The 7.7% Wake-Up Call: A Roadmap to Align Finance Teams With Non-complacent Benefit Design, With Patrick Nelli. EP509

This file was generated by Descript Episode 509. The 7.7% wake up call. Today we're talking about a roadmap to align finance teams with non complacent benefit design.

I am speaking with Patrick Nelli. American Healthcare Entrepreneurs and Executives You Want to Know, Talking. Relentlessly Seeking Value. Hi, this is Sarah Monroe in Chicago and I'm a benefits procurement leader.

And I'm curious why you think so few executives take proactive, bold action in health benefits strategy given the magnitude of opportunity. Isn't that a great question? Okay, so last week we did an Ask Me Anything episode with Lee Lewis where we answered this exact same question Sarah just asked from the standpoint of a CEO, Chief Executive Officer. This week, we're taking the same question, but from the standpoint of a CFO, Chief Finance Officer and or the finance team writ large.

And this week we're going through a very crisp roadmap for how to move forward toward proactive, bold action, in alignment with said CFO slash finance team. This roadmap though, since we are talking about finance folks here, it does double duty setting up the hardcore, why. As in, why should finance wish to upgrade benefits? Why get away from being kind of complacent and maybe a passive price taker?

I mean, consider step one of the roadmap that we're gonna cover here in a moment. Step one is to recommend that the finance team set their next year and out year forecasts at an accurate, greater than 7.7% trend. You might be able to see how that will get a finance team to find their why pretty quick.

Oh, was that a spoiler of what's to come? Why yes, it was. My guest today Patrick Nelli is currently the CEO of Aligned Marketplace, which has a really cool premise based on the power of advanced primary care. Check them out.

Patrick Nelli is also a former CFO. So yeah, you can see why he'd be a really great guest to take us through this roadmap for how folks at a plan sponsor not in finance can align with finance to move forward toward a health plan that works better and costs less. So without further ado, here's Patrick's roadmap, but for sure, listen to Patrick explain it. The points that he makes and the details that he brings up are both helpful and also really thought provoking.

Step one. Of the roadmap is stop the renewal surprise. Engage with CFO finance teams and take in the advice of John Quinn from episode 493 and Lee Lewis from last week. This is an ongoing engagement type engagement, not a see a right before renewal thing.

Step two of the roadmap is confront an accurate trend. Set year over year trend accurately, as just stated a minute ago, this trend is not CPI, the consumer price index. Trend will be two to three points, minimum above CPI, which is gonna be in the 7.7% range or higher for reasons that Patrick will lay out coming up here.

When you speak in finance talk like this and forecast these out years accurately, the why for taking bold action becomes really crystal clear. The status quo is financially untenable. There will be a link in the show notes, by the way, to a page that Patrick gave me that covers this number two forecasting step. Step three in our roadmap, offer a win-win alternative to the status quo.

So make it clear. This high estimated trend is only accurate if, and this is the important part here, if we stick with the status quo. I will say the step three is maybe a little bit more fraught than I had previously considered. Go back and listen to the show last week with Lee Lewis for more of a deep dive into this.

Step three in the roadmap. Step four, lean into proven strategies that have been shown time after time to bend said cost curve, and improve the health of employees such as, again, advanced primary care. How many times does this need to come up? Step five in the roadmap, align your incentives and also your safeguards.

So look, if you decide to implement a model like advanced primary care, you gotta ensure that the payment model actually incent the behavior you want to see. You gotta think that through. There is a Pachinko machine in the healthcare industry and a pachinko effect of incentives, so know what they are, and then put up safeguards and backstops to prevent unintended consequences if you know that the incentives are in fact misaligned. Roadmap.

Step six, optimize via your contracting, which includes direct contracting. So once you consider the incentives and figure out what you gotta watch out for, optimize contracts accordingly. And often that means finding ways to direct contract with independent practices such as primary care practices. Listen to that episode from two or three weeks ago with Ryan Jacobs link in the show notes, which is one half hour fully getting into what the perverse incentives that just batter the premise of primary care if you don't take them on board.

So that's step six of the roadmap. Optimize contracting, maybe direct contract. Step seven of our roadmap is steer and tier. Steer and tier, especially for rising risk and or to make sure employees get the highest value.

In other words, risk stratify and disproportionately engage those with rising risk steer and tier them to high value provider organizations. And look, as I said in episode 507, define value and then demand it steer and tier away from wildly expensive organizations who may not perform at the level that you're looking for. Is that easy? No.

Can you start with, for example, advanced primary care organizations with a clear mandate, who to refer to? Yes. My name is Stacey Richter, and this podcast is sponsored by Aventria Health Group. Today we got an assist from Aligned Marketplace.

They gave us some financial support to help cover our expenses around here, and for that I am very, very grateful to Aligned Marketplace. And with that, here is my conversation with Patrick Nelli. Patrick Nelli, welcome to Relentless Health Value. Thank you, Stacey.

Thanks for having me. Alright. Finance teams, CFOs are often a little off to the left when we're talking about benefits, when we're talking about design of a health plan. If I'm thinking about, I wanna get in the mix here a little bit more than I potentially am.

As a former CFO yourself, if you are thinking about the roadmap that you might lay out here, what would be your first step? Yeah, of course. It's been fun to sit on both sides of the table. When I was in the CFO role, benefits reported to me we're a public company with several thousand members spread all across the us and now I'm on the vendor side of employer health benefits.

So one of the first pieces of advice would actually be open the conversation with your benefit leaders. It's tough for employers out there because most employers are not in the business of healthcare, and it's a complicated field. So starting the conversation with benefit leaders is important. Benefit leaders focus on this every day, and I do think that's an important first step.

Recognizing that those who have been doing benefits on the likely HR team, for example, they've been doing this for a long time, and it's just really important just to walk in and engage maybe. Exactly. And I think what is sometimes missing in the industry is being able to enable that conversation between a benefit leader and a finance team so that they're speaking more of the same language? Say more.

I think one of the biggest missing pieces is enabling benefit teams to be able to speak economics to finance teams so that they can explain how many items unfortunately, are stacked against employers. So, as an example, one that I think is most important to recognize is that healthcare inflation for employers is structurally set up to outpace overall economic inflation due to a couple specific reasons. What you're saying is one of the love letters that finance is apt to receive is talking about healthcare inflation because you have finance teams who are doing calculations based on the consumer price index, CPI.

But what you just said, I have questions. What you're saying is that the healthcare inflation index is actually higher than that. And I could see how that would be an issue, like if you've got finance forecasting based on the CPI, but healthcare is going up faster, which it has been. You know, we see trends of nine, 10%.

So, first of all, I think you said it well. What finance teams love is using Microsoft Excel. Using forecasting software. So it needs to be numbers to persuade them and change their behaviors.

We say this with all the love. By the way, spoken as a recovered, uh, recovering CFO. So there's a couple reasons. Why employer medical inflation will be higher than CPI.

The first is a concept called Baumol’s Cost Disease. And the way this works is healthcare has lower productivity gains than other parts of the economy. A simple example is an hour long doctor visit took an hour a hundred years ago, and it takes an hour today. But healthcare organizations also have to compete with higher productivity sectors of the economy, like in software for talent.

So they have to raise salaries to compete for talent, but because there's lower productivity gains in healthcare. The only way for healthcare organizations to maintain the same margin is to raise pricing at higher than inflationary rates. So what this means is that you have higher than average inflation in lower productivity areas of the economy, like healthcare versus overall inflation. Okay.

When Patrick mentioned this Baumol’s Cost Disease, I am going to surprise exactly none of our listeners when I say I spent more hours than I'd like to admit on like Reddit and elsewhere, digging in hard on this. But I also. Just for the sake of context, want to point out that in the episode with Gary Campbell, he said that it's always healthcare's first instinct when they spot a gap is in his words to throw a body at it, not fix the workflow. And also the episode with Shane Cerone and Dr.

Sam Flanders, doubles down on the potential for healthcare organizations to be far more efficient than they currently are. But the problem is, many times, all the financial incentives that health systems C-suites tend to be given, incentivize revenue growth, but then there's no functioning market to constrain prices. We talk about this in the conversation coming up in T minus five minutes. Patrick Nelli and I.

So yeah, this is just a much bigger conversation relative to whether the current impact of Baumol’s Cost Disease needs to be as pronounced as it is. But to Patrick's point, Baumol’s is certainly an underlying factor here and it is inarguable that healthcare trend has not been equivalent to the CPI, the consumer price index for quite some time. So typically healthcare inflation will be two to three percentage points higher than overall inflation. Unfortunately, it gets even worse for employers, which is the second item that's stacked against them.

Is that employers are price takers in the system. The federal government actually sets prices generally, specifically on the Medicare side and hospitals in order to maintain their margin, if they're getting little to no increases on Medicare, subsequently increase their pricing for the commercial or employer population even more so that means those two factors lead to significantly higher inflation for employers. This is what I am piecing together here and, and putting together, that if we're thinking about this roadmap for how to speak the language of a finance team of a CFO, one of the things that's gonna be really important as a very initial step here after you engage to begin with.

Is to be able to accurately calculate what the inflation is going to be. Let's just say that the finance team just is like, well, it's just gonna be CPI, so it's two, 3%, and like that's now set as the, Now all of a sudden this has a lot less urgency. And if last year the trend comes in at nine, 10% and everybody's pointing fingers at all, cut. If this year they still forecasted at two or 3% or whatever the CPI happens to be, then you know, A, we're just fighting retrospectively over like what went horribly wrong last year as opposed to trying to figure out how to do things to proactively anticipate the future, which is gonna be nine to 10% again.

Exactly. So just to put a few numbers to this. Employers should likely expect six to 10% annual healthcare inflation in perpetuity if they follow the status quo. It's averaged 7.

7% over the last 20 years. And that was in an historically low inflation environment, so it will likely be north of that 7.7% in the near term, closer to 8.5%.

So if there was one recommendation I would make, it would be having benefits team work with finance teams to put in their out year models, their three, their five, their 10 year forecast, healthcare benefit inflation of 7.7 plus percent year over year, in perpetuity. Okay, so we've engaged, we've set the year over year at 7.7% trend.

What's next in our roadmap? Well, what is great is, I believe, when finance teams and benefit teams work together and see those out year numbers at 7.7%. They are not going to accept it.

And here's the wonderful part. It is not an absolute forecast. That is what will happen if employers follow the status quo on healthcare benefits if they don't do anything different. So I deeply believe that it will get employers working with all of their partners, consultants, uh, and other vendor partners to figure out what they can do proactively to help bend that curve.

And it will get a lot more organizations to be investing in their members' health. And it's really interesting what you just said there, that without intervention, there's gonna be a 7.7% year over year rise. Anyone who listens to the Inbetweenisode a couple of weeks ago, probably knows what I'm about to say.

I'm on this kind of like, what is disruption kick right now? Because a lot of times when someone talks about doing something that is not the status quo, there are those who will stop that momentum in its tracks and just bring up the disruption word. Oh, we don't wanna have disruption. Like there's this presumption that the status quo is not disruptive.

And when you start hearing stuff like 7.7% every single year, there's just a study that came out that said like, for every, I'm gonna misquote it, but it's something along the lines of, for every percentage point over healthcare becomes more expensive, you wind up with like more people in the ER. It's, it's clear what is happening here that financial toxicity is, increasingly clinical toxicity. And if every time someone gets sick on the plan, they wind up with a financial devastation or they can't afford their meds, that is incredibly disruptive.

So it's just like, do you wanna have some upfront disruption or do you want to experience it on the back end? But you gotta pick one. Okay, so step three here is align on the fact that with this updated financial model, what are we gonna do together to bend the curve? Agree.

That's what we're gonna be doing here, like shake hands and figure this out. Of course. So there are a handful of proven strategies out there to bend the cost curve. But actually to enable benefit teams to speak with their finance teams and vice versa, I think it's also important to understand an overall industry dynamic that's occurred in the last 20 years.

Which is, 20 years ago, 80% of physicians were independently employed by independent physician-owned organizations. Oftentimes, smaller organizations spread all across the country. In the last 20 years, that is inversed. Now 80% of physicians are employed by hospitals or other large corporate entities.

And hospitals play an important role in the system. Don't get me wrong, but from an economic perspective, it's important to understand a hospital's business model. Hospitals primarily make money on inpatient surgeries for employers, plan members, the commercial population. So it becomes very difficult for a hospital to primarily make all of its gross profit from commercial member surgeries and also create a thriving business model to keep people healthy and out of the hospital.

When those two business models conflict, you can imagine that on the margin decisions are gonna be made to support most of the gross profit dollars today. Clayton Christensen talks about this a lot in Innovator's Prescription. What this means is we need to get individuals to independent non-hospital owned, proactive care models that are more sustainable in the long run from a business model perspective. Obviously I could say a lot about this.

If anyone has not listened to the episode with Dr. Scott Conard, he talks about his Pelican Brief moment when his very successful independent primary care practice was sold to the local hospital and how they immediately turned around and dismantled it. The rationale that was given at the time was by the hospital executive, It is my fiduciary responsibility as a hospital to make sure that we have heads in beds. For exactly the point that you just made, Patrick, because that's how we make money and you are preventing so many heads from being in my beds.

You are preventing so many acute, you know, heart failure rehab, you're preventing so many people from needing inpatient care that it's my fiduciary responsibility to put you outta business. So this is not something that some like, oh, this is an outlier. There's also a Summer Short with Dr. Stan Schwartz, who had a similar experience.

Agreed. And while hospitals play an important role in the system, it's important to understand from a business model perspective, which business model is optimized for what outcomes. And to your exact point, if you need some kind of complex surgery, like you, you wanna obviously make sure that there's a hospital, that there are subspecialists, that there are those individuals who are gonna take care of you. For sure.

If I'm thinking about this from the standpoint of a finance person working at a plan sponsor, recognizing that this perverse incentive exists, what am I thinking here? And we we're talking about bending the cost curve. Like what's what should be crossing my mind? One of the best ways to bend the cost curve and drive savings for an employer is to keep your employees healthy and out of the hospital system.

Or only going into a hospital when it's necessary. So we can talk about a few different strategies there, but one of the great things that has occurred in the last decade, is there has been a growth in independent, advanced primary care organizations that are set up to more comprehensively provide primary care and integrated mental health, and other services and are paid under a model to keep people healthy. When you say independent, you mean not owned by the local health system?

Correct. And the point being that if they're owned by the local health system, they might not actually physically be in a hospital, but if they're owned by the local health system, then you know, again, you wind up with this weird incentive to increase throughput because the more patients that person sees, you gotta reduce the visit lengths because you kind of want the referrals, right? Like there's just a lot of stuff that winds up getting baked into that business model that might not be what a plan sponsor is looking for if they're trying to keep people out of the hospital.

And you talked about how there is this growing group of independent, advanced primary care that do, if they're getting paid by the employers, they actually now have an incentive to try to keep people healthy. Did I get that right? That's exactly right. If you're an employer, when you have acute cases, when your members have acute cases, you want them going to the highest quality, highest value hospital.

But you also want your members to engage with the highest quality independent clinical groups that are paid to keep members out of the hospital. So those are two distinct business models to think through when setting up an employer health benefit strategy. This is really interesting, and I should have highlighted this more in this conversation, that finance pros at self-insured employers really consider that there are two distinct business models of provider organizationsand to consider that as they contemplate their benefit strategy.

One business model being, of course, growing revenue from heads in beds and et cetera. And then the other business model is keeping folks healthy and out of the hospital. Why is this the case? What are the different ways that an independent, advanced primary care practice will actually start to bend this cost curve if I am thinking like a finance person?

First, it's important to understand how these independent, advanced, and direct primary care groups do drive savings. Because it is important to kind of comprehend it at a, at a relatively straightforward level. So first by getting someone out of the hospital and steering individuals towards lower cost downstream services like labs, images, colonoscopies, there are unit price savings. Hospitals have more negotiating power than independent groups, so you can just save on the prices you pay by steering people to independent labs, images, colonoscopies, and the like.

Second, by giving someone more proactive comprehensive care, it can reduce downstream utilization. So reduce emergency department visits, hospitalization specialist visits. And lastly, by giving someone a longitudinal relationship with an individual advanced primary care provider who can get to know them, it can improve that member's health to prevent future high cost claimants. There's a recent Milbank study where access to primary care increases the likelihood of timely screening for breast, colon, and cervical cancers by 20 to 50%.

So it helps catch at cancers earlier, less than 10% of an employer's members this year that are low cost but have identifiable risk will actually drive over 40% of an employer's total spend next year. So a key piece of prevention and more proactive care is actually improve individual's health to prevent. Next year is high cost claimants. So that's first is understanding the ways in which these care models can drive savings.

Let me just remind everyone that currently almost half of most plan sponsors spend goes to hospitals. Listen to the show with Vivian Ho. 6%, which is a crazy number. And 6% of spend right now on average goes to ER, emergency room usage.

Listen to the show with Al Lewis. So finding those with rising risk and treating that risk so that it stops rising is a really big deal here. Lemme ask you this though. If I'm a finance person who is overhearing and listening to this conversation, am I actually gonna write this on my spreadsheet?

Like what do I need to hear right now so that I am actually thinking to myself, this is worth the disruption? Like I have tried to do stuff in the past and it never works. Anyone who's kind of like, great, I've heard these promises in the past and it's never worked out, what would your response be? Healthcare is a complicated system.

Right, and there are no easy answers. Humility is is one of my personal cultural attributes, a cultural attribute at the company I work for. So I think it would be important to acknowledge how difficult it is. But to your point on what is truly disruptive.

If an employer does nothing, an employer needs to put into their out year forecast of 7.7 plus percent medical cost inflation. So we need to keep trying and what is wonderful about certain care models, is by trying to bend the cost curve, we're getting individuals access to higher quality, more proactive care. And ideally helping to improve individual's health so it can be set up as a win-win-win.

Yeah, I think Dave Chase puts it really well. He, he says, Put together a really high quality, high performance health plan, and the cost savings are a bonus. Can you prove that though? Like if I'm like just really a quant person, if I'm really skeptical, I'm a real skeptical CFO, and again, I've had a lot of things that were shown to me in the past and they haven't worked.

So first, independent primary care has been, and primary care in general has been one of the most well studied parts of the ecosystem. We, anyone can reach out to me. We're happy to share the dozens of articles that have been written with the commercial patient member base in mind, showing savings. But from a finance perspective, I still wouldn't believe all of that.

I think it's important to have your counterparty put their money where their mouth is. And get paid in an aligned model where they are paid to keep your members healthy, to provide great access, high quality care, high experience care. I think it's as simple as looking no further than how will they put their fees at risk and isn't in a way that's aligned with my goals. So then the next step becomes, alright, I believe that one of the things that I wanna put in my plan going forward is to make available advanced primary care to my members.

And I get that I can get an aligned payment model here because incentives really should be aligns. What do I do now? They could set up a direct contract with a local, independent, advanced primary care provider. They could set up an onsite clinic.

They could think about virtual care, or they could partner with an organization like the organization I work at Aligned Marketplace where we can help employers access independent, advanced primary care, value-based specialty care all across the country. But there are multiple ways in which an employer can now easily layer on top incremental, independent, advanced primary care providers to any of their plan options. The next step here, we just had a whole conversation about this with Ryan Wells, Adam Staviski, and Dr.

Leo Spector about actually contracting for musculoskeletal direct contracting. But same rules apply. There is infrastructure here. If I am a larger employer, I mean, if I'm a smaller employer and I have a one factory in one town, I can contract with a local doctor and the end.

But if I'm more of a national player, or I have multiple regions, it might be, let's just say unrealistic to figure out how to do direct contracts in every single geography where there might be a need. So what you're saying vis-a-vis Aligned Marketplace, which is your company, or there's other entities that are out there, to have rolled up independent, practices across the country and may be able to help any entity that needs scale. That's exactly right. Previously, if you were a large entity or geographically dispersed, it was very difficult, not impossible, but administratively very difficult to add independent, advanced primary care or value-based specialty care for your members dispersed across the country.

So fortunately, and once again, we always want to be humble and intellectually honest. There are now companies like Aligned or other options to make it easier for employers to have their members access these better care models. By the way, I just was out to dinner the other day with an employer who recently put together Advanced Primary care for their members and just like the level of feedback from those members who were choosing to take advantage of it. Was so incredibly positive.

You know, if we're talking about disruption, this might be like the opposite. Okay, so now what though? Let's just say that I am on board for this. I have figured out how to align incentives, so I'm paying to keep my members healthy.

Anything else? Yeah, there's a few other items that are important. Employers are in a very unique position versus other parts of the healthcare system, and I think it's important for employers to realize that this both finance teams and benefit teams. One is employers have the largest dispersion of risk amongst their members, of any part of the healthcare ecosystem.

Employers serve healthy 25 year olds, as well as have individuals on their plan with chronic conditions, care gaps, and missed screenings. So a general peanut butter approach to engagement, generally is not a good approach. So it is important to have a vendor risk stratify members, identify those that are high and rising risk, kind of the emerging risk members, and work to disproportionately engage those members . As far as ways to engage those members, employers also have a big advantage in that they're in charge of plan design.

The One Big Beautiful Bill Act has in it a couple regulations that now give employers even more flexibility to make various types of advanced direct primary care, virtual care options completely free for members. So there can be a positive feedback loop where as employers steer more members to these independent value-based clinicians and there are more savings, employers can provide more incentives to steer members to these more proactive independent care models. It drives affordability, drives higher quality, quick care, and drives savings.

And that is the positive feedback loop that we hope the industry gets in regardless of how they do it. To help us get away from the 7.7% future that will come under the status quo. You said a couple of things.

One, relative to the engagement. You know, anybody who's been a plan sponsor for more than 10 minutes knows that like pretty much any time or any money that's spent with a healthy, like 25-year-old is not necessarily going to have ROI, let's just put it that way. But if you are dealing with someone with high or rising risk, the ROI can be substantial. So if we're thinking about an engagement strategy, doubling down on those who, and making absolutely sure that we're communicating early and often with those individuals who can very much benefit like that's where we should be spending our time and energy.

So I think that's the first thing that you said. Then the second thing is to structure benefit design also accordingly. Like what you don't wanna have happen is you get this whole amazing benefit set up, and then it's crickets. No one goes there.

So once it's set up, figure out how to engage and steer and tier, so that the members can find their way over to these amazing clinicians and clinical organizations. Right now, there is the opportunity to offer free or really, really low cost primary care to members that hasn't been available in the past. So it's almost like stars are aligning here. Agreed.

To your point, it feels like we're at a point in time where there are now thousands and thousands of clinicians that are excited to take proactive care of employers plan members. And there's more regulatory and plan design flexibility to enable employers to steer their members to these high value options at no or low cost to members. I love this roadmap, so link in the show notes. We definitely will make a list of the steps in this roadmap for absolutely sure.

Patrick Nelli, is there anything I neglected to ask you that you want to share? Finance teams speak in numbers, so I would just summarize that benefit teams working with finance teams to put in a forecast 7.7 or more annual medical inflation will help drive the urgency and help employers become more proactive in supporting their members, not just receive high quality, higher access care, but also care that can bend the cost curve for the employer. Sage Advice.

There's also a show with Barbara Wachsman if anyone wants even more context here, that I would certainly recommend to go back and listen to. Patrick Nelli, can you explain how Aligned Marketplace fits in this mix? Happy to. We have built the only national and value-based, advanced primary care and specialty marketplace for employers.

An employer can give their members access to thousands of advanced primary care clinics all across the country. Most of these groups on our marketplace are not available to employers today through traditional insurance networks. So we're bringing incremental access to employers and their plan members. Plan members keep their current insurance and are simply provided with more high quality, free, or low cost doctor options.

While the benefits available to all plan members, we work to risk stratify and employers plan members, identify the high and rising risk numbers. And make it easy for those members to get in with the best clinic for that individual. Helping them only see those groups that have near term access, helping them schedule their first appointment and helping them with follow-ups. We pay these advanced primary care groups under a value-based model, so they are incentivized to keep members healthy.

We've really tried to create a win-win-win for all parties. And if someone is interested in learning more where would you direct them? alignedmarketplace.com or my LinkedIn, Patrick Nelli.

I would be happy to chat with any individuals out there that are trying to move the industry forward. We have a lot to learn, so I'm also, I love having these conversations so that we can be learning as an organization. Patrick Nelli, thank you so much for being on Relentless Health Value today. Thank you Stacey, and I appreciate you and all your listeners who are so motivated to help push the industry forward.

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