Healthcare sends 9 billion faxes a year. Delaware has a better idea

Speaker A: The end to a prior authorization. I never thought this day would come, but it appears to be upon us.

Speaker B: I can't even keep track of the portals that I have now.

Speaker C: You know, uh, every organization in healthcare connects to every other in a different way for a different purpose. It's like every organization built a different dirt road for every different type of car to everywhere else. Basically, Delaware has said, uh, we're going to have a dance and everybody's going to hold hands and we're going to solve this problem.

Speaker D: If we have an infrastructure that makes the technology invisible and it speeds the processes along, patients get the care they need faster.

Speaker A: Hi everybody. Welcome to the Lifers Podcast. We have got an amazing set of guests with us today to talk about one of our favorite topics, at least one of my favorite topics. And that is the end to a, uh, prior authorization. I never thought this day would come, but it appears to be upon us. So first we have Paul Meyer. You want to give us a wave? He's the CEO and co founder of, uh, uh, Smart Health Network. Aretha. Aretha Rochester is here as well. Um, and she's going to introduce herself and why she works, but she's actually a first guest that we've had on the show that represents the administrative front desk perspective. So I'm very excited to hear from her on that. And then we have Neil Hochstein, who's a practicing surgeon based in Delaware, but he also has a new job. Neil, can you tell us a little bit more about it?

Speaker D: Yeah, it's very exciting. On, um, Monday, uh, July 13th, Governor Matt Meyer created the Office of the Surgeon General for the State of Delaware and appointed me as Delaware's first, uh, Surgeon General. Uh, so I'll be seeing, uh, overseeing public health and also working on health care policy to streamline care for, uh, our million residents.

Speaker A: I love it. Um, Neil, I'm an, I'm an English, but I grew up in London, so, um, I'm a little bit ignorant on American history. But I have been reading about Delaware, um, of late and Delaware's got some special things about it, both from, ah, a health perspective and also what's meaningful to the state and the culture of the state. So maybe start us there and tell us what's special about Delaware.

Speaker D: Sure. Delaware is a unique place. It's the first state to sign the Constitution. Um, and it's a state that has a real mirror of the rest of the country. We have urban areas in the city of Wilmington. We have very rural areas. Um, we have farmers, we have migrant workers that come here to help with our agricultural business. But we also have some big industry. And so if you're ever going to try to solve a really hard problem, Delaware is a great place to do it because it's small enough to be manageable, but large enough to be meaningful. So we're very excited at some of the things on the horizon. Healthcare has been a huge focus for our governor, Governor Matt Meyer. Uh, we have a, uh, really desirable retirement, uh, community in Delaware. And so we're a state that's both growing and aging. There are very few states, uh, counties in the country that have, uh, an expanding population, but are also considered rural. And so our population is expanding with an influx of retirees. And that makes healthcare even a little more challenging. And so we're trying to solve that in all different ways. One is by improving access to care. And you can do that either by ensuring we have a robust workforce, but also ensuring that the workforce that we do have isn't bogged down with administrative burden that takes you away from caring for your patients.

Speaker A: Neil, you're a, you're a head and neck surgeon. Um, you probably didn't grow up when you were a child thinking, I want to go into medicine to fight with insurance companies. And yet that's what you have to do every day. That's what Aretha helps you do every day. So maybe I'll throw this question out to the two of you. Walk us through the realities today of what it's like to try to do good medicine and care for patients while grappling with today's healthcare system.

Speaker D: Yeah, I mean, I'll start by saying utilization management and prior authorization is actually important, but it works best when it's invisible. And that means it's invisible to the patient and it's invisible to the caregiver. Unfortunately, our system is full of friction. And thank the Lord I have Aretha and her team that make this work, uh, possible. But it's very cumbersome. I enter an order into an electronic medical record system, and the amount of behind the scenes work that it takes for that patient to get the test, even for a clean prior authorization today, it's incredibly arduous. And sometimes the problem is all of the documentation is accurate, all of the requirements have been met, but it doesn't move from point A to point B. And that friction is what we're trying to solve here. But Aretha can talk about what she's doing to get care for our patients, and it's a lot.

Speaker B: Yes, thanks, Dr. Hochstein. So, um, typically our day as test schedulers, um, and surgery schedulers to, I'm looking to be more a proactive care coordinator versus paper chasing and, um, trying to manage all the prior authorizations that we do have to obtain. So typically when I come into the office, I'm logging into multiple portals, um, because I know I'm going to have to utilize this throughout our day. Um, so when I go in, I'm logging on, I'm looking for, uh, a prior authorization that's pending. Um, typically it could still be pending days after, um, submitting the information. And then sometimes you get the authorizations that are being denied because we need more clinical information. And now we are uploading more documentation. Um, so, and this is not going to always result in it being approved. So therefore we have to go back, let the doctors know more information is being required. So it's just a lot of repetitive, um, documentation uploading, um, and then it could result in no auth is required. So therefore you just kind of waste it, maybe days, um, of time versus connecting with your patients and connecting with the facilities, making sure patients are having their proper care, um, handled. Because now we're focusing on logging into multiple portals, uh, making sure that everything is, um, moving forward with that authorization. And it could result in a delay of surgery, which we do not want the patients to have to experience. Right. So that's basically, it could be stressful on both sides.

Speaker D: And I'll just add to that the whole time the patient is excluded from those portals. Right. There's no mechanism for we can know. Uh, Paul likes to say it's like the Domino's pizza tracker. Right? You know, when someone put the pizza in the oven, when they take it out of the oven and when it's being delivered to you. But when your health is on the line and your prior authorization is pending, there's no way for you to know what's going on. And so there's fear fills information gaps. And so patients wonder, is the doctor's office just sitting on their hands and doing nothing? Uh, why doesn't my doctor care about me? This is so important to me. And meanwhile, Aretha is going moving information from our electronic medical record system, which uses one data architecture, into our practice management and billing system that uses a completely different architecture. And they don't talk to each other. And so historically, the fax machine has been that bridge,

Speaker A: Paul. There's physicians and, um, individuals like Aretha all over the country. I've talked to many, uh, provider offices that would tell you similar stories. Um, to the one that they just shared. And I think it's dead on that the patient is often left in the dock, um, wondering if they've been forgotten about. Sometimes it leads to delays in care. Um, can you fill in some of the gaps and just how you got connected initially with Neil? Um, tell us a little bit about your own entrepreneurial story and then maybe thread the needle a little bit with what's going on in Delaware, given this is such a, like we talked about, it's a revolutionary state in many ways.

Speaker C: Yeah. Um, um, I feel like I'm hopefully becoming an honorary Delawarean. Um, and I discovered, as Neil's aware, my great uncle actually was part of the vibrant Swedish community of Delaware and a faculty member of the University of Delaware. So it feels like a little bit of a homecoming. Um, no, this started in Delaware through Janice Nevin, who's the CEO of ChristianaCare, who's someone I've collaborated with multiple times in my career. First about 16 years ago when I launched a service called Text4Baby. Uh, and ChristianaCare was a big champion of that. 16 years ago.

Speaker A: Let's not gloss over Text4Baby because Text4Baby is amazing. Um, tell us just like in a few sentences what Text4Baby was and is.

Speaker C: Well, when we launched it 16 years ago, I described it as the SMS version of what to expect when you're expecting. Uh, if I were pitching it now, I'd call it an AI chatbot for maternal preventative health. But we didn't have AI chatbots 16 years ago. But it was a free public service that delivered evidence based messaging three times a week, um, uh, through, uh, pregnancy and through baby's first year. And pretty much the whole country got on board. We used to joke the only organizations in US Healthcare that weren't text for baby partners were those that hate babies. You sort of couldn't not be a partner. But for me, the principle which I think carries forward to this work is this radical idea that the human being is the central organizing point. One of the reasons that health it is such a mess is everybody builds their own separate systems for their institution, their different workflows, their different use cases and we just have this great big mess and Gordian knot. I'll never forget when I first actually went to CDC to pitch the idea for Texture Baby. I thought that texting could be a thing. Um, no one was really paying attention. And I'll never forget there were seven different divisions of CDC represented around the table. The Immunization Division, the Birth Defects Prevention. This is actually relevant to Neil and his new job overseeing public health, but basically all of the different siloed organizational functions within cdc. And I pitched this idea that Texture Baby should be a service for mom. And I'm absolutely convinced had we not launched it, there would have been the immunization reminder Service and the Birth2Vex, you know, prevention texting service. Instead we launched one. And what was amazing about it was every different stakeholder saw their own value proposition on this common thing, right? So Medicaid managed care plan saw this as a hedis improvement intervention fee for service. Pediatricians saw it as a well baby visit reminder service. Pfizer thought it was a prevnar vaccination adherence intervention. CMS thought it was a Medicaid and chip enrollment device. So again, it was one thing, but because we built it for the person, it actually served all of those different needs that otherwise would have met on a sort of a fragmented siloed basis. So as I think about the lessons that I carry forward from that and through some of the other things I've done subsequently, it really is this idea of building a common utility that is universal. And the way that Neil described and Aretha, uh, described her experience, that's just a microcosm of this systemic problem which in healthcare we've got all of these thousands of payers, hundreds of thousands of provider organizations, everybody trying to connect to everybody else for every different reason. So Aretha has to log into prior auth portals for prior auth. But then there's billing, then there is quality reporting. There are all these different reasons. And my analogy is every organization in healthcare connects to every other in a different way for a different purpose. It's like every organization built a different dirt road for every different type of car to everywhere else. It's insane. But that literally is status quo. So the real, what Smart Health Network really fundamentally is, is a hub. So you connect once and reach everybody else. Prior auth is the big burning problem that everyone's focused on. But it's just one example of one transaction type between the same group of providers, the same payers, and ultimately the same patients that really are at the heart of the architecture.

Speaker A: And it's, it's a utility. Can you speak to that?

Speaker C: Absolutely. I think we, we think of this as just sort of a foundational infrastructure. This ought to be, this is plumbing. This is universal plumbing. Another way to think about this, it's like the postal service in some ways. What are we doing digitally? We're allowing any organization the, um, Neil's ENT practice in Delaware to literally take a bundle of information. They implement what we call our gateway that basically takes that prior auth request that right now Aretha is having to go to those portals and manually enter, literally bundle that prior auth request with the accompanying clinical data, put it into a sealed envelope, send it to the smart Health hub. The hub is just a router. We don't open the envelope. All we see is, oh, this is from this practice. It needs to go to Highmark or Aetna. We route it and they respond and we route the response back. So really. And we don't, the hub can't see what's in the envelope. Right. So there's no data aggregation. That literally is just a blind router. The only person, by the way, who can see is if that prior auth request is about me, I actually have the key to open up an envelope about a, uh, prior auth request about my care. Right. So the patient is the only one who actually has the key, which is what allows this to enable the pizza tracker so that I as a person could basically say, hey, what's the status of this transaction between this provider and um, this insurer? And give me visibility into what's the status of my career?

Speaker D: And can I just add to that, it is a utility. It's a public utility as we see it, and a public benefit corporation entrenched in Delaware's corporate code. And so rather than it being a private industry trying to extract the highest rents, the goal is to have the lowest sustainable cost. I mean, ultimately, as a public health matter, we need to remove friction from the system and we have to reduce the cost of care. You know, health care costs is a public health issue for, uh, for our country.

Speaker C: Look, uh, we think of this as Neil said, as public infrastructure, right? And we had a model historically in funding public infrastructure, right? So I live in New York City. In 1919, New York and New Jersey realized we need some bridges and we need some tunnels. And New York couldn't do it, New Jersey couldn't do it. So what do we do? We created a multi state compact known as the Port Authority of New York. And New Jersey issued a $50 million bond to build the George Washington Bridge. Paid back out of tolls. Now my joke is that of course if we'd venture financed it, we would have had to sell the bridge in five to seven years to private equity and we'd be paying $100 surge pricing to get home on Friday night. Right? But somehow. So, uh, we had that Mental model in the world of physical infrastructure, but we now live in a digital first world. We've never conveyed that in healthcare. We've, we've tried to build, uh, infrastructure. I mean HIEs are a great example. Right about 20 years ago, the federal government provided a bunch of money to states to try to get ahead of interoperability. And they stood up hies in every state that did a lot of clinical data interoperability. But guess what? It was implemented state by state and in many states today those things don't connect across state lines. So one of the things that not only is Delaware, uh, a real pioneer of the corporate forum, which it's been such an interesting collaboration to think about, how do you structure a public benefit model with a governance council, a data trust to represent the fiduciary duty to patients in a structure? How does that fit within the context of Delaware law and how do we protect that? So it's been great from that perspective. It's also great because Delaware is a small state and they realize that sometimes people go to the hospital in Philly or go to Baltimore and they can't do something that only works within the territory of Delaware. So anyway, that's kind of how we think about uh, this as a utility and public infrastructure for the digital era.

Speaker A: I think you all have thoughts on this, but if you were to pitch me on a bridge, it would be an easy sell. You could get from New York to Jersey without swimming. I would say yes to that. Um, if you were to pitch me on the equivalent for exchange of health information in order for care to be processed more quickly and pay for more quickly. I mean, that sounds good from a patient perspective, but, um, give me the, what's the take that makes me go, I need this as a patient. Like explain it from the patient perspective in a way that says this is an urgent hair on fire problem that needs to be solved. What is falling through the cracks, to borrow from this, this bridge analogy, and falling into the water, because we do not have this.

Speaker D: I think you can look at it in two ways. First of all, you can look at from the provider perspective. Air providers are hurting, they're burning out and there's moral injury because you're not able to care for your patients in the way that you know you need to. And you know, some of the friction that we feel is, you know, the prior auth work is all done and yet for whatever reason it's not approved. And so you have to do a peer to peer appeal. So those are loosely scheduled. But Just like when you go to the doctor's appointment, you may be 5, 10 minutes late, 20 minutes late because you had an emergency. Well, those peer to peer calls could take five minutes, they could take 20 minutes. And so you don't know what to expect. So I can be. And God forbid you have a prior off peer to peer call waiting and you don't get there within a minute or two, that utilization management nurse or doctor is not going to wait on hold for you for five minutes. So I'm examining a patient, I'm talking to a patient about whatever problem is, is most important to them at that moment. And I have to leave and I have to walk into my office, log into my medical record system, find another patient, make sure that I have the cognitive load to be able to advocate on their behalf, only to find out that the reason we're doing this prior authorization is because the paperwork never got there. Whoever's doing this utilization management doesn't know what they're even looking at.

Speaker A: We should, I think at this moment would be a good, A good moment to pause and play a clip from a very important phone call that you had, Neil, with an insurance company. Um, this is a short clip. So, so stay tuned. Just listen to it. Because I think this will ground us in the realities of what Neil has to deal with on a daily basis as well as his team.

Speaker B: Well, if you had. So 1. We didn't have any clinical information. Well, you had my note anyway.

Speaker D: You did have my note. We did not have your note. You don't have my note. You have no clinical information on this patient? Um, I have nothing attached to this

Speaker B: patient's, um, claim request. And this is why we said we could not approve the request because we do not have enough information of the

Speaker D: symptoms, um, required, um, for approval.

Speaker B: Okay, so we didn't have, um, the

Speaker D: documentation which was what was in the

Speaker B: denial rationale or denial note.

Speaker D: So it was denied without asking for additional information.

Speaker B: Well, um, so I don't. So basically, here we are. What information do you have today?

Speaker A: Okay, Neil, um, I think that was a perfect example of where you were going. You know, it's. It must be so frustrating to have polls like this where there's no clinical information on the patient.

Speaker D: It's totally frustrating when you're on that call. And then it's even more frustrating because you now need to go back to the patient from whom you were interrupted. And you've got to start over. And that patient is likely kind and generous and willing to acknowledge what you're doing. But it slows down that next interaction and that cycle happens over. It's like Groundhog Day over and over again. And so it's bad for the providers, it increases the administrative burden, that reduces your productivity and so you care for fewer patients. So from, from the public health perspective, it's a problem. I think from the patient perspective it's that they don't know what's going on. And that delay for them could be life and death. Patients don't wake up worried about utilization management or prior authorization. They worry about their knee pain or their cancer. Can they get their injection or their MRI or whatever they need to get better. And so we need to be able to solve the cost of care and ensure that we do utilization management. But if we have an infrastructure that makes the technology invisible and it speeds the processes along, patients get the care they need faster.

Speaker B: So when there is a peer to peer, um, required, um, normally now, paperwork is going out to the patient letting them know that their surgery was now, um, denied. It does not reach the patient until we have already scheduled the peer to peer and it is usually already taken care of and the problem is solved nine times out of ten. Um, but now the patient has received this letter stating their surgery was denied. And we are taking these phone calls to kind of ease the patient's, you know, mind saying we've already taken care of everything. But unfortunately that paperwork somehow does not, it's not stopped from getting to the patient. Um, so if there's any way that we could keep the patient informed on what's going on, like hey, it was denied, but this is only due to uh, more information needed. Doesn't mean that you're not going to get that surgery done because that's where all the panic sets in. And then now we are taking phone calls from patients who are definitely concerned because they've one already put in, um, time to have uh, um, from work. Um, now they're fearful that they won't be able to get this procedure done. So to kind of eliminate that fear for that patient, how could we um, I guess let them know before that paperwork arrives at their home? How can we communicate with them, um, to let them know, don't worry, we're taking care of X, Y and Z. Like we have the doctor aware of the peer to peer, he will take care of this without that paperwork. I guess getting to the patient and causing them um, to be concerned, if that makes sense. Absolutely.

Speaker A: And they blame the doctor's office. Right. If it doesn't seem like things are being Coordinated. Well, it's always the fault of the doctor's office and they don't know it's necessarily what's happening in the background.

Speaker C: And I think I would add to that it's a structural problem. We talk to the doctor over here, talk to the insurance company over here, they talk to each other. It's the game of telephone, right? And this is not just about prior authorization. I mean think about bills, right? You get a bill from a hospital, then you get this explanation of benefit from the uh, benefits from the insurance company. If you actually take the time and realize, oh wait, they don't add up. So you spend all afternoon calling the doctor's office, calling the insurance company, trying to resolve and you basically, you know, the doctor's office says, well I don't know, talk to the insurance company. The insurance company says, I don't know, talk to the doctor. It's like we treat patients like the children of fighting divorced parents where we make the kid be the go between, shuttle back between mom and dad. It's crazy, it's abusive and that's what we put patients through. And it's a structural problem. There is no common conversation where the doctor, the insurance company and the patient are all part of the same conversation. That is the structural problem and it will never be solved with as well intentioned with one insurance company doing their thing. Oh, look at my portal. One ehr vendor doing their thing. Look at my patient portal. No, it's a structural problem. We have thousands of providers, we have hundreds of thousands of provider groups. They can't solve the problem. It's not their fault. They are structurally incapable of solving a problem because of this n times n problem. So unless there is a common hub where patients actually have a seat at the table, we won't solve this problem in a way that A creates efficiency but B empowers patients. And that's where it's been interesting. Chris. As you know, I've been championing a version of this vision for a very, very long time. And I really want to commend Neil and the state of Delaware for exercising real leadership. No one argues that this doesn't make sense. The only thing that I've been getting when I talk to insurance companies over here, I talk to hospitals over here, I talk to ehr vendors over there, it's like, well, of course apes makes sense, but we would do it. Would they do it? And the insurance companies say, well we would do it, but would the hospitals do it? And I say m, I'm talking to both of you. You both say you would do it. I'm reminded of when I was in middle school, you went to the dance. You couldn't ask the girl out. You had to have your friend ask her friend. Well, if he asked, would she say yes? And then vice versa and you can actually have, you know, dance. Well, that's what's happening. And basically Delaware has said, we're going to have a dance and everybody's going to hold hands and we're going to.

Speaker A: Delaware is a cool kid in this scenario.

Speaker C: Delaware is a cool kid. Uh, people dance when Delaware says dance.

Speaker A: Who doesn't want to talk to Delaware?

Speaker D: This is what, this is the role of government. I mean, what should government do but bring people together to solve problems? And we're talking about prior authorization today. But that's just the tip of the iceberg because really, this is an infrastructure. How frustrating is it when you go to one doctor's office and you fill out a form, you list all your medicines and you tell them what surgeries you had and your past medical history and your family history, and you see that doctor and they care for you and they say, you know what, you need to see this other doctor. And you go there and you have to fill out the same paperwork again. Right? You have no way of sharing that information. You have no way of sharing public health reporting. We have a whole different system for claims adjudication.

Speaker C: Right.

Speaker D: And we haven't even talked about when AI gets involved. And you move from a, uh, health care system in the US that we have now, where it is a low frequency, high acuity visit, as opposed to high frequency, low acuity care, when maybe you're corresponding with a bot that is helping you manage your diabetes? Right. So we don't have the plumbing, the data infrastructure to move those things around.

Speaker A: Do you all think that this is a hard, technical problem to solve in any way? And I reminded a little bit of text for Babypo where you came along and said, text messaging. And it's not like that was the greatest innovation of all time. Um, people have been texting for a long time. This is a standard way of communicating. And you just came along and said, isn't it easier to read a text message asynchronously if you are a lower income, um, mother who has a lack of time? Um, and that seemed to do the trick. So is this, is this sort of the same thing where the answer is, is so simple in a way that it sort of smacks you in the face? Or do you think this is a problem that needs to be be solved with immense technology. Um, what do you all think?

Speaker C: I don't think this is a technology problem at all. I think this is a governance and trust problem. And this, to Neil's point, is why this is a role for government, but role for government in a new way. This is not a problem that the state of Delaware can solve by itself because the problem has to work across the border in Maryland and New Jersey and Pennsylvania and vice versa. Right? Pennsylvania can't solve it, Maryland can't solve it. New Jersey can't solve it either. So government is a key catalyst, government is key stakeholder, government's a big payer. So government needs to engage as a payer for Medicaid, for state employees. So government has a huge role to play in being catalytic. But to answer your question, no, I don't think this is rocket science tech here at all. This is about how do you actually create a governance structure that people realize is neutral, is sustainable, will be independent in perpetuity. And this also gets back to corporate structure. There are clearinghouses, there are lots of people, there are lots of VC funded startups solving little bits of this problem. But structure matters. If you're under a structure where your goal is to maximize return in perpetuity for investors, you're going to sell to whoever if the price is right, which ultimately means you're not going to be trusted by the other stakeholders. So this really is sort of public infrastructure. This is why governance really matters. So that for me, I think, uh, is the real unlock, is a structure that people can trust, that the government can embrace but not operate right. Because the government operated tech isn't generally the best tech in the world. So that for me has been the real unlock, not some breakthrough, amazing AI kind of tech innovation.

Speaker D: And our job, by the way, as a state, we're first. But this is not a Delaware thing. Uh, we want to bring every other state along. Um, and Paul, I think you should probably give the visa analogy because that's really the best analogy of what we're talking about. Uh, we have a three way healthcare switch, we've got a payer, we've got a provider and we have a patient. And Paul will talk about our three way banking.

Speaker C: Yeah, well, think about it, right? I mean, what is Visa? It's a hub that connects merchants, uh, banks and consumers.

Speaker B: Right?

Speaker C: And this is a three way hub between patients, payers and providers. Now what's really interesting, and for people that may want to listen to podcasts 24 7, um, once you're done with all of Chrissy's podcast, you can read or listen to Acquired, which is also a very good podcast. But one of the best Acquired podcast episodes was the Visa one, and it's about four hours on the full history of Visa. And the real unlock of Visa was governance. Visa started as the BankAmericard in Fresno, California, in 1958. It was bank of America, which was, by the way, then just the bank of California, um, because we didn't have interstate banking licensing. And it worked. Visa, uh, sorry, bank of America started then licensing this to other banks. Other banks said, well, wait a second, we don't want to be a franchisee of the BankAmericard. So they actually got together and created a governance structure where the banks managed together. And for 50 years, effectively, it operated as a cooperative of the member bank. So, again, the real unlock here is not technical, but how do you create a governance structure, a sustainable operating model that enables this to be sort of trusted, neutral Switzerland utility.

Speaker D: Right. And so right now we have four, you know, Visa, MasterCard, Discover, and American Express. You have four payment processors that move this data around. Uh, we could function in a country if we had four of these, but we have more HIEs in health information exchanges in the US than we have states. And my Delaware HIE doesn't talk to Maryland, Pennsylvania, New Jersey, or New York.

Speaker B: Right.

Speaker D: So that data's not moving. And so if we can get ourselves close to the Visa model, then all of the movement of information that Aretha is doing manually and all of the anxiety that she's, uh, trying to alleviate. I mean, Aretha didn't mention that a lot of her job is, is. Is. Is being a psychiatrist and trying to keep our patients under control and calm when they feel like they're at their worst. And so, um, if we can get ourselves to the point where we have a one infrastructure or a very small number of infrastructures across the country, when someone twists their ankle in Ohio and has to go to the doctor, they don't have to worry about all of those issues because their health insurance is in Delaware. Their care is in Delaware.

Speaker A: Neil, what made you want to go out on the limb? Because, you know, everything you all are saying makes so much sense. And I love the analogies to other industries, like what we've seen in financial services or in physical infrastructure, but health care is inertia central. And there are constantly excuses as to why we shouldn't do things. Privacy is a, is a excuse that you hear a lot of, or it's why should we have to do it when it's somebody else's problem or it's a finger pointing? But it seems like at a certain point you said enough is enough and Delaware is going to take this problem on and be a first mover. So what got you there and gave you that courage to take the risk?

Speaker D: So the first is we had an opportunity. Um, the opportunity is uh, HR1, the biggest, uh, one big beautiful bill act that Congress passed had something called the Rural Health Transformation Program. And we really looked at this as an opportunity to transform care. It's not just to backfill potential cuts to funding or the margin degradations that we see in health care. We really thought if we're going to make a difference, we need to transform care. And you can transform care in a lot of different ways. But every doctor you talk to is going to tell you that prior authorization is a problem. And so I took a step back and I thought we've passed legislation in Delaware and most states have passed some prior authorization legislation. And I've said that it's like putting lipstick on the prior authorization pig. You just can't solve it simply by, you know, shortening the duration from five days to three days for non urgent prior auth problems. You can't stop it by saying there's no more step therapy. I mean ultimately our payers are also under pressure because their medical loss ratios are going up every year. And so I felt like Delaware was uh, in a great position to be able to invest money in this because we're a small state. Uh, we did very well in our rural Health Transformation application. We had the fifth highest per rural resident award. And I think it was our ability or our willingness to go big to really try to transform care. And the other thing we had going for us was frankly CMS set a deadline. So CMS 0057 set a deadline that uh, prior auth needs to be the electronic by January 1st. Well that deadline only applies to the payers. But my medical record system in my practice isn't mandated to connect to all those payer portals and nor is every other bespoke medical record system. And so we can only solve this problem so much on the payer side alone. We need those neutral rails. And so at the time I was not Surgeon General, I was uh, chairing the Delaware Healthcare Commission. I was a volunteer and I went out on a limb, I pitched it to the governor and he thought it was a good idea. Uh, Paul pitched it to me, I pitched to the governor and we said, you Know what? We're Delaware, we can do this. And so here we are. Someone needs to solve this problem. And it can't be solved by a provider because they're too proprietary about their data. And it can't be solved by a payer alone. And so we need to keep the data secure. I mean, that's paramount. And having those sealed envelopes moving, that's the key. And so all heads had this idea for the rails and partnerships and experience to do it. And so we literally stuck our necks out. And, uh, I'm confident that our heads aren't going to get cut off.

Speaker A: So if anybody listening to this is thinking, God, I'm so on board with this, like, prior authorization is the bane of my existence. Ah, maybe they've got Aretha's job or they're a physician or they're an entrepreneur. Just dealing with the realities of this. Um, how do we make you all successful? Is it that we've got to, like every other state's got a. Gotta pick up on Delaware's example. What can we do as patients to support this work? What can we do as providers to support you? Like, how do we get a groundswell around this concept to really get it national?

Speaker C: I want to answer that by double clicking on some dates, right? Because you pointed out, Chrissy, healthcare is lethargic and slow and there's always something more important. There are two really important dates that are relevant, first to states and secondly for payers. Um, the Rural Health transformation awards were December 31st. CMS has been really clear to states, hey, we gave you money. We now want to see results. So the states are under real pressure to actually show they're making concrete pressure. The coverage of Delaware's announcement on Monday was rural health funds to fix prior auth. Right? That's a really clear high priority use of rural health money. So the first thing is states can actually literally replicate the Delaware template, um, that was already approved through CMS to implement this model in Delaware. And they can basically do this as a model to show that they're doing something specific and concrete and transformative under their rural health funding. The second key deadline is January 1st. January 1st is the deadline for implementation of what's called CMS 0057, which is the electronic prior authorization, um, requirement. So payers have to support electronic prior authorization using this sort of modern FHIR kind of standards model. The default path is everybody implements it independently. And what's the result? Aretha still might have electronic portals to go to, but she's still got 17 different payer portals, that is not going to solve the problem. So there's an opportunity for states and states first and foremost to say, hey, you know what, we actually need to show that we can really do transformative impact with our rural health money quickly. One, number two, this deadline, all the payers are going to do something for January 1st. The question is, do we double down and end up with another generation of point to point integrations and portals or do we say like Delaware is enough is enough. We're actually not going to have another generation of portals and point to point integrations. We're going to solve this. So uh, I do think state leadership is really important. And if other states, whether it's 5 or 10 or 15 or 49, want to get on the Delaware train, there's a really clear playbook for them to do that. And then whole markets join. I think one of the challenges that, you know, there are all sorts of startups, uh, there are all sorts of companies that are trying to solve this, are trying to solve this problem customer by customer, implement, uh, it doesn't work. This is a systemic problem and it requires a whole market, even a small one like Delaware saying we're all going to go and do this together and we're all going to do it on January 1st. Who else wants to get on the January 1st, uh, cohort and launch train?

Speaker A: Aretha, would you just be so disappointed in your gut if somebody said the answer to this is just more portals?

Speaker B: Absolutely. It would be devastating. I can't even keep track of the portals that I have now. You know, different logins, um, if you don't use them within 30 days, you have to log back in. It's just a lot of, uh, it's frustrating at times and it can be overwhelming. Um, but we do it right because we know the patient needs, um, that support. But another portal. Yeah, I'm not for that.

Speaker A: I love it. Portal fatigue.

Speaker B: Yeah, there you go.

Speaker A: One of the things that I like to think about is really the high Tech act, uh, for those not familiar, it was uh, a huge tranche of taxpayer money, about 30 billion that was, that was put towards digitizing medical records and I think was, was quite successful, but did not achieve the ultimate goal of interoperability. That said, the vast majority of doctors offices now are digitized. By contrast, the Rural Health transformation program is 50 billion. So there is real money involved with this program to do real things, transformative things for the industry. So I feel like what you've all presented here today is, is something truly Transformative like do you, how do you think about it? And when you look back at kind of when we've had these opportunities in the past and I think one of the things about high tech was, you know, yes, we got, we achieved some of the goals but not all of them are there lessons to be had from that kind of um, that period that we could take forward to this opportunity we have ahead of us today.

Speaker D: I think the biggest lesson is we can't operate in silos. It just doesn't work. And we're eager to have other states join us uh, so that we don't duplicate the same mistakes. To me that's it, it's, it's, let's all work together to solve this. Our state lines are artificially drawn and our patients don't respect them and uh, they need to be on a common utility if we want to ease the administrative burden.

Speaker C: I think what I'd add to that, right, if we think about this, the historical arc, the hit historical arc if you will. So the high tech money digitized records we ignored by the way the administrative side of the transaction. So one of the things that I like to always explain is why do we still send 9 billion faxes? American healthcare because we have one system set of systems for clinical records ehrs hies, we have a whole other set of infrastructure which is the clearinghouse and X12 and they don't talk to each other as Neil said earlier. Which leads to hey Dr. Hochstein, we'd love to approve your prior auth. Can you fax us the clinical notes? And meanwhile we the patients weren't invited to either party, right? So if you want to think about it, this three way hub brings those things together in a patient centered way. But going back to high tech, you needed to digitize the practice, right? You can't integrate those old paper files with the multicolor tabs that you used to see in doctor's offices. Right? So you needed to get to the first step which is having digital records. You needed standards, right. And I want to really call out organizations like HL7 and FHIR and the huge progress that has gone into defining transactional standards. What is missing is the connectivity. You can have the best standards in the world if everybody has to connect to everybody else. Even if you've got perfect standards, it doesn't work. It just doesn't scale. And to be really concrete, DaVinci, which is the uh, HL7 standards guide around prior authorization was pioneered five years ago by Regents Blue Cross, Blue Shield and Multicare in Washington State five years ago. They proved if you had a real time connection where clinical data could basically transact in real time with a payer, you could radically basically make prior auth real time or to Neil's point, make it go away. They proved that out five years ago. The challenge is it required every payer and every provider to individually agree to do it together. So five years later, Regents is connected to a grand total of five health systems. They've gone from one to five in five years. Guess what? Multi Gear, they can do that with Regents, but they don't get to transact with any of the other payers that way. So this is not novel. Thanks to the work around all the standards. We've got the standards but we need one place to hub, one way to connect. So you connect once and then you can transact with everybody and oh, uh, by the way, do it in a uh, patient centered and patient transparent way.

Speaker D: And we can't just replace fax machines with an API because we still have the same spaghetti set of connections. We need the common utility. So we're not just replacing old tech with newish tech.

Speaker A: Yeah, I sometimes joke that it's really the healthcare industry and the drug dealers that are keeping fax machines in business.

Speaker C: And pagers too, don't forget pagers and pagers.

Speaker A: But I've heard the drug dealers have actually moved on. So it's just health care at this point in time. Fantastic. So it sounds like we need more states to raise their hands and get involved and that's a big one. As well as uh, the buy in from providers and payers. Um, for those listening to this podcast that want to support um, what's the best way to get in touch with all of you? How can they do that?

Speaker C: Well, there's a huge amount of information@smarthealthnetwork.org um, including uh, all the information on Delaware's announcement, everything. This is a utility. It's totally uh, transparent costs. They can download the software, they can read all the documentation, they can read about the governance model. Uh, everything is available transparently there.

Speaker D: If you're a government official, your Rural Health Transformation office, uh, there are great opportunities for us to connect at uh, um, Health Future Summits and through your departments and divisions of public health for your Medicaid offices. We're excited to have these conversations and work together.

Speaker A: Neil, what's the best time to visit Delaware?

Speaker D: I grew up in Delaware. I think every day is a great day in Delaware. I left for 20 years and came back. I think Delaware is. My wife, who's not from Delaware calls it a sleeper state. I think it's just a wonderful place to live, grow up, raise a family. Our beaches are incredible. Um, we have rolling hills and beautiful countryside in the Brandywine Valley. If you really appreciate Four Seasons, Delaware is a great place to be.

Speaker A: I love that it's, it's the sleeper state, but it's also the state that is going out on a limb, um, and doing, and doing something new. So thank you so much for, uh, joining me on the pod. This has been a fascinating discussion and for the sake of all of us, I hope that all of you are successful.

Speaker D: Thank you.

Speaker B: Thank you.

Speaker C: Thanks so much.

Speaker A: That's a wrap on lifers. If you know someone else grinding it out in healthcare, send them this episode. And if you want more unfiltered takes on digital health, check out the Second opinion newsletter link in the show notes.