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Becker’s Healthcare Podcast
Rethinking Prior Authorization Through Technology and Alignment with Chris Gay of Evry Health
00:21:33
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- [00:00]
A
Hello, everyone. This is Jacob Emerson with the Becker's Payer Issues podcast. Thrilled today to be joined by Chris Gay, who is the CEO of Every Health. Chris, thanks you so much for taking the time to be here with me once again on the podcast.
- [00:15]
B
Well, thank you, Jacob, for having me on the podcast.
- [00:18]
A
Absolutely. And before we dive into everything, we want to talk with you about today, Chris, for our audience that might not be familiar, can you tell them a little bit about yourself and what it is that you do at Every Health?
- [00:28]
B
Sure. Chris Gay, I'm the CEO and one of the co founders of Every Health. So I was a software developer by training and that's turned serial entrepreneur. And inside of Every Health, I mostly set the strategy and make sure that we have the resources to fulfill that strategy. And that includes a lot of talent and recruitment. And in terms of our company, we started eight years ago as a startup, trying to address issues that we felt were inequities in US Healthcare around access and quality and engagement and total cost, and started out in Silicon Valley with $120,000. Now, you can best think of us as a software company, owns a full health insurer, and we focus on the mid market, commercial mid market, fully insured. Most of our membership is in the state of Texas.
- [01:25]
A
Fantastic. So a bit of a unique structure there in terms of the wider industry landscape. Chris and I wanted to start us off by going back to the conversation that you and I had had here on the podcast about six months ago this summer. You had mentioned that Every Health has achieved a 7% prior authorization denial rate with 100% of those denials upheld on appeal, which, as you know, far out outperforms the leverage. And, and then you also offered to license your technology that has led you to achieve that to competitors. So I wonder, you know, broadly, if we're looking out across the industry. This is a topic that gets a lot of negative headlines, a lot of bad press for a lot of insurers. So, you know, and this is all, of course, the context here is, you know, this summer, nearly 50 insurers committed to standardizing electronic prior auth processes, including Every Health, in collaboration with the government. And so broadly across the industry. What, what's the biggest obstacle here? Do you think that's preventing larger insurers, especially from replicating what you've built at Every Health? Is it fundamentally a technology problem like we heard Dr. Oz suggest this summer, or is this a business model problem at its core, or is it something else? What do you think?
- [02:47]
B
Ooh, I think it's three things. So I'll answer the first one as the technology and you can come back with the other two as follow up questions. It is a technology issue and it's a technology issue. And again, I think it's the other two things as well. But it's a technology issue because of the scale. Prior authorizations are a shared frustration by both the medical provider, community health systems and physicians, and the health plan and payer side of the industry. But we have a job in population health to look across health systems, look across employers and state lines. When we do that at a large data level, you see a lot of variation in clinical care that impacts medical quality, that impacts patient experience. It also impacts the broader community. When we waste resources, it means there's less to be used for everyone else. It's not a limitless ceiling. We can't continually spend more and more and more as a society without driving higher quality medical outcomes. Happy to spend more when it corresponds with higher outcomes. But because it's a big data problem and because it spans a lot of complexity, it's perfect for technology. Let computers do the boring, challenging work of matching records, doing eligibility for patients, doing eligibility for facilities, doing eligibility for providers, doing the code checks. Computers are great at that. And that's why software is superb for the solution and why we're happy to license what we do for other people. It works. It works really well and it lets our staff work at the top of their license, allows you to turn things around in minutes instead of days back to the patient gets the benefit of that and it results in higher medical quality. So tech can really solve a lot of problems here.
- [04:51]
A
So ultimately this is a scale issue in your mind. And I wonder. I remember like I said in that original conversation that we had this summer, you had offered to license your technology to competitors. Have any taken you up on that since our conversation?
- [05:09]
B
Yes. I will tell you it's in pilot with other companies. It's pretty straightforward to do. But you know, large companies need time to make decisions and evaluate things and that's perfectly understandable. But we're pretty pleased that others want to change what they're doing and make it more patient focused with faster turnaround times and lower costs and higher quality. So that's what the software allows.
- [05:36]
A
Certainly. So you mentioned this is also a technology problem, Chris, and, and like I said in my original question, you know, I posed to you that this is a potentially a business model problem too for the industry. Do you think that that's an accurate assessment?
- [05:52]
B
Absolutely. I think you have you've got organizations on the payer and provider side on both sides that, to put it politely, are trying to maximize margin. And there are times to have margin. As the Sisters of Charity used to say, if you have no margin, you have no mission. Right. So having margin isn't a crime. None of us can build even non profits without margin. The challenge you have is you have very sophisticated large organizations and on both sides. And there is a lot of optimization going on. And I would argue my opinion there's a lot of artificial friction created and there are parties on both sides that really push the extremes and the way the business models work, you know, either side can outdo it, outdo the other. And there's. So for instance, on the payer, payer side you have organizations that in response to a bunch of garbage being submitted, expanded the number of codes that they put under the for qualification. And hey said, look, let's pump the brakes a little bit. Let's take a little more time to evaluate this. Because too many things were getting pushed through that didn't meet medical quality or standards and they erred on the side of too many codes and too slow, if you want to be particular. And then on the, on the provider side, you've got organizations that have contracted out their, what they call revenue cycle management. They're not even directly talking to the health plan. They put it to a third party and that third party is oftentimes submitting for anything they can think of and often resubmitting. So they'll fire off the same claim nine times inside of 45 days. And the payer has to respond to all nine of those, even though eight of them are dupes. Duplicates. This is just a couple of examples of how both sides kind of weaponize against each other. And it's fundamentally because the business models aren't aligned around patient care. And that's why AHIP has stepped forward and said, enough of this nonsense. 50 of us as health plans, including every health, we're going to lead the industry. We're going to say let's reduce the codes. We're going to say let's enforce more digital submission so we can clearly identify dupes faster. We want patients to get an answer quickly. And we're going to do this all based upon improving medical quality and patient experience. And so I think it's a great example of how a political organization can step in and say, everyone put the knives and forks down, but let's have a real conversation and we'll, we'll be the first to start.
- [08:45]
A
Yeah, absolutely. So AHIP has stepped in. A lot of this, I think behind the scenes has been very much pushed by cms, of course. And you say that it's a lot of the, this issue, that it's artificial, that it maybe could have been been fixed sooner and on and on top of that, that context of what's going on federally and, and with AHIP and, and all the groups that they represent, we, we're seeing around the country. It's been happening for years, but it's really ramped up, I would say the last year or two where we've seen a lot of the states take on this issue themselves. California pretty notably this year passed and, and, and enacted two prior authorization reform bills. One mandating quicker response times for these requests, another allowing the state or regulators to, to waive these requirements, services or certain approval rates that are achieved. And so I wonder, you know, from where you said, I know you're, you're operating solely within Texas, but how effective do you think state level reforms are at actually reducing friction? You know, this, this patchwork of state mandates versus what we're seeing now with, with this pledge at the federal level, with the private sector.
- [10:03]
B
I, yeah, and I'll be clear, I'm speaking personally here for myself, I'm not a fan of patchwork state regulation again because as health plans on the population health side, we're spanning states and it just creates system complexity. I'm more a fan of the voluntary initiatives that we were part of at AHIP that are looking nationally. Let's talk about some of the things in there. Effectively what they're looking for is faster turnaround times and gold carting. And I don't, I don't think you need more legislation to get there like we've proven you can, you can do this at every health with, you know, 100% upheld upon appeal and only a 7% medical denial rate. And oh, by the way, this year we're driving even lower. I think we're on track this year to be somewhere around 4 to 5% again, always upheld on appeal. So you can use technology and you can use voluntary commitments to improve the patient experience and to work with providers and improve medical quality and lower costs. It's all doable. Now having said that, I would say, you know, my goal and my organization's goal is, hey, let's go further. What if we could eliminate PAs? What if we could gold card everything? And Jacob, that requires partnership with providers, that requires partnership with the American Medical association and the American Hospital association. But we could get there as an industry. But I would put some backstory on it, right? There has to be accountability. Hey, if you want us to gold card everything, that's like saying there's going to be a blank check will prove to us that you've got the clinical. You follow your own clinical guidelines. Just follow your own guidelines. And the trouble is still a lot of large organizations and provider groups don't follow their own care guidelines. And yet we as a society gave $30 billion of taxpayer money for EHR upgrades and systems upgrades across the industry. And yet we're still getting 40, 45% of our submissions that we receive are fax and paper. And even then we got to dig through it all. So like my organization, I'd be willing to gold card everything if providers came to us and said, hey, we're following our own guidelines. It's all here in the ehr. We'll have a digital connection. And hey, if we ever want a variance on something like hey, there's a good reason we're varying from the clinical guidelines. Here's all of our documentation. Great, let's go, let's do this. And we have the technology to do this at a national level. Jacob. There's no reason we couldn't take the best care guidelines of the whole world and every major system in the United States and put it in a single system of record or open source it and say hook that up to your EHR at every point in time for any given patient. You would know the next step in their journey of care based upon the evidence. I think there's a way we could all do this nationally. The patchwork approach of state by state legislations misses the forest for the trees.
- [13:17]
A
Sure. No, I, I totally get that. And I think it's, you know, when you look into some of these state bills even more into detail, you realize they don't necessarily. They don't affect or they don't. Yeah, they don't affect the plans that most people are on a lot of self insured plans. They really only affect the plans that states themselves can, can regulate. And then of course you've got the issue where a lot of health plans, most health plans are operating in different states with, you know, employees that are covered all over the country.
- [13:45]
B
You bring up a great point about what they actually regulate. A lot of states are regulating less than 20% of the market. Yeah. Because the rest of it's federally regulated. Medicare or ACA or self insured. Your point under erisa. Yeah. And it's stop making fully insured health plans, carry all the water for everyone else like Gun Gha Din. If you're going to regulate the market, regulate the entire market, not just 20% of it, because that creates adverse selection. Yeah.
- [14:15]
A
And it's fascinating when you see the headlines as if it is affecting the whole market because I think there is just not an understanding in the media of the complexities of that. But before, before we run out of time today, I do want to make sure to ask you about the the traditional Medicare prior AUTH pilot, which is set to go into effect in just a few weeks. We know who the vendors are going to be that are going to administer this. A good chunk of them are connected to insurers in some way. Either they, they work with them already on prior AUTH or they've been funded by them. And then if this for our listeners who might not be familiar, this is the wasteful and inappropriate service reduction pilot Wiser initiative starting in January, introducing prior auth requirements for 17 services to traditional Medicare for the first time. There's been a lot of criticism this year. There's been legislation introduced in the House by Democrats to stop this entire the hospital association has been critical of the legislation specifically around the AI use that this is going to introduce to the program. In terms of decision making, it sounds like. So you know, what do you think about this, Chris, in terms of is adding prior AUTH requirements to traditional Medicare a step forward or backwards? And what should what does CMS need to get right here to avoid some of these problems that we just lightly touched on in terms of the commercial market?
- [15:43]
B
Boo. There's a lot in there, Jacob. First, it's a clever bill acronym there Wiser. And you know, the challenge being Medicare wasn't supposed to stay. I think what people forget is that Medicare wasn't supposed to stay the way it currently is, that originally Medicare Advantage was launched a long time ago and was meant to be kind of rolled back into. And so we wouldn't have part A and part B anymore in their current forms that we're supposed to learn from Medicare Advantage. But the people that launched that and the leadership and the policies have now changed and we have independent programs in the country of in effect, Medicare and Medicare Advantage, two very different programs. And what I think the administration, because I don't speak for the administrator, what I think they're trying to do is try to take some of the lessons learned from Medicare Advantage and pull it over. And one of those is that sometimes again, you've got a lot of clinical variation. And it's too much, too much clinical variation. And it has a big impact, particularly for a large federal program. And they're trying to reel that in a bit. The trick is it's very early, it's too soon to tell. We can't grade them on their performance. All they did was issue a request for proposals and they've chosen some vendors, but they haven't done any work yet. So we have no way to judge their performance. I think it can be done very well, though. Jacob. I personally don't have a problem with using AI to do all the boring work that no nurse and doctor wants to do. No nurse or doctor wants to scan through faxes and emails and go through 50 pages of notes to find the one thing that's the indication necessary support the clinical guideline. But software and AI is just software. Software does all that really well. So it can be a decision support tool presented to the nurses and doctors, say, hey, look, we found three indications of breast cancer. This supports further treatment. Let's go and let the nurse or doctor go straight to the point. In the notes that have the indications, they got directed straight to the guidelines. And so they're able to work at the top of the license and do more patient care and they get a turnaround time back to the patient. That's quick. Everybody wins. So as much as people are frustrated by Medicare all of a sudden having a potential new process to it, it may not be a bad thing. That's just my opinion.
- [18:15]
A
It'll be interesting to watch it as we go into next year. I know from, from where we sit, you know, we hear a variety of op. This from it being the end of Medicare according to some, to some saying it's the modernization and like you said, bringing over some of those lessons learned from Medicare Advantage. So definitely something we're going to be keeping our eye on as well.
- [18:37]
B
And their concern is a federal program is also cost. Right?
- [18:42]
A
Sure.
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B
One of the biggest things in the United States is just affordability. Affordability, Affordability. Right now in terms of political messaging. And HHS's budget is huge now.
- [18:53]
A
Yeah.
- [18:54]
B
Right. And it's growing at a faster rate than the economy. At this rate. It's. If it continues at this rate, it may have already eclipse it. But I think it's probably on track to equal the entire budget of dod.
- [19:06]
A
Yeah.
- [19:07]
B
And I mean, they wouldn't. The government has to look at some things and say, hey, at what point is this too expensive? Yeah, maybe we could manage this better. This may not be the correct way to manage it, but at least they're looking at some pros and cons and trade offs and they're willing to try something and experiment. Definitely. All this to be said, I would say look at it in the bigger picture of Medicare Advantage was long term originally meant to become or pull all the lessons from MA into Medicare. So if you think of it on that long arc of 15 years of policy and planning, this is really just coming back to where we started. It's not so radical.
- [19:51]
A
Well, Chris, before we go, anything that we're missing, anything you want to share with the wider industry while you have their ears or any reflections of the year that just occurred?
- [20:05]
B
Well, every time I go into a room now and it's not a room of friends and family, as soon as they learn what industry I work in or who I work for, it's like the tension automatically increases. And I think many of my peers in the industry have the same issue. And so what I would encourage people to do is engage. When they engage with us and they have real honest conversations, the temperature drops, people, oh, you've got a reason for that? Oh, that makes sense. People want a real and honest dialogue in this country right now. And I think we as leaders in the industry have an obligation for that. And we do that. We find commonality. And in that commonality, we can move entire industries forward and we can shift communities to better population health. And so I just encourage everyone over the holidays here, don't be afraid of the hard conversations. Have common ones, have candid ones, and enjoy the holidays.
- [21:09]
A
That's really great advice. Humanize your industry. Chris Gay, I really appreciate you taking the time to chat with me before year's end and really appreciate you sharing your expertise and your thoughts with our audience. Thank you.
- [21:22]
B
Thank you, Jacob.
- [21:24]
A
And to our audience. If you'd like to listen to more podcasts from Becker's, you can visit Beckershospitalreview.com.