channel:@SelfFunded
24 videos
Spencer's Guide To LinkedIn In 2025
Self-Funded
@SelfFunded
Jan 2, 2025
This video provides an in-depth exploration of building an effective LinkedIn presence for sales professionals and career advancement, particularly within the healthcare industry. The speaker, Spencer, shares his personal journey from an anonymous insurance representative to a recognized industry authority through consistent social media content creation. He emphasizes that anyone, regardless of their starting point or industry experience, can leverage platforms like LinkedIn to establish credibility, generate leads, and foster professional relationships. The presentation is structured as a practical guide, moving from foundational steps to more advanced strategies, while also addressing common fears and pitfalls that hinder individuals from starting their content creation journey. Spencer's approach is highly practical and empathetic, acknowledging the initial apprehension many feel about public posting. He outlines a stair-step method, starting with low-barrier-to-entry activities like commenting on others' posts, and gradually progressing to creating original written content, incorporating visuals, and eventually producing video or podcast appearances. A core theme is the importance of authenticity and sharing personal stories to build trust and relatability, which he argues is crucial for doing business in today's environment. He also champions the concept of "exponential awareness," where a single piece of content can generate perpetual value and reach a far wider audience than traditional cold outreach methods. The video details specific strategies for maximizing LinkedIn's potential, such as using compelling visuals to stop scrolling, leveraging guest appearances on podcasts to gain exposure, and strategically engaging with industry leaders. Spencer shares several compelling anecdotes, including how his first video on a niche subject (stop loss insurance) trended in the top 1% on LinkedIn, and a personal story about a high ER bill that became his most viral post, leading to new connections and solutions. He also recounts a direct sales success story where a client was pre-sold on his expertise simply because they recognized him from his podcast, highlighting the immense power of established credibility. The speaker concludes by stressing the importance of consistency and resilience, cautioning against the common mistakes of over-investing in equipment, striving for unattainable perfection, or giving up too soon due to a lack of immediate engagement. Key Takeaways: * **Start Small and Overcome Fear:** Many professionals hesitate to start social media content creation due to fear. Begin with low-barrier activities like commenting on other people's posts to build confidence and gradually escalate to more involved content. * **Optimize Your LinkedIn Profile:** Ensure your LinkedIn profile is complete with a professional picture, a detailed "About Me" section, and an updated resume. This forms the foundational hub for your online professional presence. * **Strategic Commenting for Network Expansion:** Actively comment on posts from respected industry figures or target prospects. Provide genuine value, perspective, or opinion to establish yourself as a credible authority and expand your reach into their networks. * **Consistent Content Creation:** Aim to write at least one post or article per week on topics you are knowledgeable about. This consistent cadence helps establish your expertise and keeps your audience engaged. * **Utilize Visuals to Enhance Engagement:** Always include a visual element (picture, graphic, or short video) with your posts. Visuals are crucial for stopping users from scrolling and drawing them into your written content. * **Leverage Guest Appearances on Podcasts:** Seek opportunities to be a guest on industry-relevant podcasts. This allows you to showcase your expertise without the burden of production, providing shareable content and expanding your reach. * **Embrace Personal Storytelling:** Share relatable personal stories, experiences, or insights (within your comfort level) to build trust and rapport. People connect with authentic human experiences, which can significantly enhance your professional relationships. * **Avoid Perfectionism and Over-Investment:** Do not delay content creation by striving for perfection or investing heavily in expensive equipment. Your smartphone and basic accessories (like a tripod and ring light) are sufficient to start; imperfections make content more relatable. * **Prioritize Consistency Over Immediate Results:** Building an audience and achieving impact takes time. Do not give up too soon if initial posts don't gain traction; consistency over months and years is key to long-term success. * **Exponential Awareness for Sales:** Social media content creates "exponential awareness," allowing a single effort (e.g., one video) to reach thousands and generate perpetual benefit, significantly amplifying your sales efforts compared to one-to-one cold outreach. * **Content Builds Credibility and Trust:** A strong online presence establishes credibility before you even meet a prospect, making them more receptive to your message and significantly shortening the sales cycle. * **Learn from Industry Leaders:** Follow and observe successful content creators in your industry. Analyze their styles, topics, and engagement strategies to inform your own approach without needing formal coaching. **Tools/Resources Mentioned:** * **iPhone:** Recommended as the primary device for video and content creation, negating the need for expensive cameras. * **Amazon:** Suggested source for affordable tripods and ring lights. * **Nathaniel:** An editor mentioned as a resource for video editing. * **Goodbill:** A company mentioned in Spencer's personal story that helped lower his medical bill. **Key Concepts:** * **Exponential Awareness:** The idea that a single piece of content, once published, can continuously reach a vast audience over time with minimal ongoing effort, generating leads and building authority far beyond one-to-one outreach. * **Self-Selecting into Your Ecosystem:** When prospects discover your content and proactively engage with you, signaling their interest and effectively "opting in" to learn more about what you offer, leading to warmer leads. **Examples/Case Studies:** * **First Viral Video:** Spencer's initial video on the niche subject of "stop loss and insurance," created with an iPhone and no prior experience, trended three times in the top 1% of all LinkedIn content, demonstrating that niche topics can find an audience. * **$4,200 ER Bill Post:** A personal story shared by Spencer about receiving a large, unexpected bill for his son's urgent care visit, accompanied by a picture of him and his son. This post became his most viral, generating significant engagement, new connections, and even leading to a service (Goodbill) that helped reduce the bill. * **Kansas City Broker Sales Conversion:** A direct sales example where a young producer in a meeting recognized Spencer from his podcast, immediately establishing credibility. This rapport led to a contract being signed with the agency before Spencer even returned home, illustrating the power of a pre-established reputation.
What An Intentional Company Culture Looks Like | with Rob Gelb
Self-Funded
@SelfFunded
Aug 1, 2025
This video provides an in-depth exploration of Vālenz Health®'s intentional company culture, as presented by CEO Rob Gelb during an office tour. The primary purpose of the discussion is to illustrate how a deeply ingrained culture, built on specific tenets and philosophies, drives innovation and success within a healthcare company dedicated to making healthcare "smarter, better, and faster." Gelb elaborates on the origins of the company's name, its evolving mission, and the core values that shape its operations, partnerships, and employee experience. The discussion delves into several key themes, beginning with the etymology of "Veilance" (Latin for strong, vigorous, and healthy) and how this concept permeates their brand promise to build strong partnerships and empower individuals in their healthcare journeys. Gelb explains how their mission statement, initially focused on optimizing cost, quality, and utilization, was refined to emphasize "high-value healthcare" and patient protection after a strategic acquisition. A significant portion of the video is dedicated to Vālenz Health®'s unique cultural tenets, such as encouraging "spilled milk" – a metaphor for celebrating learning from failures – and adopting a "yes, and" mindset, borrowed from improvisational comedy, to foster collaborative idea generation and trust among team members and partners. The progression of ideas moves from foundational identity to operational philosophy and leadership principles. Gelb highlights how language is intentionally used throughout their office design to communicate core values, such as breaking down "challenge" into "look, listen, enable" to drive change, and balancing "aspirational" dreams with "perspirational" execution. The conversation also covers the importance of fearlessness, embracing criticism as a gift, and building "player-led" teams where accountability is shared. The video culminates with a powerful affirmation of their innovative culture, evidenced by customer feedback collected in a word cloud where "innovative" was overwhelmingly the largest and most frequent descriptor, reinforcing that their cultural practices directly translate into how they are perceived by their clients. Key Takeaways: * **Intentional Culture as a Strategic Asset:** Vālenz Health® demonstrates how a meticulously crafted company culture, from its name's meaning to its office aesthetics, serves as a foundational pillar for its business strategy and market differentiation. This intentionality helps align employees, partners, and customers with the company's core values. * **Evolving Mission for Refined Focus:** The company's mission statement, initially broad, was strategically refined to "optimized utilization, high-value healthcare" and "protecting patients and helping employers." This highlights the importance of adapting a mission as the company grows and gains deeper market understanding, ensuring it remains relevant and impactful. * **"Smarter, Better, Faster Healthcare" as a Brand Promise:** Vālenz Health®'s brand promise emphasizes efficiency and effectiveness in healthcare delivery, with cost optimization being an implicit outcome rather than the sole focus. This positions them as a value-driven partner focused on holistic improvements. * **Embracing "Spilled Milk" for Learning and Growth:** A core cultural tenet is the encouragement and celebration of "spilled milk," meaning learning from failures. This fosters psychological safety, allowing employees at all levels to experiment, take risks, and grow without fear of punitive consequences. * **The "Yes, And" Mindset for Collaboration:** Inspired by improvisational comedy, the "yes, and" principle promotes additive thinking and collaborative storytelling within the company and with partners. This encourages building upon ideas rather than shutting them down, fostering innovation and stronger relationships. * **Language as a Cultural Driver:** Rob Gelb emphasizes the deliberate use of language and wordplay to instill company values, such as dissecting "challenge" to reveal "change" (Look, Listen, Enable) or balancing "aspirational" dreams with "perspirational" execution. This shows how words can be powerful tools for shaping mindset and behavior. * **Fearlessness and Limitlessness in Innovation:** The company promotes a culture of being "limitless" and "fearless," encouraging employees to dream big, be unafraid to fail, speak unpopular truths, and view criticism as a valuable gift. This mindset is crucial for continuous innovation and breaking new ground. * **Player-Led Teams for Enhanced Accountability:** Vālenz Health® aspires to be a "player-led" organization, where every team member understands their role, knows how to execute for success, and holds peers accountable. This decentralizes leadership and empowers individuals, leading to higher performance and ownership. * **Consistency Over Occasional Greatness:** The philosophy of striving to be "consistently good" rather than "occasionally great" underscores the importance of maintaining high standards and reducing performance variability. This leads to more reliable outcomes and builds trust with partners and customers. * **Customer-Validated Innovation as an Affirmation:** The video highlights how customer feedback, specifically a word cloud overwhelmingly featuring "innovative," serves as a powerful affirmation of their culture. This external validation reinforces that their internal practices of embracing failure and continuous learning translate into perceived innovation by their market. * **Focus on Unmet and Underserved Needs:** Vālenz Health® approaches potential clients not with a sales pitch, but with an invitation to discuss their "unmet and underserved needs" in healthcare. This problem-solving orientation positions them as a caring partner genuinely interested in finding solutions. Key Concepts: * **Vālenz (Veilance):** Latin for strong, vigorous, and healthy, reflecting the company's aspiration for its business, partnerships, and members. * **Spilled Milk:** A metaphor for learning from failures, encouraged as a vital part of growth and innovation. * **Yes, And:** A principle from improvisational comedy adopted to foster collaborative idea generation and build trust by accepting and expanding on others' contributions. * **Challenge = Change:** An internal philosophy where "challenge" is broken down into "Look, Listen, Enable" to facilitate meaningful transformation. * **Aspirational & Perspirational:** The balance between dreaming big (aspirational) and executing diligently (perspirational) to achieve goals. * **Player-Led Organization:** A team structure where individuals are empowered to understand their roles, execute, and hold each other accountable, rather than relying solely on top-down leadership. * **Unmet/Underserved Needs:** The core of Vālenz Health®'s problem-solving approach, focusing on identifying and addressing gaps in the healthcare industry.
The Tokio-Marine HCC 2025 Stop-Loss Report: 5 Key Takeaways
Self-Funded
@SelfFunded
Aug 15, 2025
This video provides an in-depth exploration of the Tokio Marine HCC 2025 Stop-Loss Report, breaking down five key takeaways that illuminate the current hardening market for stop-loss insurance. The speaker, a self-proclaimed "stop-loss geek," aims to equip listeners with critical knowledge to navigate projected medical cost increases of 9-10% in 2025 and increasingly challenging renewals. The analysis delves into the specific trends driving these shifts, offering a granular look at the frequency and severity of large claims, the surprising cost implications of COBRA claimants, the prevalence of policy "lasers," and the crucial concept of loss ratio maturity. The presentation systematically unpacks the report's findings, starting with diagnostic categories, differentiating between those most frequently leading to large claims (e.g., neoplasms/cancer, cardiovascular diseases) and those driving the highest severity costs (e.g., transplants, congenital anomalies, blood diseases like hemophilia). It then transitions to a striking analysis of large claims over time, revealing a dramatic increase in the frequency of multi-million dollar claims, which have necessitated a redefinition of what constitutes a "catastrophic" claim. The speaker attributes some of these trends to the impact of the Affordable Care Act (ACA), particularly the removal of lifetime and annual maximums, and the rise of expensive treatments like gene therapies. Further insights are provided on the financial burden posed by COBRA claimants, who are shown to be significantly more likely to incur large claims than active employees, prompting a discussion on potential solutions for employers. The video also clarifies the concept of loss ratio maturity, explaining how a policy's loss ratio at different points in its term can predict its final outcome, which is highly relevant for renewal negotiations. Finally, the analysis covers the frequency of "lasers" (specific deductibles for named individuals) on stop-loss policies, comparing market averages with Tokio Marine's own practices and discussing the influence of "no new laser" provisions and captive insurance models. The overarching message is that the market is experiencing a significant rebound and hardening, partly due to underwriters misinterpreting the post-COVID cost plateau as normal rather than a unique event, leading to artificially suppressed rates that are now correcting sharply. Key Takeaways: * **Hardening Stop-Loss Market:** The stop-loss market is experiencing significant hardening, with renewals becoming tougher due to projected medical cost increases of 9-10% in 2025, a trend expected to continue for several years. * **Dramatic Increase in Large Claims:** Claims exceeding $2 million are now 1,250% more frequent than in 2013, while $500,000 claims are up 250%. This necessitates a redefinition of "catastrophic" claims, with $1 million no longer considered exceptionally large and $2 million becoming the new benchmark. * **Key Diagnostic Cost Drivers (Frequency):** Neoplasms and cancer consistently rank as the most frequent large claim categories, followed by cardiovascular, musculoskeletal, and digestive diseases. Nervous system diseases (e.g., Multiple Sclerosis, with expensive medications) have recently moved into the top five. * **Key Diagnostic Cost Drivers (Severity):** Transplants remain the most expensive category, with congenital anomalies (e.g., malformations, premature babies in NICU) and blood diseases (e.g., hemophilia, often requiring costly gene therapies or ongoing medication) also being major drivers of severe costs. * **Impact of Medical Advances:** Advances in medical technology, particularly gene therapies, are significant contributors to the rising cost and duration of large claims, as they often involve ongoing, expensive treatments rather than cures. * **High Cost of COBRA Claimants:** Individuals electing COBRA are substantially more expensive on average than active employees. They are 13.5 times more likely to have a $200,000 claim, 14.1 times more likely for a $500,000 claim, and 15.5 times more likely for a $1 million claim, highlighting a significant risk for plan sponsors. * **Employer Solutions for COBRA:** Employers should consider offering solutions or guidance to COBRA-eligible members to explore open market options. This can help mitigate the significant financial risk associated with retaining high-cost claimants on the employer's plan. * **Loss Ratio Maturity for Renewals:** Understanding loss ratio maturity is crucial for renewals. The further into a policy period (e.g., 9 months), the more predictable the final loss ratio becomes, allowing stop-loss carriers to price renewals more accurately and potentially less conservatively. * **Laser Frequency Trends:** On average, about one in four policies in the market has a "laser" (a specific deductible for a named individual), with an average of one laser per policy. However, carriers like Tokio Marine HCC demonstrate significantly lower laser frequency, suggesting better data, larger case sizes, or higher risk tolerance. * **Influence of "No New Laser" Provisions:** The growth of "no new laser" provisions and captive insurance models is likely contributing to a slight decrease in the overall number of policies that have lasers placed on them. * **Post-COVID Rebound Effect:** The current market hardening is exacerbated by stop-loss underwriters having viewed the cost plateau in 2021-2022 (due to COVID-related deferral of care) as normal credible experience rather than a unique event. This artificially suppressed rates, leading to a more severe "boomerang" effect now. * **Contributing Factors to Rising Costs:** Beyond medical inflation and large claims, other factors include supply and demand dynamics, lower Medicare reimbursements shifting costs to the commercial sector, and the post-COVID rebound in healthcare utilization. Key Concepts: * **Stop-Loss:** Insurance that protects self-funded employers from catastrophic claims. * **Laser:** A specific, higher deductible applied to one or more named individuals on a stop-loss policy, carving out their exposure. * **Loss Ratio Maturity:** The concept that a policy's loss ratio at different points in its term can predict its final loss ratio, with predictability increasing as the policy matures. * **Medical Inflation/Trend:** The rate at which healthcare costs are increasing over time. * **Leverage Trend:** The amplified impact of underlying medical trend on stop-loss costs, as stop-loss covers only the portion of claims above a certain deductible. * **ACA (Affordable Care Act):** Legislation that impacted healthcare coverage, including medical loss ratio (MLR) requirements and the removal of lifetime and annual maximums, contributing to changes in large claim frequency. Tools/Resources Mentioned: * Tokio Marine HCC 2025 Stop-Loss Report (linked in the video description) * Paro (speaker's partner)
We Played "Guess the Pharma Ad" and Failed Miserably
Self-Funded
@SelfFunded
Oct 31, 2025
This video features a game titled "Guess the Pharma Ad," where hosts attempt to identify direct-to-consumer (DTC) pharmaceutical drugs based solely on their visual commercials, with all drug information obscured. The primary purpose of the segment is to highlight the often-confusing, abstract, and seemingly disconnected nature of pharmaceutical advertising, particularly the reliance on generic "B-roll" footage rather than direct depictions of conditions or drug effects. The hosts, Nathaniel Smith and Kyle Minick, react with amusement and frustration as they try to match vague visuals to specific medications, ultimately demonstrating how difficult it is for even informed viewers to discern the purpose of these high-budget advertisements. Throughout the game, the discussion naturally pivots to the staggering costs associated with these advertised drugs. As each commercial's true identity is revealed, the annual out-of-pocket costs for medications like Eylea, Ponvori, Nerdt ODT, Renvoke, and Skyrizi are disclosed, ranging from tens of thousands to over a hundred thousand dollars annually. This financial revelation underscores the significant economic implications of these drugs for patients and healthcare systems. The hosts also touch upon the specific indications for each drug, noting how broad some of them are (e.g., Skyrizi for multiple inflammatory conditions) and the often tenuous link between the ad's narrative and the drug's therapeutic target. The video progresses through five distinct commercials, each prompting guesses and commentary on the ad's production value, narrative, and perceived target demographic. From a ballet performance to anime sequences and celebrity endorsements, the diverse advertising styles are critiqued for their lack of clarity and direct relevance to the conditions they treat. The segment concludes with a reveal of how poorly the participants performed in the guessing game, reinforcing the central thesis that DTC pharma ads are inherently confusing and often fail to clearly communicate their message, despite their high production costs and the critical nature of the products they promote. Key Takeaways: * **Prevalence of DTC Pharma Advertising:** Direct-to-consumer pharmaceutical commercials are ubiquitous, particularly in media targeting older demographics (e.g., NASCAR broadcasts), indicating a significant investment by pharmaceutical companies in this marketing channel. * **Abstract and Confusing Ad Content:** Many DTC pharma ads rely heavily on generic "B-roll" footage (e.g., happy families, nature scenes) that bears little to no direct relation to the drug's indication or mechanism of action, making it difficult for viewers to understand what the product is for. * **High Production Values:** Despite their often vague messaging, these commercials frequently boast high production values, including elaborate animation (e.g., a French anime commercial for Ponvori) and celebrity endorsements (e.g., Lady Gaga for Nerdt ODT), suggesting substantial marketing budgets. * **Staggering Drug Costs:** The annual out-of-pocket costs for many specialty drugs advertised are exceptionally high, with examples including Eylea ($10,000), Nerdt ODT ($13,000-$20,000), Renvoke ($17,000-$30,000), Ponvori ($84,000-$100,000), and Skyrizi ($120,000-$240,000). * **Broad Indications for Specialty Drugs:** Several high-cost drugs, such as Renvoke and Skyrizi, are approved to treat multiple conditions (e.g., rheumatoid arthritis, Crohn's disease, ulcerative colitis, psoriasis), positioning them as multi-purpose solutions for inflammatory and autoimmune disorders. * **Challenges in Patient Education:** The abstract nature of these commercials presents a significant challenge for patient education, as the ads often fail to clearly communicate the drug's purpose, benefits, or the specific condition it treats, potentially leading to confusion or misinformed inquiries. * **Impact of Rebates on Drug Pricing:** The discussion briefly highlights how rebates, often negotiated through Pharmacy Benefit Managers (PBMs), can significantly reduce the net cost of a drug, impacting the actual out-of-pocket expense for patients versus the list price. * **Demographic Targeting:** Ads are often tailored to perceived demographic interests, such as basketball for an arthritis medication, although the connection to the actual drug's benefit can still be tenuous. * **Regulatory Compliance Implications (Implicit):** While not explicitly discussed, the confusing nature of these ads implicitly raises questions about how pharmaceutical companies balance creative marketing with regulatory requirements for clear and non-misleading communication about drug efficacy and safety. * **Opportunity for AI in Marketing Analysis:** The observed disconnect between ad content and drug purpose suggests an opportunity for AI and LLM solutions to analyze the effectiveness of pharmaceutical commercial operations, potentially identifying patterns in successful patient engagement or optimizing content for clarity and compliance. Key Concepts: * **Direct-to-Consumer (DTC) Pharma Advertising:** Pharmaceutical companies marketing prescription drugs directly to the public through mass media. * **B-roll:** Supplemental or alternate footage intercut with the main shot, often generic or illustrative, used to establish a mood or provide visual context without direct narrative. * **Specialty Drugs:** High-cost, high-complexity medications often used to treat chronic, rare, or complex conditions, typically requiring special handling, administration, or monitoring. * **Indications:** The specific conditions or diseases for which a drug is approved and prescribed. * **Annual Cost (Out-of-Pocket):** The estimated yearly expense a patient might incur for a medication, often before insurance or rebates. Examples/Case Studies: * **Eylea:** An eye disease medication (e.g., age-related macular degeneration) with an annual cost of approximately $10,000. Its commercial featured a grandmother watching ballet. * **Ponvori:** A multiple sclerosis (MS) treatment, costing $84,000-$100,000 annually. Its ad was a high-production-value French anime sequence. * **Nerdt ODT:** A drug for treating and preventing migraines, with an annual cost of $13,000-$20,000. Featured Lady Gaga in its commercial. * **Renvoke:** Treats rheumatoid arthritis, Crohn's disease, and ulcerative colitis, costing $17,000-$30,000 annually. Its commercial showed men playing basketball. * **Skyrizi:** Treats rheumatoid arthritis, psoriasis, Crohn's disease, and ulcerative colitis, with an annual cost of $120,000-$240,000 (before rebates). Its ad featured a music teacher.
Best Content for LinkedIN
Self-Funded
@SelfFunded
Dec 27, 2021
This video provides an in-depth exploration of effective content strategies for LinkedIn, based on the speaker's personal experience and data from his 2021 posts. The presenter, Spencer Smith from Self-Funded, shares his analysis of over a year's worth of LinkedIn content, categorizing posts by type and ranking them by average views to identify what resonates most with his professional network. His primary goal for using LinkedIn is for prospecting, sales, and building brand awareness, particularly relevant for individuals and companies in professional services. The speaker immediately challenges the conventional wisdom that LinkedIn should be strictly professional, advocating for the inclusion of personal content. He details seven content categories, presenting them in descending order of average engagement. The top-performing category, "Family," surprisingly garnered the highest average views, demonstrating the power of human connection. This is followed by "Business Insights (Picture)," "Memes," "Podcast Promotional Pics," "Personal Lessons," "Podcast Promotional Clips," and "Business Insights (Video)." He emphasizes that even personal posts should have an underlying professional message or value system, serving as a delivery vehicle for deeper insights. Throughout the analysis, Smith provides specific view counts for his top-performing posts and average views per category, offering concrete data to support his claims. He discusses the nuances of each content type, such as the initial success and subsequent saturation of memes, and the difference in engagement between picture-based business lessons and video-based ones. A key point he highlights is the discrepancy in how LinkedIn counts views for pictures versus videos, noting that videos require a minimum three-second watch time. Despite lower average engagement for his video content, he expresses a commitment to video due to its ability to convey deeper, long-form messages, citing Dr. Eric Bricker of Healthcare Z as an example of someone who successfully leverages video on the platform. The video concludes by stressing the importance of consistency, frequency, and showing up regularly on LinkedIn to exponentially grow one's network and achieve business objectives. Key Takeaways: * **Embrace Personal Content with Purpose:** Contrary to popular belief, personal content, especially family-related posts, can be highly effective on LinkedIn. The speaker's "Family" posts achieved the highest average views (12,700), demonstrating that humanizing your brand and sharing relatable aspects of your life, infused with a professional message, fosters connection and engagement. * **Prioritize Pictures for Business Insights:** While both picture and video formats for business lessons are valuable, the speaker found that picture-based business insights significantly outperformed video, averaging 5,500 views compared to 1,800 for video. This suggests that concise, visually supported text insights are often more digestible for the LinkedIn audience. * **Leverage Memes Strategically:** Memes can be a successful way to communicate professional messages succinctly and engagingly, using culturally relevant templates. However, the speaker noted a drop in engagement over time due to saturation, indicating that this strategy might require freshness and originality to maintain effectiveness. * **Consistency is King for Brand Building:** Regular posting, even if not every post achieves viral status, is crucial for building a consistent presence and brand awareness on LinkedIn. The speaker used his weekly podcast promotions (pictures and clips) as a consistent reason to post, reinforcing his frequency. * **Video Engagement Nuances:** LinkedIn's view count for videos requires a minimum three-second watch time, which can artificially lower reported engagement compared to picture views (which count a millisecond scroll). While the speaker's videos had lower average views, he still advocates for video for its depth and long-form communication potential. * **Personal Lessons Humanize Your Brand:** Similar to family content, sharing personal lessons (e.g., from college, sports) that offer value and are relatable helps humanize your brand and allows your audience to connect with you on a deeper level, fostering trust and rapport. * **LinkedIn as a Free Prospecting and Sales Tool:** The platform offers immense potential for growing a professional network, prospecting, driving sales, and building company awareness, especially for those in professional services. The speaker emphasizes that consistent effort can yield significant results within a year. * **Adapt Content to Platform and Audience:** The speaker's experience highlights that different content types perform differently. While he found videos less engaging for his specific style, he acknowledges others, like Dr. Eric Bricker, who excel with video by honing a particular format (e.g., whiteboard videos). * **Analyze Your Own Data:** The speaker's methodology of reviewing his own 2021 posts and categorizing them by engagement provides a practical framework for others to analyze their content performance and refine their LinkedIn strategy. * **Focus on Underlying Message:** Regardless of the content type (family photo, meme, business lesson), the speaker stresses that every post should have an underlying message or purpose that aligns with your professional brand or value system. Tools/Resources Mentioned: * **LinkedIn:** The primary platform for content strategy discussion. * **YouTube:** Mentioned as a platform for the speaker's podcast. * **Spotify:** Mentioned as a platform for the speaker's podcast. * **iTunes:** Mentioned as a platform for the speaker's podcast. * **Dr. Eric Bricker / Healthcare Z:** Cited as an example of successful video content creator on LinkedIn, known for whiteboard videos on healthcare topics. Key Concepts: * **Content Engagement:** The metric used (views per post) to determine the effectiveness of different content types on LinkedIn. * **Humanization of Brand:** The strategy of sharing personal or relatable content (e.g., family, personal lessons) to make a professional brand more approachable and trustworthy. * **Content Saturation:** The phenomenon where a particular content style (e.g., memes) becomes overused, leading to decreased engagement over time. * **Professional Services:** The target audience for whom the LinkedIn content strategies are particularly relevant, encompassing consulting, advisory, and specialized expertise firms.
Marty Makary's FDA, Operation Stork Speed, Healthcare Cybersecurity | Last Month In Healthcare
Self-Funded
@SelfFunded
Apr 4, 2025
This video provides a monthly overview of significant news and developments in the healthcare sector for March 2025, presented in a podcast format by Nathaniel and Spencer Smith. The discussion covers a range of topics, from high-level regulatory appointments and government restructuring to specific public health initiatives, the escalating threat of healthcare cybersecurity, and the growing trend of technology investments by health systems. The hosts offer their perspectives on these headlines, often drawing on personal experiences and broader industry implications, aiming to inform listeners about the evolving landscape of healthcare in the United States. The episode begins by highlighting the confirmation of Marty Makary as the new FDA Commissioner, a development viewed positively by the hosts given his balanced political stance and medical background. This segues into a broader discussion about government efficiency, specifically the Department of Government Efficiency (DOGE) within the Health and Human Services (HHS) administration, which announced a restructuring involving 10,000 job cuts across key agencies like the FDA, CDC, NIH, and CMS. This initiative is framed as part of a larger "Make America Healthy Again" (MAHA) agenda, focusing on addressing chronic illnesses through improved food systems, clean water, and environmental toxin elimination. The hosts debate the potential benefits and risks of such large-scale workforce reductions, particularly concerning the potential loss of essential personnel. Further into the MAHA agenda, the podcast delves into Texas's legislative efforts (SB25) to increase student physical activity, improve nutritional education, and implement stricter food warning labels, citing alarming statistics on childhood obesity and early-onset cancers. This theme continues with "Operation Stork Speed," an HHS and FDA initiative aimed at expanding options for safe and nutritious infant formula, including increased testing for heavy metals and studies on long-term health outcomes. The hosts share personal anecdotes about the challenges of finding healthy baby formula, underscoring the importance of this initiative. A more controversial topic discussed is RFK Jr.'s proposal to ban soda and candy from SNAP (food stamp) benefits, sparking a debate on government overreach versus public health necessity, and the role of industry lobbying. The latter part of the episode shifts focus to critical operational challenges within healthcare, particularly the increasing cybersecurity risks faced by providers. Citing statistics on the surge in cyberattacks and ransomware (with healthcare being the number one affected sector in 2023), the hosts emphasize the vulnerability of sensitive patient data, referencing major incidents like the Change Healthcare breach. They highlight the daily exposure of hundreds of thousands of health records and the financial and operational impact on healthcare organizations, especially rural hospitals. Finally, the discussion touches on health system corporate venture arms boosting tech investments, exemplified by Tampa General Hospital's TGH Ventures. This segment underscores a growing trend of health systems investing in technology, including AI, to enhance efficiency, reduce administrative burdens on physicians, and ultimately improve patient care, addressing long-standing issues like repetitive data entry in electronic health records. Key Takeaways: * **Significant Regulatory Leadership Changes:** The confirmation of Marty Makary as FDA Commissioner signals potential shifts in regulatory priorities and approaches, directly impacting pharmaceutical and life sciences companies operating under FDA oversight. * **Government Efficiency Drives in Healthcare Agencies:** The HHS restructuring and 10,000 job cuts across FDA, CDC, NIH, and CMS under the "Department of Government Efficiency" (DOGE) aim to streamline operations and reduce redundancy, which could affect regulatory processes and interactions for industry stakeholders. * **Broad Public Health Initiatives:** The "Make America Healthy Again" agenda, including efforts in Texas (SB25) and proposals like banning soda/candy from SNAP, indicates a growing government focus on preventative health, nutrition, and physical activity, potentially influencing market demand and product development in the health sector. * **Enhanced Scrutiny on Product Safety and Nutrition:** "Operation Stork Speed" for infant formula highlights increased regulatory attention on ingredient safety, contaminants (e.g., heavy metals), and long-term health outcomes, setting a precedent for other regulated products in the life sciences. * **Pervasive and Escalating Healthcare Cybersecurity Threats:** The healthcare sector is the primary target for ransomware attacks, with hundreds of thousands of health records exposed daily. This necessitates robust cybersecurity investments and strategies for all entities handling sensitive patient data, including pharmaceutical companies and their partners. * **Critical Need for Data Security and Compliance:** The discussion around data breaches and ransomware underscores the paramount importance of secure data engineering, compliant software solutions, and adherence to regulations like HIPAA, which is a core offering for IntuitionLabs.ai. * **Growing Tech Investments by Health Systems:** Hospitals and health systems are actively increasing their spending on technology, including AI, through corporate venture arms (e.g., TGH Ventures). This trend creates significant opportunities for AI and software development firms specializing in healthcare. * **AI as a Solution for Operational Inefficiencies:** The desire to empower physicians by reducing administrative burdens and improving data flow (e.g., eliminating repetitive data entry in EHRs) directly aligns with the value proposition of AI and LLM solutions for intelligent automation in healthcare operations. * **Market Demand for Integrated and Efficient Solutions:** The challenges highlighted, from regulatory compliance to data silos and cybersecurity, point to a strong market need for integrated, compliant, and efficient technology solutions that can optimize commercial operations, manage clinical data, and ensure regulatory adherence. * **Understanding Political and Lobbying Influences:** The discussion around RFK Jr.'s food stamp proposal and the uncovering of paid health influencers by lobbying committees illustrates the complex interplay of politics, public health, and industry interests that shape the healthcare landscape. Tools/Resources Mentioned: * Verta Health (a company focused on reversing obesity and diabetes) * Paro (mentioned as a potential partner for Verta Health) * True Network Advisors (an industry network) * Change Healthcare (example of a major cybersecurity breach victim) * Tampa General Hospital (TGH Ventures - an example of a health system's corporate venture arm) Key Concepts: * **FDA Commissioner:** The head of the U.S. Food and Drug Administration, responsible for regulating food, drugs, vaccines, and other products. * **HHS Restructuring / Department of Government Efficiency (DOGE):** An initiative within the Health and Human Services administration aimed at reducing government size and improving efficiency. * **Make America Healthy Again (MAHA) Agenda:** A broad public health initiative focused on improving national health outcomes through various policy changes. * **Operation Stork Speed:** An FDA/HHS initiative to enhance the safety and nutritional quality of infant formula. * **SNAP (Supplemental Nutrition Assistance Program):** The federal food stamp program providing food assistance to low-income individuals and families. * **Ransomware:** A type of malicious software designed to block access to a computer system until a sum of money is paid. * **Corporate Venture Arms:** Investment divisions of larger corporations that invest in startups or other companies, often to gain strategic advantage or access to new technologies. * **Electronic Healthcare Records (EHRs):** Digital versions of patients' paper charts, containing medical and treatment histories. * **Turbo Cancers:** A term used to describe cancers that accelerate in growth incredibly fast, often discussed in the context of increasing cancer prevalence in young people. Examples/Case Studies: * **Marty Makary's Confirmation:** His appointment as FDA Commissioner and the lengthy confirmation process. * **HHS Restructuring:** The announcement of 10,000 job cuts across FDA, CDC, NIH, and CMS as part of a government efficiency drive. * **Texas SB25 Bill:** A bipartisan effort to increase student physical activity, improve nutritional education, and implement stricter warning labels on foods. * **Operation Stork Speed:** The initiative to improve the safety and health of baby formula, including increased testing for contaminants. * **RFK Jr.'s Food Stamp Plan:** A controversial proposal to ban soda and candy purchases using SNAP benefits. * **Change Healthcare Breach:** A significant cybersecurity incident that impacted healthcare providers nationally. * **Rural Hospitals and Cybersecurity:** The vulnerability of rural hospitals to cyberattacks and extortion attempts. * **Tampa General Hospital's TGH Ventures:** An example of a health system expanding its technology investments through a corporate venture arm.
MAHA, Steak 'n Shake, and AI Prescriptions | Last Month In Healthcare
Self-Funded
@SelfFunded
Mar 13, 2025
This video provides an in-depth exploration of key healthcare news and trends from February 2025, as discussed in the "Last Month In Healthcare" podcast. The hosts, Nathaniel Smith and Spencer Smith, delve into a range of topics, starting with new administrative policies and progressing through market dynamics, pharmaceutical trends, and the rapidly evolving role of artificial intelligence in the healthcare sector. The discussion highlights the interconnectedness of public health initiatives, economic pressures, and technological advancements shaping the industry. The discussion begins with an analysis of the "Make America Healthy Again" (MAHA) commission's broad mandate, which extends beyond traditional medical interventions to encompass the entire food system, environmental factors, and lifestyle choices as contributing causes to chronic disease. This sets a tone for a holistic view of health. Following this, the hosts examine executive orders aimed at healthcare price transparency, noting the challenges in implementing and enforcing such policies due to the complexity of machine-readable data and the influence of lobbying efforts. The conversation then shifts to market-specific trends, including the growing influence of telehealth companies in direct-to-consumer drug advertising, particularly for GLP-1 medications, and the significant increase in employer-sponsored coverage for these drugs, reflecting a massive shift in consumer demand and benefit design. A substantial portion of the video is dedicated to the impact of artificial intelligence on healthcare. The hosts explore the dichotomy between the high hopes doctors place on AI to alleviate burnout (e.g., for note-taking, EMR management, symptom checking) and the widespread public distrust stemming from concerns over AI's role in claims denials, algorithmic biases, and broader societal fears. The most forward-looking discussion centers on a proposed bill to classify AI as a licensed practitioner, enabling it to prescribe drugs, potentially leveraging "digital twin" technology for personalized simulations. This segment underscores the regulatory and ethical complexities inherent in integrating advanced AI into clinical decision-making and patient care. Key Takeaways: * **AI as a Solution for Physician Burnout:** A significant majority of doctors (93%) experience burnout, with 80% believing AI can alleviate stress by automating tedious tasks like note-taking, transcribing, and managing electronic medical records, allowing them to focus more on patient care. * **Public Distrust of AI in Healthcare:** Despite potential benefits, 65% of American adults distrust AI in healthcare, fueled by concerns over its application in automated claims denials, perceived algorithmic biases, and a general fear of AI's increasing autonomy, potentially influenced by "predictive programming" in media. * **The Future of AI in Prescribing Drugs:** A proposed bill aims to classify AI as a licensed practitioner, enabling it to prescribe medications. The concept involves AI ingesting vast amounts of patient data to create a "digital twin" for simulated drug testing, raising significant questions about regulatory oversight, liability, and the human element in care. * **Surging Demand for GLP-1 Medications:** One-third of Americans would consider switching jobs for GLP-1 access, and employer-sponsored coverage for these drugs jumped from 30% to 63% in one year, indicating a massive market shift and potential for these drugs to become a leading expenditure category. * **Telehealth's Role in Drug Accessibility:** Telehealth companies like Hims & Hers and Ro are significantly boosting ad spending, making drugs more accessible by reducing friction in obtaining prescriptions for conditions ranging from ED to weight loss, and offering a private, direct-to-consumer model. * **Challenges in Healthcare Price Transparency:** While executive orders aim to increase price transparency, the current system often involves hospitals providing complex, machine-readable-only files, making effective enforcement and consumer access difficult. True transparency requires robust data processing and clear, actionable information. * **Scrutiny of PBM Practices:** The FTC's lawsuit against major PBMs (CVS, Express Scripts, Optum RX) for alleged price fixing through discounts highlights ongoing concerns about drug pricing models, rebates, and the lack of transparency in the pharmaceutical supply chain. A "Cost Plus" model is suggested as a more transparent alternative. * **Holistic Approach to Public Health:** The "Make America Healthy Again" commission's mission to fight chronic disease adopts a broad scope, considering factors like diet, toxic material absorption, environmental influences, and corporate practices, signaling a comprehensive view of public health determinants. * **Data Engineering for Healthcare Insights:** The discussion on price transparency underscores the critical need for sophisticated software and data engineering capabilities to process, clean, and make actionable the vast amounts of healthcare data, transforming raw information into usable insights for competition and cost reduction. * **Regulatory Compliance in AI Development:** The potential for AI to prescribe drugs and its role in claims denials emphasizes the paramount importance of regulatory compliance (e.g., FDA, 21 CFR Part 11) for any AI solution deployed in the healthcare sector, ensuring safety, efficacy, and ethical use. **Key Concepts:** * **Digital Twin:** A virtual replica of a physical entity (in this case, a patient) that can be used for simulations and testing, particularly for personalized drug prescriptions. * **GLP-1s (Glucagon-Like Peptide-1s):** A class of medications primarily used for treating type 2 diabetes and obesity, experiencing massive growth in demand and market impact. * **PBMs (Pharmacy Benefit Managers):** Third-party administrators of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, and other government programs. * **Cost Plus Model:** A drug pricing model where the cost of the drug is determined by its acquisition cost plus a small, transparent margin, often bypassing traditional insurance and rebate systems. * **Price Transparency:** The practice of making healthcare service and drug prices openly available to consumers, intended to foster competition and reduce costs. * **Telehealth:** The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration. **Examples/Case Studies:** * **FTC Lawsuit against PBMs:** The Federal Trade Commission is suing major PBMs (CVS's Caremark, Cigna's Express Scripts, and UnitedHealth Group's Optum RX) over alleged price-fixing and anti-competitive practices related to drug discounts and rebates. * **Luigi Manon Case:** Referenced as an example of AI's application in automated claims denials by insurance companies, contributing to public distrust in healthcare AI. * **Steak 'n Shake Beef Tallow Fries:** An example of a food industry company adopting a healthier cooking oil (beef tallow instead of vegetable oil) in response to broader public health discussions, aligning with the "Make America Healthy Again" initiative's focus on food systems.
Top 10 Reasons to Podcast
Self-Funded
@SelfFunded
Mar 25, 2022
This video provides an in-depth exploration of the top ten reasons why individuals and businesses, particularly those in sales, should consider starting a podcast. The speaker, Spencer Smith, presents a compelling argument for podcasting as a powerful tool for business development, brand building, and lead generation, drawing from his personal experience with his "Self-Funded" podcast. He frames podcasting not merely as a content creation activity but as a strategic sales and marketing initiative that can significantly accelerate traditional business growth cycles. The presentation progresses through a structured list of ten benefits, starting with immediate brand recognition and moving through various stages of relationship building, credibility establishment, and ultimately, lead generation and content longevity. Smith emphasizes that a podcast allows the host to control the narrative, invite industry experts, and build a platform that positions them as a thought leader. He contrasts the traditional struggle to gain a "seat at the table" with the empowerment of creating one's own table, inviting high-profile guests, and shaping the discourse around relevant topics. A core theme throughout the discussion is the shift from transactional selling to value-driven engagement. Smith highlights that a podcast inherently sells value and ideas, offering free information and fostering trust without an immediate product pitch. This approach, he argues, builds rapport and credibility far more effectively and quickly than conventional sales methods. He illustrates how consistent content creation leads to a library of reusable assets that can serve as perpetual lead generation tools and follow-up resources, significantly reducing the manual effort typically required in the sales process. The speaker's perspective is highly practical and results-oriented, focusing on the tangible benefits for a salesperson or business owner. He shares anecdotal evidence from his own podcasting journey, including how listeners have approached him for demos after months of consuming his content, demonstrating the long-term, passive lead generation potential. The underlying methodology is that by consistently providing value and expertise through a podcast, one can cultivate an audience that trusts and respects them, making the eventual sales conversation much easier and more effective. Key Takeaways: * **Immediate Brand Recognition:** Podcasting offers a direct path to establishing personal or company brand recognition. By consistently producing content, individuals and organizations can become known to a target audience, fostering familiarity and recall. * **Create Your Own Platform:** Instead of seeking invitations to industry discussions, a podcast allows you to create your own "table," inviting experts and high-profile guests, thereby positioning yourself as a central figure in relevant conversations. * **Association with Expertise:** Hosting experts on your podcast allows you to associate your brand with their knowledge and credibility, enhancing your own perceived expertise even if you're not the sole subject matter expert on every topic. * **Represent Company Values:** Podcasting provides a unique medium to articulate and consistently demonstrate your company's core values, mission, and what you stand for, resonating with an audience that shares similar principles. * **Control the Conversation:** A podcast grants the host control over the topics discussed, the guests invited, and the overall flow of information, enabling strategic shaping of industry narratives and thought leadership. * **Value-Driven Selling:** Podcasting inherently focuses on providing free value, ideas, and insights rather than directly selling a product. This builds trust and positions the host as a helpful resource, making future sales conversations more natural and less transactional. * **Accelerated Rapport Building:** Regular listeners develop a sense of knowing, liking, and trusting the host over time, significantly shortening the rapport-building phase typically required in a traditional sales funnel. * **Instant Credibility:** Consistently hosting intelligent conversations and weighing in with valuable insights on a podcast establishes instant credibility, which is a powerful asset when engaging in sales discussions or attending industry events. * **Proactive and Passive Lead Generation:** Podcasting generates leads both directly (e.g., through calls to action or direct outreach to viewers) and passively (e.g., listeners reaching out after consuming content for an extended period), reducing the need for active prospecting. * **Perpetual Reusable Content:** A single podcast episode can be repurposed into multiple clips, articles, or social media posts, creating a vast library of evergreen content that can be used for lead nurturing, follow-ups, and ongoing marketing efforts in perpetuity. Key Concepts: * **Brand Recognition:** The extent to which a consumer can identify a brand by its name, logo, or other visual elements. Podcasting accelerates this by providing consistent exposure. * **Thought Leadership:** The position of being an authoritative expert in a particular field, whose expertise is sought out and whose opinions are respected. Podcasting facilitates this by allowing hosts to curate and lead discussions with other experts. * **Value-Driven Content:** Content that prioritizes providing free, useful, and insightful information to the audience, rather than directly promoting a product or service. This approach builds trust and long-term relationships. * **Sales Funnel Acceleration:** Strategies and tactics that shorten the time it takes for a prospect to move through the various stages of the sales process, from initial awareness to conversion. Podcasting achieves this through pre-built rapport and credibility. * **Content Repurposing:** The practice of taking existing content and transforming it into different formats or distributing it across various channels to maximize its reach and utility. A single podcast recording can yield numerous derivative content pieces. Examples/Case Studies: * **"Self-Funded" Podcast:** The speaker's personal podcast, which serves as a primary example of how he applies these principles to build his brand and generate leads. * **"Plan Site":** Mentioned as the speaker's company or product, indicating how his podcasting efforts directly support his business endeavors. * **"Stop-Loss Videos":** A previous content series created by the speaker, highlighting his history of creating valuable, niche-specific content to establish expertise.
GLP-1s: The PBM Perspective (with Justin Jasniewski)
Self-Funded
@SelfFunded
Oct 1, 2024
This video provides an in-depth exploration of the Pharmacy Benefit Management (PBM) market in 2024, focusing on its complexities, the drive for transparency, and the significant impact of emerging drug classes like GLP-1s and gene therapies. Justin Jasniewski, CEO of Serve You Rx, discusses how PBMs often complicate a system that isn't inherently complex, highlighting the need for greater clarity and value for self-funded employers. The discussion traverses the competitive landscape of the PBM industry, the evolution towards more transparent practices, and the critical role of PBMs in managing the escalating costs and unique challenges presented by novel pharmaceutical treatments. The conversation delves into Serve You Rx's approach, emphasizing highly customized benefit plans, exceptional service, and flexibility for mid-market self-funded employer groups (200-5,000 covered lives). Jasniewski explains how his company differentiates itself in a crowded market by owning its assets, ensuring direct employee contact, and focusing on delivering value rather than merely critiquing larger PBMs. A significant portion of the discussion is dedicated to cost management strategies, including the effective use of "point solutions" like patient assistance programs and alternative funding to mitigate high drug expenses, and uncovering hidden fees and structural loopholes within the broader PBM ecosystem, such as rebates held by Group Purchasing Organizations (GPOs) or co-manufacturing deals for biosimilars. The video then transitions to specific drug categories, offering a detailed look at GLP-1s and gene/cell therapies. For GLP-1s, the discussion covers their effectiveness in blood sugar reduction and weight loss, their associated side effects, the surge in demand, supply chain issues, and the low persistence rates among patients, underscoring the necessity of integrating these drugs with comprehensive lifestyle programs for sustained outcomes. Regarding gene and cell therapies, the conversation highlights their exorbitant price tags (e.g., $1M+), the implications for stop-loss carriers and reinsurance, and the need for robust strategies involving centers of excellence and diversified risk pools to manage these high-cost, potentially curative treatments. The future outlook for PBMs is also explored, predicting increased regulatory scrutiny, a shift towards transparent pricing, changes in rebate handling, and a greater demand for PBMs to be flexible and nimble in integrating new point solutions and risk-sharing models tied to actual spend. Key Takeaways: * **PBM Complexity and Transparency:** The PBM system is often made complicated by PBMs themselves, leading to a lack of transparency in pricing, fees, and rebate handling, which ultimately disadvantages employers and members. * **Customized Solutions for Mid-Market:** Mid-market self-funded employers (200-5,000 lives) benefit significantly from PBMs that offer highly customized benefit plans, prioritize service, and demonstrate flexibility in integrating various point solutions. * **Differentiation in a Crowded Market:** PBMs can stand out by emphasizing a strong track record, owning their operational assets, providing direct customer service with their own employees, and focusing on delivering superior value rather than just criticizing competitors. * **Proactive Employer Engagement:** Successful employer clients are those who are service-focused, actively seek to take control of their drug spend, and prioritize actual cost reduction over chasing high rebate numbers or low spreadsheet prices. * **Leveraging Point Solutions:** Utilizing patient assistance programs, alternative funding programs, and specialty patient advocacy initiatives can effectively move high-cost claims off the primary plan, significantly reducing employer drug spend. * **Uncovering Hidden PBM Fees:** Employers should be vigilant about various ways money can be siphoned from the system, including rebates held by GPOs, co-manufacturing deals for biosimilars, and other opaque arrangements that reduce true transparency. * **GLP-1s: Efficacy vs. Persistence:** While GLP-1s are highly effective for conditions like type 2 diabetes and weight loss, they often come with unpleasant side effects and low persistence rates (only 30-40% of weight loss patients remain on them after a year), indicating a need for integrated lifestyle programs. * **Gene and Cell Therapy Management:** The multi-million dollar price tags of gene and cell therapies necessitate robust strategies involving stop-loss carriers, reinsurance, centers of excellence, and diversified risk pools to manage the financial impact on employer groups. * **Future of PBMs: Regulatory & Flexibility:** The PBM industry faces increasing regulatory scrutiny, pushing towards transparent/pass-through pricing and mandated rebate pass-through. Future success will depend on PBMs' flexibility to integrate new point solutions and adapt quickly to market changes. * **Risk-Sharing and Outcome-Based Models:** The future of PBM contracting will likely involve risk-sharing models where PBMs tie their fees to actual spend outcomes (per member per month drug expense) rather than just savings percentages, providing greater predictability and control for employers. * **ROI Challenges for Wellness Solutions:** The high employee churn rate (average person switches employers every two years) makes it difficult for employers to see a clear ROI on long-term wellness and point solutions, as the benefits may accrue to a subsequent employer. * **Importance of Clear Communication:** Employers should choose PBMs that can explain complex concepts in a straightforward, understandable manner, ensuring full comprehension of what they are getting, who is being paid, and what the expected outcomes will be. **Tools/Resources Mentioned:** * **Sponsors:** Paro Health, Claim.do, PlanSight * **Point Solutions/Partners:** Paul, Payer Matrix, Script Sourcing * **Emerging Therapy Management:** Emerging Therapy Solutions (ETS) **Key Concepts:** * **Pharmacy Benefit Manager (PBM):** A third-party administrator of prescription drug programs for commercial health plans, self-insured employer groups, Medicare Part D plans, and government programs. * **Self-Funded Groups:** Employers who directly pay for their employees' healthcare claims, rather than paying premiums to an insurance company. * **GLP-1s (Glucagon-like peptide-1 receptor agonists):** A class of drugs used to treat type 2 diabetes and, in some formulations, for weight management, by affecting blood sugar and satiety. * **Gene and Cell Therapy:** Advanced medical treatments that modify genes or cells to treat or prevent disease, often involving extremely high costs. * **Stop-Loss Insurance:** Insurance purchased by self-funded employers to protect against catastrophic claims that exceed a certain threshold. * **Reinsurance:** Insurance for insurance companies, used to transfer risk from one insurer to another, particularly relevant for high-cost claims like gene therapies. * **Patient Assistance Programs (PAPs):** Programs offered by pharmaceutical manufacturers or non-profits to help patients afford their medications. * **Alternative Funding Programs:** Strategies to help patients access high-cost drugs, often by leveraging manufacturer programs or other non-traditional funding sources. * **Group Purchasing Organizations (GPOs):** Entities that help healthcare providers realize savings and efficiencies by aggregating purchasing volume and negotiating discounts with manufacturers, sometimes holding rebates. * **340B Programs:** A U.S. federal government program that requires drug manufacturers to provide outpatient drugs to eligible healthcare organizations and pharmacies at significantly reduced prices. * **Net Promoter Score (NPS):** A widely used market research metric that typically takes the form of a single survey question asking respondents to rate the likelihood that they would recommend a company, product, or service to a friend or colleague. **Examples/Case Studies:** * **Serve You Rx's Business Model:** Focuses on mid-market self-funded groups, offering highly customized benefits, flexibility ("seek to say yes"), and a commitment to service, standing out by owning assets and providing direct employee contact. * **Successful GLP-1 Use Case:** A family member with uncontrolled type 2 diabetes, combined with nutrition coaching and exercise, successfully used a GLP-1 to get off other diabetes medications and normalize A1C levels, demonstrating its potential when integrated with lifestyle changes. * **Luxturna:** Mentioned as a gene therapy that cures a certain type of blindness, highlighting the challenge for employers who pay for such a high-cost treatment only for the employee to switch jobs shortly after.
A Fiduciary's Guide to Data Analytics with Agility Innovation Partners
Self-Funded
@SelfFunded
Nov 17, 2022
This video provides an in-depth exploration of how data analytics, particularly in the context of the Consolidated Appropriations Act (CAA), is transforming health plan management for employers and the role of benefits brokers. Brian Behnken, Chief Data and Analytics Officer, and Drew Calistead, Chief Strategy Officer for Agility Innovation Partners, discuss the evolution of healthcare data analysis, the challenges faced by brokers and employers, and the opportunities presented by new regulations and advanced data platforms. They emphasize that the CAA, which mandates transparency in healthcare pricing, has shifted the employer's responsibility from a passive payer to a proactive fiduciary, necessitating the use of sophisticated data tools. The discussion highlights the historical difficulties in accessing and utilizing healthcare claims data, from floppy disks in the 90s to today's complex digital landscape. Agility Innovation Partners addresses two primary challenges for brokers: the high cost of data analytics platforms and the difficulty in effectively using them without specialized staff. Their solution involves offering "at-scale pricing" for their chosen platform, Innovu, to small-to-mid-market brokers, coupled with a "data wingman" service – a dedicated data analyst who consults and assists brokers in maximizing their platform investment. This approach aims to democratize access to powerful analytics, enabling brokers to drive measurable changes to health plans and better serve their self-funded clients. A significant portion of the conversation focuses on the post-CAA landscape, where employers now have access to claims and pricing data, empowering them to benchmark costs and ensure compliance. Innovu's platform integrates a CAA fiduciary tool stack, allowing benchmarking against millions of lives for plan design, claims costs, and fixed costs. Crucially, it also incorporates hospital transparency data, which reveals contracted rates by procedure, hospital, and payer. This unprecedented access to pricing information allows employers to compare what they are paying through traditional networks versus cash prices or alternative arrangements like Reference-Based Pricing (RBP), uncovering substantial opportunities for cost reduction (estimated 20-30%). The speakers present a compelling case for brokers to embrace data as a competitive advantage, transforming their role from merely managing renewals to actively leading clients towards more affordable and transparent healthcare solutions. Key Takeaways: * **CAA's Transformative Impact:** The Consolidated Appropriations Act (CAA) has fundamentally changed healthcare transparency, moving employers from passive payers to proactive fiduciaries responsible for ensuring reasonable health plan costs and compliance. Fines for non-compliance can be substantial ($100/day per employee). * **Low Data Analytics Adoption:** Despite its importance, only about 10% of brokerage consulting firms are "all in" on data analytics platforms, indicating a significant market opportunity for those who embrace it. * **Common Broker Challenges:** Brokers typically face two main hurdles: the high cost of data analytics platforms and the lack of internal expertise or staff to effectively utilize them, often leading to underutilized "shelfware." * **Agility's Solution: At-Scale Pricing & Data Wingman:** Agility Innovation Partners addresses these challenges by offering Innovu, a data analytics platform, at "at-scale pricing" for mid-market brokers (5-15 self-funded cases), making it affordable. They also provide a dedicated data analyst ("wingman") to help brokers leverage the platform effectively, acting as an outsourced, part-time team member. * **Innovu's Fiduciary Tool Stack:** The Innovu platform includes a CAA fiduciary tool stack that enables benchmarking of claims costs, fixed costs, and plan design against a database of over 4 million lives, helping employers determine if they are paying reasonable costs. * **Hospital Transparency Data Integration:** Innovu integrates hospital transparency files, which detail contracted rates by procedure, hospital, and payer. This allows employers to compare what they are paying through their networks to what they "could have paid" under different arrangements (e.g., cash price), exposing significant cost discrepancies. * **Unlocking the "Black Box" of Healthcare:** The combination of CAA regulations and integrated hospital transparency data effectively "unlocks the black box" of healthcare pricing, providing unprecedented visibility into costs and enabling informed decision-making. * **Actionable Cost Reduction Strategies:** With data insights, employers can pivot from traditional networks to alternative arrangements like narrow networks, direct contracting, or Reference-Based Pricing (RBP) to reduce costs. RBP, for instance, is seen as a stepping stone, potentially 10-15% above cash/Medicare prices, but still significantly below traditional commercial rates. * **Significant Savings Potential:** The speakers suggest that leveraging these data insights could lead to 20-30% cost reductions in healthcare spend, a dramatic shift from the typical 5-10% adjustments seen with traditional population health initiatives. * **Proactive vs. Passive Purchasing:** Data empowers plan sponsors to transition from being "passive payers" to "proactive purchasers," making informed decisions about healthcare services based on transparent pricing and value. * **Competitive Advantage for Brokers:** Brokers who proactively embrace data analytics can transform their marketing strategy, win new business by demonstrating tangible value and savings opportunities, and significantly improve client retention. * **Long-Term Strategic Decision:** Investing in a data analytics platform is a long-term, lifestyle change for a firm, not a cyclical or reactionary measure. It requires a commitment to becoming a data-driven organization. * **Getting Started:** The process of onboarding data onto a platform typically takes about three months. Brokers are encouraged to start educating themselves and their clients on CAA and data now, even during Q4, to be ready for January 1. **Tools/Resources Mentioned:** * **Innovu:** The specific data analytics platform partnered with by Agility Innovation Partners. * **CAA Fiduciary Tool Stack:** A feature within Innovu for benchmarking and compliance. * **Hospital Transparency Data:** Publicly available files from hospitals, integrated into Innovu, detailing contracted rates. **Key Concepts:** * **Consolidated Appropriations Act (CAA):** Federal legislation establishing protections for consumers related to surprise billing and transparency in health care, imposing fiduciary responsibilities on employers. * **Fiduciary Responsibility:** The legal and ethical obligation of employers to act in the best financial interest of their health plan participants, now requiring due diligence on health plan costs and services. * **At-Scale Pricing:** Offering a premium service or platform at a reduced price point by leveraging collective buying power, making it accessible to smaller entities. * **Data Wingman:** A dedicated data analyst provided as a service to assist brokers in utilizing a data analytics platform, effectively acting as an expert consultant. * **Hospital Transparency Data:** Mandated public disclosure of contracted rates by procedure, hospital, and payer, providing unprecedented insight into healthcare pricing. * **Reference-Based Pricing (RBP):** A healthcare payment model where providers are paid a set amount based on a reference price (often Medicare rates plus a percentage), rather than negotiated rates with traditional networks.
Self-Funded w/ Spencer - Mike Kohl - Episode 36
Self-Funded
@SelfFunded
Feb 15, 2022
This video provides an in-depth exploration of "next generation wellness" and "whole person healthcare" within the context of employer-sponsored health plans. Featuring Mike Kohl, VP of Sales for Vida Health, the discussion, hosted by Spencer, delves into the evolution of wellness programs and the critical need for integrated mental and physical health support to address chronic conditions and rising healthcare costs. Kohl, drawing from his 30 years of experience in the insurance industry, offers a seasoned perspective on the complexities of self-funding and the strategic shift towards more effective member engagement strategies. A central theme of the conversation is Vida Health's "whole health perspective," which posits that physical chronic conditions, such as diabetes, are frequently intertwined with mental health issues like stress, anxiety, and depression in approximately 70% of cases. Kohl emphasizes that merely treating the physical aspect provides only "half a solution," as true and sustainable health improvement necessitates addressing the underlying behavioral and emotional drivers. This integrated approach aims to guide individuals from an unhealthy to a healthy lifestyle by tackling the root causes of their health challenges, rather than just managing symptoms. Vida Health's methodology involves an app-based enrollment process where members undergo initial assessments using PHQ and GAD scores to establish a baseline for stress and depression levels. Following this, members are empowered to choose a personalized coach from a diverse pool, including health coaches, psychologists, pharmacists, or licensed clinical managers, and then engage in a structured cognitive behavioral therapy pathway. A crucial aspect of their strategy is "meeting the member where they are," offering flexible communication channels such as text and asynchronous discussions to overcome initial resistance and cater to individual preferences and schedules. The company also strategically leverages claims data and advanced analytics to proactively identify and outreach to high-priority members, ensuring timely and targeted interventions. The discussion highlights the significant impact of this integrated approach, with Vida Health reporting substantial "15 or 16 claim savings" for employers by effectively managing both mental and physical health. A critical societal problem addressed is the severe shortage of mental health providers in the United States, with only about 27% capacity available, leading to lengthy wait times for care. Vida Health aims to bridge this accessibility gap by providing immediate access to support, often within 24 hours, thereby diminishing the timeframe for individuals to receive necessary care and achieve a better overall health state. Key Takeaways: * **Evolution of Wellness Programs:** Traditional wellness initiatives, such as providing pedometers or promoting healthy eating with superficial incentives, often lacked the deep member engagement required for long-term effectiveness, necessitating a shift towards more integrated and data-driven approaches. * **Interconnectedness of Health:** Effective health management must recognize and treat the profound interconnectedness of physical and mental well-being; chronic physical conditions are frequently co-morbid with mental health issues, with approximately 70% of individuals with diabetes also experiencing related mental health challenges. * **Addressing Underlying Behavioral Drivers:** Sustainable health improvement goes beyond symptom management, requiring a deeper understanding and intervention into the behavioral, emotional, and psychological factors that drive unhealthy choices and contribute to chronic conditions. * **Personalized Coaching and CBT:** Tailoring support through member-chosen coaches (e.g., health coaches, psychologists) and structured cognitive behavioral therapy (CBT) pathways significantly enhances member engagement, adherence to treatment plans, and overall health outcomes. * **Flexible Engagement Models for Participation:** Overcoming member resistance and increasing participation rates in wellness programs demands meeting individuals "where they are" through flexible communication channels like text and app-based interactions, allowing for asynchronous discussions and engagement at their own pace. * **Data-Driven Member Identification:** Utilizing claims data and advanced analytics is crucial for proactively identifying high-priority members who would benefit most from early intervention, enabling targeted marketing and engagement strategies to optimize resource allocation. * **Immediacy of Mental Health Care:** The severe shortage of mental health providers in the US (only 27% capacity) underscores the critical need for virtual solutions that offer immediate access to care, reducing prohibitive wait times and providing support during crucial emotional moments. * **Significant Financial Impact:** An integrated approach to mental and physical health can lead to substantial cost savings for employer-sponsored health plans, with reported figures indicating "15 or 16 claim savings" by improving overall member health and reducing high-cost claims. * **Complexity of Self-Funded Plans:** Self-funded health plans, while offering significant control and flexibility to employers, are inherently complex and require deep expertise from consultants and brokers to navigate effectively and maximize their financial and operational benefits. * **Importance of Continuous Professional Education:** The dynamic healthcare and insurance industries necessitate continuous education and professional designations (like CEBS or CSFS) to maintain credibility, expand specialized knowledge, and differentiate expertise in a rapidly evolving landscape. * **Lifestyle as a Foundation for Health:** Personal choices regarding exercise, diet, and stress management form the foundational elements of physical and emotional well-being, highlighting the importance of fostering healthier lifestyles to prevent the onset and progression of chronic diseases. * **Technology as a Healthcare Enabler:** Technology, through app-based platforms and specialized "point solutions," is revolutionizing healthcare delivery by enabling personalized, accessible, and data-driven approaches to wellness and chronic disease management. **Key Concepts:** * **Whole Person Healthcare:** An integrated approach to health that recognizes and treats the interconnectedness of an individual's physical and mental well-being, addressing both simultaneously for comprehensive improvement. * **Cognitive Behavioral Therapy (CBT):** A common type of talk therapy that helps people identify and change destructive or disturbing thought patterns that have a negative influence on behavior and emotions. * **PHQ (Patient Health Questionnaire) & GAD (Generalized Anxiety Disorder) Scores:** Standardized screening tools used to assess the severity of depression (PHQ) and anxiety (GAD) symptoms, providing a baseline for mental health status. * **Self-Funded Health Plan:** An employer-sponsored health plan where the employer directly pays for employees' medical claims rather than paying a fixed premium to an insurance carrier. This offers greater control and potential cost savings but also higher risk. * **Point Solutions:** Specialized, often technology-driven, healthcare services or products designed to address a specific health condition or need (e.g., a diabetes management app, a mental health coaching platform). **Examples/Case Studies:** * **Vida Health's Origin Story:** The company was founded by Stephanie Telenius, whose personal struggle navigating the complex healthcare system for her father's chronic physical and mental conditions highlighted the critical need for a more integrated and user-friendly approach to care. * **Diabetes and Mental Health Co-morbidity:** The statistic that approximately 70% of individuals with diabetes also experience co-occurring mental health issues (stress, anxiety, depression) serves as a compelling example of why a whole-person approach is essential for effective chronic disease management. * **Mental Health Provider Accessibility Crisis:** The alarming statistic that only about 27% of the US population can access reasonable care from a psychologist, leading to significant wait times (e.g., 30 days), illustrates the critical accessibility challenge that virtual health solutions like Vida Health aim to solve by providing immediate support.
How To Manage A Merger | with Diane Dooley
Self-Funded
@SelfFunded
Apr 24, 2025
This video provides an in-depth exploration of the critical role of Human Resources (HR) in Mergers and Acquisitions (M&A), from the initial due diligence phase through post-acquisition integration. Diane Dooley, a seasoned CHRO and consultant with extensive experience in the private equity portfolio space, discusses the multifaceted challenges and strategic opportunities for HR leaders during these complex corporate transformations. The discussion emphasizes that each acquisition is unique, with distinct players, financials, and due diligence requirements, moving beyond the simplistic view of M&A. The conversation delves into the pre-acquisition phase, highlighting the importance of HR due diligence alongside financial assessments. While financial experts scrutinize EBITDA and valuation, HR focuses on evaluating the "people" component, including owners, senior leaders, and their potential legal or employee relations issues. A significant portion of the pre-deal analysis also addresses benefit plans, scrutinizing health and welfare costs, voluntary benefits, and the complexities of integrating disparate plans across different geographic regions. The speaker underscores the confidential nature of pre-deal activities, which often limits the depth of organizational assessment. Transitioning to the post-acquisition environment, the video stresses the paramount importance of change management and robust communication strategies. Dooley explains the need to educate both the acquiring and acquired companies about the upcoming changes, proactively addressing employee concerns about personal impact ("What's in it for me?"). She categorizes employee reactions into "resistors," "early adopters," and "waiters," suggesting tailored engagement strategies, particularly for talented resistors. The discussion also covers the emotional aspect of M&A, including "founder syndrome" where entrepreneurs struggle to relinquish control, and the strategic use of financial incentives like stock options to drive retention and align interests during a sale. The video concludes by looking at the future of the M&A market, particularly in the middle market, and offering advice for HR professionals to be proactive business partners and for individuals to own their career growth. Key Takeaways: * **M&A is Highly Nuanced:** Each acquisition possesses unique "fingerprints," meaning financials, players, and due diligence processes differ significantly, requiring a tailored approach rather than a one-size-fits-all strategy. * **HR's Strategic Value in M&A:** HR is not merely administrative but a critical value-add function in M&A, contributing to people integration, economic assessment, cultural alignment, and overall deal success. Proactive HR leadership is essential. * **Pre-Deal HR Due Diligence:** Beyond financial vetting, HR must conduct thorough due diligence on owners and senior leaders, including background investigations, identifying potential legal issues, nefarious activities, or employee relations problems that could derail a deal. * **Benefit Plan Analysis is Critical:** A key part of pre-acquisition due diligence involves understanding the acquired company's benefit plans (medical, dental, voluntary), their funding status, claim spends, and how they compare to the acquiring company's offerings to manage costs and employee expectations. * **Cultural Fit is Challenging to Evaluate:** Assessing cultural elements like accountability, education, kindness, and drive is difficult but crucial. It's important to recognize that corporate culture can differ from office or branch cultures and that B and C players often have a greater impact on daily culture than A players. * **Change Management is Transformational:** Post-acquisition, educating both the acquiring and acquired companies on change management is vital to set expectations, mitigate discontent, and provide insights into what employees can expect. * **Pronounced Communication is Key:** Effective communication is paramount on day one and throughout the integration period, not just for the acquired company but also for the existing organization, to address natural concerns and manage potential shock. * **Understand Employee Personas:** Employees react differently to acquisitions: "resistors" (often talented, requiring engagement), "early adopters" (fully committed), and "waiters" (observing before deciding). Tailored communication and engagement strategies are necessary for each group. * **Founder Syndrome Impact:** Founders' emotional attachment to their "baby" can complicate integration post-sale. Understanding their motivations (financial, retirement, family) and potentially structuring deals with equity or earnouts for key personnel can help manage this. * **Talent Retention is a Deal-Breaker:** High turnover rates (e.g., 50-60%) significantly devalue a company. Strategic incentives, such as offering stock options at the manager level, can be transformative for retention and align employee interests with company growth. * **Healthy Turnover vs. Problematic Attrition:** A 7-8% annual turnover rate is considered healthy, fostering new ideas and exchanges. However, double-digit turnover indicates deeper issues that leaders must address to prevent loss of value and critical talent. * **Scalable M&A Playbooks:** Building repeatable processes through "workstreams" (e.g., M&A playbook, benefits, operations, sales, learning & development) ensures consistent and successful integration across multiple acquisitions. * **Integration Timelines Vary:** Smaller deals typically integrate quickly, while larger acquisitions involving hundreds or thousands of people can take a year or more to fully iron out complexities like territories, systems, and culture. * **Middle Market M&A Dominance:** The middle market (companies with a few hundred to a few thousand employees) sees the highest volume of M&A activity, often driven by the desire for change, greater resources, and expanded career opportunities for employees. * **Own Your Career Growth:** Individuals should proactively manage their own career advancement, embracing periods of discomfort and new responsibilities as opportunities for significant personal and professional growth. **Key Concepts:** * **IBIDA (EBITDA):** Earnings Before Interest, Taxes, Depreciation, and Amortization. A common financial metric used by buyers to assess a company's operating performance and valuation. * **Founder Syndrome:** A phenomenon where the founder of a company struggles to let go of control or adapt to new leadership after selling their business, often leading to friction during integration. * **Change Management:** A structured approach to transitioning individuals, teams, and organizations from a current state to a desired future state, particularly crucial during M&A to minimize resistance and maximize adoption. * **Workstreams:** Organized, parallel efforts or teams focused on specific functional areas (e.g., HR, IT, sales, operations) during an M&A integration to manage different aspects of the transition systematically. **Examples/Case Studies:** * **Deal Derailment:** Diane Dooley recounted instances where issues identified during due diligence on owners or senior leaders (e.g., legal problems, incendiary public behavior) caused an acquisition deal to be abandoned or significantly re-evaluated. * **Founder Remorse:** An example was given of founders who, after selling their company, struggled so much with relinquishing control that the acquiring company eventually sold the business back to them after a year or two. * **Succession Plan Miss:** A case where an acquiring company bought a highly successful business primarily for its EBITDA, but failed to adequately assess the lack of a succession plan for the key leader. This created a significant challenge as the leader approached their earnout period, leaving a gap in revenue generation. * **Turnaround via Stock Options:** Dooley described a company with 50-60% turnover rates that was successfully prepared for sale by implementing a program to offer stock options at the manager level, which was highly unusual. This initiative dramatically improved retention and employee motivation, allowing the company to be sold at a fair market value within nine months.
Is Virtual or In-Person Sales Better? The Pros & Cons of Each
Self-Funded
@SelfFunded
Oct 11, 2022
This video provides an in-depth exploration of the advantages and disadvantages of virtual versus in-person sales approaches, offering a balanced perspective on which method is more effective in different scenarios. The speaker, a seasoned salesperson with experience in SaaS, shares insights derived from adapting to virtual selling during the pandemic after years of traditional in-person engagement. The core purpose of the video is to help sales professionals understand the shifts in the sales landscape and equip them with the knowledge to navigate both virtual and physical sales environments successfully. The discussion begins by highlighting the significant efficiencies offered by virtual sales. The speaker emphasizes that virtual platforms like Zoom enable salespeople to conduct significantly more meetings in a single day—potentially 8 to 12 back-to-back—an impossibility with the travel demands of in-person interactions. This efficiency directly translates to cost savings, as virtual selling eliminates expenses related to travel, gas, flights, hotels, and event spaces. However, the video quickly transitions to the critical drawbacks of virtual sales, primarily the difficulty in building genuine rapport and relationships over a screen. The speaker notes the challenge of gauging audience attention and engagement when cameras are off, leading to a less human and potentially less effective interaction. Conversely, the video champions in-person sales for its unparalleled ability to foster deep relationships and build trust. Being physically present allows for the reading of non-verbal cues, shared experiences like meals or happy hours, and a more human connection that is difficult to replicate virtually. The speaker argues that trust, a foundational element of business, is more effectively established when individuals meet face-to-face, allowing for a better understanding of a person's "vibe" and presence. Despite these profound benefits, in-person sales come with substantial financial costs, with the speaker citing examples of trips costing thousands of dollars for just a few meetings. Furthermore, in-person selling drastically limits the number of meetings possible in a day due to travel time and logistical complexities, and scheduling has become increasingly difficult as fewer people are inclined to meet physically. The speaker concludes by advocating for a hybrid approach, acknowledging the inherent value in both methodologies. While expressing a personal preference for the relationship-building aspects of in-person sales, the speaker cannot deny the undeniable efficiency and outcome-driven success achieved through virtual selling, particularly for SaaS products. The overarching message is that the sales industry has permanently shifted, and modern salespeople must adapt and adopt virtual selling skills, not as a replacement for the human element, but as an augmentation to their overall sales capabilities, requiring flexibility to excel in both realms. Key Takeaways: * **Virtual Sales Efficiency:** Virtual platforms allow for a significantly higher volume of meetings per day (8-12), making the sales process much more efficient compared to in-person engagements. * **Cost Savings in Virtual Sales:** Eliminating travel expenses, including gas, flights, hotels, and event spaces, makes virtual selling substantially cheaper from a profit and loss perspective for companies. * **Rapport Building Challenges Virtually:** It is considerably harder to build deep rapport and strong relationships over a screen, as non-verbal cues and genuine human connection are often diminished. * **Audience Engagement Issues in Virtual Settings:** Salespeople may struggle to ascertain if their audience is truly attentive during virtual calls, especially when cameras are off, potentially leading to less effective communication. * **Superior Relationship Building In-Person:** In-person interactions are paramount for fostering deeper relationships, allowing for better reading of non-verbal cues, shared experiences, and a more human connection. * **Trust as a Foundation of In-Person Sales:** Building trust, which is crucial for business transactions, is significantly enhanced through physical presence, as it allows for a more comprehensive assessment of a person's character and intentions. * **Higher Cost of In-Person Sales:** Traditional sales methods are expensive, with travel, accommodation, and entertainment costs easily accumulating to hundreds or even thousands of dollars for just a few meetings. * **Limited Meeting Capacity In-Person:** The logistical demands of in-person sales, such as travel time between locations, drastically reduce the number of meetings a salesperson can conduct in a single day (e.g., 4-5 meetings compared to 10-12 virtually). * **Increased Difficulty in Scheduling In-Person Meetings:** Post-pandemic, scheduling physical meetings has become more challenging as fewer individuals are inclined or available to meet in person, often requiring longer lead times. * **Hybrid Approach is Optimal:** The most effective sales strategy involves leveraging both virtual and in-person methods, utilizing virtual for efficiency and reach, and in-person for critical relationship and trust building. * **Adaptation to Virtual Selling is Crucial:** Sales professionals must develop and embrace virtual selling skills as a core competency, recognizing that this approach is here to stay and augments, rather than replaces, traditional methods. * **SaaS Sales Benefits from Virtual Efficiency:** For products like Software as a Service (SaaS), virtual demonstrations and sales processes are highly efficient and can lead to better outcomes due to the ease of screen sharing and remote interaction. Tools/Resources Mentioned: * Zoom * Microsoft Teams * WebEx Key Concepts: * **Virtual Sales:** Conducting sales interactions and presentations remotely using video conferencing platforms. * **In-Person Sales:** Traditional sales methods involving physical meetings and face-to-face interactions. * **Rapport:** A close and harmonious relationship in which the people or groups concerned understand each other's feelings or ideas and communicate well. * **Efficiency:** The ability to achieve maximum productivity with minimum wasted effort or expense. * **Trust:** Firm belief in the reliability, truth, ability, or strength of someone or something, crucial for business transactions. * **Non-verbal Cues:** Communication through body language, facial expressions, gestures, and other physical signals, often more easily interpreted in person. Examples/Case Studies: * The speaker's personal experience selling SaaS (Software as a Service) and adapting to virtual selling during the pandemic. * An example of covering the Oklahoma City and Tulsa markets from Dallas, illustrating the time and logistical challenges of in-person travel and limited meeting capacity (3-hour drive, 4-5 meetings max per day).
Fixing Healthcare's $528 Billion Mistake | with Chris Grilli
Self-Funded
@SelfFunded
Sep 3, 2025
This video provides an in-depth exploration of how personalized, DNA-guided medicine, specifically through genomics, can address the staggering $528 billion annual cost of medication errors and inefficiencies in healthcare. Chris Grilli, a pharmacist and genomics expert from RxMapper, discusses the critical need to move beyond "trial-and-error" prescribing by leveraging a patient's unique genetic makeup. The core premise is that by accurately identifying the most effective medication for an individual from the outset, significant financial waste can be eliminated, patient outcomes dramatically improved, and the overall burden on the healthcare system reduced. Grilli details RxMapper's methodology, which involves analyzing an extensive 36 million data points from a patient's genome. This comprehensive genomic analysis allows for medication recommendations with nearly 90% accuracy, a substantial improvement over traditional pharmacogenomics approaches that might only identify meaningful recommendations 3-4% of the time. He clarifies the distinction between genetics (inheritable traits) and genomics (the study of an individual's entire DNA variation), emphasizing that RxMapper focuses on the latter to understand how unique variations impact drug response, food allergies, and disease susceptibility. The conversation traces the historical advancements that made this technology possible, from the Human Genome Project providing the first reference genome to the exponential progress in next-generation sequencing, which has driven down costs and enabled widespread application. The discussion also delves into the practical application and impact of RxMapper's services. Grilli shares a deeply personal anecdote about his grandmother's preventable death due to an adverse drug event, which served as the impetus for building RxMapper. This personal mission underscores the human cost of medication errors and the drive to provide better, data-driven care. The company targets individuals struggling with medication side effects or ineffectiveness, using claims data (PBM or TPA) to proactively identify patients who could benefit most. RxMapper partners with brokers, consultants, and PBMs, positioning itself as a complementary solution that enhances existing healthcare frameworks by ensuring efficacy first, then cost-effectiveness. The long-term vision includes influencing future drug development and expanding accessibility to broader populations, including Medicare beneficiaries, to ultimately drive the $528 billion in medication mistakes closer to zero. Key Takeaways: * **Massive Cost of Medication Errors:** Healthcare spends an estimated $528 billion annually fixing mistakes related to medicines, significantly more than the cost of the drugs themselves ($460-$480 billion). This highlights a profound inefficiency in the current "guess and check" prescribing model. * **Precision Medicine through Genomics:** RxMapper utilizes a patient's unique DNA signature to identify the best medicine, moving beyond population-level data. This personalized approach aims to get the right drug to the right person the first time, preventing adverse events and improving therapeutic outcomes. * **Genomics vs. Genetics:** Genomics, as practiced by RxMapper, involves collecting vast amounts of data (e.g., 36 million data points per patient) to study all the variations in an individual's DNA, rather than just inheritable traits. This comprehensive view significantly increases the predictive power of medication recommendations. * **High Accuracy and Predictive Power:** RxMapper's data shows that following their process leads to a meaningful recommendation almost 90% of the time, compared to 3-4% for narrower pharmacogenomics panels. This high accuracy is attributed to collecting more data and using powerful computational algorithms. * **Significant Cost Savings Per Patient:** Implementing genomic-guided medicine can save over $8,600 per patient in drug costs alone, and potentially up to $12,000 in overall medical costs by avoiding ineffective treatments and their associated complications. * **Impact on Employer Health Plans:** For self-insured employers, RxMapper can substantially reduce overall drug spend by preventing patients from escalating to expensive specialty drugs. Data shows a 15% reversal in specialty drug growth in a short period after implementation. * **Focus on Generics:** A surprising 80% of RxMapper's recommendations are for small molecule generics. By identifying effective generic alternatives that might otherwise be overlooked, the program slows the progression to high-cost agents like GLP-1s, even if the initial generic was ineffective. * **Complementary to PBMs:** RxMapper works in partnership with PBMs, enhancing their ability to guide patients to the most cost-effective drugs *after* efficacy has been established through genomic insights. This creates a synergistic relationship that benefits both patient outcomes and cost containment. * **Evidence-Based and Peer-Reviewed:** All recommendations are evidence-based and peer-reviewed, specific to the drug in question, avoiding extrapolation. This rigorous clinical validation ensures trust and reliability in a regulated environment. * **Patient-Centric Approach:** The service is voluntary, and patients receive their results directly. RxMapper also engages the patient's care team, providing them with evidence-based reasoning and support to manage the patient's therapeutic journey. * **Proactive and Targeted Outreach:** RxMapper uses claims data (PBM, TPA) to identify individuals who are struggling with their current medications or have conditions where genomics has proven helpful, allowing for targeted interventions. * **Beyond Drug Selection:** The service includes comprehensive pharmacist-led screening, assessing drug-drug interactions, dietary considerations (e.g., statins and grapefruit), and even vitamin deficiencies, ensuring holistic patient care. * **Reducing "Lasering" Risk:** By managing significant conditions with low-cost, effective generics, RxMapper can reduce the incidence of "misadventures" in care that lead to large, expensive claims, potentially mitigating the need for "lasering" in stop-loss insurance. * **Long-Term Partnership:** The service is designed for the long haul; once sequenced, the information is digitized and stored, allowing for ongoing guidance as therapies change over a patient's lifetime. The data is portable, allowing individuals to maintain membership even if they change employers. Key Concepts: * **Genomics:** The study of an organism's entire genome, including all of its genes and their interactions, to understand how unique variations impact various biological processes, including drug response. * **Pharmacogenomics:** A subset of genomics that studies how genes affect a person's response to drugs. RxMapper's approach is a more comprehensive form of this, looking at a much broader set of genetic variations. * **Next-Generation Sequencing (NGS):** Advanced DNA sequencing technologies that have dramatically reduced the cost and time required to sequence an entire genome, making personalized genomic analysis economically viable. * **Polygenic Risk Score:** A score that estimates an individual's risk for a particular disease or trait based on the combined effect of many genetic variants. Chris Grilli's work at Mayo Clinic includes focus on these scores. * **Adverse Drug Event (ADE):** Harm experienced by a patient as a result of medication, which can be preventable or non-preventable. The video highlights the significant human and financial cost of preventable ADEs. * **Step Therapy:** A common practice in prescription drug plans where patients must try a lower-cost drug first before progressing to more expensive alternatives if the initial treatment is ineffective. RxMapper aims to optimize this process. Examples/Case Studies: * **Rheumatoid Arthritis Patient:** A patient on methotrexate (standard first-line therapy) was found through genomic analysis to have a poor genetic fit for the drug. They were then escalated to adalimumab (Humira, an $80,000+ specialty drug), which also showed poor response and increased side effect likelihood based on genomic data. RxMapper identified leaflunamide, a typically skipped generic, as a strong therapeutic suggestion. Switching to leaflunamide resulted in a positive response, saving significant costs and improving patient outcomes. * **GLP-1s and Weight Gain:** While GLP-1 effectiveness in diabetic patients is well-studied, RxMapper is intensively studying the genetic variations that impact GLP-1 effectiveness for weight gain, a newer indication. They emphasize a disciplined, evidence-based approach to avoid misleading recommendations in this high-demand area. * **Grandmother's Preventable Death:** Chris Grilli's personal story of his grandmother's death from a preventable adverse drug event during a routine procedure due to an undisclosed genetic mutation for bleeding. This incident was the catalyst for developing RxMapper to ensure such information is available to care teams.
Fasting Explained - Everything You Need to Know About Fasting
Self-Funded
@SelfFunded
May 24, 2022
This video provides an in-depth exploration of fasting, its scientific underpinnings, and its profound health benefits. Hosted by Spencer Smith of the "Self-Funded" podcast, the episode features Mark Testa, a chiropractor, acupuncturist, and expert in fasting and stem cells. The discussion builds upon a previous conversation about bone marrow concentrate and stem cells, extending into how fasting can be a powerful tool for metabolic health, disease prevention, and even reversal. The overarching theme is a proactive approach to healthcare, emphasizing lifestyle and dietary interventions to address the root causes of chronic conditions rather than solely focusing on "back-end" treatments. Mark Testa shares his personal journey with fasting, including a transformative 5-day water fast that led to significant weight loss and a renewed sense of energy. He explains the science behind fasting, detailing how the body undergoes a metabolic switch from burning glucose to burning fat, leading to a state of ketosis. The conversation delves into critical cellular processes like autophagy and mitophagy, where the body cleans out old, weak cells and mitochondria, respectively, paving the way for cellular renewal. This cellular "house cleaning" is highlighted as a key benefit, with implications for reducing inflammation, preventing disease, and even mobilizing stem cells for repair. The speakers also address the broader implications of fasting for public health, particularly in the context of the "healthcare crisis." They discuss the rampant issue of insulin resistance and pre-diabetes in America, linking high glucose levels to inflammation, microvascular damage (kidney disease, eye damage), and the upregulation of growth signals that can contribute to cancer. Dr. Jason Fung's work on reversing diabetes through fasting and low-carb diets is cited, along with Verta Health's success in this area within the self-funded healthcare space. The video concludes with practical advice for beginners, emphasizing a gradual approach to fasting, aligning with circadian rhythms, and the importance of nutrient-dense refeeding, while also cautioning against fasting for certain individuals. Key Takeaways: * **Fasting Definition and Types:** Fasting is defined as an unfed state, not starvation. It encompasses various durations, from intermittent fasting (e.g., 16-18 hours daily) to extended fasts (24-hour, 3-day, 5-day water fasts) and Fasting Mimicking Diets (FMDs). * **Metabolic Switch and Ketosis:** Fasting triggers a metabolic switch, causing the body to transition from burning glucose (stored as glycogen) to burning fat for fuel. This process leads to the production of ketone bodies (e.g., beta-hydroxybutyrate) and a state of ketosis, which can enhance brain function and reduce inflammation. * **Autophagy and Mitophagy:** After 24-36 hours of fasting, the body initiates autophagy, a process where it consumes and recycles weak, dying, or damaged cells, including those that could potentially turn into cancer. Mitophagy is a similar process specifically targeting old, dysfunctional mitochondria, leading to the regeneration of new, stronger mitochondria. * **Inflammation Reduction:** Fasting significantly reduces inflammatory markers and insulin levels. Rampant glucose and insulin resistance contribute to systemic inflammation, which is a driver for chronic diseases such as diabetes, dementia, cardiovascular disease, and arthritis. * **Diabetes Reversal Potential:** The video highlights the work of nephrologist Dr. Jason Fung, who has successfully helped patients reverse type 2 diabetes through therapeutic fasting, by reducing insulin production and mobilizing fat stores. Verta Health is also mentioned as a company achieving diabetes reversal through diet in the self-funded healthcare space. * **Impact on Abdominal Fat:** Fasting is particularly effective at targeting abdominal fat, which is pro-inflammatory and, in men, can convert testosterone into estrogen via aromatase, impacting hormonal balance. * **Mtor and Amp Kinase Regulation:** Fasting helps regulate key cellular signaling pathways. It periodically calms down mtor (mammalian Target of Rapamycin), a growth signaler activated by protein and glucose, which is crucial for growth but can contribute to cancer when constantly active. It also triggers AMP kinase, a nutrient sensor activated by a lack of calories, promoting energy balance. * **Stem Cell Mobilization:** Studies from USC (Valter Longo's team) suggest that extended fasting (e.g., 4-5 days) can lead to the body releasing and mobilizing stem cells from the bone marrow to rebuild itself, offering a "boost" of natural repair mechanisms. * **Practical Fasting Progression:** For beginners, a gradual approach is recommended, starting with a 12-hour fast (e.g., 7 PM to 7 AM), then incrementally extending the fasting window by an hour each week until reaching 16-18 hours. This helps the body become "fat adapted." * **Extended Fasting and Fasting Mimicking Diets (FMDs):** Once comfortable with intermittent fasting, individuals can progress to 24-hour fasts (dinner to dinner) and then 3-day or 5-day fasts to achieve deeper ketosis and autophagy. FMDs, like ProLon developed by Valter Longo, offer a plant-based, low-carb, high-fat dietary protocol that mimics the effects of fasting while allowing some food intake, making it psychologically easier for some. * **Importance of Refeeding:** Breaking a fast requires careful reintroduction of food. It's crucial to eat nutrient-dense, unprocessed foods (e.g., salads with healthy fats) and avoid large, heavy meals, as the digestive system needs to be gently reactivated. * **Who Should Avoid Fasting:** Fasting is not recommended for individuals with a BMI below 18 (underweight), those with eating disorders, or anyone on insulin or Metformin without strict medical supervision due to the risk of hypoglycemia. * **Hunger Management Hacks:** Strategies to manage hunger during fasting include drinking water, consuming a pinch of high-quality salt (Himalayan or Celtic sea salt), going for walks, or meditating. * **Circadian Rhythm Alignment:** Aligning fasting windows with the body's natural circadian rhythm is beneficial, recommending stopping eating by 7 PM at the latest and generally 3 hours before bed, as digestion slows significantly after 6 PM. * **Challenging Food Propaganda:** The speakers question long-held beliefs like "breakfast is the most important meal of the day" and the traditional food pyramid, suggesting that societal dietary advice has sometimes been contrary to optimal health. **Tools/Resources Mentioned:** * **Documentary:** "Fasting" by Doug Orchard (features Valter Longo and Jason Fung). * **Books:** "The Diabetes Code" and "The Obesity Code" by Dr. Jason Fung. * **Health Program:** Verta Health (uses low-carb diets for diabetes reversal in the self-funded space). * **Fasting Mimicking Diet:** ProLon (developed by Valter Longo's team at USC). **Key Concepts:** * **Fasted State:** A period when the body is not consuming food. * **Intermittent Fasting (IF):** Cycling between periods of eating and voluntary fasting on a regular schedule. * **Autophagy:** A cellular process where the body cleans out and recycles damaged cells and cellular components. * **Mitophagy:** A specific type of autophagy that targets and removes damaged mitochondria. * **Ketosis:** A metabolic state where the body primarily burns fat for energy, producing ketone bodies. * **Metabolic Switch:** The body's shift from using glucose as its primary fuel source to using fat. * **Insulin Resistance:** A condition where the body's cells don't respond well to insulin, leading to higher blood sugar and insulin levels. * **Mtor (Mechanistic Target of Rapamycin):** A protein kinase that regulates cell growth, proliferation, and survival; often activated by protein and glucose. * **Amp Kinase (AMPK):** An enzyme that plays a key role in cellular energy homeostasis, activated by low energy states (e.g., during fasting). * **Gluconeogenesis:** The metabolic pathway that results in the generation of glucose from non-carbohydrate carbon substrates. * **Circadian Rhythm:** The natural, internal process that regulates the sleep-wake cycle and repeats roughly every 24 hours. * **Fat Adaptation:** The process by which the body becomes more efficient at burning fat for fuel. **Examples/Case Studies:** * **Dr. Jason Fung's Clinical Work:** A nephrologist who successfully helped patients with end-stage kidney disease (often due to diabetes) reverse their diabetes by implementing fasting protocols. * **Verta Health:** An organization in the self-funded healthcare space that utilizes low-carb diets to achieve diabetes reversal for its members. * **Mark Testa's Personal Experience:** His first 5-day water fast resulted in a 12-pound weight loss, primarily from abdominal fat, and a significant boost in energy. * **Spencer Smith's Personal Experience:** Intermittent fasting helped stabilize energy, improve mental clarity, manage weight, simplify dieting, and reduce inflammation (e.g., from consuming bread).
This Pharmacy Went Cash-Only, Lost 70% Of Customers, & Doubled Profits | With Brad Hart
Self-Funded
@SelfFunded
Aug 5, 2025
This video provides an in-depth exploration of the "cost-plus" pharmacy model and its disruptive potential within the opaque and often exploitative pharmaceutical industry. Brad Hart, owner of Forest Park Pharmacy, shares his journey from a struggling traditional independent pharmacy, mired in the complexities and poor reimbursements of the insurance-based system, to a thriving cash-only, cost-plus operation. He details how this radical shift, initially leading to a 70% loss of customers, ultimately doubled his profits by eliminating the predatory practices of Pharmacy Benefit Managers (PBMs) and providing transparent, significantly lower drug prices. Hart highlights the systemic issues plaguing the industry, particularly the role of PBMs in inflating drug costs through "spread pricing" and the deceptive "low copay trap" that misleads consumers about the true cost of their medications. He provides startling examples of Medicare overpayments, where common generic drugs costing pennies or a few dollars are reimbursed for thousands, leading to billions in annual waste. His use of social media, particularly TikTok, to expose these discrepancies by comparing his pharmacy's prices to Medicare reimbursements, garnered viral attention and transformed his business, despite initial challenges in managing the influx of inquiries for brand-name drugs he couldn't assist with. The discussion also delves into the logistics of operating a cost-plus pharmacy, including the necessity of dropping all insurance contracts due to restrictive clauses that prevent transparent pricing and direct-to-consumer models. Hart explains his pricing structure (acquisition cost + 15% + $10 fee) and the importance of a robust online "price checker" tool for customer education and transparency. He touches on the challenges of scaling such a model, including state-specific licensing requirements for pharmacists and the inability to compete on brand-name drugs due to the rebate-driven pricing structure. The conversation concludes with a forward-looking perspective on PBM reform, the emergence of direct-to-consumer models from pharmaceutical manufacturers, and the critical role employers can play in driving systemic change by demanding transparency and adopting alternative benefit designs. Key Takeaways: * **PBMs Drive Independent Pharmacies Out of Business:** Independent pharmacies often struggle to survive under the insurance-based reimbursement model, with PBMs paying below acquisition cost, forcing pharmacies into unethical workarounds like falsely claiming drugs are out of stock. PBMs explicitly aim to run independents out of business to consolidate market share for their own pharmacies. * **The "Low Copay Trap" Masks True Costs:** Consumers are often misled by low copays, which incentivize them to use insurance without understanding the actual, significantly higher cost of the drug to their employer or the healthcare system, ultimately driving up premiums. * **Cost-Plus Model Can Double Profits Despite Customer Loss:** Forest Park Pharmacy's experience demonstrates that abandoning insurance and adopting a cost-plus model (acquisition cost + 15% + $10 fee) can lead to a substantial increase in profitability, even after losing a significant portion of the original customer base. * **Billions in Medicare Overpayments for Generics:** Public data reveals egregious overpayments by Medicare for common generic drugs, with examples like Aberdarone costing $96 at a cost-plus pharmacy but being reimbursed for $3,400, leading to billions in annual waste across various drugs. * **Social Media as a Disruptive Force:** Brad Hart's viral TikTok videos, comparing his pharmacy's transparent prices to Medicare reimbursements, proved highly effective in raising public awareness and driving business, demonstrating the power of social media for industry disruption and education. * **Binary Choice: Insurance vs. Cost-Plus:** Pharmacies cannot operate a true cost-plus model while simultaneously accepting major insurance plans, as PBM contracts contain restrictive clauses that prevent transparent pricing, direct shipping, and other operational flexibilities. * **"Specialty Generic" is a Misnomer for Inflated Prices:** The term "specialty generic" is often used to justify absurdly high prices for drugs that are otherwise cheap, highlighting another area of market manipulation by PBMs and manufacturers. * **Average Wholesale Price (AWP) is a Fabricated Metric:** AWP, often used in reimbursement calculations, is a proprietary, privately set price that bears no resemblance to actual wholesale acquisition costs, often being 100 times higher than what pharmacies actually pay. * **Direct-to-Consumer Models are Emerging and Disruptive:** Pharmaceutical manufacturers like Eli Lilly and Novo Nordisk are launching direct-to-consumer models with significantly lower non-insurance prices, challenging traditional distribution and pricing structures. * **Employer-Sponsored Healthcare is the Biggest Lever for Change:** With 165 million Americans covered by employer-sponsored health insurance, employers have immense power to drive systemic change by demanding transparency, challenging PBM contracts, and adopting alternative benefit designs. * **GLP-1 Compounding Highlights Price Discrepancies:** The ability of 503b outsourcing facilities to batch compound GLP-1s during shortages created a massive price differential (e.g., 10x cheaper than brand names), demonstrating the potential for significant savings through alternative drug sourcing. * **Legislation Alone May Not Solve the Problem:** While PBM reform legislation is gaining traction at state and federal levels, it often addresses minor issues or opens new loopholes; true, lasting change requires market-driven solutions and employer action rather than centralized price controls. * **Transparency Tools Empower Consumers:** Online price checkers that clearly display drug acquisition costs plus a transparent margin empower consumers to understand true drug prices and identify overpayments, prompting them to seek more affordable options. * **"Usual and Customary Price" Manipulation:** Insurance companies often require pharmacies to set an absurdly high "usual and customary price" to qualify for reimbursement, effectively forcing pharmacies to inflate their cash prices if they also want to accept insurance. **Tools/Resources Mentioned:** * **Forest Park Pharmacy's Price Checker:** An online tool on their website that provides transparent pricing for over 10,000 drugs based on acquisition cost plus a fixed margin and fee. * **Diversify RX:** A local conference for pharmacy owners where Brad Hart learned about the cost-plus model. * **Blueberry Pharmacy (Kyle):** One of the first cost-plus pharmacies, serving as an inspiration for Forest Park Pharmacy. * **costpluspharmacies.com:** A search tool created by Kyle (of Blueberry Pharmacy) to help consumers find cost-plus pharmacies across the country. * **NABP (National Association of Board of Pharmacies):** Mentioned for an upcoming national certification exam for pharmacists, which could streamline multi-state licensing for mail-order services. * **FTC Reports on PBMs and Specialty Generics:** Referenced as comprehensive reports that exposed the problematic practices of PBMs, particularly concerning specialty generics. **Key Concepts:** * **Cost-Plus Pharmacy Model:** A business model where drug prices are determined by the pharmacy's acquisition cost plus a transparent, fixed percentage margin and a dispensing fee, without involving insurance. * **Pharmacy Benefit Managers (PBMs):** Third-party administrators of prescription drug programs for health insurance companies, Medicare Part D plans, and large employers, often criticized for their opaque pricing practices and role in inflating drug costs. * **Low Copay Trap:** The phenomenon where low patient copays for prescription drugs obscure the actual high cost of the drug, disincentivizing patients from seeking cheaper alternatives and contributing to higher overall healthcare premiums. * **Spread Pricing:** A practice by PBMs where they charge the payer (e.g., employer) a higher price for a drug than they reimburse the pharmacy, keeping the "spread" as profit. * **Specialty Generic:** A term often used to classify certain generic drugs as "specialty" to justify significantly higher prices, despite their low acquisition cost. * **Average Wholesale Price (AWP):** A benchmark price for prescription drugs that is often used in reimbursement formulas but is a proprietary, inflated price that does not reflect actual wholesale costs. * **503b Outsourcing Facilities:** Facilities that can batch compound drugs and sell them to pharmacies, providing a legal pathway for large-scale compounding, particularly relevant during drug shortages. * **Usual and Customary Price:** The price a pharmacy typically charges cash-paying customers, which PBMs often require to be artificially inflated to qualify for insurance reimbursement, hindering transparent cash pricing. * **Comparative Effectiveness Analysis:** An approach to evaluating drugs based on their clinical effectiveness and value compared to other treatments in the same class, rather than solely on rebate potential. * **Most Favored Nation Pricing:** A concept where a buyer (e.g., a government) demands the lowest price offered to any other buyer globally, aimed at reducing drug costs but potentially leading to unintended consequences like price increases in other nations. **Examples/Case Studies:** * **Forest Park Pharmacy's Business Transformation:** The core example of converting from an insurance-dependent model to a cash-only, cost-plus model, losing 70% of customers but doubling profits due to elimination of PBM inefficiencies. * **Aberdarone Overpayment:** A specific example where Medicare reimbursed $3,400 for a drug that cost Forest Park Pharmacy $96, illustrating billions in potential waste. * **GLP-1 Compounding:** The case of compounded GLP-1s (e.g., Semaglutide) being significantly cheaper than brand-name versions, driving substantial business for independent pharmacies until regulatory changes around shortage lists impacted their ability to batch compound. * **Walgreens' Struggle without a PBM:** Mentioned as an example of a large pharmacy chain struggling to remain profitable without its own PBM contracts, highlighting the PBMs' market dominance. * **Eli Lilly and Novo Nordisk Direct-to-Consumer:** Examples of major pharmaceutical manufacturers launching direct-to-consumer platforms offering lower prices for their drugs outside of insurance, signaling a potential shift in drug distribution.
Patient Advocacy with Graith Care - Priscilla Romans
Self-Funded
@SelfFunded
Nov 29, 2022
This video provides an in-depth exploration of patient advocacy through a conversation with Priscilla Romans, CEO and Founder of Graith Care. Romans discusses the origin story of her independent patient advocacy firm, detailing her personal and professional journey from a nursing background and entrepreneurial family to identifying critical gaps in the healthcare system. The core purpose of Graith Care is to empower patients by providing transparency, control, and comprehensive options for their healthcare decisions, ultimately aiming to improve outcomes, efficiency, and cost-effectiveness. The discussion highlights the systemic challenges within the current healthcare model, where patients often feel disempowered, uninformed, and constrained by institutional policies and financial incentives. Romans elaborates on the practical application of patient advocacy, explaining how Graith Care operates as an independent entity, free from hospital or insurance company affiliations, to solely serve the patient's best interest. She describes the process of clients engaging with Graith Care, from initial contact to being matched with one of their 20+ specialized advocates who possess diverse backgrounds in critical care, insurance, naturopathy, and therapy. A significant portion of the conversation focuses on real-world scenarios, including complex hospital cases where patients' primary ailments are overlooked due to COVID-19 protocols and incentives, and situations where patients seek alternative or complementary treatments not offered by their primary care providers. Graith Care acts as a "second set of eyes," helping families navigate medical decisions, plan discharges, and even facilitate critical patient transfers between facilities when standard care pathways are insufficient or undesired by the patient. The discussion also delves into the future of patient advocacy, emphasizing the growing need for a collaborative approach that integrates allopathic (conventional) medicine with alternative and holistic treatment options. Romans advocates for a shift in mindset within the healthcare industry, urging for greater recognition and coverage of complementary therapies, such as high-dose IV ascorbic acid for cancer patients, which are often dismissed despite being relatively inexpensive and potentially beneficial. She attributes the bias against such treatments to doctors' limited training in nutrition and holistic approaches, coupled with the systemic pressures of short patient visit times and productivity scores. Romans passionately argues for a return to patient-centered care, where informed consent and individual choice are paramount, and where collaboration between all healthcare stakeholders—from physicians to nurses and advocates—prioritizes the patient's well-being over institutional constraints. Key Takeaways: * **Empowering Patient Control and Transparency:** Graith Care's mission is to restore control and transparency to healthcare consumers, ensuring patients are fully informed of all options to make the best decisions for their unique situations. This counters the common feeling of disempowerment within the complex healthcare system. * **Independent Advocacy Model:** Graith Care operates independently of hospitals and insurance companies, allowing advocates to provide unbiased advice and recommendations. This independence removes the "blinders of policies and procedures" that often constrain institutional providers. * **Diverse Advocacy Services:** The firm offers over 40 types of advocacy services, ranging from navigating insurance claims and appeals to finding transplant advocates, exploring holistic alternatives, and managing pediatric to adult care needs. This breadth addresses the multifaceted challenges patients face. * **Addressing Systemic Gaps in Care:** The video highlights critical gaps, such as the neglect of primary medical issues due to hospital incentives for specific protocols (e.g., COVID-19), and the lack of comprehensive discharge planning, which contributes to high readmission rates. * **Facilitating Patient Transfers:** Graith Care assists patients in transferring to facilities that offer desired treatments or protocols not available at their current hospital. This often involves complex logistics, collaboration with physicians, and sometimes legal pressure to ensure patient choice is honored. * **Challenging the Allopathic-Only Mindset:** Romans advocates for integrating complementary and alternative treatment options alongside conventional medicine, citing examples like high-dose IV ascorbic acid for cancer patients. She emphasizes that these are not "fufu" but scientifically supported options that should be covered by insurance. * **Physician Constraints and Bias:** Doctors often lack comprehensive training in nutrition and holistic treatments, and are constrained by short appointment times (e.g., 15 minutes) and productivity metrics. This systemic pressure limits their ability to discuss broader treatment options or engage in deeper patient-physician relationships. * **Proactive vs. Reactive Healthcare:** Graith Care emphasizes proactive planning to prevent health crises, arguing that it is more cost-effective and leads to better outcomes than reacting to problems. This approach aims to keep individuals out of the "hands of crisis" where bad decisions are often made. * **Importance of a Collaborative Network:** The success of Graith Care relies on a strong network of diverse professionals, including nurses, insurance experts, naturopaths, physical therapists, and occupational therapists, who can collectively address the wide range of patient needs. * **Transparency in Pricing and Services:** Graith Care maintains transparent pricing and FAQs online, and commits to quick follow-up, especially for critical hospital cases, demonstrating a commitment to accessibility and responsiveness. * **The "Molly and Jim" Case Study:** This example illustrates the challenges of patient choice in a high-tier hospital where a doctor refused to consider alternative treatments or transfer, highlighting the need for external advocacy to ensure patient options are presented and pursued. * **Impact of Information Suppression:** The speaker's experience with a viral TikTok video promoting cash price negotiations being taken down suggests a broader issue of information suppression regarding patient empowerment and alternative healthcare options. Key Concepts: * **Patient Advocacy:** The act of supporting and representing patients to ensure their rights, wishes, and needs are met within the healthcare system, especially when they are unable to do so themselves. * **Informed Consent:** The ethical and legal requirement that patients understand the risks, benefits, and alternatives of a proposed medical procedure or treatment before agreeing to it. * **Independent Advocacy:** Advocacy services provided by an entity not affiliated with hospitals, insurance companies, or other healthcare providers, ensuring unbiased representation of the patient's interests. * **Allopathic Medicine:** The conventional Western medical system that treats diseases with drugs, surgery, or radiation. * **Complementary and Alternative Medicine (CAM):** A group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. "Complementary" means used together with conventional medicine; "alternative" means used in place of conventional medicine. * **Cash Price Negotiations:** The practice of patients asking for and negotiating the direct cost of medical services or pharmaceuticals, often bypassing insurance, which can sometimes lead to lower prices. Examples/Case Studies: * **COVID-19 Hospital Protocols:** Patients admitted for primary issues (e.g., colitis) being diagnosed with COVID-19 via PCR tests, leading to neglect of their original ailment due to hospital incentives for COVID protocols. Graith Care helps families redirect focus to the primary issue and immune support. * **Patient Transfers for Alternative Treatments:** Cases where patients in critical care (e.g., with COVID-19) desire specific "Frontline doctors protocols" (e.g., IV ascorbic acid, Ivermectin) not offered by their hospital. Graith Care facilitates transfers to facilities willing to provide these options, involving complex logistics like air ambulances. * **"Molly and Jim" Story:** A patient in a high-tier South Dakota hospital whose doctor refused to offer or facilitate alternative treatments or a transfer. Graith Care intervened, navigating institutional resistance to successfully transfer the patient, emphasizing the patient's right to choose. * **Cancer Treatment Alternatives:** Discussion of cancer patients seeking to combine conventional treatments (chemo, radiation) with complementary options like high-dose IV ascorbic acid for immune support, highlighting the need for oncologists to be open to these alternatives.
Private Equity 101- Everything You Need to Know About Private Equity
Self-Funded
@SelfFunded
May 3, 2022
This video provides an in-depth exploration of the private equity world, demystifying its mechanics, terminology, and strategic considerations. Host Spencer Smith interviews Kyle Coots, Co-Founder and Managing Director of Miramar Equity Partners, who shares his career journey and expertise. The discussion begins with Coots' background in accounting, consulting, and various private equity roles, setting the stage for a comprehensive explanation of how private equity operates, from early-stage funding to mature investments. The conversation highlights the ubiquity of private equity in various sectors, including the insurance and healthcare industries, which is particularly relevant to the host's audience. Coots breaks down private equity into a spectrum of investment stages, starting from seed equity for nascent ideas, progressing through venture capital for growing concepts, and then into growth equity and lower middle market private equity for businesses with established profitability or significant growth potential. A core theme is the valuation of businesses, explained through the concept of "multiples" applied to cash flow (EBITDA) or recurring revenue, driven by factors like growth profile and risk. The speakers also delve into the three primary ways private equity firms generate returns: growing the business (increasing EBITDA), enhancing its intrinsic value (leading to a higher multiple), and financial engineering (leveraging debt). A significant portion of the discussion addresses common misconceptions about private equity, emphasizing that successful PE investment often involves professionalizing and growing businesses, which can lead to job creation and improved products, rather than solely cost-cutting. Coots stresses the importance of cultural fit and strong relationships between private equity partners and the management teams they invest in. The video further explores the strategic decision for a company to remain private versus going public, outlining the advantages and disadvantages of each path, particularly concerning regulatory burdens, investor input, and long-term strategic flexibility. Notably, Coots discusses Miramar Equity Partners' interest in the healthcare sector, focusing on ethical investments that improve patient care, access, and overall system efficiency through tech-enabled services and other innovative solutions. Key Takeaways: * **Private Equity Spectrum:** Private equity encompasses a range of investment stages, from seed equity (for initial ideas and prototypes) to venture capital (for product development and early growth) to growth equity and lower middle market private equity (for established businesses with profitability or significant scaling opportunities). * **Business Valuation through Multiples:** The value of a private business is often assessed using "multiples," which are a shorthand for the present value of future cash flows. These multiples can be applied to metrics like cash flow (EBITDA), recurring revenue (for software), or book value (for financial services). * **Drivers of Multiples:** A business's multiple is influenced by its growth profile (large addressable market, strong performance history, customer dynamics, pricing power) and its risk profile (sustainability, predictability, ability to service debt). Lower risk and higher growth typically lead to higher multiples. * **Three Ways PE Firms Make Money:** Private equity firms primarily generate returns by: 1) growing the business (increasing EBITDA), 2) making the business more valuable (achieving a higher multiple through diversification, scale, or improved margins), and 3) financial engineering (using debt to finance transactions and paying it down over time, increasing equity value). * **Strategic Use of Debt:** While equity represents ownership, debt is a lower-cost form of capital and is often used by private equity firms to efficiently capitalize a business. However, it requires a certain level of financial sophistication, predictable cash flow, and robust financial reporting that many founder-led businesses may lack. * **Beyond Misconceptions:** Private equity's reputation is sometimes negatively skewed, but many firms aim to professionalize and grow businesses, creating jobs, improving products, and providing better careers for employees, rather than solely focusing on aggressive cost-cutting. * **Importance of Relationships and Culture Fit:** Successful private equity partnerships heavily rely on strong relationships, shared values, and cultural alignment between the investors and the management team. This ensures effective collaboration, especially when navigating challenges or disagreements. * **Public vs. Private Considerations:** Going public offers liquidity and access to a diverse investor base but comes with increased financial reporting requirements, greater transparency, and potential pressure for short-term performance. Staying private allows for more long-term strategic decision-making without quarterly earnings pressure. * **Ethical Healthcare Investment:** Miramar Equity Partners focuses on healthcare investments that aim to improve patient care, increase access, and enhance system efficiency. Examples include ambulatory infusion centers (reducing hospital waste) and tech-enabled services for medical record sharing, emphasizing making money while doing good. * **Preference for Recurring Revenue:** Private equity firms often favor businesses with recurring or highly reoccurring revenue streams (e.g., software subscriptions). These models offer greater predictability and sustainability, allowing management to focus on strategic growth rather than constantly re-acquiring revenue. * **Common Reasons for Deal Failure:** Deals can go south due to poor management team fit, overly aggressive growth bets, the business not being as strong or sustainable as initially perceived (e.g., reliance on a single key relationship), or unforeseen external factors like pandemics. * **Pathways into Private Equity:** Aspiring professionals are advised to start their careers in investment banking or management consulting. Key personal attributes include intellectual curiosity, a continuous desire to learn, actively seeking mentorship, and developing an "investor perspective" by constantly evaluating the value and sustainability of businesses. **Key Concepts:** * **Private Equity:** Capital invested in companies not listed on a public stock exchange. * **Seed Equity:** Early-stage funding for ideas or prototypes. * **Venture Capital (VC):** Funding for startups and small businesses with long-term growth potential. * **Growth Equity:** Investment in relatively mature companies seeking capital to accelerate growth without a change of control. * **Lower Middle Market Private Equity:** Investment in established, profitable businesses, often with EBITDA between $1 million and $10 million. * **EBITDA:** Earnings Before Interest, Taxes, Depreciation, and Amortization; a measure of a company's operating performance. * **Multiples:** A valuation metric that expresses the value of a business as a ratio of its earnings, revenue, or other financial metrics. * **Discounted Cash Flow (DCF):** A valuation method used to estimate the value of an investment based on its expected future cash flows. * **Financial Engineering:** The use of financial instruments and strategies to achieve financial goals, often involving debt to enhance equity returns. * **Recurring Revenue:** Revenue that is likely to continue in the future, often from subscriptions or long-term contracts. * **M&A (Mergers & Acquisitions):** Transactions in which the ownership of companies, other business organizations, or their operating units are transferred or consolidated. * **IPOs (Initial Public Offerings):** The first time that the stock of a private company is offered to the public. **Examples/Case Studies:** * **Ambulatory Infusions:** Miramar Equity Partners invests in businesses that provide ambulatory infusions, moving procedures out of hospitals to save costs for payers, offer convenience for patients, and allow for better data tracking by doctors, while freeing up hospital capacity. * **Pharmaceutical Businesses:** Mentioned as an area of investment for Miramar Equity Partners. * **Tech-Enabled Services in Healthcare:** Examples include solutions for more efficient sharing of medical records, aiming to make the healthcare system more efficient and provide better access to care. * **Construction Firm vs. Software Business:** Used to illustrate the difference between non-recurring project-based revenue (construction) and predictable, recurring subscription revenue (software), highlighting the sustainability and strategic advantages of the latter. * **United Rentals (Hypothetical):** A hypothetical example of a long-standing business relationship with a large client (United Rentals) that could be jeopardized by the retirement of a key contact, illustrating the risk of relying on single relationships for revenue.
Can Market-Based Pricing Save Healthcare? (with Dr. Keith Smith)
Self-Funded
@SelfFunded
Apr 30, 2024
This video provides an in-depth exploration of the dysfunctional United States healthcare system, advocating for a return to market-based pricing and transparent, bundled services. Dr. Keith Smith, founder of the Surgery Center of Oklahoma (SCO), shares his journey and insights into how the current system, driven by misaligned incentives and government intervention, leads to price gouging and inefficiency. The conversation highlights the stark contrast between the prevailing "revenue generation" model in healthcare and Dr. Smith's "value delivery" approach, emphasizing mutually beneficial exchanges and patient empowerment through upfront pricing. Dr. Smith recounts his early career as an anesthesiologist and the profound impact of Medicare's Resource-Based Relative Value Scale (RBRVS) in the early 1990s, which drastically cut physician payments while hospitals simultaneously grew in power and revenue. This experience led him to "rebel" and co-found SCO in 1997 with a mission to provide high-quality care with complete financial transparency, never accepting government money. The initial challenge of establishing bundled prices for procedures over the phone, and the eventual decision to post all prices online in 2009, are presented as pivotal moments in challenging industry norms and exposing systemic "scams." The discussion delves into how the traditional insurance model, with its opaque pricing and complex billing, incentivizes higher charges and benefits intermediaries rather than patients or even many providers. Dr. Smith exposes practices like carriers profiting from repricing inflated claims, hospitals maintaining non-profit status through "lost revenue" claims (which are then subsidized by Disproportionate Share Hospital (DSH) payments), and volume-guaranteed discounts that deter network inclusion of lower-cost providers. The video also touches on the transformative power of self-funded employers, particularly those offering zero-deductible plans, in driving better outcomes and cost savings by empowering employees to make informed healthcare choices. The Free Market Medical Association (FMMA) is presented as a key resource for fostering this alternative, parallel healthcare economy. Key Takeaways: * **Critique of Traditional Healthcare Billing:** The prevailing model in the U.S. healthcare system is driven by revenue generation, often leading to practices like upcoding (e.g., a $3,500 bill for a minor ER visit) and a lack of transparency, which exploits patients and creates an inherently inefficient system. * **Physician Ownership and Patient Advocacy:** Physician-owned facilities, where doctors have direct control over billing, can offer greater flexibility and advocacy for patients regarding their bills, in contrast to hospital-employed physicians who have no say in pricing. * **Distortion by Government Intervention:** Medicare's Resource-Based Relative Value Scale (RBRVS) in the early 1990s drastically cut physician payments while simultaneously leading to hospitals becoming "grossly overpaid," creating a fundamental imbalance and distorting market signals. * **The Power of Bundled Surgical Pricing:** Offering an "all-in" cash price for surgical procedures (including surgeon, anesthesia, facility, and pathology) eliminates financial surprises for patients and forces providers to operate efficiently and predictably, with the price itself serving as a proof of quality and repeatability. * **Strategic Price Transparency:** Publicly posting prices online, as Dr. Smith did for the Surgery Center of Oklahoma, empowers patients to shop for care, allows them to leverage better deals, and exposes the inflated costs and hidden practices of the traditional system. * **Exposing Industry "Scams":** The video reveals how various stakeholders profit from the dysfunctional system, including insurance carriers who make more money by repricing higher initial charges, hospitals that secure large volume discounts from carriers, and the use of "uncompensated care" claims to maintain non-profit status and receive federal Disproportionate Share Hospital (DSH) payments. * **Benefits of Self-Funded Employers:** Self-funding, even for smaller groups (e.g., 24 employees), can lead to significant cost savings by giving employers control over their healthcare spend. Offering zero-deductible, zero-copay plans incentivizes employees to seek necessary care promptly, preventing conditions from worsening and ultimately reducing overall costs. * **Buyer-Driven Market Change:** When self-funded employers and individual buyers insist on direct, honest, and transparent purchasing of medical services, it forces providers to adapt and offer competitive, upfront pricing, thereby driving market discipline. * **The Free Market Medical Association (FMMA):** This organization serves as a crucial resource for connecting buyers (self-funded employers, consultants) and sellers (transparent providers, direct primary care physicians) in a market-driven healthcare ecosystem, fostering mutually beneficial exchanges. * **The "Parallel Healthcare Economy":** Instead of attempting to reform the existing, deeply entrenched system, a more effective approach is to build an alternative, parallel market for medical services that operates on principles of transparency, value, and direct buyer-seller relationships, allowing the old system to "wither and die." * **Government as a Primary Conspirator:** The federal government is identified as the "primary conspirator" in the dysfunction of the U.S. healthcare system, with its interventions and regulations creating the very problems (e.g., price controls, subsidies) that are often mistakenly attributed to a failure of the free market. * **Optimistic Outlook for Change:** Despite the current challenges, there is a strong belief that increased awareness among the American people about the true causes of healthcare dysfunction will lead to a significant shift towards a more market-driven and efficient system within the next 10-15 years. **Tools/Resources Mentioned:** * **Free Market Medical Association (FMMA):** An organization that brings together industry professionals (buyers, sellers, intermediaries) to facilitate mutually beneficial exchanges in a transparent, free-market healthcare model. * **Paro Health:** A sponsor of the podcast, described as a manager of a large employee benefits group captive focused on improving health benefits and making self-funding simple for midsize employers. * **Claim.do:** A sponsor of the podcast, described as a medical claim auditing and member advocacy company providing fiduciary services to employer-sponsored benefit plans. * **PlanSight:** A sponsor of the podcast, described as an end-to-end RFP solution for benefits agencies to streamline the insurance renewal process. **Key Concepts:** * **Bundled Surgical Procedures:** A pricing model where a single, all-inclusive price is quoted for a surgical procedure, covering all components such as surgeon's fee, anesthesia, facility costs, and sometimes pathology. * **Resource-Based Relative Value Scale (RBRVS):** A payment system implemented by Medicare in the early 1990s that assigns a relative value to every physician service, which Dr. Smith argues distorted market pricing and led to physician underpayment. * **Disproportionate Share Hospital (DSH) Payments:** Federal government subsidies provided to hospitals that claim to provide a significant amount of "uncompensated care," which Dr. Smith argues incentivizes hospitals to inflate charges and claim losses. * **Self-Funded Employers:** Companies that directly pay for their employees' healthcare claims rather than purchasing traditional insurance plans, allowing them greater control over costs and plan design. * **Parallel Healthcare Economy:** The concept of creating an alternative, market-driven system for healthcare delivery and financing that operates alongside the existing traditional system, allowing consumers and employers to choose a more transparent and value-based option. **Examples/Case Studies:** * **Spencer's Son's ER Trip:** An anecdote where a three-year-old's minor breathing issue resulted in a $3,500 bill for a "level four ER" visit, highlighting the problem of upcoding and opaque pricing in traditional hospitals. * **Surgery Center of Oklahoma's First Breast Biopsy:** Dr. Smith's initial challenge in quoting a bundled price for a breast biopsy, leading to an all-in price of $1,900 compared to a hospital's $19,000 facility charge, demonstrating the immediate cost savings and transparency of the model. * **SCO's Experience with Blue Cross:** A brief, 16-month period where SCO contracted with Blue Cross, which resulted in zero profit due to complex, illogical payment structures and gross underpayment for services, illustrating the challenges of integrating transparent models into traditional insurance networks.
The Connective Tissue of a Health Plan - Planned Administrators Inc
Self-Funded
@SelfFunded
Jun 13, 2023
This video provides an in-depth exploration of the evolving role of Third-Party Administrators (TPAs) in the self-funded healthcare landscape, featuring George Stiles, President and COO of Planned Administrators Inc (PAI). The discussion centers on PAI's approach to TPA services, emphasizing partnership, flexibility, and leveraging data analytics to optimize health plans. Stiles shares his career journey, highlighting the value of foundational understanding in the complex healthcare industry and the concept of "corporate entrepreneurship" within a large organization like Blue Cross Blue Shield of South Carolina. The conversation delves into PAI's core services, including traditional Administrative Services Only (ASO) for groups ranging from 250 to 1500 lives, and their growing focus on level funding for smaller groups (down to 10 members) as a stepping stone to full self-funding. A significant portion of the discussion is dedicated to the benefits of Direct Primary Care (DPC) models, with PAI's successful partnership with Proactive MD serving as a key example. This model, which prioritizes quality care and tight coordination, is presented as a powerful tool for reducing overall medical spend and improving member outcomes, even for geographically dispersed populations through telehealth and scalable clinic models. Furthermore, the episode explores the critical role of data analytics in effective benefits management. PAI's "PAA Analytics" platform, built on Deerwalk, is highlighted for its comprehensive reporting capabilities and the transparency it offers to brokers, consultants, and employers. The dialogue also touches upon the impact of new healthcare transparency regulations, including gag clause attestations, and the broader implications of increased access to hospital and claims pricing data. Stiles expresses optimism for the future of healthcare, driven by innovation, data-driven decision-making, and the potential of emerging technologies like AI, while also stressing the importance of nurturing the next generation of industry talent and fostering collaborative relationships between TPAs and their partners. Key Takeaways: * **TPA as a Strategic Partner:** A TPA's primary role is to act as a partner and the "connective tissue" of a health plan, integrating various solutions and providing expertise to create a cohesive benefits package for employers and members. * **Importance of Data Analytics and Transparency:** Robust data analytics, like PAI's Deerwalk-based platform, are crucial for self-funded plans, enabling employers and consultants to measure, manage, and impact claims trends, ultimately leading to better decision-making and cost control. * **Level Funding as a Growth Opportunity:** Level funding serves as an effective stepping stone for smaller groups (e.g., down to 10 members) to transition into self-funding, offering claims experience and potential savings, provided the administrative approach remains streamlined and scalable. * **Direct Primary Care (DPC) for Quality and Cost:** DPC models, exemplified by Proactive MD, offer significant value by focusing on quality of care, tight coordination with specialists, and proactive health management, which can lead to reduced hospital admissions and overall medical spend. * **Scalability of DPC Models:** DPC can be scaled for diverse populations through a network of clinics, telehealth services, and a model that doesn't require high volume, making it viable even in rural areas. * **Navigating Healthcare Transparency Regulations:** New regulations, such as gag clause attestations and requirements for pricing transparency, are intended to empower employers and members with data, despite initial implementation challenges, and are expected to drive positive changes in the healthcare system. * **Value of Long-Term Stop-Loss Relationships:** Constantly switching stop-loss carriers for minor rate reductions can be detrimental, as it erodes relationships that are crucial for navigating complex year-end claims and securing favorable outcomes. * **Corporate Entrepreneurship (Intrapreneurship):** Opportunities exist within large organizations for individuals to act as "fixers" or "startup guys," taking on new challenges and developing innovative solutions with the backing and resources of an established company. * **Attracting and Developing Future Talent:** The healthcare industry faces the challenge of attracting and preparing the next generation of leaders and innovators, emphasizing the need for foundational business understanding over immediate high-level positions. * **TPA Role in Vendor Vetting and Security:** A reputable TPA thoroughly vets its vendor partners, ensuring robust system security, compliance protocols, and due diligence (e.g., SOC reports) to protect client data and prevent breaches. * **Flexibility in Solution Integration:** A strong TPA partner offers flexibility to integrate with a client's preferred third-party solutions (e.g., PBMs, enrollment systems) while ensuring all data is consolidated for comprehensive analytics. * **Exploration of Iqra Administration:** TPAs are exploring roles in Individual Coverage Health Reimbursement Arrangement (Iqra) administration, providing support for plan design, employee decision-making, and back-end reporting for employer contributions. * **Optimism for Healthcare Innovation:** The industry is ripe with opportunities for improvement through captives, DPC, AI technology, and increased transparency, suggesting a potential "renaissance" in healthcare. **Tools/Resources Mentioned:** * **PAA Analytics:** PAI's proprietary data analytics solution, built on the Deerwalk platform. * **Proactive MD:** A Direct Primary Care (DPC) provider based in South Carolina, operating in 17 states, with whom PAI partners. * **Blue Cross data center:** PAI leverages this highly secure, high-volume data center for its operations, processing billions of claims annually. * **SIA (Self-Insured Institute of America):** Mentioned as an organization with a TPA workgroup discussing industry issues. **Key Concepts:** * **Third-Party Administrator (TPA):** An organization that processes claims and performs other administrative services for a self-funded health plan. * **Self-Funded Health Plan:** An employer-sponsored health plan where the employer directly pays for employees' medical claims rather than purchasing traditional health insurance. * **Administrative Services Only (ASO):** A contract under which an insurer or TPA provides administrative services for a self-funded plan without assuming any risk for claims. * **Level Funding:** A hybrid self-funded model where an employer pays a fixed monthly amount, covering administrative costs, claims funding, and stop-loss insurance, with potential for refunds if claims are low. * **Direct Primary Care (DPC):** A healthcare model where patients pay a recurring fee (e.g., monthly) directly to their primary care provider for a defined set of services, often bypassing insurance. * **Stop-Loss Insurance:** Insurance purchased by self-funded employers to protect against catastrophic claims that exceed a certain threshold. * **Iqra (Individual Coverage Health Reimbursement Arrangement):** An HRA that allows employers to reimburse employees for health insurance premiums purchased on the individual market, as well as other qualified medical expenses. * **Gag Clause Attestations:** A regulatory requirement under the Consolidated Appropriations Act (CAA) for health plans to attest that they are not restricting access to cost and quality information. * **Corporate Entrepreneurship / Intrapreneurship:** The act of behaving like an entrepreneur while working within a large organization, often by developing new products, services, or processes. **Examples/Case Studies:** * **George Stiles' Career Progression:** His journey from a Medicare claims processor at Blue Cross Blue Shield to President and COO of PAI exemplifies internal career growth and the ability to take on diverse roles within a single large organization. * **PAI's DPC Partnership with Proactive MD:** PAI successfully partnered with Proactive MD for a university client, implementing a model where employees are mandated to use the DPC for primary care, with referrals required for specialist coverage, leading to improved quality and cost outcomes. * **PAI's Data Center Infrastructure:** PAI leverages the highly secure Blue Cross data center, which processes billions of claims annually and features advanced security measures like retinal scans and fingerprints, demonstrating a commitment to data integrity and protection.
Access to Healthcare Simplified | with Ryan Coplon
Self-Funded
@SelfFunded
Mar 18, 2025
This video provides an in-depth exploration of simplifying access to healthcare and optimizing employer-sponsored health plans, featuring Ryan Coplon, co-founder of HealthWallet. The discussion begins by establishing HealthWallet as a "member experience as a service" company, functioning as a benefits aggregation and engagement platform. Its core purpose is to consolidate disparate healthcare services and use this centralized "chassis" to communicate and engage effectively with members, thereby reducing fragmentation in the healthcare experience for employees. The conversation highlights the critical need to improve member engagement to reduce health plan expenses, ensure employees understand their healthcare options, and ultimately design more effective health plans. Coplon details his journey from a benefits broker to a technology founder, identifying a significant market problem: while employers were increasingly unbundling self-funded plans and adding innovative point solutions, employees often failed to utilize them due to confusion, lack of awareness, and poor accessibility. This underutilization not only negated the intended benefits but also contributed to unnecessary plan expenses. HealthWallet was initially developed to address this within Coplon's own brokerage programs, demonstrating the power of solving a personal problem that resonated with a broader market need. The platform's success led to its external market launch, driven by demand from TPA partners who recognized its value in their own client portfolios. A key aspect of HealthWallet's approach is its flexibility and vendor-agnostic "platform as a service" model. Instead of curating a fixed suite of vendors, HealthWallet integrates third-party point solutions (e.g., virtual care, pharmacy benefits, EAP) at the request of its partners, perpetuating the "strategist's strategy." This modularity allows for highly customized member experiences, where two HealthWallet implementations might be functionally unrecognizable from each other. The platform aims to simplify complex health plans by providing a consistent "front door" for members, regardless of the underlying carriers or point solutions. It also significantly reduces the burden of high-volume, low-complexity service requests (like "where's my ID card?") from member-facing service units, allowing them to focus on higher-complexity care navigation. The discussion culminates in a theoretical exercise of designing a "perfect" self-funded plan, emphasizing reference-based pricing, value-based primary care, robust care coordination, and strategic bill review to achieve optimal outcomes and cost efficiency. Key Takeaways: * **Fragmentation is a Major Problem:** The unbundling of self-funded health plans, while offering potential cost savings and specialized solutions, often leads to a fragmented member experience, causing confusion and underutilization of valuable benefits. * **Engagement Drives Utilization and Savings:** Effective communication and easy accessibility are paramount to ensuring members understand and use their health plan benefits. Improved engagement directly correlates with better health outcomes and reduced overall health plan expenses. * **Benefits Aggregation Platforms are Essential:** Solutions like HealthWallet centralize disparate healthcare services and information (accumulators, plan designs, virtual care, PBMs) into a single, user-friendly platform, simplifying the member journey. * **Vendor Agnosticism Enhances Scalability:** A platform-as-a-service model that integrates third-party solutions by request allows for greater flexibility and scalability, enabling partners (TPAs, brokers, payers) to maintain their preferred vendor ecosystems while still providing a unified member experience. * **Relieve Service Burden with Self-Service:** Mobile platforms can automate responses to high-volume, low-complexity member inquiries (e.g., ID cards, deductibles), freeing up care navigation teams to focus on complex, high-value cases. * **Timely, Actionable Communication is Key:** Leveraging automation logic for instance-based engagements (e.g., push notifications for pre-op/pre-cert, allergy season reminders) ensures members receive relevant information at critical moments, driving behavior change. * **Incentivize Member Behavior:** Plan designs should be structured to financially incentivize members to choose optimal care paths (e.g., free care at direct contract facilities, waived deductibles for centers of excellence), making the beneficial choice the obvious and easiest one. * **Digital Fulfillment Reduces Costs:** Transitioning from physical to digital ID cards and EOBs can lead to significant cost savings for TPAs and health plans, with some clients seeing over 90% reduction in print and mail expenses. * **The "Perfect" Plan Foundation:** An ideal self-funded plan often includes a reference-based pricing chassis for catch-all, a blend of direct primary care and value-based provider arrangements, and a mandatory pre-op/pre-cert process managed by a dedicated care coordination unit. * **Strategic Care Navigation:** The care navigation unit should act as the "brain trust" of the plan, executing on the plan-level strategy, guiding members through the healthcare journey, and alleviating the "onus of consumerism" from the individual. * **Long-Term Strategy Over 12-Month Cycles:** Employers should shift their mental paradigm from a 12-month insurance purchase to a long-term healthcare purchasing strategy, recognizing that sustainable cost reduction and quality improvement require a multi-year horizon. * **Market Shift to Self-Funding:** The benefits of self-funding are increasingly accessible to smaller employers, leading to a flattening of growth in the fully-insured market and a potential "adverse selection" scenario where fully-insured pools retain higher-risk populations. * **Regulatory Scrutiny on PBMs and Vertical Integration:** There's growing attention on the lack of transparency and potential conflicts of interest in the PBM sector and the vertical integration of insurers owning providers, suggesting potential future regulatory changes. **Key Concepts:** * **Member Experience as a Service (MXaaS):** A business model focused on providing platforms and services to enhance how members interact with and utilize their health benefits. * **Benefits Aggregation and Engagement Platform:** A centralized digital tool that consolidates information about various health benefits and point solutions, making them easily accessible and promoting member interaction. * **Self-Funded Plan:** An employer-sponsored health plan where the employer directly assumes the financial risk for providing healthcare benefits to its employees, rather than paying a fixed premium to an insurance carrier. * **Captive:** A type of self-funded arrangement where multiple employers pool their risks together, often gaining more control and potential savings than traditional self-funding. * **Reference-Based Pricing (RBP):** A payment methodology where healthcare providers are reimbursed based on a reference price (e.g., a percentage above Medicare rates) rather than negotiated rates with traditional networks. * **Value-Based Care:** A healthcare delivery model where providers are paid based on patient health outcomes rather than the volume of services provided, incentivizing quality and efficiency. * **Care Coordination/Navigation:** Services that help guide members through the complex healthcare system, assisting with appointments, referrals, understanding benefits, and finding high-quality, cost-effective care. * **Digital Fulfillment:** The electronic delivery of documents and services (e.g., ID cards, Explanation of Benefits) that traditionally would have been physical, reducing print and mail costs. **Examples/Case Studies:** * **Aha Moment for HealthWallet:** The realization at a group captive member meeting that cool, shiny point solutions were underutilized due to ineffective communication and lack of accessibility, leading to "egg on the face" of consultants and increased expense ratios. * **Micro Member Experience for Optimal Care Paths:** A TPA client with a reference-based chassis and direct contracts offers totally free care at specific facilities. HealthWallet created a micro-experience with "free healthcare" messaging, prompting members to choose this option or watch an explainer video if unsure, thereby steering them to optimal, cost-free care. * **Digital ID Card Savings:** A 300,000-life Mech plan client saved 90% on print and mail costs by offering digital ID cards and EOBs as the default, with less than 10% opting for physical copies. * **Personal Experience with Emergency Care:** Ryan Coplon, despite being a benefits navigation expert, defaulted to an expensive, private equity-owned urgent care for a motorcycle injury, highlighting that consumerism often fails in emergent situations.
Mark Cuban's Healthcare Tweet, Healthcare Is America's Top Employer | Last Month In Healthcare
Self-Funded
@SelfFunded
Jul 18, 2025
This video provides an in-depth exploration of recent headlines and trends in the healthcare industry, presented as a monthly news review. The hosts, Spencer and Nathaniel, discuss a range of topics from policy debates and public health concerns to technological risks and healthcare system reform, interspersed with reviews of related podcast episodes and a lighthearted game. The discussion aims to inform listeners about the dynamic landscape of healthcare, highlighting both challenges and potential solutions, particularly within the context of self-funded healthcare. Key themes explored include the significant influence of pharmaceutical advertising and lobbying on policy, the alarming rise of pre-diabetes rates among youth, and the critical issue of patient data security in the age of AI. The hosts delve into Mark Cuban's speculative healthcare reform ideas, which aim to disrupt the traditional insurance model, and reflect on healthcare's growing economic dominance as a top employer across the United States. The latter part of the video transitions into a "Self-Funded Review," summarizing recent podcast episodes that cover innovative solutions for employers, such as integrated health plans, functional medicine, and comprehensive care navigation, alongside practical advice for managing stop-loss insurance renewals. Throughout the discussion, the speakers offer their perspectives on the implications of these trends. They express concern over the financial power of the pharmaceutical industry and its impact on drug pricing and advertising regulations. A significant portion of the conversation is dedicated to the risks associated with healthcare workers using personal AI tools, underscoring the urgent need for robust compliance and secure, proprietary AI instances to protect Protected Health Information (PHI). The segment on Mark Cuban's plan reflects an appetite for disruptive innovation in healthcare, while the "Self-Funded Review" emphasizes the evolving role of HR professionals as fiduciaries and the importance of strategic healthcare planning for employers. The video also touches on broader societal issues, such as the impact of processed foods on public health and the long-term economic implications of the US economy shifting from manufacturing to a service-heavy healthcare sector. The "Ask Spencer Anything" segment provides practical consulting advice on navigating stop-loss renewal challenges, offering a blend of market reality, claims analysis, and strategic adjustments like raising specific deductibles. Overall, the video serves as a comprehensive snapshot of current events and strategic considerations within the complex and ever-changing healthcare ecosystem. Key Takeaways: * **Pharmaceutical Advertising Influence:** The pharmaceutical industry spends billions on direct-to-consumer advertising ($5 billion in 2024 by top 10 companies) and exerts significant lobbying power (2.5 times more than military and another large industry combined), influencing policy and potentially leading to over-prescription of expensive drugs. * **Global Rarity of Drug Ads:** The United States and New Zealand are reportedly the only two countries that permit direct-to-consumer advertising for pharmaceuticals, highlighting a unique regulatory environment. * **Alarming Pre-Diabetes Trends:** Pre-diabetes rates in children aged 12-17 have tripled in 23 years (from 11.6% in 2000 to 33% in 2023), with 38% of adults currently pre-diabetic, raising significant public health concerns linked to processed foods. * **AI and Patient Data Leakage Risk:** A study by NetScope reveals 71% of healthcare workers use personal AI accounts (e.g., Google Gemini, ChatGPT) for work, posing substantial HIPAA and PHI leakage risks, even if names are not explicitly entered. * **Importance of Secure AI Instances:** Healthcare organizations must prioritize using closed, proprietary AI instances that are not connected to open-source networks and are vetted by security and IT teams to mitigate data privacy and compliance risks. * **Enhanced Compliance for AI Use:** The proliferation of AI tools necessitates increased emphasis on compliance regulations and training to ensure healthcare workers understand the risks and proper protocols for handling patient data with AI. * **Mark Cuban's Healthcare Reform Vision:** Mark Cuban proposes a disruptive healthcare model involving cash pay options, untethering insurance from employers, a family reinsurance cap at $50k/year for $400-500/month, elimination of PBMs, and government net pricing for Medicare/Medicaid. * **Healthcare as a Dominant Employer:** Healthcare is now the top employer in 38 out of 50 US states, reflecting its significant economic footprint and contribution to the GDP (around 18%), but also raising concerns about long-term sustainability and potential resource shortages like nurses. * **Strategic Employer Healthcare Solutions:** Solutions like Veilance One offer integrated approaches for self-funded employers, combining stop-loss, member engagement, network design, and cost containment to improve member experience. * **Functional Medicine in Employer Space:** Functional medicine, focused on treating the root cause of disease, is gaining traction as a deployable solution in the employer space, offering advanced diagnostics and personalized care. * **Care Navigation and Simplification:** Companies like Amaze Healthcare aim to simplify the complex healthcare landscape by providing a single point of contact for members to navigate care, triage needs, and reduce reliance on numerous point solutions. * **HR as Healthcare Fiduciaries:** HR professionals are increasingly recognized as fiduciaries of their organization's healthcare plan, requiring them to actively understand and strategize healthcare benefits as critically as sales and operations plans. * **Addressing Stop-Loss Renewal Hikes:** When facing significant stop-loss rate hikes, employers should be informed about market realities (e.g., 9-10% medical trend, poor loss ratios), analyze specific claims driving costs, and consider raising specific deductibles for potential premium reductions. * **Hidden Ingredients in Processed Foods:** Even seemingly healthy or "protein" foods (like protein cookies or bars) and common staples (like bread) often contain a surprisingly high number of ingredients, including preservatives, seed oils, and sugar alcohols, impacting their nutritional value and digestive comfort. Tools/Resources Mentioned: * Google Gemini (AI tool) * ChatGPT (AI tool) * NetScope (Cybersecurity company) * Veilance One (Integrated health plan solution) * Amaze Healthcare (Care navigation platform) * HCC (Stop-loss carrier) Key Concepts: * **Direct-to-Consumer (DTC) Drug Advertising:** Pharmaceutical companies marketing prescription drugs directly to the public, a practice common in the US and New Zealand. * **Pre-diabetes:** A condition where blood sugar levels are higher than normal but not yet high enough to be diagnosed as type 2 diabetes. * **Protected Health Information (PHI):** Any information about health status, provision of healthcare, or payment for healthcare that can be linked to an individual. * **HIPAA (Health Insurance Portability and Accountability Act):** US legislation providing data privacy and security provisions for safeguarding medical information. * **Closed vs. Open-Source AI:** Refers to AI systems that are proprietary and contained within an organization's secure environment versus publicly accessible AI models. * **Self-Funded Healthcare:** An employer-sponsored health plan where the employer directly pays for employees' medical claims rather than paying premiums to an insurance carrier. * **Stop-Loss Insurance:** Insurance purchased by self-funded employers to protect against catastrophic claims that exceed a predetermined threshold. * **Functional Medicine:** A personalized, systems-oriented approach to healthcare that addresses the root causes of disease, rather than just treating symptoms. * **PBMs (Pharmacy Benefit Managers):** Third-party administrators that manage prescription drug programs for health insurance companies, often criticized for their role in drug pricing. * **Fiduciaries:** Individuals or entities legally and ethically bound to act in the best interests of another party, in this context, HR professionals managing healthcare plans for employees. Examples/Case Studies: * **Mark Cuban's Proposed Healthcare Plan:** A hypothetical model for US healthcare reform, emphasizing cash pay, untethered insurance, and direct pricing. * **Veilance One Solution:** An example of an integrated health plan offering for self-funded employers, aiming for a holistic approach to benefits. * **Amaze Healthcare's Care Navigation Model:** A service designed to simplify healthcare access and decision-making for individuals by providing a central point of contact for all medical needs. * **Colorado Legislation Lobbying Example:** An anecdote shared about a proposed healthcare legislation in Colorado that was reportedly "poo-pooed" at the last second due to lobbying efforts, illustrating the influence of special interests in politics.
Medxoom - One App To Connect It All! - Pricing, Communications & Payments for Health Plans
Self-Funded
@SelfFunded
Feb 14, 2023
This video provides an in-depth exploration of Medxoom, a technology platform designed to unify health plan management, communications, pricing, and payments through a single, intuitive application. James Walsh, EVP of Strategy and Growth at Medxoom, details how the platform aims to significantly improve financial outcomes for both health plans and their members by tackling the pervasive issues of healthcare cost opacity and member disengagement. The discussion highlights Medxoom's role as a cutting-edge problem-solving technology in the healthcare space, emphasizing its ability to bring cohesion to traditionally siloed healthcare components. The core of Medxoom's value proposition lies in its true white-labeled member experience. The platform integrates a myriad of health plan solutions—ranging from Telehealth and Direct Primary Care to carved-out PBMs and Reference Based Pricing—into one singular, easy-to-use application. This consolidation allows members to access a benefits wallet, search for care, engage with care navigators, and align with providers on pricing, all from a single point of access. A key to Medxoom's success in driving member engagement, with reported adoption rates exceeding 70% within the first week of launch for some clients, is the strategic decision by employers to go fully digital, often eliminating traditional plastic ID cards. Medxoom also stands out for its robust data engineering capabilities and intelligent automation. The platform ingests vast amounts of data, including machine-readable files from 3rd-party providers, to ensure compliance with the Consolidated Appropriations Act (CAA) and facilitate price transparency for members. An innovative future initiative involves proactive care intervention: the app will be able to recognize when members search for potentially serious procedures and trigger an immediate outreach from a case manager. This proactive approach aims to prevent negative health outcomes, optimize care pathways, and negotiate better pricing, thereby reducing the need for costly reactive interventions. Furthermore, Medxoom addresses the critical payment problem in healthcare through its "Single Payment Credential" (SPC Card), a single-use virtual credit card loaded with plan dollars, enabling closed-loop transactions and full payment to providers at the point of service. This system has achieved 100% provider acceptance and demonstrated a remarkable 40% reduction in unit costs compared to traditional network arrangements. Key Takeaways: * **Addressing Healthcare Opacity:** The current healthcare system intentionally keeps individuals in the dark about costs, leading to financial burdens and suboptimal decisions. Medxoom aims to reverse this by providing transparent pricing information. * **Unified Member Experience:** Medxoom offers a white-labeled application that consolidates all health plan components (Telehealth, DPC, PBMs, RBP, PPO, no-network plans) into a single, user-friendly interface for members. * **Driving Member Engagement:** High adoption rates (over 70% downloads/enrollment) are achieved by strategies such as eliminating physical ID cards and leveraging proactive outreach from care navigators. * **CAA Compliance & Data Integration:** The platform ingests machine-readable files from various data sources to ensure compliance with CAA transparency laws, allowing members to search for CPT codes and understand unit costs. * **Proactive Care Intervention with AI:** Medxoom's app can detect searches for serious procedures and trigger an alert to a case manager, enabling proactive outreach to members to guide them to appropriate, cost-effective care. * **Innovative Payment Solution (SPC Card):** The "Single Payment Credential" (SPC Card) is a single-use virtual credit card loaded with plan dollars, facilitating direct, full payment to providers at the point of service. * **Significant Financial Impact:** The SPC Card has achieved 100% provider acceptance and resulted in an average 40% reduction in unit costs compared to traditional network arrangements, solving common friction points like balance billing. * **Empowering Plan Fiduciaries:** The CAA places a greater onus on employers to act as fiduciaries, and Medxoom provides the tools and data necessary for them to make informed, cost-effective decisions for their plans. * **Marketplace for Healthcare Services:** Medxoom functions as a marketplace, aggregating direct contracts, bundled services, and content providers to offer members a wide range of vetted, cost-transparent care options. * **Scalability Across Employer Sizes:** The platform is an enterprise-level solution that serves employer groups of all sizes (from 1 to tens of thousands of employees) through TPAs, health plans, and brokers, with the greatest impact seen in the self-funded space. * **Industry Collaboration for Systemic Change:** The speaker emphasizes the need for continued collaboration, innovation, and a "grassroots effort" to educate consumers and collectively steer the healthcare system towards greater affordability and efficiency. * **Addressing Healthcare Waste:** The discussion implicitly acknowledges significant waste in the healthcare system, with estimates suggesting 30-40% of procedures or spending may be unnecessary, highlighting the potential for substantial savings through smarter payment and care navigation. **Tools/Resources Mentioned:** * **Medxoom App:** The core technology platform for unifying health plan management. * **Single Payment Credential (SPC Card):** A proprietary single-use virtual credit card for direct provider payments. * **Machine-Readable Files:** Data sources used for price transparency and CAA compliance. **Key Concepts:** * **White-Labeled Member Experience:** A customizable platform interface that reflects the branding of the client (employer, TPA, broker). * **Reference-Based Pricing (RBP):** A health plan strategy where payments to providers are based on a reference price, often leading to balance billing issues that the SPC card helps mitigate. * **Consolidated Appropriations Act (CAA) Compliance:** Regulations requiring health plans to disclose pricing information, which Medxoom helps facilitate through data ingestion and transparency tools. * **Unit Cost Reduction:** The decrease in the cost of a single healthcare service or procedure, significantly achieved through Medxoom's payment solutions. * **Care Navigators:** Third-party or in-house teams that guide members through their healthcare journey, now integrated and enhanced by the Medxoom platform. * **Direct Primary Care (DPC):** A model of healthcare delivery that removes insurance from primary care, often integrated into Medxoom's unified platform. **Examples/Case Studies:** * **Knee Replacement Cost Analysis:** A large client's historical claims showed knee replacements costing $68,000-$92,000, while Medxoom's marketplace offered direct contracts for the same procedure at $18,000, highlighting massive potential savings. * **Foot Doctor Cash Payment:** The speaker's personal experience of paying $36 cash for three X-rays, demonstrating how direct payment can drastically reduce costs compared to insurance billing. * **High App Adoption:** Clients who eliminated plastic ID cards saw 70%+ download and enrollment rates for the Medxoom app within the first week of launch.
The Secret to a Perfect Broker-Partner Relationship
Self-Funded
@SelfFunded
Nov 25, 2025
This video provides an in-depth exploration of building strong, trust-based broker-partner relationships in the self-funded healthcare benefits industry, while also delving into broader themes of personal and professional development, particularly for women in leadership. The hosts, Cara Kirsch and Libby Henry, share their journey of forging a highly effective partnership, emphasizing radical transparency, integrity, and the ability to navigate difficult conversations. They illustrate how these principles led to significant cost savings for a client, transforming a 74% fully insured renewal into a self-funded plan that saved millions. The discussion progresses from the personal anecdotes of their initial "virtual lunch" meeting during COVID-19 to the professional strategies that underpin their success. Key themes include the importance of clear expectations, mutual respect, and a commitment to solving problems together rather than assigning blame. They highlight that the best partnerships are not solely driven by the lowest numbers on a spreadsheet but by unwavering trust, especially when challenges arise. The conversation also touches on the unique pressures faced by working mothers in high-powered careers, offering insights into balancing professional ambition with family life and the importance of instilling independence in children. Furthermore, the video shifts to a critical analysis of the self-funded healthcare market, advocating for employers to take greater control over their healthcare spending. Cara Kirsch recounts a pivotal experience where she challenged a 74% renewal increase for a client, ultimately saving them $3 million by implementing a reference-based pricing, self-funded plan. This case study underscores the power of education, transparency, and innovative financing mechanisms in an industry often plagued by misaligned incentives. The speakers also forecast future trends, anticipating increased financial strain on hospitals, a growing demand for transparency in claims management, and a continued bifurcation of the risk pool as more employers explore self-funding. They stress the fiduciary responsibility of employers under ERISA and the need for consultants to act as stewards of the craft, empowering clients with knowledge and options. Key Takeaways: * **Radical Transparency and Integrity in Partnerships:** The foundation of a strong business relationship lies in radical transparency, honesty, and integrity. Partners should be able to have difficult conversations without fear of damaging the relationship, fostering an environment where mistakes are owned, and solutions are sought collaboratively. * **Beyond the Spreadsheet Numbers:** The most effective partnerships are not solely based on the lowest price or "best deal" but on the ability to trust and rely on each other, especially when things go wrong. This long-term trust often leads to better outcomes than short-term cost-cutting. * **Clear Expectations and Mutual Respect:** Establishing clear expectations early in a partnership, even if it means initially turning down business that doesn't fit the established process, builds respect and long-term commitment. This allows for more frank and productive discussions later. * **Continuous Learning and Adaptability:** Successful professionals in the healthcare industry must be "stewards of the craft," continuously learning and adapting to rapid changes. It's crucial to be open to different approaches and learn from others, even if they don't align with one's initial methods. * **Fiduciary Responsibility for Employers (ERISA):** Employers, as plan sponsors, have a fiduciary responsibility under ERISA to use their employees' healthcare dollars appropriately and transparently. This mandates a proactive approach to understanding and managing healthcare benefits, not just accepting the status quo. * **Challenging the Status Quo in Healthcare Benefits:** Employers should challenge their consultants and carriers, especially when faced with exorbitant renewal increases. Innovative solutions like self-funded plans and reference-based pricing can provide power and control, leading to significant cost savings. * **Data-Driven Claims Management:** Self-funded plans offer greater visibility into claims data, enabling employers to understand the "how and why" of healthcare spending. This actionable information is crucial for implementing cost management tools and addressing issues like specialty drug costs and inpatient care. * **Misaligned Industry Incentives:** The current healthcare benefits industry often has misaligned incentives, where brokers and consultants may earn more as fully insured costs rise. Employers need to be aware of this and seek consultants who prioritize their clients' best interests and education over traditional commission structures. * **Managing Healthcare Cost Drivers:** Employers should focus on understanding and managing key cost drivers such as inpatient care and specialty drugs. Solutions exist in these areas, and employers should ensure their administrative partners support the implementation of these solutions. * **Bifurcation of the Risk Pool:** The healthcare market is likely to see a bifurcation of the risk pool, with employers willing to embrace self-funding and active management achieving better outcomes, while those reluctant to change face worsening risk pools and higher increases. * **Empowering Women in the Industry:** The video emphasizes the importance of women claiming their seat at the table in male-dominated industries like healthcare. It encourages male colleagues to support and defend women, and for women to mentor and empower younger generations to enter and succeed in these fields. * **Prioritizing Personal Well-being:** Balancing high-powered careers with personal life, especially motherhood, requires intentional prioritization and acknowledging that "balance" is often a myth. It's important to set boundaries, delegate, and make time for personal well-being without guilt. * **Instilling Independence in Children:** For working parents, fostering independence, problem-solving skills, and personal responsibility in children is a valuable outcome. This prepares them for adulthood and allows parents to manage their demanding careers more effectively. * **"Follow the Money" and "A Closed Mouth Doesn't Get Fed":** Employers are advised to "follow the money" in healthcare spending and to "ask more questions" until they fully understand the answers, even if they don't like them. This proactive questioning is essential for informed decision-making. **Tools/Resources Mentioned:** * **Paro Health:** Described as the largest benefits captive in the United States, making self-insurance simple and accessible for small to midsize employers and arming them with cost management tools. * **Nomi Health:** Positioned as a company that has rebuilt self-funded benefits from the ground up, offering solutions like no co-pays, no deductibles, and zero out-of-pocket costs for members. * **Claim Doc:** A medical claim auditing and member advocacy company providing fiduciary services to employer-sponsored benefit plans. * **Veilance:** An integrated ecosystem solution driven by data that manages and simplifies medical claim costs for self-insured employers. * **Gallagher:** Mentioned as having robust data, specifically regarding the 40% increase in cancer costs since 2020. **Examples/Case Studies:** * **74% Fully Insured Renewal to $3 Million Savings:** Cara Kirsch recounts a pivotal experience in 2017 where a home healthcare company faced a 74% increase on their fully insured plan. By developing a reference-based pricing and self-funded plan, she saved them $3 million over three years, demonstrating the power of challenging the status quo and innovative financing. * **Walmart and Mayo Clinic:** The example of Walmart requiring employees to go to Mayo Clinic for certain treatments is cited as a large employer strategy to control healthcare costs, suggesting that middle-market employers can explore similar solutions. * **Iowa Employment Conference Client:** Cara mentions that a group from the Iowa Employment Conference in 2024 became her client after 14 meetings and a year and a half, highlighting the long sales cycle and the importance of educating clients about their consulting agreements, compensation, and compliance.