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- [00:00]
Jacob Emerson
Hello, everyone. This is Jacob Emerson with the Becker's Payer Issues podcast. Thrilled today to be joined by Chris Gay, who's the CEO of Every Health. Chris, thanks so much for taking the time to be with me on the podcast today.
- [00:13]
Chris Gay
Well, thank you, Jacob. Thanks for having me.
- [00:15]
Jacob Emerson
Yeah, absolutely. And before we dive into everything, we want to talk with you about, Chris, can you tell us a little bit more about yourself, your background in terms of your career and what it is that you're doing today at Every Health?
- [00:27]
Chris Gay
Oh, goodness. Well, what I'm doing today at Every Health, I'm the CEO. I used to have beautiful long, flowing hair in a ponytail. Now I'm bald, which tells you what responsibility does to a man. I enjoy my role and most of my time, though, is really spent overseeing community and just kind of pushing us forward in population health. I'm a serial entrepreneur and I came to healthcare by way of personal experience. I had friends and family that had some pretty horrible healthcare experiences. And my co founders and I started this because we feel that in hindsight when we looked at those shared experiences, that a little bit of human attention or a little bit of money at the right point in time can change lives. The challenge is, Jacob, when you step back at it all, how do you do that systemically across the whole nation, to be in the right place at the right time, with a level of trust with someone that they'll trust you enough to share, they'll trust you enough to accept help? That's the hard part. And it turns out insurers are ideally suited to affect large population health change because insurers control the data, they control the technology, they control a huge portion of the patient member experience. And they're ideally positioned to work with physicians and medical providers that want to improve population health. So you can think of us as a software company that owns an insurance company.
- [02:03]
Jacob Emerson
Understood? Understood. And you know, we're going to talk about something today that is going to affect, in theory, a majority of the American population. And I'll get into that in just a second. But just so we set some context for our audience, Chris, Every Health, how many members do you serve and what markets are you in today?
- [02:22]
Chris Gay
Sure, we are a commercial insurer. So we do large group, fully insured. We only underwrite right now in the state of Texas. So we're a small insurer with about 5,000 lives.
- [02:34]
Unknown Speaker
Okay.
- [02:35]
Chris Gay
And we also own our own medical network.
- [02:37]
Jacob Emerson
Fantastic.
- [02:38]
Chris Gay
10,000 provider locations are directly contracted by us.
- [02:42]
Jacob Emerson
Fantastic. No, I appreciate the context there. So let's dive into a Big announcement from the wider insurance industry earlier this week. It was June 23rd. Insurers announcing a series of commitments to what they're calling streamlining, simplifying and reducing prior authorization requirements across commercial Medicare Advantage and managed Medicaid plans. I just mentioned that's expected to affect over 250 million Americans. And nearly 50 insurers have committed to this. And that includes every health. That includes things like standardized submission processes for electronic prior authorizations, reductions to the overall amount of requirements that the providers and of course, members have to face, and an easier appeals process among a few, few other things. So we are hearing from stakeholders all across the industry about this. Some, some positive, some negative and some, you know, I think just laying in wait to. Lying in wait to see what's going to come ultimately from this over, over the next few years or so. But, but ultimately it is being hailed as a significant step forward for the healthcare system. So from your perspective, Chris, what was the driving force behind the industry's decision to, to coalesce around these major changes? And how do you think that health plans and policymakers all align to make these reforms a reality?
- [04:14]
Unknown Speaker
Hmm.
- [04:15]
Chris Gay
Put me on the hot seat. The. Well, I can't speak for some of my peers in the industry, for AHIP itself. I mean, we're a member of ahip, we're a signatory to this announcement. You know, we believe it every. That this prior authorization, voluntary commitment, set of standards, it's a step in the right direction. Why did it happen? You know, I think, you know, I'm speaking personally here. I think there is a large amount of modernization that still is yet to occur in our industry, broader industry of healthcare, and there's still opportunities to improve customer service and reduce any points of friction or latency. And I believe the population has just gotten to the point where their voices are being heard inside organizations and outside as the consuming public, and they want better service. And I think that's perfectly understandable.
- [05:17]
Jacob Emerson
Yeah, no, absolutely. And I, you know, I, well, from our perspective, when, when we look at industries being ranked by customer service quality right now and expectations, it is generally the insurance industry that, that falls behind, you know, like I said, in national rankings. So it's interesting you say that this is, a lot of this is coming from that, that customer service expectation from, from the wider public call.
- [05:43]
Chris Gay
You know, it's like, talk about the problem in the middle of the room. The reason it is so challenging for legacy insurers is they are responsible for a massive amount.
- [05:53]
Unknown Speaker
Yeah.
- [05:54]
Chris Gay
Compliance, medical quality, and they provide A vital service, but it's hugely complex and they get pulled and you know the big legacy insurers are pulled in 50 different directions by 50 different state legislators.
- [06:05]
Unknown Speaker
Sure.
- [06:06]
Chris Gay
Legislatures. So it is challenging. They're not subject to the same customer service standards that someone is that checks into a hotel.
- [06:15]
Unknown Speaker
Yeah, very fair.
- [06:16]
Chris Gay
Give them a measure of flexibility. I mean they're dealing with life and death stuff. Huge amounts of evidence based literature and a lot of complexity that would crush most businesses. But on the flip side, the consuming public doesn't understand that.
- [06:33]
Jacob Emerson
Yeah, no, that's a great point.
- [06:34]
Chris Gay
Just goes, hey, from my small point of view, I feel this wasn't good enough. And the industry has not done a good job over the past 30, 40 years of explaining why population health is necessary, why what we do is vital and that without us and the population health things would be radically different and not in a positive way.
- [07:00]
Unknown Speaker
Sure.
- [07:00]
Chris Gay
Empathy move. Know there's a gap there between reality and what people believe and that's causing a lot of frustration.
- [07:08]
Jacob Emerson
Yeah, no, certainly. And I mean, you know, when people do interact with a company like yours and some of the companies on this list, it is of course some of the most emotional situations of that they've encountered in their lives. So of course, you know, there's there, there's a lot of emotions evolved and often misunderstandings. So your point is well heard. And let's talk a little bit about that complexity because now let's say over the next 18 to 24 months, you and, and our industry are being tasked with making these reforms or these, these promises actual tangible reality for your members. So, so from every's perspective, specifically what does that actually look like? What are some of the conversations you're having internally? What are, what's the technical changes that have to occur for you to meet these commitments?
- [07:55]
Chris Gay
Yeah, you need to take, you need to get to the point that doctors or physicians and their patients and get answers the majority of the time in minutes while the patient's still in the room with the physician rather than days. That's the goal. My goal at Every Health is we want to drive prior authorization denials to zero, period. And we're really close to achieving that. The broader industry, the challenge that they're fighting a lot of my peers are dealing with is the medical provider industry overwhelmingly still run like it's 1980. It's 40% of the inbound prior authorization requests are still fax. They're not even good faxes, Jacob. They send them over. It'll be like everything between both sides of a manila jacket folder, a huge stack of paperwork. It'll be skewed 30 degrees, it'll have two different persons, handwriting on it, stamps on it, and each state's different with its own regulated form. So, yeah, it's quite a challenge technologically. You've got to do a lot of inbound document cleanup. It's not just OCR work. You've got to verify eligibility of the member and the provider, check the medical codes against the, are those legitimate? Are those, are they submitting for the right thing? You know, is the billing code match the procedure code request? Then you got to compare it to all the evidences and if it moves on to a medical evaluation, you've got to take a look and see if the medical information submitted matches up with the request and the care guidelines, which is all evidence based. It is not a small challenge. And then you got to get that back to someone in minutes. It's a huge lift. Very doable, but it's a huge lift.
- [09:56]
Jacob Emerson
I can't imagine. I can't imagine. And how are you feeling about the timeline of all of this? Even just again, from your company's perspective, do you feel prepared to meet this timeline?
- [10:06]
Chris Gay
Yes. I mean, we've built the technology, we've built software systems that allow us to do this already. We're already compliant with the things that the company can be compliant with on these voluntary commitments. We already do this electronically. We already do in real time, and we're happy to license that software to our competitors. We want Population Health to increase. To give you an idea how well that's working behind the scenes, the industry average for prior authorization denials is 25 to 35%.
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Unknown Speaker
Okay.
- [10:39]
Chris Gay
Every health. Our prior authorization denials in the past calendar year were only 7%.
- [10:44]
Unknown Speaker
Wow.
- [10:44]
Chris Gay
And 100% of those were upheld upon appeal, which means we are following the science. It's evidence based. Whereas the industry average for denials being upheld on appeal is probably closer to the mid-50s in terms of percentage, like 56% or so based upon Kaiser or Healthcare.gov.
- [11:04]
Unknown Speaker
Sure.
- [11:05]
Chris Gay
So it can be done.
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Unknown Speaker
Okay.
- [11:07]
Chris Gay
It's just, it's a hard lift.
- [11:08]
Unknown Speaker
Yeah.
- [11:09]
Chris Gay
Well.
- [11:09]
Jacob Emerson
And you know, it's, I, I, I want to go back to what you just mentioned, that often on the provider side of things, and I suppose on the insurance side of things as well, often the system is operating like it's the 1980s, but we're, you know, we're obviously not in the 80s any. There's so much more technology available to companies like yours to hopefully make this a little bit of an easier process. You know, I know this is a bit of a simplified question to a very complicated problem, but do you think that new technology, I hate to use the AI buzzword, but can AI make this a much easier lift compared to the past?
- [11:45]
Chris Gay
Absolutely. We use AI powered tools to do administrative approvals and administrative denials and to prepare all the casework to summarize things for our nurses and doctors. We never use AI to make a medical denial or a final medical determination about a denial. Sure, it is really useful. You got to keep in mind, sometimes we get a stack of paperwork, sometimes 130 pages of medical notes that can span entire patient's history, send us the whole thing over as a fax. And nurses and doctors don't want to spend their time digging through 130 pages trying to figure out, hey, what is relevant for this PET scan request or what's relevant for this knee surgery request. AI powered tools do a great job of quickly summarizing and tagging what is relevant in the medical case so that the nurses and doctors can work at the top of their license and get a speedy response back to that doctor and patient. And sometimes we found the AI powered clinical summaries and guideline checks, evidence based guidelines, find things that even our nurses and doctors didn't find. It's a great decision support tool. And I think we as an industry should be adopting every technology we can that improves medical quality and population health. Absolutely. Point earlier customer service, like, let's get this down to minutes instead of days.
- [13:17]
Jacob Emerson
Absolutely. And I can't imagine, you know, you were talking earlier about the complexity of some of these larger organizations that are signed on to these commitments. I can't imagine what they're trying to sort through in terms of, you know, meeting, meeting these deadlines. But I also want to ask you about some of the criticism we've already been hearing from, from providers, from, from the trade groups to represent them, basically laying out concerns about this, saying that, you know, we've heard these types of promises in the past from the industry that really never came to fruition, or that, you know, a lot of the companies are, are publicly traded and that they still have to meet their commitment to investors and, and that this will just shift administrative burdens to other areas. How would you respond to that? I mean, how do you think that the success of these reforms will ultimately be measured?
- [14:12]
Chris Gay
I think ultimately they're going to be measured at the denial rates. Ultimately for me, that's the KPI I would focus on over the long term that a prior authorization denial rate should decline over time. If you're working in partnership with physicians providers making sure that they're submitting it the best way, the first time, the quickest way so you can get them an answer. The goal is we all serve the patient. But I understand the criticism. Some of that in my opinion is misinformation that people don't understand that prior auths. It's not about billing. You don't make money. At least at every health we don't make money by denying prior auths. Prior auths are purely driven about evidence based care, what is best for a patient given the scientific medical literature. Sure, that's the only goal, that's the only criteria. And then we're independently as industry, all of us in industry that are part of medical quality standards like URAC or ncqa, which every is a part of, we're independently accountable on our medical quality and our prior authorizations are reviewed. And you even have something called intra rater reliability. So anytime you have a medical quality review, independent committee comes in, pulls a statistically random sample of your, your prior auths and your medical decisions and reviews them. And like the industry standard on that is anywhere from you really want to be above 90% interrater reliability and industry can float between 72 and 94.
- [15:52]
Unknown Speaker
Okay.
- [15:53]
Chris Gay
We at Every Health are at 100% and that's our target. I hope we can maintain it. But all this to say I think the, a lot of the pushback is just misinformation about what a prior authorization is and what it's meant to do.
- [16:09]
Jacob Emerson
Yeah, no, it's fair, it's great insight. It's really interesting. What else are we missing on this, Chris? I mean what have you been hearing the last few days since this announcement that, that you want to talk about, that you want to address. You've got the ears of a lot of other healthcare leaders, a lot of other health plan leaders out there listening in. What do you want to say to them about the next few months and, and couple years to come around this?
- [16:41]
Chris Gay
I think we have a fantastic opportunity to address a nash nationwide concern. And our industry needs to move quickly. And if we move quickly and it's an opportunity to address that gap again that we talked about at the beginning between public perception and reality and that our industry just hasn't done a good job of educating the public about the necessity and value of what we do. If we do this as an industry and move quickly, we have more credibility. Our opportunity to educate the public will be extended and that can reap huge benefits across the industry and society if we're seen to be working with providers to solve real tangible human problems that all of our friends experience around the dining table. So I mean big picture, that's how I think of it, Jacob.
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Unknown Speaker
Sure.
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Chris Gay
Smaller picture, you know, smaller stuff. We have the technology. We can do this. It's it, it is the beautiful thing about technology is it scales to big problems really quickly. And you know, we're already doing it here at every health and we're happy to help power all of our peers to do it themselves.
- [17:59]
Jacob Emerson
Fantastic. Well Chris, I want to thank you for taking the time to chat with me and for sharing your, your insights and your expertise with our audience. We really appreciate it.
- [18:10]
Chris Gay
Sure. Thank you very much.
- [18:13]
Jacob Emerson
And to our listeners, if you'd like to listen to more podcasts from Becker's Healthcare, you can visit Beckershospitalreview.com.