EP496: Plan Sponsors Spend About $1.20 to Buy $1 of Healthcare, and Clinical Organizations Receive 80¢ for Every $1.20 Spent, With Mark Newman
I'm gonna do a little series here called "The Inches Are All Around Us," and in this series, at least to start, all of the inches I'm gonna mention are full-on administrative waste—waste that is particularly egregious because it has nothing to do with patient care. That's why when Shane Cerone said, "The inches are all around us" in episode 492 about hospitals and hospital prices, I really perked up. Because by fixing this friction, this administrative waste, we can actually improve patient care and reduce costs simultaneously. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Along these same lines, I have also heard Zack Cooper, PhD, talk about the 1% steps to healthcare reform project, where he's like, look, find 10 or 30 or whatever 1% problems, and you'll probably transform healthcare faster than if you're trying to find a 10% or 30% solution. So, same idea. And finding these inches, these 1 percents, even in and of themselves, it's big dollars when it comes to how much the U.S. spends on healthcare, which is, by the way, projected to reach $5.6 trillion in 2025, according to NHE (National Health Expenditure) projections from federal actuaries. So, I decided to go on a bit of a quest for these inches—you know, get a bead on where they may be nestled for anyone looking on behalf of their plan or their country or their state maybe. To this end, also recall or be aware of the episode with David Scheinker, PhD (EP363). But David Scheinker in that episode gets into how much every industry pays something like 2% to administer a transaction. But in healthcare, the provider pays something like 14%, and the payer pays another 14% to submit and get paid for a claim, which is healthcare for a transaction. Don't get me wrong, it's the plan sponsors such as self-insured employers, members, and USA taxpayers who are ultimately paying for those two 14 percents. So that 28% of full-on administrative costs—most of which, we could agree, could go away and probably be better for patients, not worse—this, too, is coming out of the pockets of the ultimate purchasers of healthcare. Those costs are getting passed along. I say all this to say, to kick off this "the inches are all around us" exploration, I wanted to dig in a little more specifically into what goes on during these aforementioned transactions (ie, what this life of a claim kind of, like, looks like on the ground). I wanted to start here because, yeah, we haven't done this before; and this exploration is gonna continue into next week because we're gonna dip heavy into clearinghouses with Zack Kanter and what they do all day. And then after that, I'm talking payment integrity programs. I'm talking prepayment review programs with Mark Noel, because you know what? Employers don't wanna be bringing a knife to a gunfight. And I realized in the course of these conversations that any self-insured plan sponsor that is not doing, for real, payment integrity programs, for real, prepayment review, post-payment review. I'm getting ahead of myself, but when you listen to the show next week with Zack Kanter, you will so totally see what I mean. Today, as I mentioned earlier, I am speaking with Mark Newman, who is the CEO and founder of Nomi Health. Nomi aims to simplify the act of buying and paying for healthcare for self-insured employers. Look 'em up if that sounds intriguing. I also do need to thank Nomi Health for so generously offering to donate to RHV to cover the expenses of producing this episode. So, thank you so much to Nomi Health. Okay, lastly here, just to set the basic framework for this conversation that follows, Mark gets into two main revelations, reasons that kind of sit behind all a large part of the waste and friction in healthcare transactions. Again, otherwise known as a claim getting paid. And these two reasons are data isn't data isn't data. In other words, as a claim moves through the system to different stakeholders, the data starts to change and morph and come and go. Different people have different use cases for that data, so it starts to get added and subtracted, but nobody really has the universal level to tote up the difference in any organized fashion. So, we talk about that first. Then Mark Newman doubles down with another reason for the friction and waste. Here's the second revelation: A dollar isn't a dollar isn't a dollar. And same kind of rules apply here. A plan sponsor might spend a dollar and, yeah, is that dollar spent or is that dollar accrued to spend? Which is kind of wonky, but also relevant. And if you didn't understand that, we'll get to it. And then just because a dollar gets spent doesn't mean the provider gets that dollar. And by the way, I don't just mean, oh, there's spread pricing. How shocking. I mean that a plan sponsor could roll up to a hospital and say, "We spent $10 million last year," and the hospital could say, "No, you didn't. You only spent five." And spoiler alert, in this case, it's not about spread pricing, although it might be. It's also about how much was the member responsibility that the members didn't pay. So, a dollar is not a dollar for a whole bunch of different reasons. This podcast is sponsored by Aventria Health Group, and today, it's also sponsored by Nomi Health. Also mentioned in this episode are Nomi Health; Shane Cerone; Zack Cooper, PhD; David Scheinker, PhD; Zack Kanter; Mark Noel; Aventria Health Group; Preston Alexander; Eric Bricker, MD; Sam Flanders, MD; Andrew Tsang; Sandra Raup; Stan Schwartz, MD; ZERO.health; Cristin Dickerson, MD; and Matt Christensen. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at nomihealth.com or reach out to Mark at [email protected]. You can also follow Mark and Nomi Health on LinkedIn. Mark Newman is the co-founder and CEO of Nomi Health, on a mission to rebuild America's healthcare system to serve all stakeholders: providers, employers, and patients. A recognized healthcare innovator and entrepreneur, Mark previously founded and built HireVue into the world's largest provider of AI-driven talent assessment solutions before its acquisition by the Carlyle Group. His commitment to improving the healthcare system stems from a desire to address systemic issues that have long plagued the industry. Under his leadership since its inception in 2019, Nomi Health has focused on creating a more direct and transparent healthcare experience: reducing an organization's spend by over 30% per patient while increasing a provider's payments. Through Nomi Health, Mark continues to advocate for a more efficient, service-centered approach to healthcare that prioritizes known costs for employers, zero out of pocket for patients, and near-real-time payments for providers. 06:48 What is actionable to know about the life of a claim? 08:14 How data can change as it moves through the claims process. 11:45 Why a dollar isn't a dollar in healthcare. 18:50 Why employers are actually paying more than a dollar to access a dollar of healthcare (the medical loss ratio). 21:54 Why cutting out the "friction" is actually better for employees and members. 22:48 EP482 with Preston Alexander. 22:50 EP472 with Eric Bricker, MD. 23:36 EP490 and EP492 with Sam Flanders, MD, and Shane Cerone. 23:53 Infographic by Andrew Tsang showing 27 streams of income. 26:53 How do we fix these issues? 28:05 LinkedIn comment from Sandra Raup. 28:59 How Nomi Health is experimenting with a no co-payment, no deductible model. 31:29 INBW42 with Stacey on moral hazard. 32:26 EP486 with Stan Schwartz, MD. 32:31 EP485 with Cristin Dickerson, MD. 32:56 The Innovator's Dilemma by Clayton M. Christensen. 34:55 How does Nomi Health work with and help employers? You can learn more at nomihealth.com or reach out to Mark at [email protected]. You can also follow Mark and Nomi Health on LinkedIn. @markhirevue discusses #plansponsor #healthspend and #clinicalorg pay on our #healthcarepodcast. #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW45), Stacey Richter (INBW44), Marilyn Bartlett (Encore! EP450), Dr Mick Connors, Sarah Emond (EP494), Sarah Emond (Bonus Episode), Stacey Richter (INBW43), Olivia Ross (Take Two: EP240), John Quinn
