Two of the most notable payer venture funds, Optum Ventures and Cigna Ventures, just headed up a $30 million dollar Series A funding round for Flume Health, a startup that basically builds “challenger” health plans. How did this go down? Cédric Kovacs-Johnson CEO & Founder of Flume introduces us to his company which offers providers, digital health co’s, brokers, reinsurers, and just about any other healthcare org a tech stack for creating their own hyper-niche, super personalized health plans.
The suite of services to “build-a-plan” includes things like claim processing, payments, enrollment management, digital health point solutions integration, and other API functionality – replacing the traditional TPA with tech and the one-size-fits-all plan with a new opportunity for nichey-ness that can customize coverage for patient populations based on health conditions, location, employer, and so on.
Cédric talks us through the benefit to his target client – the care provider – who, while taking on more risk anyway, may consider building their own plan to capture more premium dollars and gain better control over the end-to-end patient experience. Wait a minute – is all this “Challenger Health Plan” talk just a re-brand of value-based care? I ask point-blank and get a new buzz phrase in return; welcome to the lexicon, “Commercial Advantage.” Lots to unpack in this one including Flume’s rev-gen model and plans for growth – they’re already onboarding one new challenger plan per month!
There is still health tech funding going on in late July? Wow! On Episode 138 of Health in 2 Point 00, Jess asks me about Ro getting $200M from General Catalyst to expand their telehealth platform, Indigo Diabetes raising 38M Euros to develop its CGM Sensor, Angle Health landing $4M to create a health plan for startups, and Sidecar Health closing a $20M for their point-of-service payments! — Matthew Holt
Episode 12 of “The THCB Gang” was live-streamed on Friday, June 5th from 1PM PT to 4PM ET. If you didn’t have a chance to tune in, you can watch it below or on our YouTube Channel.
Editor-in-Chief, Zoya Khan (@zoyak1594), ran the show! She spoke to economist Jane Sarasohn-Kahn (@healthythinker), executive & mentor Andre Blackman (@mindofandre), writer Kim Bellard (@kimbbellard), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), and patient advocate Grace Cordovano (@GraceCordovano). The conversation focused on health disparities seen in POC communities across the nation and ideas on how the system can make impactful changes across the industry, starting with executive leadership and new hires. It was an informative and action-oriented conversation packed with bursts of great facts and figures.
If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt
When it comes to money back guarantees in health care, it’s
often less about the money and more about the guarantee.
That’s the biggest takeaway shared by two organizations—Geisinger
Health System and Group Health Cooperative of South Central Wisconsin (GHCSCW)—that
separately rolled out closely-watched campaigns to refund patients their
out-of-pocket costs for health care experiences that fell short of expectations.
Both programs started as a way to inject a basic level of
consumerism into a process long bereft of one. In fact, as consumer frustration
over medical costs rise, a money back guarantee has the potential to win back a
But like many experiments in health care, the effort
produced some unexpected results as well. Instead of a rush on refunds,
executives from both systems said their money-back pledge served even better as
a continuous-improvement tool, with patients providing almost instantaneous
feedback to staff who felt newly empowered to address problems.
Among its less appreciated but more worrisome impacts, COVID-19 threatens to destabilize America’s health care provider infrastructure. Patients have largely been relegated to sheltering at home and, to avoid infection, are avoiding in-person clinical visits. The revenues associated with traditional physician office visits have been curtailed. Telehealth capabilities are gradually coming online, but are often still immature. The concern is that many practices will be financially unable to keep the doors open, compromising access and healthy physician-patient relationships.
Health plans have become health care’s bankers, controlling the funding that fuels larger care processes. Health insurance companies and health plan administrators rely on networks of doctors and hospitals to deliver health care services. They also rely on premium payments from employers to administer and pay for health care. In conventional fee-for-service, pay as you go arrangements, providers are paid after they have delivered care services. The stability of this approach, of course, assumes an unhindered flow of patients receiving care.
When the stability of that flow is disrupted, as it has been with COVID-19, physician practices become vulnerable. Solving that vulnerability would give members access to critical services – primary care, specialty care, urgent care and pharmacy coordination – during this epidemic. Without these resources, members will be forced to turn to overburdened hospitals, where they risk increased COVID-19 exposure.
At kitchen tables everywhere, ordinary Americans have been grappling with the arcane language of deductibles and co-pays as they’ve struggled to select a health insurance plan during “open enrollment” season.
Unfortunately, critical information that could literally spell the difference between life and death is conspicuously absent from the glossy brochures and eye-catching websites.
Which plan will arrange a consultation with top-tier oncologists if I’m diagnosed with a complex cancer? Which might alert my doctor that I urgently need heart bypass surgery? And which plan will tell me important information such as doctor-specific breast cancer screening rates?
According to Matt Eyles, president and chief executive officer of America’s Health Insurance Plans (AHIP), insurers over the last decade have made a “dramatic shift” to focus more on consumers. That shift, however, has yet to include giving members the kind of detailed information available to corporate human resources managers and benefits consultants (one of my past jobs).
What’s at stake could be seen at a recent AHIP-sponsored meeting in Chicago on consumerism. Rajeev Ronaki, chief digital officer for Anthem, Inc., explained how the giant insurer is using artificial intelligence to predict a long list of medical conditions, including the need for heart bypass surgery. Information on individual patients is passed on to clinicians.
Ali Diab, CEO & Co-Founder of Collective Health, wants to talk about healthcare affordability and the fact that consumerism doesn’t really exist when it comes to healthcare because we don’t really have a functioning market. The “Real” buyers — from the federal government to large employers — have no idea what things cost in traditional health plans and are making healthcare purchases for their constituents without full price transparency. So, what has he and Collective Health learned now that they’re 6 years into trying to offer these buyers an alternative to that traditional health plan experience? Nothing is more complex than health insurance innovation, but Collective Health is making significant headway and, according to Ali, has made it past the “homicide phase” of being a digital health startup.
Filmed at HLTH 2019 in Las Vegas, October 2019.
Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew Holt.
Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.
Today THCB is spotlighting Lumeris which creates a platform to help set-up and develop health plans and manage care delivery for patients. Working with its associated medical group Essence, Lumeris has been creating actionable steps to reduce Medical Cost Rates (MCRs) and is now taking that process to other health systems that want to set up Medicare Advantage plans. Lumeris is working with 12 health systems and is growing rapidly. Recently, Lumeris partnered with Cerner to bring their product to market.
Matthew Holt interviewed Matt Cox, Chief Marketing Officer at Lumeris to find out the details.
A number of years ago, a family doc friend of mine took me on a tour of his small group practice. He proudly showed me the exam rooms, his medical equipment, and other parts of the facility that related to patient care. Then we came to a large room with a bunch of desks piled high with paper. He explained, bitterly, that this part of his office was for the people he had to keep on the payroll to do nothing but deal with insurers. This administrative expense was cutting his margins to the bone and did not help him take better care of his patients. He eventually left practice, to pursue a second career as a physician executive – a job that was, for him, more remunerative and more satisfying.
Part of the problem is that physicians in the US have to deal with multiple health plans – each with its own set of managed care rules, formularies (or list of approved drugs), requirements for prior authorization, rules for billing, submission of claims, and adjudication. Until recently, almost all of this administrative work was done by phone or fax. Picture this: rooms full of practice-based nurses talking to insurance company nurses about the details of a case that may or may not lead to payment for medical care.
Risk adjustment in health insurance is at first glance, and second, among the driest and most arcane of subjects. And yet, like the fine print on a variable-rate mortgage, it can matter enormously. It may make the difference between a healthy market and a sick one.
The market for individual health insurance has had major challenges both before and after the Affordable Care Act’s (ACA’s) risk adjustment program came along. Given recent changes from Washington, like the removal of the individual mandate, the market now needs all the help it can get. Unfortunately, risk adjustment under the ACA has been an example of a well-meaning regulation that has had destructive impacts directly contrary to its intent. It has caused insurer collapses and market exits that reduced competition. It has also led to upstarts, small plans and unprofitable ones paying billions of dollars to larger, more established and profitable insurers.
Many of these transfers since the ACA rules took effect in 2014 have gone from locally-based non-profit health plans to multi-state for-profit organizations. The payments have hampered competition not just in the individual market, which has never worked very well in the U.S., but in the small group market, which arguably didn’t need “help” from risk adjustment in many states.
The sense of urgency to fix these problems may be dissipating now that the initial rush for market share under the ACA is over and plans have enough actuarial data to predict costs better. There has been an overall shift to profitability. But it would be a serious mistake to think that just because fewer plans are under water, the current approach to risk adjustment isn’t distorting markets and harming competition.