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Outlier Clauses: Healthcare's Best Kept Secret | with Ryan Bojrab — Transcript

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0:00If there's a high roller and you're out
0:01in Vegas and you know a casino sees
0:03somebody that's rolling up with a you
0:05know a lot of money and willing to put a
0:06lot down, that's how they make a lot of
0:08their money as a casino. You use that
0:10same analogy on the hospital side. These
0:13outlier clauses are where the hospital
0:15contracts make majority of their money.
0:17>> You're listening to self-funded, the
0:19podcast about making healthc care better
0:21together. Let's get to work. So I I
0:23don't know if it's maybe the one of the
0:25best kept secrets, but you know, you and
0:27I are pretty well informed. We've been
0:28in this business for a long time. I'm
0:30sure a consultant's listening to this
0:31and go, "I've known about outliner
0:32clauses forever, but it does seem like
0:34it's something that isn't not is not
0:36discussed very openly very often. You
0:38know, I think I reached out to you right
0:40six, eight weeks ago when I saw you
0:42comment on somebody else's post
0:43regarding it and two to three weeks
0:46prior was the first time I heard
0:47somebody cite the outlier cause as a
0:49rationale for why some of the pricing
0:51was very dramatically different between
0:53carrier networks we were looking at."
0:54And I go, "Wait a second. Why have I not
0:57really had anybody sit and explain this
0:59to me? And how did I didn't how did I
1:01not know that it had such an outsiz
1:03impact one on the cost of a claim but
1:05two the underwriting of that particular
1:07network and it just like mind-blow right
1:09and that was why I reached out to you
1:11and said dude come on come on the show
1:12and we started talking and anyways
1:14background um for you getting here you
1:16were down here already Ryan but I
1:18appreciate you coming on and you know
1:20what I'd love for you to do is really
1:21quickly tell us who you are and what you
1:23do and then let's dig a lot into what
1:25you know because I think you can help
1:26the audience tremendously. Well, thank
1:28you and it's a pleasure being here,
1:29Spencer, and finally getting to meet you
1:30in person.
1:31>> I know, right? It's weird. We've known
1:32each other virtually for years, man.
1:34>> For years. For years. And so, Ryan
1:36Bojab, I reside in Indianapolis,
1:38Indiana. I've been in healthcare my
1:39whole career. I have a very different
1:41background than most folks you talk to
1:43that are on the broker consulting side.
1:45I actually started my career as a
1:46clinician. Okay. I've got my doctor in
1:48physical therapy certified in lifestyle
1:50medicine um and mobilizations and
1:54manipulations in regards to self-care
1:56and well-being. I did a lot of uh
1:59biocschosocial approaches in regards to
2:01like behavioral coaching when I was a
2:04practicing physical therapist and so not
2:06the normal side of PT
2:08>> and I was pretty good at what I did.
2:11>> Were you working with athletes quite a
2:13bit? I was working with a blend of both
2:15uh chronic care because a lot of my
2:17practice was within a federally
2:19qualified health center. So I I I
2:21treated a lot of patients that were uh
2:23underserved population and have a lot of
2:25resources, but I also treated a lot of
2:28the employees of the hospital I worked
2:30for that had a lot of resources. And so
2:33it was kind of two different sides of
2:34the spectrum. Um and it really did
2:36challenge me a lot. You know, it's it's
2:38different treating somebody with knee
2:39pain that I'll never forget, you know,
2:42same day I saw somebody with knee pain
2:44that uh one made 100,000 plus a year and
2:47had all the resources in the world to
2:49help take care of the knee pain. And
2:50then the other guy lived three miles
2:52underneath the uh three three miles down
2:54the road underneath the bridge and his
2:55main source of transportation was a bike
2:57and he hurt his knee wrecking his bike.
2:59>> Oh man. So like to me, you know,
3:02completely different like uh in regards
3:04to course of treatment of how I was
3:06helping this individual versus the other
3:08and getting that guy a bike, which is
3:10what I actually did help him get.
3:12>> Oh wow.
3:13>> Was more important to that guy and
3:15actually helping him rehab his knee than
3:17it was anything I could do for the
3:18individual. That's amazing. Right. And
3:20so like that story,
3:22>> it's been a long time actually since I
3:24brought that up, but that that story
3:25really resonated with me. And so um
3:29>> well what so okay I I want to comment on
3:31that but I also want to hear what drew
3:33you out of that world because apparently
3:35you were attracted to it but then
3:37something caused you to
3:38>> that's a great question and so one thing
3:41you know so you know it doesn't matter
3:42if you're in med school uh nursing
3:44school
3:46physical therapy school etc. Nobody
3:48teaches you about the what I would call
3:49the business side of healthcare. Y
3:51>> and so, you know, when I got out about
3:54maybe it was pretty quick actually
3:56within a year or two of of practicing as
3:58a as a new grad, um I just remember like
4:02getting told how many visits I could see
4:03a patient for. And I'm like, well, wait
4:06a second. Like this person though isn't
4:08like better yet. Like I I know like if I
4:10had a handful of more visits, like I'll
4:12get them over the line based on how they
4:14want to get back to their function of
4:16life, right? And that's when I first
4:18learned of how much like, you know, the
4:20the the carriers have influence over how
4:24many visits you can see.
4:25>> And so I just started who I am. I'm a
4:27very curious person. I just started
4:28asking more questions. So I'm like,
4:30>> well, who else is involved in healthcare
4:32that I'm unaware of? [laughter]
4:33And so that was when I started to learn
4:35about uh the whole industry, right? I
4:37started to learn about who I who a TP I
4:39don't know what a TPA was. Who's a TPA?
4:40what's an ASO, a PBM,
4:43>> brokers and consultants, you know, all
4:46the vendors in this space, stoploss,
4:48like that whole world is really where I
4:51started learning more as a practicing
4:53clinician. And long story short, what I
4:55realized was that I could actually
4:57influence at scale
5:00>> somebody's health more
5:02being on the benefits consulting side
5:05based on the plan design and the and the
5:08um and the access of care and what's at
5:11play today for that member than I could
5:13actually treating as a clinician.
5:15>> Sure. And so my whole career has drove
5:18me on how can I make a bigger impact at
5:22scale to help impact access and cost and
5:25quality of care for anybody who's
5:27accessing health care for the
5:28organization that I work for.
5:30>> Yeah. And so um so so basically what
5:33happened was I was in that role for a
5:36while and actually about three years
5:38after practicing I had this opportunity
5:39to take on more of population health and
5:42well-being initiatives uh for the health
5:44system really in the lens of employee
5:46well-being but it started to trickle
5:48more into how does that impact uh
5:50clinical care pathways and our
5:52brick-andmortar primary care clinics
5:54because our employees were engaging in
5:55our own healthare system right because I
5:57was working for a hospital system.
5:58>> Yeah. and um that you know so it was
6:01like the roughly 6,000 members that were
6:03on our health plan helping improve the
6:05care within our uh primary care clinics
6:07in partnership with our registered
6:09dietitians. We had health coaches that
6:10worked for us too.
6:12>> And so um you know during that time I
6:14had every vendor you can think of under
6:16the sun that plays in the employee
6:17benefit space come my way.
6:19>> Sure.
6:20>> And so um
6:21>> you got to be on the receiving end
6:24seeing their vendors, right? And so at
6:25that time we were talking about 10 15
6:27years ago like you know the wellness
6:29space was really like kind of ballooning
6:30then so it was a lot in that space but I
6:33remember the early days of the point
6:34solution companies like Vera and Omada
6:37like very early.
6:38>> Yeah.
6:38>> I remember talking to them when they
6:40were just you know some of it was just
6:41conceptual um or they you know just very
6:43early in their days and that you know
6:45just went public and Vera's you know a
6:47unicorn company now.
6:49um and on-site nearsight clinics.
6:51Actually, Indianapolis was one of the
6:52hubs where those f were founded. And so,
6:55like I'm very familiar with, you know,
6:57our health who then, you know, became um
7:00uh Marathon and now all underneath one
7:02umbrella um Marathon today. I think
7:05Everside blended with them. But, you
7:07know, that space and we had an on-site
7:09clinic for our own employees at the
7:10hospital. So long story short, I kind of
7:13we we had a great success there, great
7:15outcomes and and what we were doing, but
7:18I also realized that, you know, a lot of
7:21this I thought being in my own bubble
7:22that all all employers were doing these
7:25things that we were doing at the
7:26hospital [laughter] and that just wasn't
7:27the case.
7:28>> Little did you know you pulling that
7:29thread and like the whole sweater ends
7:31up unraveling. I appreciate your
7:32curiosity though, the asking of the why
7:34right behind it.
7:35>> Yeah. Little did you know, right, this
7:37sent you on a 15-year journey or so down
7:39this path, but I mean the why is
7:41probably the most important question to
7:43ask. Could you have ever envisioned
7:45though when you were doing the growing
7:46up doing this?
7:47>> No. No. Never. Like if you had asked me
7:49even four or five years ago where I am
7:50today, I would have never never in my
7:52life. It just I it just took me where it
7:55took me. And um I just had an I always
7:58have an eager for curiosity and learning
7:59and growth. And so, you know, I end up
8:02going to a local uh brokerage consulting
8:04firm and they
8:05>> did they recruit you or how they
8:06>> uh they recruited me and they had data
8:08uh and had a data warehouse in play, but
8:10they didn't know how to effectively use
8:11it. Okay.
8:12>> And so I got brought in in this unique
8:14role where um I helped get the most out
8:16of the platform that they were using in
8:18the lens of cost containment and
8:19clinical strategies, but also to a
8:21degree served almost as a dual
8:23consultant for some of the their top you
8:25know 20 accounts to help maximize the so
8:28what now what with the data and then if
8:30they do something how do you measure
8:32that over time? And then during that
8:34time um I got recruited by a data
8:37warehouse company and I got to serve on
8:39the opportunity there to lead on the
8:40product leadership team there.
8:42>> Okay.
8:42>> To help with packaging and pricing,
8:44product strategy, product development,
8:47um a lot of in the go to market side
8:49too. So work very closely with our sales
8:50and marketing team and that was an
8:53amazing experience. I'll never forget my
8:55boss who happens to watch this. Uh I'll
8:58never forget he told me Ryan what took
8:59me 10 years to learn you're going to
9:00learn in a year. It was like an NBA
9:02school. uh school on steroids. And so
9:04that was just an amazing experience
9:06during that time scaling. We were in a
9:08scale up mode too. So I was just hiring
9:09a lot of people and team cohesion and
9:11camaraderie and how we're all rowing in
9:13the right direction.
9:14>> And we had a lot of great success there.
9:17And then during that time, price
9:18transparency laws came out and I was
9:21aware of them. And after I did my own
9:23due diligence, I realized how disruptive
9:26this really was when this came when they
9:28came out
9:29>> all the way back in, you know, January
9:31of 2021.
9:32And um I knew that if I could be on the
9:36ground level of this and figure out how
9:37to best use this information and for the
9:41employer lens uh and then eventually
9:43trickle that into other facets of
9:44healthcare, but starting with the
9:45self-funded employer, how could this
9:47make a big impact? And so since then
9:50I've had a couple different stances, but
9:52I'm currently serving as the on the
9:55leadership team at AON
9:57>> helping lead all new solution and
9:58development, but really it's been in the
10:00lens of price transparency, uh, network
10:03analytics and also how do you overlay
10:06quality with that information too is
10:07like I flipped the coin, right? Like
10:08price has been really important. We've
10:10never had the ability to get to that
10:12level of detail, but there's the other
10:13side of the coin, too. That's quality.
10:15And so really helping get into the lens
10:18of that space. I help with other facets
10:20based on my background across the firm.
10:22But that's really the the two main
10:24focuses for me.
10:25>> Were you NFP prior to AON or
10:27>> I was at I was at NFP prior. Okay. I
10:29just I thought I remember we met
10:31originally I think when you're NFP and
10:33right now I realize you guys are under
10:34the same umbrella now but so you've have
10:36you guys been fully folded up and a
10:39[clears throat]
10:40>> we we are but I think what's unique
10:41about NFP and AON is that you know the
10:44marketing out there is true in regards
10:46to we are independent but connected. So
10:48NFP very much today still does operate
10:50independently but we do have
10:52opportunities where we definitely uh
10:54cross-pollinate right and I think you
10:56know in my lens where I'm at today
10:58there'll probably be some opportunity
10:59from a health and benefits analytics
11:02perspective where we already doing some
11:04um I'll call it pilot type work where
11:06we'll start to help more of that. Um but
11:09uh you know we'll just see how that
11:10plays out in time.
11:10>> Well I got a question for you and a lot
11:11of people don't know this but why is
11:13Indiana such a self-funded friendly
11:15state? Um, it is I think it's the third
11:18most uh as a percentage basis I think
11:21third highest percentage of self-unding
11:23in the nation. Why of Indiana and not to
11:25say of all places but you would think
11:27it's the large metros right the the New
11:29Yorks the Californiaiforns the Dallas
11:31what makes Indiana as a state so
11:33self-funded friendly? It's a great
11:35question and something that once again
11:37when I was at the hospital I thought I
11:38was in my own I was in my own bubble and
11:40then I went to the Indianapolis uh
11:42independent consulting firm I was at
11:45also thought all the employers were
11:46doing the things we were doing there
11:48across the country so I was in my own
11:49bubble and then I was like well why is
11:51Indiana different to your point
11:53>> and I think it's really boils down to in
11:56my mind two main things the first is
11:58that we have a lot of manufacturing
12:00business in Indiana
12:02>> and their profit margins are very narrow
12:04Okay.
12:05>> And so they want to figure out whatever
12:08they can do to pull those levers to
12:10control on cost.
12:11>> So necessity is the mother of invention.
12:13So out of need
12:14>> out of need. And so like on-site clinics
12:16one of the reasons for that, right?
12:17They're very geographically located,
12:19right? So they're like as one of the,
12:20you know, kind of founding hubs of where
12:22on-site clinics uh on-site nearsight
12:24clinics developed. Manufacturing was a
12:26big part of that, right? It's easy to
12:27kind of build one on site there and
12:28right the single source of truth of like
12:30where your quarterback of care is and
12:31help that trickle into other areas. So
12:34that was kind of uh those two things
12:36kind of go hand in hand to a degree and
12:37that's where you know a lot of
12:39innovation also starts in Indiana. We're
12:40not just the flyover state that you hear
12:42all the time.
12:42>> No, I don't think that whatsoever. But
12:44it is if I asked anybody in this
12:45business, name the top five markets for
12:47selfunding. You wouldn't say Indiana top
12:50five. And I just I'd uncovered that a
12:52number of years ago. And I even
12:54discovered Oklahoma of all places,
12:57right? You again, you trying to think,
12:58you think big states, right? That must
12:59be the predominance. Now Oklahoma is a
13:02very selfund friendly state, too. And I
13:04was just trying to uncover the why, just
13:06like you, behind that. What makes that
13:08the case? businessfriendly environments
13:10like you said, but you squeeze margins
13:12and necessitate looking outside the box.
13:14I was just genuinely surprised when I
13:16uncovered this information.
13:17>> Well, and then there's a sec the second
13:19reason though and I believe this is the
13:21case is that we have really good
13:23independent consulting agencies.
13:26>> Yeah.
13:27and quite a few of them that are, you
13:29know, geographically located within the
13:32central Indiana market, but also the
13:35bigger brokerage firms as well also have
13:37a offices and geographic footprint
13:40there. So, there's a lot of competition
13:43>> there that also is driving innovation
13:46too because employers are talking to
13:48each other, right? And like if you're
13:50doing this thing and I'm doing this
13:51thing, right? And so that that is uh I'm
13:52sure there's other levers of of why but
13:55to me those are the two and the the the
13:57first I think is important in regards to
14:00manufacturing and like how innovation
14:01has evolved from that but the second is
14:03just a lot of cutthroat competition in
14:06that market.
14:07>> Hey guys, I want to take a moment to
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14:55Hey man, I mean that's that's economics
14:58101, right? It's competition should
14:59create a reduction in price over time
15:02because businesses are competing fairly
15:04with one another. The reality is the
15:06broad-based healthcare system doesn't
15:07have a true competitive market, you
15:09know, that resembles what we think of
15:11elsewhere. So I'm glad to hear that's
15:13the case, right? Competition drove the
15:14invention or innovation there. And I
15:17don't know how it compares on a PPY
15:19basis to cost across the country if it's
15:22you probably do know the answer to this.
15:24>> Unfortunately,
15:25>> it's it's not actually
15:26>> it's not good. I mean, now on the
15:28employer side, you know, there's
15:29definitely strategies that are alive and
15:31well for them to actually get a wrangle
15:33and and control costs in Indiana. Um but
15:35unfortunately like I can't remember the
15:37actual stat but we're in the top 10
15:38states uh roughly uh of one of the most
15:41expensive healthcare states in the US
15:43>> and um similar to Dallas actually which
15:46what I wasn't like fully aware of until
15:48I really got the lens of the
15:49transparency data up until a few years
15:51ago
15:52>> we actually have similar markets like
15:53Indianapolis has if I remember right
15:56three level one trauma centers uh that
15:58are pretty close to each other within
16:00central Indiana. You know somebody might
16:01quote me on this. There might be one or
16:02two others, but I think there's there's
16:04roughly three. And they're they're very
16:05close drive. They're like within 15 20
16:08minutes of each other. And that's
16:09important to know because generally if
16:10you're a level one trauma center, you
16:12you normally can cover almost all
16:14spectrum of other service types. Um but
16:17Dallas, there's literally five level one
16:19trauma centers within 10 miles of each
16:22other. Like I don't know if we have
16:23another market like that in the United
16:24States.
16:25>> Yeah, Dallas is a weird outlier in a
16:27bunch of different ways. But I also
16:29think I've been doing this for 15 plus
16:31years and you know I remember 15 years
16:33ago working in agency and their whole
16:35thing was conversion from fully insured
16:37to selfunded and let's master that in
16:38the middle market which you think might
16:40have been innovative at the time now
16:42it's pretty common but I mean back then
16:44it was still the move and they built a
16:46really healthy business on that. I do
16:47want to move into I think what brought
16:49us here which is this conversation
16:51originally and we'll see where it goes.
16:53There's other topics to cover, but this
16:55idea of an outlier clause, we hinted at
16:59it at the start of the podcast. I want
17:01to dig into what does that even mean and
17:03what sort of problems in your mind is
17:05that creating for the marketplace. So,
17:06first, why don't if you don't mind,
17:08Ryan, can you describe what the outlier
17:10provision or outlier clauses are in a
17:12network contract?
17:14>> Yeah, so it's a it's a meaty topic. So,
17:16let me [sighs and gasps] think of this
17:17in the simplistic terms. If if a
17:20hospital today is undergoing a contract
17:22with a carrier,
17:24>> Mhm.
17:24>> they'll have
17:26unit cost prices of of either that's
17:29either a certain percentage off of build
17:31charges is how they do that contract or
17:33they could do that from a bottomup
17:35approach. Some might do it as a percent
17:36of Medicare as part of that contract.
17:38Generally speaking, it's normally a
17:40percent off of build charges. So that
17:42that in essence, let's just say that the
17:44hospital has you know uh 55% discount as
17:47an example off of build charges that you
17:50know could then then uh um go through to
17:53like what a discount analysis might be
17:55that gets brought through the market. So
17:57but what most people don't realize is
17:58that as and that's just we'll we'll dig
18:00into that here in a second. But what
18:01what there's also part of these
18:03contracts um and I like to call them the
18:05the high rollers like the high rollers.
18:08It's no different than if there's a high
18:10roller and you're out in Vegas and you
18:12know a casino sees somebody that's
18:14rolling up with a you know a lot of
18:15money and is willing to put a lot down.
18:17>> Um that's how they make a lot of their
18:19money as a casino.
18:21>> You use that same analogy on the
18:22hospital side. These outlier clauses are
18:25where the hospital contracts make
18:28majority of their money. And so some of
18:30this is helping cover their costs for
18:33more um uh uh you know sicker patients
18:37that are in the hospital for longer
18:38terms. Um but the way in which they're
18:42structured though uh is very opaque and
18:44most people are unaware of what the heck
18:46they are and how that actually impacts
18:47their cost.
18:49>> And so if you're expecting as an
18:50example, let's keep numbers simple.
18:53Let's say you're expecting a
18:5650% discount.
18:57>> Mhm. And so let's say that the uh the
19:01build charges of that's 100k, right? So
19:0450% discount. Now it's $50,000. But
19:07let's say that that procedure is for an
19:09open heart surgery, which open heart
19:11surgeries are known as uh in the medical
19:13terms a cabbage or a coronary artery
19:15bypass graph. Those generally are
19:18structured based on the the fee
19:21schedule. Okay.
19:22>> That they hit the outlier clause
19:24majority if not all the time.
19:28So what does that mean? Yeah,
19:29>> that means that somebody comes in and
19:32has an open heart surgery,
19:34>> they'll structure an outlier clause to
19:36say, look, if somebody's coming in, it
19:38could be for a certain service line or
19:39it could be for a specific procedure
19:41code that if some if if you know if
19:44Spencer comes in and he has a cabbage
19:47done or an open heart surgery done that
19:50they generally are going to see that the
19:52total bill charges are anything that's
19:54over $100,000 and $1. you know, anything
19:57over $100,000, it will actually flip
20:00over to a different contract provision.
20:03>> So, if you're expecting a 50% charge,
20:06>> generally speaking, and these all vary
20:07across the United States, right? Like
20:09I'm what I'm telling you right now is
20:10could be completely different if you
20:11actually look at the contract.
20:13>> But just for easy numbers, let's just
20:15say that anything that flips over to
20:17100K,
20:18>> you'll pay the entire portion of that
20:22episode of care while they're in the
20:23hospital up uh and maybe it's only 70%
20:27uh of bill charges or a 30% discount.
20:30So, if you were expecting a 55 or a 50%
20:33discount off of that, you know, actual
20:35DRG for that because there's a DRG tied
20:38to and then a DRG is a bundled procedure
20:41code that is build for an inpatient
20:43charge.
20:43>> Y
20:44>> if you're expecting to pay 50K, but it
20:47hits an outlier clause, that's why and
20:49to me the one of the number one reasons
20:51why high-cost claimants are where they
20:54are today is because of these outlier
20:55clause provisions. And so that that
20:58could instead of paying, you know, half
20:59a mill or 50k, you could be paying
21:01upwards of three, four, five, $600,000
21:04for a procedure that you were expecting
21:06to get a 50% discount off of that
21:08specific code.
21:10>> And it and it's, you know, even me, I
21:13feel like I'm very astute in healthcare.
21:14I really didn't even fully understand.
21:15And I've been in the data analytics
21:17space on from on the consulting side for
21:18majority of my career. And I really
21:20didn't fully understand what a contract
21:22provision and outlier clause was in this
21:24space up until about two years ago.
21:26>> Yeah. Well, I mean, if you think about
21:28it, the obvious perverse incentive that
21:30that creates is like you said, set that
21:33DRG to $101,000
21:36so it eclipses whatever that outlier
21:38threshold is. And then therefore, you
21:40automatically trigger the lower discount
21:42or the lesser of the discount. So what
21:44disincentive does a provider have to not
21:47breach that threshold if they're going
21:49to be paid more if and when they do?
21:51Isn't that a weird thing to We were
21:54talking our initial conversation was the
21:55rationale of how you defend this, right?
21:58So like
21:58>> if you were to post a oppose a defense
22:02on behalf of why outlier clauses exist,
22:05what is the argument? you think even if
22:07you have to suspect what it is, what's
22:08the argument to support that kind of
22:10outlier clause?
22:11>> From a hospital's perspective, they're
22:13going to state that if somebody is
22:16coming in for that procedure,
22:18they they're going to generally say,
22:20well, that procedure is going to cost,
22:22you know, x, y, or z in regards to time.
22:25They're normally in the hospital for,
22:26you know, x amount of days.
22:28um you know, it's an extensive amount of
22:30of of of team members and support and
22:33staff and medications to support that
22:35individual.
22:36>> And so to help cover their cost, they
22:39justify that they need these these
22:41outlier clauses and pay to help justify
22:43the cost because there's a lot of these
22:45>> cases and normally these cases by the
22:46way to be clear are not with everyday
22:49shoppable services. They're normally
22:51procedures that generally um are a
22:54higher percentage that can have
22:55complications. Okay? And so like in
22:57their mind like you know complications
22:59you know that means the individual's at
23:01the hospital more that means there's
23:02more time effort and injury that means
23:03individuals in the bed longer they're in
23:05the hospital longer just all cost more
23:07money and so from a hospital's point of
23:09view it's helping cover their costs
23:11>> you know on the flip side hospitals
23:13generally don't do and this is not for
23:14today's podcast but Dr. Bricker is done
23:16a great uh um overview of this, but
23:18hospitals generally don't do cost
23:19accounting in regards like what it
23:22actually costs to to actually deliver a
23:26total knee procedure as an example. And
23:28so some of this is subsidizing
23:32areas of which they're not getting
23:33reimbursed on the Medicare and then of
23:35course the Medicaid side to cross
23:37subsidize some of that. So that that's
23:38part of it.
23:39>> Um
23:40>> but think about just the construct of
23:41that for a second. Let's like let's use
23:43in something analogous to what we would
23:45experience in our everyday life, right?
23:47You go buy an item and it's full cost.
23:50Oh, but if you were to buy three, we'll
23:52give you 20% off, which is the
23:54incentive. I'm going to go buy three
23:55candy bars or three energy drinks. I'm
23:57going to get a discount per unit if I
24:00buy more. But this is the opposite.
24:03>> That's crazy, right?
24:04>> It's it's it's crazy to think about.
24:05Like that's why when I once again
24:06[snorts] when I and I I knew these like
24:09once again I worked at the hospital.
24:10Like I knew these things were at play. I
24:11just didn't really, you know, I didn't
24:12really I wasn't on like the actual
24:14contract. I didn't really realize that
24:16the how this was actually impacting an
24:18employer spend, right?
24:20>> And then when I first like got in the
24:22weeds of it, like to your point, like I
24:23was scratching my head. I was like, is
24:25this like
24:25>> So wait, if I buy more, you charge me.
24:27This doesn't make any sense, right?
24:28>> Basically, if I'm in the hospital
24:29longer, I I get I you know, my bill goes
24:32substantially higher,
24:33>> right, than actually gets reduced. And
24:35so it is something that, you know, it's
24:37hard to wrap your head around. $27,000,
24:41the price of a new sedan. And in 2026,
24:44it's also the annual price of family
24:46health insurance premiums. We often talk
24:48about rising health care costs. The
24:51question is, what can we do about it?
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25:49But um
25:50>> but I've seen it play out to how does it
25:52impact employers and I won't say
25:53specifically which network versus which
25:55network but there was a network where
25:57we're looking at a group coming into the
25:59captive and it was one network versus
26:01the other and we go and look at the
26:03pricing side by side and there was a
26:04huge disparity in moving from one
26:06network to the other and I'm like well
26:08the discount overall discount basis
26:10can't be that big of a difference and
26:12then it was explained to me well part of
26:14the driver in this is this particular
26:16carrier's network has worse if you will
26:18outlier clauses within it. And so
26:20therefore, the larger claims are
26:23disproportionately more impactful to the
26:25plan. So it's not the average stuff like
26:26I described earlier. It's literally the
26:28outliers that are causing the difference
26:30in pricing. And it was leaving the
26:32consultant scratching their head. It was
26:33actually leaving my salesperson in a
26:35position having difficulty explaining
26:37it. And once I dug in a little bit
26:38further with my own underwriters, I was
26:40able to uncover the why behind it, which
26:42I then trickled that down. That's the
26:44answer to how it's costing employers
26:46more money.
26:46>> Yeah, it totally is. And I think, you
26:48know, I've been in the price
26:49transparency space ever since the data
26:51came out 5 years ago. And we're at a
26:53point now that we can produce insights
26:57for an employer that are unlocking the
27:00contract black box that we've never had
27:01access to before.
27:02>> Great.
27:03>> You know, but we yet to have access to
27:06the outlier clauses, right? Some of this
27:09information you can glean in the files
27:11based on the uh you know, I'm not going
27:12to get too much in the weeds of the
27:14difference between what the carriers
27:15post and what the hospitals are. two
27:16different price transparency data sets
27:18out there. But in the hospital files,
27:20there is a uh like an open section to be
27:23able to see certain outlier clauses that
27:25is a hit or miss compliance field that's
27:27in there. Um we actually uh
27:32just there was an open um uh comment
27:35period for what's to come future state
27:38for the transparency and coverage rule
27:40which is the carrier files for the V3 uh
27:43format they call the schema and we are
27:46advocating for contract terms like you
27:49know uh what happens year-over-year in a
27:51contract right does it go up based on
27:53consumer price index because some of
27:54these contracts by the way follow the
27:56consumer price index so if it goes up 3%
27:58% a year. These contracts are going to
27:59go up just 3% a year.
28:01>> Or some of them go 3% a year plus an
28:04additional CPI plus an additional two,
28:06[clears throat]
28:06>> right? But we we don't the everyday
28:08public and even the employer, even the
28:10consultant doesn't even really know how
28:12those play out.
28:13>> Um or what happens pre- post
28:15negotiation, right? Like you know these
28:17contingent negotiations that you see on
28:19the news, right? In the transparency
28:21today, we we are actually able to
28:22uncover what happens pre- post
28:25negotiation. And I'll tell you, some of
28:26these recent contracts have been
28:28substantial increases in some markets,
28:30>> you know, more than what you would
28:32expect even beyond trend. Um, and so,
28:36you know, if you got a lot of members
28:37going to in a certain market, going to
28:39that facility within that certain
28:40network, like you need to be aware of
28:42that. Yeah.
28:43>> Like that's a big decision-m point for
28:44you.
28:45>> Um,
28:46>> when you mentioned beyond trend, what do
28:47you what do you think trend is, medical
28:49loss or medical trend is for 2026? Do
28:53you think it's a double digit trend?
28:54Well, I mean, you know, right now at
28:55AON, we're projecting anywhere, [sighs]
28:57you know, 8 9% uh increase. Um, and so,
29:01you know, I don't see that letting off.
29:03I, you know, and we're we're having more
29:05conversations than not today
29:07>> in regards to employers wanting to and
29:10considering doing things differently
29:12than just purchasing a traditional broad
29:14network. Yep. Right. And so, it's very
29:16um exciting to do that. And one thing
29:18that I like to say is that price
29:20transparency,
29:22it's not the end all beall in regards to
29:24helping them make the best informed
29:26decision. You know, there's nothing in
29:27life as a silver bullet, right? But it's
29:29very powerful and it unlocks the ability
29:32to have objective data to have a better
29:35decision on why they should consider
29:37doing something different.
29:38>> Sure. Sure. And so that's really what's
29:40been great and powerful having these
29:42conversations over the last 3 four
29:43years. But more specifically, the
29:45traction has starting to pick up over
29:48the last 12 months. I'm actually seeing
29:50RFPs, RFIs, ask specifically around how
29:53we're using price transparency data to
29:55make a better informed decision. So
29:57that's really good. And I, you know,
29:58that's been more a large market. I
30:00expect some of that to start to come
30:01down market.
30:02>> Um, but we're not there yet on outlier
30:04clauses. And
30:05>> I say, let's close the loop on that,
30:06though. So we've got the we know what
30:09now. Yeah.
30:10>> What do we do about it? Right. What the
30:11so what now? So if I am aware that
30:14either I'm using a carrier network that
30:16has these exorbitant and outlier uh
30:17clauses or the threshold is very low
30:19comparative to another network. It's not
30:22as simple as just changing networks to
30:24fix it. Right? So then what what is the
30:26um push back if you will that employers
30:28can make to try to limit how damaging
30:31this may be to their spend? I think one
30:33thing is just purely advocating and
30:37asking. I think you know um and that's
30:39easier said than done. And so I think
30:41part of this could also be, you know, as
30:43you're going through, you know, uh, a
30:45renewal or you're looking to go to
30:47market, could you have some of this
30:49terminology in your, um, RFP contract
30:53language that you you could get exposed
30:56access to a outlier clause, maybe just
30:59in your top markets where members reside
31:01based on headcount, like you're not
31:02looking at across every facility across
31:04a broad network as an example, right?
31:06But healthcare is local, right? So what
31:07happens in one market is completely
31:08different than another. And so maybe
31:10there's the ability for you just to
31:11drill into a couple of the key markets
31:14where majority of your members reside.
31:16>> Yeah.
31:16>> And so that could be, you know, one
31:18lever just in regards to like how you're
31:21comparing networks. You know, a lot of
31:22it's really been in the lens of, you
31:24know, fixed fees and potentially
31:26variable costs, right? But then you got
31:28this other layer now that's the contract
31:29terms that we're talking about here that
31:32could be as part of that process. I
31:34think the other lever that is getting
31:37pulled more is in the lens of, you know,
31:40all these alternative strategies out
31:41there, right? So, some of these more,
31:43I'll call curated networks that are out
31:46there that are helping employers pull
31:49the trigger on direct contracting,
31:52>> you know, and I I like to think of D
31:53County as a spectrum, right? So people
31:55just think it's like, oh, I got to go
31:56knock on the door, talk to a hospital or
31:58an ASC or an independent radiology
32:00center myself and we have
32:02>> just put some menu of prices across the
32:04table and you sign the paper, right?
32:05Like like sure that can be done and if
32:08you're a large employer like you have
32:10the weight and you want to go down that
32:11route. Absolutely. But there's been a
32:14lot of solutions over the last three,
32:15four, five years that have come to the
32:17market um that have been in the market
32:18longer than that too. that just making
32:20more traction that actually an employer
32:22can just tap on to that contract.
32:24>> Okay.
32:25>> Right. And so I think understanding
32:27what's in there and asking specifically
32:29on they know if they're going to be
32:31bringing this forward most likely
32:32they're going to be in the transparency
32:34space too. So starting to I mean just
32:36ask has the have the wherewithal of
32:38actually asking what's in that contract
32:40in regards to an outlier clause.
32:42>> Yeah.
32:42>> Because if it is a direct contract well
32:44what's included? Is it just elective
32:45surgeries? Is it, you know, is it
32:47because that's majority of them
32:48potentially, right? Or is it the whole
32:50shebang, right? Is it like all services
32:52covered? And if so, is there an outlier
32:54clause or not?
32:55>> So, like, you know, as an example here
32:56in Dallas, I'm not going to call it
32:58specific hospital, but there's uh uh
33:01large hospitals here that have many
33:03different direct contracts with many
33:06different companies. M and so if you're
33:08looking to compare and contrast like
33:10understanding those uh terms I think
33:12will be really important especially as
33:14price transparency uh you know trickles
33:17into the industry. I think that
33:19information is going to be really
33:20powerful but I think this kind of next
33:22wave is going to be really understanding
33:24contract terms.
33:25>> Yeah.
33:25>> And so you know the fir we're still very
33:27early in the early stages of price
33:29transparency. But I think in uh you know
33:31and then not to say that like contract
33:33terms in regards to like what's actually
33:35being written the contract that's not
33:36what I mean. I'm saying the actual
33:38contract between the facility and the
33:39pro uh and the provider. Yeah.
33:41>> Uh or or the sorry the carrier the
33:43carrier and the facility like
33:45understanding what's in that um is
33:48really important because that ultimately
33:50is going to be a key decision maker for
33:52an employer.
33:52>> And who's best suited to help you
33:54navigate that discovery of the what's in
33:56that contract between between provider
33:58and carrier? Is that a consulting firm?
34:01Is that, you know, uh, our friends over
34:03at the FIA Group? Like, who's who's
34:04going to help me uncover that? Or is it
34:06one of the parties and entity like an
34:07EHN or a Centivo Nomi that are setting
34:10up those kind of bundles of direct
34:11contracts?
34:12>> That's a great question. How do you
34:13start?
34:13>> I think it's a few things. One, you
34:15know, we're we're actively at AON
34:17playing in this space right now. So, I
34:19think, you know, we're we're helping
34:21figure out how we best, you know, and
34:23some of this is we're still early,
34:24right? I mean because we we've been ve
34:25very focused over the last 12 to 18
34:28months on the unit cost side right and
34:30then you know you just kind of start to
34:32trickle into these other areas when you
34:33start to like learn all the nuances of
34:35the price side what about all these
34:37other sides that's happening within the
34:39contract so I think the broker
34:40consulting community can play a space
34:41there. I think the ones uh in regards to
34:44trying to unlock some of this
34:45information through a general BUA
34:48network and just getting some intel if
34:50we're trying to compare as an example
34:52you know a BUA contract in a in a
34:54specific market with top hostiles
34:55members go and if you know as an example
34:58if there were the likes of like a COE or
35:00a curated network through Nomi or
35:02through Centivo um as you're mentioning
35:05here kind of uh Centiva more locally
35:07here Dallas base
35:09>> how do those compare and contrast
35:10>> right and you You can look at the unit
35:12cost side. So you can start to look you
35:14compare that but then also asking more
35:16around well what's your outlier clause
35:17with this facility versus what's through
35:19a general bua network.
35:21>> Yep.
35:21>> Yeah. And I mean a very I would say
35:25complicated discovery process, right?
35:27Probably a multi-year discovery as well,
35:29right? And I think that just speaks to
35:31the levels of complexity that exists.
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36:18and I are having a conversation that a
36:20very large percentage perhaps of just
36:22the normal market would just go, "What
36:24the heck are those guys talking about?"
36:25And I'm still I myself struggling to
36:28keep up. But the point is is these
36:29things exist. These things are inside of
36:31your contracts today. these things are
36:33impacting the costs that you're paying
36:34for healthcare and even just a general
36:36level of awareness to know that they
36:38exist in the first place to go okay I
36:40should go talk to my consultant and
36:42figure out what I'm what am I supposed
36:43to do about that right or should I
36:44explore a non-net network solution like
36:47reference based pricing to some extent y
36:50>> so I can get my inch myself away from
36:52these things or should I use a non
36:54network so I can have audit capabilities
36:56for the you know the adjudication of the
36:58claim I mean there's all sorts of things
37:00that you you don't quite know what to do
37:02and I'm sure every single one of them is
37:04on a case-by case basis with the
37:06employer where they're located, their
37:07risk tolerance, their change tolerance,
37:09etc. It just means you and I will have a
37:11job for the foreseeable future. Right.
37:14But I'm just trying to bring a level of
37:16awareness to the marketplace in general
37:18that helps us just ever so slightly move
37:21the needle in the direction that we want
37:22it to go. Yeah.
37:23>> So, anything else that we want to talk
37:25about on the outlier uh component?
37:26because I wanted to bring up prompt uh
37:28pay providers as well, but anything else
37:31you think we need to do to talk about
37:32that particular subject?
37:33>> No, I think it's just important to know,
37:36you know, that an outlier like that that
37:38it exists. I think that, you know, just
37:40knowing that an outlier clause,
37:42generally speaking, are going to hit
37:45certain service lines that maybe the
37:47hospital specializes in that you might
37:48hear them even marketing to the market
37:50[laughter]
37:51um uh or specific um procedure codes.
37:55And there's just a very rigorous process
37:57like it's just not picking something out
37:59of the air. Yeah.
38:00>> Like there's a very rigorous process
38:01that they go through of why they're
38:03picking what they're picking that hits
38:04an outlier clause. Um and so just being
38:07aware of that, asking some questions
38:09around that, getting more information
38:11related to that, uh and knowing that
38:14that's a big driver to your high cost
38:15claim at spend. I think it's just a
38:17really important takeaway that I want,
38:18you know, employers.
38:19>> Well, even the outlier clauses, I'm just
38:21thinking about the paro principle and
38:23the 8020, right? It's maybe more like
38:249010 or 955, but there's a very small
38:28percentage of your claims that are
38:30driving a large percentage of the
38:32overall spend, right? So, like let's
38:34find that 10 to 15 to 20% that are the
38:37majority of your spend and let's go ask
38:39questions about how we solve for that.
38:41Yeah. You know, the other side of this
38:43is prompt pay providers. So, you and I
38:45talked about this last time when we had
38:47our virtual call as well. Another
38:49concept that was relatively new to me
38:52recently and I didn't realize what this
38:54actually would do to plans. So I can
38:56leave it up to you or I'll describe
38:58prompt uh pay. Okay. So
39:00>> a prompt pay provider and it's PPP so
39:02it's very difficult to say prompt pay
39:04provider is a certain provider within a
39:06carrier network that my understanding is
39:09when they render a service they have to
39:11be paid in a very quick amount of time.
39:14So call it 30 days. So what does this do
39:16to a plan? Well, if it's the large claim
39:19that's ultimately a specific deductible
39:21hit, meaning the carrier is now on the
39:23hook for reimbursement. It essentially
39:25negates or dilutes the ability for spec
39:28advance or immediate reimbursement of
39:29the stop-loss claim. Well, what is that?
39:32Claim goes over spec. We pen that claim,
39:34send it over to the carrier, let them
39:36review it really quickly, and turn
39:37around and reimburse the employer for a
39:39spec hit as quickly as possible. Well, a
39:41prompt pay provider essentially
39:43eliminates our ability to do that. And
39:45so what you'll have happen is you don't
39:47know who they are on your network. You
39:49don't know as an employer when it's
39:50going to hit you. And then when it does
39:52hit you, they have the ability to
39:54extract those funds essentially from the
39:56claims account without any ability to
39:58get reimbursed quickly as an employer.
40:01So therefore now I might have $250,000
40:04just taken out of my claims account with
40:05nothing to do as a recourse and I've got
40:07to go now try to backtrack and file with
40:09my stop-loss carrier and try to get
40:11reimbursement. That could take four,
40:13six, eight weeks or so. So, I'm on the
40:15hook for that money until I get it back.
40:17I did not know this was happening inside
40:19of plans until recently. So, have you
40:21had any experience here of how to
40:22perhaps solve that particular problem?
40:25>> A little bit. And um
40:27>> and I'm sure I'm missing some detail.
40:29So, let me be very clear about that. I'm
40:30probably I'm painting with a broad
40:31brush, but this is just a description of
40:33the problem. There's probably other
40:35specifics in there, but I became aware
40:37as we got a claim coming through the
40:39captive that was owed reimbursement and
40:41the consultant was really upset that
40:44Spec Advance didn't work in that
40:45situation and they dug in and found out,
40:47oh, prompt pay provider. Well, crap.
40:49What do we do about it now?
40:51>> Yeah. And I think that the way I like to
40:54describe this in a simplistic term of
40:56the prompt pay provider.
40:58>> Yeah. Say three times.
40:59>> Yeah. it's hard to do is, you know, it
41:01I'll call it just a suppression of prior
41:03authorization. Yeah. Right. Like they're
41:05they're just limiting the the hurdles
41:08and the jumps
41:09>> of prior authorization.
41:11>> And you know, there's uh I think there's
41:15probably strong opinions on that in the
41:17industry, right? Um
41:19>> you know, I I think that the doctors go
41:22to school to, you know, to to
41:27I mean, they have a lot of passion,
41:28right? I mean me personally too, right?
41:29I had a lot of passion to help people.
41:31Yeah. Right.
41:32>> You want to render care.
41:33>> You want to render care and I don't, you
41:34know, we we we as practicing clinicians
41:37want as little as barriers as possible
41:40to make sure our patients get the best
41:42optimal care that can possibly available
41:44for that specific condition, diagnosis,
41:48etc. across any spectrum of specialty
41:50that you can think of. Um, having said
41:53that,
41:55you know, there there's always bad
41:56actors, right, in any industry. I don't
41:58care outside of healthcare, too, right?
42:00Just any industry you look at. And so
42:02there's a there's a give or take. And
42:04that's why I like to use the word
42:05suppression. I don't I don't think that
42:07if we go to this, you know, this world
42:09where like there's just no prior off at
42:11all. I think that could potentially be
42:14bad. But I also know that the world that
42:15we're in today is also not going as
42:18expected for providers and for for
42:20employers.
42:22>> And so I think that where I see this
42:25going and where I see some solutions
42:26heading
42:28>> is if we're going more towards this this
42:31future where there's uh suppression of
42:33prior authorization. How can you do
42:36basically a pre-claim review
42:39>> uh in real time and stringent on that
42:42like not you know just like letting it
42:44fly right like actually doing a review
42:48of of medical necessity uh and I think
42:50that's actually where AI is going to
42:53help with this quite a bit
42:54>> okay
42:55>> um you know I'll talk the flip side of
42:57that in regard to like the upcoding side
42:59with AI because I'm you know there
43:01there's actually the uh blue cross which
43:02I just put out I felt like a really good
43:04article
43:05related to what they're seeing on their
43:06end of providers upcoding more severity
43:10of codes. Yeah,
43:11>> that's not medically justified and AI is
43:14helping do that through the EMR.
43:16>> Okay.
43:16>> And so, you know, that's the that's the
43:18negative side of AI.
43:19>> Well, whose AI is going to win is really
43:21the problem. Who's got the
43:22>> is it going to be a competition between
43:24the carrier and the hospital's AI that
43:26are eventually bots competing against
43:27each other? I don't know. But what I do
43:30know is that, you know, uh, you know, in
43:32this lens of suppression of prior
43:34authorization, I think whoever figures
43:37out a way to do this effectively,
43:40uh, with a a robust pre-claim review
43:43process and is transparent in that
43:46process and how that's done and what are
43:48the service categories that are even
43:50looked at because, you know, today we
43:52don't really know like per se what's
43:53actually being prior or not, right? like
43:57have a good sense of what that is, but
43:59you don't really know what's actually
44:00getting prior off or not. So, like just
44:02getting clarity of what that is and then
44:04if we're suppressing what that bucket
44:06is, are we clear and aligned of what is
44:09actually still being prior off and can
44:10we do that more effectively so we're not
44:13hindering the patient or the the
44:14clinicians and the patients, you know,
44:17clinical care uh we'll call it just
44:19improvement pathway, right? as they're
44:21trying to improve whatever's going on in
44:23their current um you know
44:25>> to me though we've lost all relationship
44:28to like reality when it comes to claims
44:30costs in and of themselves. So I
44:32understand the prior authorization step
44:34I totally do and I don't want to abandon
44:36it whatsoever. But if you're going to
44:38charge 150,000 or $250,000 for a
44:42procedure, which today gets you a
44:44Lamborghini or a nice starter home in
44:46certain parts of the country, think how
44:48long and convoluted the process is to go
44:50buy a house, yet you just want to very
44:54quickly be able to render services that
44:55are a quarter million dollars without
44:57any checks and balances whatsoever and
44:58then get paid immediately as well. That
45:01doesn't make sense to me. that that
45:02suggests you're trying to rush something
45:04through because of the monetary gain
45:06that results from that. So, we should
45:08have these checks and balances and maybe
45:10those are great providers that render
45:12these services very often, which is why
45:14they necessitate some incentive to get
45:16paid quicker. Yep. Okay, fine.
45:18>> Give me some checks and balances on the
45:19front end to prevent you from just
45:21funneling through as many claims as
45:23possible to maximize revenue, right?
45:25like it's it's a constant tension that
45:28in a in a healthy kind of system that
45:31tension would keep everything in check.
45:32The problem is is you just have these
45:34massive swings back and forth of power
45:36and AI and things like that that are
45:38really breaking both sides of the the
45:40spectrum right now. It's frustrating as
45:42somebody that you think about your
45:44average consumer that's just literally
45:45caught in the middle.
45:46>> They don't know any of this is going on.
45:48>> Quite frankly, they don't care. They
45:49just know I need to get my knee fixed.
45:51you have all these entities behind the
45:53scenes kind of duking it out of what
45:55should be paid and how quickly and how
45:56often etc. And it's just it's
45:58mind-numbing sometimes how difficult of
46:00a system we've constructed.
46:02>> It really is. It's it's uh it's very you
46:05know when people say I work in
46:07healthcare and my you know my mom and
46:08dad ask me what I do it's they just it's
46:10hard for me to explain it because it is
46:12so complicated. But the folks that can
46:14keep it simple and for folk and you know
46:17simplicity is key in this very complex
46:18world. Um, you know, the way when you
46:21were just describing that, it also made
46:22me think of the unintended consequences,
46:24right? Like, you know, like like, you
46:26know, you could go we could go on and on
46:27of just the the laws that have been in
46:29play over the last 15 years and
46:32>> even most recently actually wild then
46:34since we're in Texas right now, the no
46:37surprises act that went out very good
46:39intentions of that. There has been a
46:41negative consequence with that where the
46:43amount of NDR or um uh the R cases Yeah.
46:48these out of network cases
46:50uh and the amount of money they're
46:53spending over what they should be
46:54spending on the qualified payment amount
46:56is substantially higher.
46:59>> And there's actually uh Dallas
47:01specifically
47:03um is one of the the highest markets of
47:07R cases in the United States.
47:10>> And so we won't get into some of the
47:11nuances of that, but there's there's
47:13some lawsuits out recently. But they're
47:15they're um you know just my point is
47:17it's an unintended consequence of of a
47:19of of good intentions potentially. I'll
47:22just call it though you know rooted in
47:24good intentions put in play and then you
47:25know this negative side effect that came
47:27out of that.
47:28>> Health care costs keep rising. Quality
47:30of care feels inconsistent. And for many
47:33employers there's no clear picture of
47:35what's actually working or why. At
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48:27Which is why, man, I I don't really sit
48:29around and wait for us to legislate or
48:32regulate ourselves out of this problem.
48:33It's it's got to be to me private sector
48:36solutions with people that are morally
48:38and ethically trying to conduct a
48:40business in the right way and are
48:42looking where all these margins exist in
48:44order to rather than let those margins
48:46continue to be extracted. We want to
48:48erode those margins that might be
48:49inefficient. problem is is we shouldn't
48:51have a system that can insert 15
48:53entities into the equation and each one
48:55of them can save money within those
48:56margins. You would argue well why do we
48:59need all these other entities if we
49:00would just have built the framework
49:02properly in the first place which I'm I
49:04was telling you before we got on the
49:05show very keenly interested in what is
49:08healthcare 3.0 look like or 4.0 0 and
49:11you we don't have to necessarily do it
49:12all as a thought experiment here, but
49:15it's almost are we at the point where we
49:17have to stop trying to fix the existing
49:21system because we'll always be two to
49:22three steps behind and instead try to
49:24reconstruct or recreate a better one,
49:27right?
49:27>> Yeah. You know, it's uh I think a big
49:30thing, you know, growing up in
49:31healthcare is um one thing that you
49:34think about when you when there's a lot
49:36of things, of course, and probably not
49:37for today's call, but the one thing I
49:39always come back to is
49:41um I feel like
49:44who ultimately is your entryway and
49:48quarterback of care,
49:50which is ultimately really good rooted
49:52primary care.
49:53>> Mhm.
49:54ultimately does help impact the
49:56downstream pathway. Yeah. Within the
49:59system
50:00>> and that within the fee for service
50:03model today is very much a strong
50:07referral pathway within very expensive
50:09services within a hospital system. Most
50:11people don't realize is that if you get
50:13a referral, you can actually go wherever
50:14you want within that state for that
50:16referral or even beyond the state
50:18depending on the state regist. But, you
50:20know, the patient doesn't always know
50:21that when they get a referral from their
50:22doctor that they trust,
50:24>> rightly so, right? And the doctor
50:26doesn't even know either what the cost
50:27of that care is either when they refer
50:29that in house. And so, I think like one
50:32step uh and I just read a stat recently
50:34where um like it was just within the
50:37last week where there was an article
50:38that came out for all the residency
50:41spots that were being filled in the
50:42United States, no shocker probably to
50:45you, uh that uh primary care was not
50:48filled. you know, so all these other
50:50specialty services where um you know,
50:52like orthopedic surgery or neurology or
50:55things of that nature that are more
50:56higher income um services, those are
51:00getting filled. And so you've got this
51:02still continuation of shortages for
51:04primary care. And so you're going to see
51:06more like we have today, more advanced
51:09primary care or advanced practitioners
51:10like um physician assistants and nurse
51:13practitioners helping fill that void.
51:15But I think that that to me is a really
51:18really good, you know, kind of rooted
51:20starting point.
51:21>> Uh, and there's solutions out there
51:23today, too, like that are great that,
51:24you know, almost like a network of
51:26primary care clinics that you can tap
51:28into and so you don't have to think
51:30about always just like building your own
51:32clinic, right? And so I think that that
51:34to me is a foundational kind of step in
51:37regards to as an employer to your point,
51:39we're not, you know, not looking for the
51:41>> the overarching federal government to
51:42solve this. Like if an employer wanted
51:44to take action today, I think that's a
51:45really good thing to consider based on
51:47your population.
51:48>> Yeah. I mean just simply decoupling
51:50primary care from insurance altogether
51:52is like a great first step. Allowing it
51:55then to care coordinator or navigate
51:57inside of the health plan, allowing that
52:00uh provider to understand the benefits
52:02package that those employees have, which
52:04I know might be difficult sometimes to
52:06educate that provider on if they're
52:08pulling people from different employers
52:11to fill out their panel. They may not
52:12always know, but then they can help with
52:14the steerage component outside of
52:16primary care to get them to the most
52:17cost-effective and highquality location
52:20for specialties and things like that.
52:22But if you have those have you at least
52:24decouple primary care from insurance,
52:26that's step one. Add in that layer of
52:28care navigation, that's step two. And
52:30then you start building the house on top
52:32of that foundation. I think it would
52:33behoove most employers to find some form
52:36of direct primary care to start. Yeah,
52:38that's that's my strongly held opinion.
52:40And then we can go anywhere from here,
52:42man. I just you covered the two subjects
52:44that I was really interested in. Maybe
52:46I'll [snorts] ask you now, and this is
52:47more open-ended. What are the stuff that
52:48you're currently passionate about like
52:50today in 20126?
52:52>> I think a few things. One, because I
52:54live this every day, is
52:57h letting employers and you know the how
53:02how can employers today leverage price
53:05transparency data to make a better
53:07informed decision for their members? And
53:08I think a lot of that is eye opening
53:11when they see this information for the
53:13first time. Um, you know, and they start
53:16to see these big variance in costes
53:17within a market. Some of that's hard to
53:19wrap their head around, right? Because
53:21it's like, yeah, it'll all shape out at
53:23the end of the day, right?
53:25Um, you know, one of the things, so that
53:27that that's one, just like getting this
53:29information out there, letting it drive
53:32a conversation to bring more
53:34transparency into the medical
53:37>> uh cost space. I think the second that
53:40I'm super passionate about is quality.
53:43And, you know, there's no gold standard
53:45today on how you define quality in
53:48healthcare. There's a couple vendors uh
53:50and that I'm sure you're aware of that
53:52are working towards how they define that
53:54space in regards to becoming the gold
53:56standard.
53:57>> Um there's more than a couple. I mean,
53:59there's a handful of companies out there
54:00that are all working in this space, but
54:01I think
54:03>> that has been very difficult
54:06to align price and quality and
54:09healthcare. Like there's been companies
54:10that have tried to do this in the space
54:12wall and then and not to say they're not
54:13doing a good job,
54:14>> but we've not had access to the
54:16transparency data before like we have
54:17today.
54:18>> And so, you know, bringing both the cost
54:21and quality insights forward to both the
54:23employer and eventually leveraging
54:25transparency and quality down to the
54:27member um to help them make a for better
54:30informed decision and tie that to a plan
54:31design. So, if they do make a
54:33cost-effective and quality decision,
54:35they have less out-of- pocket costs for
54:36the member. So there's some
54:38>> health is difficult, man. Like I I I
54:41would love a world for a member to be
54:42more empowered and the everyday consumer
54:44beled
54:46consumer and if I god forbid had
54:48something happen to me, I would want
54:49somebody to help me navigate the health
54:51care system too. Yeah.
54:52>> Right. Like now the everyday care I can
54:54do that for the most part myself, right?
54:57I feel strong about that. But even then,
54:59man, like I said, if something like my
55:00mom and dad needed to get something
55:02done, right, it's hard to it's hard to
55:04navigate. It's just hard.
55:05>> It's hard to navigate. And then what
55:06does your benefits package look like?
55:07Right? So mom and dad might have
55:08Medicare, but like if your a friend
55:10calls you and dude, what do I do?
55:12>> What does your plan design look like?
55:14What what what options do you have
55:15inside of your plan? And then then what?
55:18Right? And so like they just go, well,
55:19I've got I think I've got Etna or I
55:21think I got UAC. You're like, okay,
55:22well, that's not really going to help me
55:23tremendously to really do the things
55:25that you're talking about doing. Another
55:28uh piece of the quality component, it's
55:31not just outcomes or readmission rate.
55:34did the appropriateness of care, did
55:36they need to provide that procedure in
55:38the first place? Yeah. Or is it a back
55:41surgeon or a hip surgeon whose first
55:43conversation with you after you complain
55:44of some pain is, let's get you an MRI,
55:46and I think you're probably a candidate
55:48for surgery. You're like, whoa, okay, he
55:50may be or she may be the best hip
55:52surgeon in the world, but maybe he or
55:55she is doing 30, 40, 50% more surgeries
55:57than they need to do. So, the skill is
55:59there, but was it appropriate in the
56:01first place? How do we measure
56:02appropriateness in your mind?
56:03>> It's a great question. So, I think you
56:05know um I almost like to think of it
56:07like if there's just a a line here on
56:09the table and like right in the middle
56:11here is uh when the when the surgery
56:13happens, right? The cut
56:15>> Yeah.
56:15>> happens, right? So appropriateness to me
56:18is what are all the non-invasive things
56:21that they should be doing based on their
56:23specialty, based on the service line
56:24that they're treating, based on
56:26peer-reviewed clinical research, and
56:28also by a I'll call it panel of
56:31specialists within that specific field.
56:34>> Yeah.
56:34>> That deem what are all the
56:36non-appropriate things that you should
56:37do prior to cutting. And so like easy
56:40example would be like for and I'm going
56:42to simplify this down right now, but if
56:44if somebody's having an orthopedic
56:46surgery,
56:47>> right? Like did you have physical
56:49therapy for x amount of time, have you
56:52tried uh um a non-steroidal dose pack as
56:55an example before you cut on somebody?
56:57Did you try epi um an ESI, an epid
57:00epidural uh steroid injection? So that's
57:03like you trying to like the pill form
57:05basically and then you go to actually an
57:06injection form. And so those are just
57:08like three just general examples, right,
57:11of of what you could do going down this
57:12pathway before you cut.
57:14>> Yeah.
57:14>> And then after you cut, how effective
57:17was that, right? Did you have any
57:19readmissions? Do you have any
57:20complications?
57:21>> Um, you know, what were the outcomes of
57:23that procedure? And so, but majority of
57:26the time it's been focused on this this
57:28this clinical outcome side. But it's uh
57:31and I think there's a big opportunity
57:33here. Um, and we're actively going down
57:36this pathway right now
57:38>> of of the actual appropriateness. And so
57:40I think, you know, so I'm happy you
57:41brought that up because I I when I think
57:43of clinical um I think of quality
57:46outcomes, I think of it really in
57:49>> three buckets, but there's a fourth
57:51bucket. The So the first bucket of
57:52quality is appropriateness. The second
57:54bucket is outcomes. The third bucket is
57:57uh patient satisfaction.
57:58>> Okay. The fourth bucket though is also
58:02volume and rec because because I think
58:04that there's there's definitely been
58:05research out there to support like and
58:07once again volume in a good way meaning
58:09that like if a if a provider is doing
58:11you know let's call it um 40 normal um
58:15uh for delivering 40 babies a year
58:17versus another one's doing like 400 like
58:20they're probably more skilled and
58:22there's research once again to support
58:23this and so but once again these are all
58:25data sets are all sitting by themselves
58:27right how do these all things fit
58:28together into a quality picture. Yeah.
58:30>> So, I'm very keen into that right now.
58:32>> Yeah. Not to mention, there's a
58:33subjective component of the member
58:35saying, "I am in pain, and how dare you
58:37say that I don't need this procedure
58:39because my physician told me if I get
58:40the surgery, my pain's going to go away
58:42as soon as I get it done." So, who are
58:44you to tell me that I need to do some
58:46physical therapy first or the the
58:48steroidal injection, blah blah blah.
58:50It's like, I'm in pain. I have
58:52insurance. Doctor says I need surgery.
58:54I'm going to go get it, right? And I'm
58:56>> okay. I mean, your argument is also
58:58sound on the other side of that, but you
58:59know, I have a friend that's going
59:00through surgery right now,
59:02>> and he has tried every single step for a
59:05back issue that he's had, and he's
59:07delayed the time that the surgery was
59:10required. And it's a relatively
59:11minimally invasive surgery, I think, but
59:13he did everything he could to prevent
59:16that from happening. And he's now
59:17unfortunately at the point that that is
59:19actually the appropriate course of
59:20action. but he attempted to do a lot
59:22less invasive things, multiple things
59:25first to try to stave it off or at least
59:27delay the need for it. So, I'm not even
59:29suggesting that surgery isn't indicated
59:31in a lot of situations. It's just not
59:34always indicated if you go to a surgeon
59:36where they immediately suggest that to
59:37be the case. So, what sort of checks and
59:39balances of appropriateness can we
59:41introduce into the equation? That
59:42doesn't stop the provider from doing
59:44their job. It doesn't stop the member
59:45from getting the care they need. It's
59:47just taking it at the right time. We're
59:49doing it at the right time. That's all.
59:50Yep. Right.
59:51>> Yeah. And I like to think about it um
59:54you know, really in this lens to sum it
59:55up, you know, so cost and quality is
59:57just top of my mind right now.
1:00:00>> And I like to think about it today
1:00:03almost like in a quadrant.
1:00:04>> If it was just like an XY axis and you
1:00:07had um let's call it cost on the X and
1:00:10quality on the Y like today you're you
1:00:13know in a general network uh broad
1:00:15network contract. There's just just you
1:00:18could just put a scattered of dots all
1:00:20all on there, right?
1:00:22>> And I like to say like if my mom or dad
1:00:24or my best friend or my brother needed
1:00:26to have surgery, I would want him to go
1:00:29to the um if it's cost and quality here,
1:00:32right? I'd want him to go to the the
1:00:34most reasonable cost and highest quality
1:00:36provider. Of course, right? And today
1:00:39it's hard to know that. Um and so
1:00:41>> not to mention there's a third component
1:00:43to that which is the convenience. like
1:00:45where is that access to?
1:00:46>> Yeah. Located
1:00:47>> located, right? But, you know, I've also
1:00:50seen employers and employees willing to
1:00:52like if car shares wave, like they're
1:00:54willing to travel and we have some of
1:00:55that going on in Indiana today right
1:00:57now, too.
1:00:58>> And so, I think that uh so it is
1:01:00important, but I do think that uh
1:01:02members are willing to travel more if if
1:01:04cost share can be waved.
1:01:05>> Yeah. Oh, yeah.
1:01:06>> Um you know, kind of the zero tiered
1:01:08out-of- pocket plan design.
1:01:09>> Yeah. And if you're in have a
1:01:11life-threatening procedure and you have
1:01:13diagnosis of cancer, you might say, "I
1:01:15don't care what it costs me. I'm going
1:01:16to MD Anderson or as an example, right?
1:01:18Because quality and costs are secondary
1:01:21to is this the best place to be for me,
1:01:24even if it's a perception, I will do
1:01:26anything to get to that location, right?
1:01:28So just the there's always the human
1:01:32behavior element that impacts this as
1:01:35well." And I think that's really
1:01:36important to note because uh so
1:01:38basically down to that four quadrant
1:01:39tier, right? Like you know I I don't
1:01:41like the word narrow because I think
1:01:43it's just more of a curated um
1:01:45>> in terms of network
1:01:46>> network. Yeah, it's it's a curated
1:01:47network for being able to custom but the
1:01:48the great thing is is that what and what
1:01:50you just mentioned I think you know
1:01:52maybe part of the closing is that you
1:01:54know I'm not here to say that you have
1:01:55to just do one or the other. You could
1:01:56actually offer both and so you're
1:01:58actually giving members more choice.
1:02:00like they can still go potentially where
1:02:02they want, right? And but they have
1:02:04their normal plan, design, and play
1:02:06today. Or you could go to this more
1:02:07curated side and there's a benefit to
1:02:10the member and there's a benefit to the
1:02:12employer and there's also benefit to the
1:02:13provider um in regards to their you know
1:02:16suppression of prior authorization as an
1:02:18example. Their utilization is driven to
1:02:20them. So they're able to give better
1:02:21unit costs uh pricing savings for the
1:02:24employer and in return the employer is
1:02:26willing to give more um uh reduction in
1:02:30out-of- pocket costs or maybe wave
1:02:32dependent upon the the savings
1:02:33opportunity to that member. And so once
1:02:36again if if MD Anderson as an example uh
1:02:38potentially wasn't on that list as an
1:02:40example they could still go here right
1:02:43but it's up to them if they wanted to go
1:02:44to an independent like oncology center
1:02:46as an example down the road they could
1:02:48go there. really great care too by the
1:02:50way. Uh but you know potentially the
1:02:52cost share is different for them. So I
1:02:54do see more of that happening in regards
1:02:56to like a slice offering in markets as
1:02:58employers are like just kind of you know
1:03:00>> yeah and let's let's
1:03:02end, you know, kind hinted that we were
1:03:04getting towards the end and I do agree.
1:03:06>> Let's play this out especially the
1:03:08network conversation. I think earlier on
1:03:10or off camera you alluded to you know
1:03:11Mark Cuban's exploring the space or
1:03:13getting into this idea of like open
1:03:15networks and things like that. I do
1:03:17think there is potentially a cascade
1:03:19that will happen in the very near future
1:03:21where you'll look at these traditional
1:03:23broad-based PPOs, you know, that have 97
1:03:2699% crossover in in what doctors are in
1:03:29network and at that point like what are
1:03:30you really getting in terms of
1:03:31differential? And a lot of people are
1:03:33asking the question, should I use a
1:03:35reference based pricing plan? Should I
1:03:37leverage direct contracts? Should I tier
1:03:39and steer in Texas? You know, things
1:03:40like that. I think we're gonna the
1:03:43market's going to push ourselves to that
1:03:44direction, especially if there's a lure
1:03:46that's being dangled of cost savings in
1:03:48front. A lot of employers will sign up
1:03:50for any perceived disruption because 25
1:03:53to 35% delta on spend is worth powering
1:03:56through that. So, give me your
1:03:58perspective on perhaps in the next few
1:03:59years where we're going, not just in
1:04:01terms of networks, but networks is a big
1:04:02component of that. Where do you think
1:04:04healthcare is going in the next couple
1:04:05of years?
1:04:06>> It's a great question. Um, the other
1:04:08thing, you know, outside of cost and
1:04:10quality, it's a big focus of mine is is
1:04:12the question you just asked. And I and I
1:04:14I I think with access to technology that
1:04:18we have today, um, and somebody best
1:04:21figuring out a tiering and steering
1:04:23strategy from a plan design perspective,
1:04:26leveraging price transparency data and
1:04:27potentially, you know, you pick your
1:04:30quality vendor. I'm not going to get
1:04:31into that today, [laughter]
1:04:32>> but um
1:04:34>> you know it's it hasn't it's it's been
1:04:36difficult to effectively do that at
1:04:38scale today.
1:04:39>> Yeah.
1:04:39>> And so I think that that is potentially
1:04:42the next thing.
1:04:43>> Um
1:04:43>> yeah, you could do it a very locally
1:04:45very effectively.
1:04:46>> Locally very effectively, but doing it
1:04:48at scale that's been very difficult to
1:04:50do. And so I I do think that that is a
1:04:54potential whoever cracks that I think
1:04:55will be really successful uh in regards
1:04:58to there's just a big benefit for the
1:05:01member, the employer and the provider
1:05:03doing it that way. And and what I love
1:05:05about that is that
1:05:07>> you know one of the people asked me,
1:05:09Ryan, what what's what's the what's the
1:05:11future look like now that price
1:05:13transparency is out? Right? And I and I
1:05:15like to think of that as on the employer
1:05:16lens, the hospital lens, and the carrier
1:05:18lens because my response is different.
1:05:20Mhm.
1:05:21>> And what I hope doesn't happen is a
1:05:23world where all boats rise, meaning that
1:05:25the cost just continues to rise, right?
1:05:28>> But today, there's really no incentive
1:05:32for a provider to keep their costs low
1:05:34when there's no steerage to them to
1:05:37reward them for keeping their costs low.
1:05:39>> Correct.
1:05:40>> And so I truly believe that if if we can
1:05:43do this tearing and steering strategy,
1:05:44it will reward providers for keeping
1:05:46their costs reasonable. um and uh you
1:05:50know within we'll call it market
1:05:51average. But if there's if there's
1:05:55utilization from a commercial side
1:05:57driven away from very expensive
1:05:59facilities, it's going to drive them to
1:06:01change some of their behavior. Yes.
1:06:02>> And lot and you know tighten their belt
1:06:04up etc. of what they're doing.
1:06:06>> And so sure some of these other
1:06:07strategies like more direct contracting
1:06:09and RBP are definitely getting traction
1:06:11in the market. I'm not downplaying that.
1:06:12But I'm also seeing that that's another
1:06:15and there's definitely traction there.
1:06:17But I'm also seeing that with this data
1:06:19a tearing and steering strategy would
1:06:21happen where you know you're not just
1:06:23like doing cuz some some of those
1:06:24solutions are still you know once again
1:06:26they're still market specific. Yep.
1:06:27>> I'm talking about like a broad I'm with
1:06:30you as well. I haven't seen anybody been
1:06:32able to effectively extend it across the
1:06:34geography that the United States, which
1:06:36we don't often remind ourselves. This is
1:06:38a massive country, not only in terms of
1:06:41population, but massive in terms of
1:06:43geography. So, it's almost I won't say
1:06:45it's an impossible task, but it's an
1:06:47uphill battle to replicate something
1:06:49you're doing in Amarillo, Texas, and
1:06:50then turn around and go do it in New
1:06:51York and LA and Seattle, Washington
1:06:53simultaneously. It's very difficult to
1:06:55do, and I I appreciate that. The other
1:06:58thing that I've heard as an argument and
1:06:59I do want to ask your opinion and we'll
1:07:01fully lay the plane. I've heard the
1:07:03argument that transparency when you
1:07:05expose and make it very obvious to
1:07:07hospitals how much is being charged for
1:07:08certain services that the guy or gal
1:07:11running a hospital that realizes they're
1:07:13an outlier on the low end and instead of
1:07:15using that as a lure to increase uh
1:07:18volume to them, they just bring their
1:07:20prices back up in line with everybody
1:07:22else. So, do you think that's a risk
1:07:23with price transparency?
1:07:24>> 100%. And I've had numerous
1:07:26conversations over the last four to five
1:07:28years with heads of managed care
1:07:30hospitals in that exact lens.
1:07:32>> Yeah.
1:07:32>> And so,
1:07:34>> you know, why not for them, right? I
1:07:37mean, they So, you know, generally, just
1:07:38for folks awareness, like when they go
1:07:40into contract negotiations with
1:07:41carriers, generally the the deck is the
1:07:44deck of cards is stacked against them.
1:07:46They don't have any intel of, you know,
1:07:49where their competitor's contracts sit
1:07:51relative to their contracts, right? And
1:07:54once again, you're not getting all the
1:07:55details of what's in a contract like
1:07:57like the outlier clauses and and and the
1:07:58the yearly uh increases in those
1:08:01contracts, but the unit cost is a big
1:08:03component of that contract. And so now
1:08:06that they're getting access to this
1:08:08information, they are the deck is more
1:08:10uh even going into these contract
1:08:12negotiations.
1:08:13>> And the carriers are also looking at
1:08:15this data too.
1:08:16>> So not only the hospital contracting
1:08:18team, but the carrier contracting teams
1:08:19are looking at this information. And so
1:08:21what do you think would happen is to
1:08:23your point, right? Like and so the the
1:08:24ones that are less expensive, they're
1:08:26trying to be like, well, wait a second.
1:08:28Why can't we why why can't we get a
1:08:30better rate than this? And so I think
1:08:31one of the things for folks to realize
1:08:33is that the hospital um you know, it's
1:08:37not the quality of the the facility.
1:08:39It's not um the location of the
1:08:41facility. It's ultimately the market
1:08:42presence and dominance of that hospital
1:08:45is really the biggest driver to the the
1:08:49increases that they get in these
1:08:50contracts.
1:08:51>> And so, you know, the the the smaller
1:08:53facilities as an example, even though if
1:08:55they want higher rates, they might they
1:08:57don't have as much leverage at times as
1:08:59the other ones. And so I definitely
1:09:01think that the the all boats rise thing
1:09:03could happen in time,
1:09:05>> but my hope is that we reward the ones
1:09:07that are keeping prices lower reasonably
1:09:09in check and we start to take some
1:09:11utilization away. So eventually like we
1:09:13get to a more stable point. Yep.
1:09:15>> Um but that that is of course future
1:09:17thinking, right? And so I think like as
1:09:19anything we can do to baby step in that
1:09:21direction, I think it's just a positive
1:09:22for the member and the employer.
1:09:24>> Agree. Well, so you and I nerded out for
1:09:25about an hour or so, and I appreciate
1:09:27you nerding out with me, but if you were
1:09:29to perhaps sum up the conversation that
1:09:31we just had, or maybe leave the the
1:09:33listener with how do I simply think
1:09:35about what to do next? What is a way
1:09:37that you'd like to finish the episode?
1:09:39And I will firmly admit this is always
1:09:41the hardest question I pose to anybody
1:09:42on the show. Sum up an hour's
1:09:44conversation in 10 seconds, you know?
1:09:46>> Well, I think first and foremost is that
1:09:49understanding that price transparency is
1:09:50here. Mhm.
1:09:52>> It's unlocking the contract black box
1:09:54that we've never had access to before
1:09:56and the ability to start to get into
1:10:00market specific information of like down
1:10:02at the hospital level which we've never
1:10:04been able to see will produce better
1:10:07data and better insights to make a
1:10:09better informed medical network
1:10:11decision. I think that's a big takeaway.
1:10:13I think the second takeaway is also to
1:10:15realize contract terms is a big driver
1:10:17to your overall health plan spend. Mhm.
1:10:19>> So thinking about how you gain or ask
1:10:22better questions to get access to that
1:10:24information is also a second lever to
1:10:26consider polling.
1:10:28>> And then I think third is just this
1:10:30industry is evolving very fast in this
1:10:32space. Um and so some of the things I'm
1:10:34talking to you about now I know are
1:10:35probably being worked on by companies
1:10:36that maybe I'm not even aware of.
1:10:38>> Yeah. Yeah.
1:10:38>> And so just like keeping an eye out of
1:10:41of what's happening today and staying on
1:10:43top of some of these emerging solutions
1:10:44I think is really important. Um and also
1:10:47understand too that when you get into
1:10:50the quality space to your point earlier
1:10:52Spencer you know making sure that you
1:10:54know what you're looking at you
1:10:55understand because the definition of
1:10:57quality can be uh different depending on
1:10:59who you talk to. So just understanding
1:11:01you know as you're look if you're
1:11:02looking into that space just clearly
1:11:04understanding what you're looking at and
1:11:05asking questions around is
1:11:07appropriateness of care included is it
1:11:09just outcomes is patient status included
1:11:11how is volume taken into consideration
1:11:14those type of things I think are really
1:11:16important because cost and quality at
1:11:18the end of the day in this transparency
1:11:19space I think will continue to evolve
1:11:21and you know it somewhat has got a I
1:11:24wouldn't call it a bad rep but we have
1:11:25it you know we took a first pass at this
1:11:27right like 10 15 years ago with some of
1:11:28the navigation companies They've done
1:11:30fairly well in the space. But I think
1:11:32this next evolution of this data is
1:11:33going to take it to another level.
1:11:35>> Okay.
1:11:35>> And I think that what to look out for
1:11:38the coming years to come is some type of
1:11:40tiering and steering strategy. Um
1:11:42leveraging this data at scale
1:11:44nationally. I think that's going to be
1:11:45interesting to see how that plays out
1:11:47and it wouldn't surprise me if a company
1:11:49cracks it.
1:11:49>> Yeah. So you and I get to go now sit in
1:11:52some rush hour traffic in Dallas. And
1:11:53Nathaniel, thanks for hanging out after
1:11:55hours uh today as well. But Ryan, I
1:11:57really appreciate you, man, and thanks
1:11:58for making this a part of of your trip.
1:12:00Um, can't wait to release the episode
1:12:02and hopefully this isn't the last time
1:12:04we sit down, man.
1:12:04>> Yeah, I really appreciate being here.
1:12:06>> Yep.
1:12:07>> Great to finally meet you in person,
1:12:08man. And everybody, by the way, his new
1:12:10office is great. His new setup is great
1:12:12here. So,
1:12:12>> thanks, dude. Appreciate it. Thank you.

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