’s better to have a career than a job but much better than a career is a calling. The old Mark Twain said, “Two most important days of your life are the day you’re born and the day you figure out why.”
It's better to have a career than a job, but much better than a career is a calling. Click To Tweet
When those people figure out why and they’re unleashed, it’s incredible. It’s hard work but I don’t know about you. I’ve never seen anything great in life that wasn’t a ton of work, whether it was somebody getting into med school or a competitive athlete. We all worked hard. We had lots of dirt and mud on our faces, teeth and all that but it was so rewarding. It’s the same thing here. You can make easy money and do it the other way but that’s the reason people have midlife crises. That’s why people have willful ignorance sometimes because they know something’s not quite right. That doesn’t feel good. That’s not whom people want to look in the mirror and see.
When they make that transformation, that’s a game-changer. To give you the other thing that lights me up, then they can do the things for members like the $40 pregnancy and being able to afford medications that somebody couldn’t afford before they had to use all their disposable income so they could never even take a vacation. I love those stories. I love when people like you who are on the ground working with specific employers and employees tell me those stories because it’s hard work. We get kicked in the teeth every day but it’s easy to keep coming back for more when you see people’s careers get reinvigorated and then the member’s human impact is beyond belief. It’s not like we got to wait ten years for the payoff. It’s pretty much immediate.
I say all the time, “It took me 30 years to get 5 years of experience.” I was the expert and that’s what scared me. I felt I was a pawn. We’re all playing checkers but we’re on a chessboard and that’s part of the problem. Once I had my a-ha moment, I knew immediately, “I’m not going to be the same.” We’re starting to do open enrollment in person again, which was great. I got back from Miami and it was amazing with the new client. There hasn’t been enough of that interaction with people but for many years, I would do 100 a year. At the end of the meeting, I always tell the members, “I’m going to stick around because you may have a personal question that you don’t feel comfortable asking in front of your coworkers.”
Inevitably, there’s always 1 or 2 people that would come up. Way too many times, people would break down and cry because we raised the copay on a prescription by $20, which doesn’t sound like a lot. It’s not a lot to a lot of people but for many people it is. I get choked up a little bit because when someone tells you, “I have 7 prescriptions and I’m already taking only 5 of them. I’m going to have to give up another one.” You understand what I came to understand that all of the prices and hidden profits, they’re manipulating things. It doesn’t matter what you do to the plan, they’re just going to raise the price and hide it in another spot.
That’s what started us on these journeys so we don’t have to have those hard conversations quite as often anymore but here’s what happened when we did change it. This one was impactful to me. Most people follow the plan that the doctor sends them. They don’t ask questions and don’t have access to the price beforehand. We had a gentleman on a plan that we had repurposed into independent partnerships.
I got an email. This was the very first one. We never get emails like this before but now we were because of where we had placed his account. The TPA emailed me and ten minutes later, I got an email from a pharmacy supplier that we’re working with that said, “We got pre-certification notes through the network.” We’re still using a network. We haven’t gone with reference-based pricing yet. “We see that a pre-certification of an injectable medication came through. It’s $115,000 for this injection twice a year. We can do it for $30,000 twice per year.” $60,000 instead of $230,000 is great. To me, that’s important because that’s a lot of money.
The reason why they were brought to my attention is we want to get in touch with that member and let them know that we exist because people aren’t used to their insurance carriers calling them and saying, “We have an option for you so here’s your option. You can go where you were going to go. We’re not going to force this on you but it’s going to cost you $7,500 out of your pocket because it’s an injectable medication in a doctor’s setting. It’s a medical claim and the plan year started, you haven’t met your deductible or co-insurance yet so it’ll be $7,500 or we can send someone to your home because it’s medically appropriate. We can do it as the guidelines say and it costs you zero.”
This young man in his late 20s, a father of 2 and had no spouse in the picture, I don’t know the story there but he’s on disability. He’s about to come back to work and then immediately at the human level, what I realize we did is the old way. He goes to the doctor’s office and gets the shot. 3 to 4 weeks later, he gets a bill and an EOB. It says he owes $7,500.
My worst nightmare is that his quality of life goes through the roof. He feels better. He’s a better dad. He goes back to work, skipping and jumping and never gets the shot again. That’s the reality for a lot of people. They find out afterwards. We don’t want that to happen. We want them to know their choices ahead of time. We saved the employer $90,000 a year because the $115,000 was the estimate and the carrier would’ve paid $80,000 each time so that’s $160,000. We procured it for $60,000 all-in with the administering of it in the home and all of that stuff.
The employer’s thrilled but more important to me, that young man gets to have this shot for zero for as long as he’s an employer of this company. It’s the choice of going on vacation with his family. Maybe he continues the shot, gets a second job somehow and can go on vacation. My mind spins at the human level, all the possibilities that this unleashes on everybody. This is being done under the Health Rosetta model with all of the advisors. How many advisors are there in 2022?
A little over 200.
I was in the third cohort.
That sounds right. Collectively, you all steward about five million lives.
It’s amazing and it’s not enough. I probably have 2 or 3 conversations a month with advisors that ask me, “Can I talk to you about Health Rosetta?” They get a little intimidated. This isn’t just signing up.
No mail-in diploma. That’s what some people want.
There’s a vetting process. You want to make sure that people aren’t walking around with this Health Rosetta label and they don’t have their hearts in the right place. They’re not looking to make an impact.
That’s the biggest criteria. We have a bunch of career switchers who knew zero other than having received benefits but they had the passion and will so we’re fine with that. There are plenty of folks who had been doing things the old way that wanted to reinvent themselves. They’re not going to have the most successful jump into the deep end and do the most extreme thing but they can step into it. We want to meet everybody where they’re at in that journey.
We’re going to try to filter for what we call the giver and doer mindset. This mantra, “Give 1, get 10,” that’s one of the things that’s been powerful. I’m sure you’ve experienced it where a lot of the industry, there’s this scarcity mindset and people keep their little secret list of vendors or information. Here, it’s the opposite. People know this is tough. They’re going to need help from others. They ask for help. They have this great brain trust. Even if they’re super savvy, there are always new challenges that come along with having that. They’re doers.
You could go to industry events for at least a decade where people would talk a good game and you’d say, “Where’s the beef? Where are the results?” “It was a great PowerPoint.” We want people to produce the results. One of the things that we delivered since the official launch is we’ve been marinating internally on this thing we call a Plan Grader that was used for the initial joining of the program and then renewals. We’re very confident that we know the 40 most important factors that drive a high-performance health plan.
Even if you don’t have a great grade as an individual plan, it gives you a benchmark of where you’re at and then starts chipping away. You can be in the most improved candidate pool. That’s fine. We all had our a-ha moments. It’s not like people were born with this knowledge. Whether it’s the employer, broker, advisor or consultant, as long as they’ve got their heart in the right place and want to walk the talk, we’d love to collaborate with them.
It had to be LinkedIn when I stumbled across the conversations that I’ve been thinking to myself, “I’m the pink elephant. I must be the only one that’s thinking this.” I got involved and started having conversations with those amazing women and men in benefits. I’ve been in this industry for many years but I never had a community or friends in the industry. I can call out 20 names that I can get on the phone in 5 minutes, email or text. It helps to multiply the knowledge by immense help for me and my clients.
The most important thing that we take away and wrap up for an HR or benefit decision-maker is that the conversation is complex but the solutions are simple. You have to understand that there’s a problem. If you don’t think there’s a problem, then you’re not going to fix it. Everybody has a problem and we know that. There are no any Bupa-type programs that don’t hide profits and artificially inflate all of the prices but that’s beside the point. There are plenty of people that know they have a problem. They’re intimidated by the prospect of changing it. They believe nothing can be done.
We’ve seen it firsthand. I know that you and the hundreds of brokers or advisors that you speak with are all doing it. Five million lives are a little scratch. We need to make a dent next and a real impact but we are making an impact. I have a pretty good pulse on the language that the carriers are choosing to use and the different ventures that they’re getting into. They understand that certain profit centers are going to dry up because the consumers are getting smarter. More and more advisors are going to go down this path. They’re inventing new ones. There are always going to be this problem to solve. They are not going to be shocked and give up 20% of their stock price. They’re not going to do that very easily.
If the consumer wakes up and takes their business elsewhere, they must react. To me, that is the purpose of this show. It’s to awaken the American healthcare consumer. That’s the employer. We want to make individuals smarter consumers of insurance products and also smarter consumers once they enter that healthcare system. They know where to go, how to look and know that they have rights. They don’t have to go where their doctor sends them down the hall for that MRI because that net is being cast larger and larger every day. The healthcare systems own every component of it and they’re trying to let the fewest patients escape.
When that member’s good to go, we’re trying to help people understand that they have options. Anything you want to say as a takeaway if you were talking to an employer? Go to HealthRosetta.org. You can find the advisors there. That’s one key place I would say to start. They’re all over the country. If you’re connected with me on LinkedIn, you could reach out to me but if it’s in Texas, Florida, Ohio, North Carolina, Seattle or anywhere, there is a Health Rosetta advisor out there that’s more than happy to speak with you, share their thoughts and start there.
There’s a better way. It’s easier than you think and there are successes for organizations like yours. We can help you make that happen. Something as important as a health plan like the Plan Grader I mentioned, you can think of that as a second opinion. If you had a serious condition like cancer, you’d want a second opinion. Go to somebody like Lou and ask for that second opinion. You can get a sense of where you’re at so you know where you need to go.
It’s a very different conversation I can promise you that they’ll have with an advisor that’s on this track. Sometimes I have conversations and on the other side of the desk, you get that deer in the headlight moment. You have to wonder, “Did I lose them or did I get them into such deep thought that they’re not going to be able to go back to doing it the same way again?” Sometimes it takes 2 or 3 years. Some of our recent successes started a few years ago and I knew we were planting a seed at that moment.
Another few years of the status quo, pay more, get less, eventually was going to resonate with that decision-maker and they were going to say, “He was right.” In a couple of years, it’s going to double. We have a problem when our insurance costs double in a couple of years so you better start addressing that now because if you wait until then, it’s too late. I want to thank you.
It’s been a great chat.
You too. I will talk to you soon. Take care.
- Health Rosetta
- This Job Could Save America – Forbes Article
- Healthcare Stole the American Dream – Here’s How We Take It Back – YouTube
- LinkedIn – BritePath