Navigating High-Cost Claims: Employer Strategies for Managing Complex Healthcare Cases with Dr. Christine Hale, Chief Medical Officer, US Benefits at Gallagher

Speaker A: M Healthcare costs are rising, benefits are confusing and the system doesn't always work for the people who need it most. But it doesn't have to be that way. Smart employers and their brokers are flipping the script, cutting costs, making things simpler, and creating a health benefits experience their people love. Welcome to the benefits playbook. I'm Kirk McConnell and in each episode we uncover the bold strategies that are rewriting the rules of self funded health benefits. Today I'm thrilled to be joined by Dr. Christine Hale, Chief Medical Officer at U.S. benefits at Gallagher. Dr. Hale, thank you so much for joining us today.

Speaker B: I'm so happy to be uh, here. Thank you, Kirk.

Speaker A: Now, I want to spend a lot of time talking about and thinking about what you're doing at Gallagher, but let's take a couple steps back. Tell folks what was your path to Gallagher? What is your background?

Speaker B: Well, let's just say my career path was serpentine, not linear. I am a pediatrician, but very early on I became frustrated with some quality and inefficiency issues and decided to get an mba. I then serendipitously ended up as a strategy consultant providers with McKinsey. And then I had possibly the most formative experience to my career that wasn't part of my career, which was I was a year year or three months, so 15 months total as a patient full time on disability, trying to navigate my own complex health situation. And that taught me more about what was wrong with our healthcare system than possibly any other experience I've had. So when I came back, I jo a health system to try to tackle these problems from within. And then one more act of serendipity ended up in employee benefits, working on complex cases and never looked back. And that was almost a Decade ago

Speaker A: Now Dr. Yale, tell me more about your patient experience. What were the elements that really opened your eyes?

Speaker B: Yeah, I think you know the number one was that I had been a arguably top performer working my way towards election as a partner and suddenly my performance dropped off. And so I will tell you as employers out there, if you have employees who on a good trajectory and all of a sudden they have a fall off in performance, that might be an indicator something's going on. Once I did finally take the step to get to disability, then I had a month after month battle. First of trying to convince my doctors of what I knew my right diagnoses were. And then once I finally achieved that, having to go medication after medication after medication, partly because of step therapy, partly because we didn't have good testing to know which Drugs were gonna work well for me and then it turned out I had a whole second condition. So we finally got one under control and that uncover rinse and repeat. Rinse and repeat.

Speaker A: And so what led you to Gallagher specifically?

Speaker B: I joined Gallagher just this past January. I was very attracted to a couple of things. First of all, very well positioned with such rich resources, all the way from well being pharmacy but also in leave and disability we have the largest work comp TPA and the ability to start to bring together that whole person view with a very sophisticated data lake, data warehouses that feed that and clinical analysts was a very exciting opportunity where I felt that we could do some really unique things to both help members and also help plans contain their cost.

Speaker A: So let's talk about those unique things because when you hear chief medical Officer you don't think of that living in a place like Gallagher. So kind of what is your remit within Gallagher?

Speaker B: I have so many hats that I wear which I love. So there is the piece that is developing our best practices, our clinical strategies. That's both amongst our own experts that we hold internally and all those specialties and more that I mentioned, but also working with external partners who have data we may not have, who have solutions we might be able to tap into, who have knowledge that they're creating through research and other avenues. And so really bringing that all together and saying again with the member at the center, but also understanding what it takes to run a health plan today and how dramatic some of the cost pressures have become. How do we think creatively? And this is where I get excited with my. I put my old management consultant hat on and I say we have a big strategic problem in healthcare right now, which is we feel strongly that employer sponsored benefits are critically important and that having the flexibility to serve one's own population is incredibly valuable. But we are, we have such significant cost pressures right now that that threatens the model as a whole. And there are some people who would like to see that model go away. I am not one of them. So really putting on that, taking it very seriously and thinking outside the box and saying if we've tried things and we think they should work, why aren't they then what are the things we haven't even thought of yet that maybe we could tackle this problem from a completely different angle. And that's the exciting part is to be able to come up with those new approaches, solve the long, long held problems, but also find new ways, try new ideas and see what's actually going to make a meaningful difference.

Speaker A: Well, so let's look at something from a different angle. Let's talk about high cost claimants. You know, you talk about the employer journey. So many employers I think think of man, I am unlucky, um, if I get a high cost claimant. But what are you going to do? Statistically it is what it is. Let's think about that differently. What do you think employers should be thinking about differently in things like high cost claimants?

Speaker B: Well, I think first of all it's really important to think about what is a high cost claimant. This is the first question I always ask. If it used to be 50,000 and up was what everyone was looking at. I would assert, now that's table stakes, right? Everyone has autoimmune cases that are on especially drug that's costing over $50,000 a year. So not that that's not important, but that requires you, uh, know, more of a plan level or you know, procedural level type approach or programmatic. On the flip side, you know, we are now seeing this confluence of very high cost claimants because the sky's the limit now. So multimillion dollar and sometimes multi tens of millions of dollar individual claimants coupled with what almost keeps me up more at night. So everyone says, ah, gene therapy is keeping me up at night or those big NICU cases. And I'm like, yeah, but if you can't tolerate that risk, you probably have some kind of insurance coverage to back you up. Where I get really stressed when I think about my clients frankly is the ongoing. So when I put my doctor hat on, I say, even when I was in medical school, which was not yesterday, but not a long time ago, cancer was basically a binary disease. You either got better or you passed away. And that was the sad truth. We can now keep patients alive for over a decade, um, on suppressive therapy, treating cancer like a chronic condition, living very happy, productive, fulfilling lives. That's incredible. However, insurance was not really set up for ongoing risk. It was set up for unknown risk and to spread that unknown risk. And so that's where I see a lot of organizations getting into trouble is they say, well, I bought stop Loss. Well, if you have someone on an $800,000 a year regimen and they're going to be on it forever, the stop loss coverage is going to run out after a few years. They're going to say that's known risk and we can't, our business model doesn't support that. Right. And so that's been the real challenge is trying to figure out how to balance strategies that help you mitigate the lightning strike shock and all claims, coupling it with, wow, the water level's really rising on these ongoing claims and how expensive those are getting. And that requires a different way of thinking.

Speaker A: When you think about whether to use your words, kind of the lightning strike versus the ongoing, what are the points of failures in the healthcare system you typically see surrounding those members on the lightning strikes?

Speaker B: This one is very interesting. They're often hospital based claims. Right? Sometimes it's a gene therapy, which also can be hospital based, but a lot of times it's somebody who's been sitting in an ICU month after month. And one of the big challenges we see there, in addition to just overpricing, which, uh, frankly a lot of people don't really pay enough attention to because they're told, oh, that was paid on a case rate or a drg. They may not know that most providers have contracts with the payer networks that say, above a certain amount, it's now considered exceptional or an outlier and it's going to revert back to a percentage of charges. So people just stop paying attention because they've sort of been lulled into complacency. Right. But the other really big thing that concerns me when I dig in these big long hospital stays is, you know, and I was there, I almost went into intensive care medicine. And when you are the attending physician, you might only be on that ward for one week and then you go back to your lab or teaching or whatever, you're just trying to figure out how to stabilize that patient and keep them going. Right. You're not really thinking long term down the road. And we'll find cases like NICU babies that have been sitting on inhaled nitric oxide, which is for the audience. All you really need to know is it's really expensive, frequently $6,000 a day or more. And if you look at any treatment guidelines, really you should only be on it for to maybe four weeks. And we've seen these outrageous NICU claims where patients just sat on the drug for four months and you know, it's not the most risky drug out there, which is why I think it doesn't. The clinicians don't necessarily like prioritize it, but it's not totally innocuous and it's $6,000 a day. But the providers, much like the patients or the family members, don't often don't know what these things cost. Right. So there's no impetus to really get ahead of that because they don't really understand the implications of It. So there's a lot of things that can go wrong when you're in there for a long time and you're just kind of glide pathing. And people forgot to change the level of care when you started to get better. And, you know, just some of these things that had you gone in for one visit, it would be fine, but it's because you've been there and things have been going up and down that they can get lost in the shuffle.

Speaker A: Uh, I'm sure there's a lot of employers listening to that hearing. That's terrifying. But what do I do about it? So from your perspective, how do you coach your clients to think about intervening and supporting members like that?

Speaker B: That's a great question. I get that question a lot because people say, well, that's really interesting, but Dr. Hale, we're not doctors and we're not claim experts, so how do we get our arms around this? And I tell them the first job they have is to ask good questions. So I love to give employers rules of thumb, like my rule of thumb on a hospital case before I even open the case. If they were in an ICU, if it's more than 30 grand a day, I'm asking questions about it, right? So there's a lot of these thumbnails that we can give to employers to say, like, wow, this should, should, you know, pique your interest and just go back and start asking questions. Why is it so high? Was there a complication? And then have really good partners that you trust that can actually verify the details and help you stay on top of these things, because you will quickly, if you trying to be a very good steward of both your members care that they're receiving and make sure they're getting the best outcomes. And also your plan dollars. It's pretty sophisticated. And you're going to need some clinical resources and some claims advocates that can really coach you through some of the nitty gritties that's happening behind the scenes. But anyone could ask questions. Every employer should be doing that.

Speaker A: But maybe this is too fundamental of a question. But to whom do you ask those questions?

Speaker B: It might vary. Certainly you should be holding a lot of questions forward to your plan administrator to your pbm, but you also should have some independent parties. It might be a benefits consultant, it might be a vendor solution if you have a solution for that particular area, that particular disease state or type of care, even other employers. So I love to encourage employers to participate with employer coalitions if there's one in their area, because that's an opportunity to talk to other employers, say, hey, I'm seeing this, Are you seeing this? What have you done about it? And really share those ideas, knowing that the person on the other side of the conversation doesn't have skin in the game on the answer that is presented forward.

Speaker A: So step one, make sure you're asking the right questions when it becomes time to actually support the member. How do you think about the service levels, the types of support that you think are most important for members?

Speaker B: There are a number of things. So first of all, right, diagnosis. I cannot underscore this enough, the number of cases I've seen. And people talk about waste in the system all the time. Right. I think most of our employers would think about waste in some very highly publicized things like hospital pricing at certain hospitals, not all hospitals, but some are really marking up the bills. Most employers know about things like PBM rebate shenanigans, I'll call them, and things like that. But what a lot of people don't understand is just how much waste is because members either don't have a correct and complete set of diagnosis diagnoses or they're on a treatment that isn't helping them, or both. So I'll give an example because I had a member who was diagnosed with multiple sclerosis. Obviously that's a devastating diagnosis and was put on a medication. It was being, I will say overcharged at $300,000 a year, but needless to say, it still would have been over 100,000 even if it had been priced in line. And yet I'm looking at this case and I'm looking at the trajectory and you know, getting the case notes and looking at the symptoms. And I'm saying, I don't think that this is act Ms. We get a second opinion, sure enough, not Ms. So this member has now been on for months and months a $300,000 a year medication that isn't doing them a lick of good. They're lucky it didn't harm them. And meanwhile they had an untreated back condition that could have caused paralysis had we not figured out the error. So getting the right diagnosis, getting the right treatments that are, you know, FDA approved, if there aren't FDA approved treatments that work for this member, getting them in a clinical trial is an option. And then certainly a huge piece is care rendered to members in a way that is, you know, convenient, accessible, safe and affordable for them because if they don't use the, the treatment because they can't access it or it's inconvenient or it costs too much, it doesn't do any good. So those are all areas where we can help members and then help the plan at the same time.

Speaker A: And do you help them through again, giving them, um, tools and ideas on how to get a second opinion? Do you think it's important to actually give folks access to second opinion programs? How do you think about closing that gap?

Speaker B: That's a great question. Second opinions in particular, I'm very, I'm a very big advocate of, particularly with certain conditions or certain lack of diagnoses. I would say a lot of employers that go directly and say, I'm just going to get a broad based second opinion bidder. I love that because I do like when people have access to a second opinion when they feel they need it. The problem with just putting that in place and then just putting a flyer out and saying you have it is for most employers, very few people actually use it. In fact, I've had some of my own colleagues at a prior employer who were also in employee benefits come to me saying, I need a referral to this specialty center. And I'm like, you forgot that we have free second opinions, right? So we have to make sure if we're going to put a solution in place that we are proactively engaging, both making members aware they can utilize it. But then really, the secret sauce for the complex cases in particular, I was, uh, very passionate about this so much that when I first started in the benefit space, I, I started referring cases directly to a complex care program with the Mayo Clinic. I haven't found another one like them yet, or I'll be happy to promote that one too. But this is a unique program where you have people who can't get a diagnosis. Maybe they've seen four neurologists or they've seen seven different types of specialists and nobody seems to know what's going on. And you can get somebody in and they might spend three days there, see eight specialists, have a few additional tests and get a whole comprehensive report on their diagnoses, suggested treatment options to get back to their local community. A, uh, really unique offering. Probably something that would have saved me 10 months of my disability journey, frankly, and has even saved some people's lives. But people don't find their own way to those solutions. Right. It really takes a specialized team who are following and seeing the patterns in the data. And you know, crazy things like, I've had people who went to one member, 135er visits in one year for migraines. And I said, I have Migraines. The last place I want to be is an er. Something else is going on here. Right. So there need to be not only avenues where an individual member can self refer and then giving them reminders, access, easy, you know, plan designed to help make that happen. But also there are going to be cases where they don't even think to ask for it and they would really benefit. And frankly, they tend to be the ones that are the most appreciative. So we have to also find ways to support members on that journey.

Speaker A: You're in a really unique spot where you see so much and I'm sure there's a lot of solutions. You're impressed by some that leave you wanting a little bit more. How do you balance helping people navigate solutions versus just rolling up your sleeves and kind of building it or putting it together yourself?

Speaker B: That's such a great question. And I think particularly in today's environment, point solution fatigue is real. Members are confused. They, you know, log in, they see 15 different options and they don't know which one to go to. So it can be very difficult. That said, my default is always each employer. Just like each member is different, each employer is different and they have built a unique ecosystem that with the best advice they have put together to serve the unique needs of their population. So my default is always it's our job, I feel, to understand the sophistication and offerings of those solutions, what they can do, what they can't do, and make sure people are getting the best utilization of what they have in place. The places where we then come in and build a solution are where we see gaps, right? Where we see that there is something like complex cases, diagnosis where we can't find. Nobody seems to have that, so let's actually go. And also it often tends to be where there's a smaller population. So maybe it doesn't make sense for that employer to have a whole solution just for, you know, maybe to use it once or twice a year. Those are opportunities where we can actually build something or stand up a unique partnership on behalf of the companies we worked with to then say it's okay, you don't have to have 50 contracts, right? This might come up once every five years for you, but we have a relationship, we can handle that. If it gets to that and your providers don't have something in that arena, we can solve that for you.

Speaker A: Keep going on that. Tell us more about Stella, a new program within Gallagher.

Speaker B: I'm so excited about Stella. So Stella is very interesting. Its origin comes from actually our work comp TPA, we have a thousand nurses, I'm not kidding, 1,000 nurses in our work comp TPA. And they don't just come from occupational health backgrounds. They actually come from a lot of interesting diverse specialties. So icu, cardiac, you know, a lot of things that we would see also popping up on the high cost claims side. And so we've taken and really looked again to fill that need that hole. So we know that, you know, there are some plans that have great experiences with their current case management solutions. They may have enhanced case management for certain conditions like maternity or cardiac. On the flip side, we have other groups that have said they've gone all in and they say we want navigation for our whole population, but that's not necessarily cheap. And not every employer can, you know, or does have the resources to deploy a whole group level plan like that. And so we've pulled out some of our specialty nurses that have decades of experience with navigation, know how to move roadblocks, know how to have conversations with members and make relationships with them, um, and built out a solution specifically geared towards complex cases. Navigation, including having a designated nurse that is assigned or nurses depending on size to that employer so that people aren't just calling and getting whoever answers the phone, they're calling and they're getting nurse Susie or they're getting nurse Tim and they know that person and they built a relationship. And then when their colleague has a really complex problem, they can say, wow, well you should just call Tim because he was really helpful for me. And then what we did was he said even further again, because we know there are certain unique specialty situations that might arise that an employer may not have enough of them to want to build a whole solution. We've embedded solutions like provider quality data to assist our nurses in navigation, like access to infusions in non hospital based settings like Mayo, uh, complex care. And we continue to add more specifically though anchored in what will help these really complex members who need help the most. They are the most vulnerable population.

Speaker A: One of the things you talked about though is it's not just the medical care. You mentioned leave. And some of those pieces I think so often point solutions have a swim lane and they say leave's not in my swim lane. And that's left to the member to figure it out. Why do you think that holistic support is so important for members?

Speaker B: You know, I liken it to, if anybody listening has had a complex medical condition or conditions like I have, you realize that you start to feel like you have A left pinky toe doctor and a right eyeball doctor. But they don't actually talk to each other. I have literally had specialists say to me, oh, I think the drug you're on doesn't have good coverage for my thing. Go ask your other doctor if we can get a better option. And the other doctor says, I think your coverage is great and you're the patient and I'm a doctor and I can't even manage this. So the same thing happens when we decide to carve individual human beings up into different claims, right? So we kind of start to lose the forest for the trees. So we see the medical claims over here, pharmacy claims, their leaves, disability, work comp. Well, we can't, first of all, we can't fully serve a member if we're only seeing part of what's wrong with them. We may be able to pull in solutions that are helpful to them and it's all connected, right? It's like one body. So, you know, we may get more insights and information into what their true needs are and have better ways to help them, help them be productive, help them live happy, longer lives. If we see the full picture, we also have a better opportunity to understand what interventions are truly making a difference in the cost of providing benefits to our employees if we take a holistic view. So, uh, I, for example, had a meeting recently where somebody said, hey, can you come talk to this employer, happens to be a client of ours, they are interested in musculoskeletal solutions. And I said, that is great. I am more than happy to come talk, but I also want to understand what's going on in their work comp situation, what's going on in their leave. And I want to talk about metabolic conditions because. And it was, it was actually quite insightful because as soon as I said metabolic, because I know as a provider that when you're carrying around excess weight that causes a lot of trauma in your joints. It also makes you at more risk for work comp injuries, for disability claims, chronic pain and things like that. And so I, I mentioned this and they said, oh my goodness. Well, it turns out that these are truck drivers and they just spent oodles of money refitting their trucks with special seats because. Because their drivers were too big to fit in the old seats. And so they were like, wow, you just unlocked a connection. And I said, yeah, you would be really amazed at how m. Many things are connected. So getting those multiple viewpoints and then getting really smart people that think about these things differently, things like intermittent leave I was having a conversation about autoimmune disease and how we can think about that holistically with our leave team. And they said, well, Dr. Hill, one of the biggest problems in autoimmune is they don't necessarily have one period of time where they need to take some time off and then they come back and they're totally better. This is something where it's going to flare and then it's going to remit and it's going to relapse and it's going to remit. And so having an intermittent leave policy, thinking about workplace accommodations. Right. These are things you may not need for other groups of individuals, but you certainly do if you have a large autoimmune population.

Speaker A: Well, let's try to supercharge the people who are listening right now so they can all be. Dr. Hale, when you get a request like come talk to us about msk, what are the questions you're thinking through in your head that employers or folks on this vein can start asking themselves?

Speaker B: Well, my first thing is, please don't stop with that high level diagnosis. So I frequently will go in and say, you know, let's have a conversation. And they say, yes, cancer is a big deal for us. And they'll say, well, we have this solution. And I'm like, that's a great solution. How'd you arrive at them? Well, we talked to another employer that has cancer problems too, and they have it. Then I'm like, okay, but is their cancer problem the same as your cancer problem? Because you know, or let's say a screening initiative. Right. Please don't walk away thinking, I'm telling you, don't work on screening, you should, if you have poor screening compliance rates, absolutely should work on that. However, if you're trying to solve a high cost cancer problem, and if all of those members have pancreatic cancer and ovarian cancer, you can do the recommended screenings all day long and never pick that up. So you really have to understand what is that problem. So try to ask the five whys, if you will, and say, like, let's dig a little deeper. Truly understand the nature of that problem before you ever get to then, okay, what are the solutions that I can either build or buy or partner with in order to solve that problem?

Speaker A: I know one of the solutions that you're especially passionate about are centers of excellence. What are the whys that you have gotten to personally that make you think that COEs are such a good solution for the right clients?

Speaker B: Clients. Well, before I tell you why I Love them. M. I'm going to give a disclaimer, which is unfortunately, uh, I think the term center of excellence has become way overutilized. You look at some of the COE networks out there, and it feels like everybody's in them. In which case I'm like, well, what makes you excellent if you're in the top? You know, 80%, you're just average at that point. So I've started using terms like center of distinction, because I think what we're really looking for here is making sure that when you do have something that's off the beaten path. So I'll be the first person to say, even, you know, with more common types of cancer, for example, often the best care is at your community oncology center. Frankly, you know, you're close to home, you're surrounded by families, but if you have cancer of the appendix, there's probably only five, maybe 10 centers in the country that are truly equipped to deal with that problem. And in those cases, uh, you know, we've known it in surgery for years. It applies to other areas of medicine as well. The more you encounter something, the better you will be at it. And if you're going to a place and you're going to have brain surgery, but they don't have cancer brain surgeons there, maybe this one is pretty important. Maybe you want to go to a place that actually has some real solid experience and proven outcomes. In doing that, we're further pushing now our centers of distinction, and we're looking at not only the medical quality of their outcomes. So I would say there's really three defining factors, right? The uniqueness of the service. Do they have something special that truly you can't get somewhere else? Secondly, or is it delivered in a special way, like Mayo complex care, where you can see eight providers in three days? The second piece, really then, is the quality. Is there demonstrable impact on the outcomes that the member receives? And third, and historically, maybe one of the harder ones to find is it have an actual impact on the cost for the plan. But I had the privilege of working alongside Mayo for probably seven years prior to even starting at Gallagher. Now I'm continuing that relationship. But over that amount of time, it was great because we were following. We had all the data, uh, for our members on the plan. So when we referred someone, we could continue to follow not only their clinical progression, but their cost. And we were finding on average now varied based on how much they were running before we referred them. But on average, we were saving 80 to $100,000 per member referred and that actual impact persisted because now they had a correct diagnosis, they were on the right treatment, and if their local care team had questions, they could call for advice. That's what I think makes a real center of distinction. A, that you know, they have unique services, B, they have superior outcomes, C, they're lowering cost in the long term because they're doing the right care, and then finally that they're willing to continue to partner so that the member just doesn't end up right back with them again on the back end.

Speaker A: You know, you just said that having the data to track outcomes are so important. I think you've also said that having the right data to get specific about what the problem is. When you think of employers using data, what are things you wish they did differently or more to truly unlock the power of it?

Speaker B: That's a great question. I've already kind of alluded to this a little bit, but going below the surface level. So first of all, I would assert in this day and age, a data warehouse that integrates medical and pharmacy data at a member level is table stakes. If you haven't already explored that with your consultant or whoever advises you on such things, I highly encourage you. There's a lot of really good solutions out there. Some of them you have a lot of add on bells and whistles. Some of them are basic. But at its most fundamental form, you have to be able to integrate these pieces of data. Why? Because we have cases, for example, where a member might get a gene therapy for $2.1 million. I'll let you guess which one it is. And that's running through the medical plan, right? Because that was done in a hospital. And then because they carved out their pharmacy, which has a lot of benefits for managing your plan. But now on the pharmacy side, they're still continuing to fill the maintenance medication at $600,000 a year. And neither side can be blamed because they can't see each other's data. So the only way you discover problems like that is by reconnecting the data in a place where a skilled reviewer can say, wait a minute, that doesn't make any sense. How do you know if the gene therapy worked when you're still continuing the maintenance drug? So these kind of, uh, observations are critical to being able to move forward. So you have to have some way to unify that data. Data warehouse is going to the best way to accomplish that. Now, once you have that, you do have to have sophisticated providers that either the data warehouse themselves, or a consultant or someone else who can help you not only interpret that data. So dig below. If you get chemotherapy, 500,000, please ask for like you need to know what body part, what kind of cancer it is, what drugs they're on, what dose of the drugs they're on. Right. Uh, you have no way to know if they're getting good treatment at a reasonable price. Price. If all you know is factors influencing health stats for 400,000, that's my favorite. So you need sophisticated analysis to help you hotspot problems. But then just knowing you have a problem, why spend money to know you have a problem? Right. You really need to have partners who can help you not only craft solutions and then help you make sure those solutions get accomplished. And that's. That last piece is where I find most things drop off, is you may have a partner who says, okay, we did this really sophisticated query also. You should have a partner who's willing to do custom queries for you. If you have a unique situation, you're trying to like, dig into it, but that's great. And then they say, yep, here's the problem. And maybe, you know, if you're lucky, okay, and here's some options for how to tackle it. Good luck. I, uh, will tell you the success rate on those is not superior. A lot of organizations, they don't have the bandwidth, they don't have the political clout with their partners, they have competing priorities or they just don't want to be that deep in their members medical data. Data really need some help actually making sure things get accomplished.

Speaker A: Help me diagnose this a little bit. So you talk about that employer who sees chemotherapy, $400,000 for that employer. Why do you think they may not ask for more? Do they not know more data exists? Do they, are they daunted to get it? Are they shell shocked? Because they've been asked before and they're not, they're told no. What do you see as the common thing?

Speaker B: D All of the above.

Speaker A: Yeah.

Speaker B: So when I first started doing this work about nine years ago now, I was really shocked frankly at the number of employers that I talked to. And we would say, hey, we want to talk about high cost claim management. And they said, well, there's nothing we can do about it. And I was like, there's a lot you can do. And they said, well, you know, we've been told for years, sorry for your luck, please write us a check for, you know, $700,000. And they just had to write a check for $700,000 dollars. I think that's Changing, right? I think I know that's changing, frankly, from my conversations with employers. They are becoming emboldened to ask more questions. They are requiring more data. I think a lot of it is because we do have coalitions and meetings and other venues where we're bringing employers together and they're having those conversations. I love being in meetings where I'll go around, I'll ask employers a question about something they saw in their data, and I'll have one employer who's with a certain administrator or certain pbm and they say, oh, I have all of the. Here's all the nuance I found. And the employer sitting next to them has the same administrator or the same pbm, uh, and says, well, they only told me chemotherapy for 400,000. Why? And that presents an opportunity to empower an employer to say, like, wait a minute, if they got it, why can't I get it? So I'm very excited that we still have work to go. Right. Because there's a little bit of unlearning that learned behavior of the just accepting it. But I also think with the. They've gotten kind of accustomed to like, okay, you got a 7% increase this year, you got a 9% increase this year. When you get a 30% increase. Now people are saying, we can't sustain this. So, you know, that has really changed. That conversation of, like, can probably, you know, it'll be all right to, like, now it's not going to be all right. We have to do something. They're getting something different. We want it over here. And I think that makes this a really exciting time. Time.

Speaker A: What do you think is going to be the unlock for true data transparency? Do you think it's going to be employers finally saying, I can't afford it? Uh, you have to change. Is it tech is just going to make it easier? Is there's just going to be industry pressure to do it? What is that unlock?

Speaker B: I think a lot of it will come. The fastest tools that we have are the technology, because that's advancing so quickly and allowing us to take very complex, complex data and, and get to those insights and solutions faster. Right. And with less sophistication on the part of the reviewer. I think that's incredible. Right. So technology for the win there, as long as it's used, right? Definitely. I think emboldened employers are demanding it now. That's allowing us. But at the end of the day, people are going to keep finding ways to go around the system unless we have good regulation and policies. I'm not saying universal healthcare, folks. But what I'm saying are things like the PBM reform that just passed, that very important. It basically just said you have to pay fairly. Right? One of my favorite cases I worked on because it was so gratifying, $250,000 knee replacement, one knee. And it was in Texas, guys. This was not in Alaska, where things are really, really expensive, right? And you know, so roughly 8 to 10 times the market rate. And my clinician brought that to me and I was like, what in the world? Like, go, go ask for an itemized bill. Well, of course, the, the, and this is true. A lot of employers don't understand this. Many payers in their contracts with providers are not allowed to ask for an itemized bill. And I said, what in the world else do you buy for a quarter of a million dollars? We're not allowed to know what you bought. So we were able to work with the state attorney general, concern about possible fraud. They required the bill to be released to us and sure enough, buried in the or charges for $163,000. Top line item on the bill was placental tissue. Now you may be wondering, what in the world purpose would placental tissue have in a knee replacement? That's where you get stem cells. And we went back and we pulled the plan document. Sure enough, experimental investigational got a refund for the client for $163,000. Okay. That should not be allowed to be hidden, right? That's only because we were good detectives and we didn't take no for an answer. But until the parties at play are required to provide the information needed to manage the cases, clinical information or billing information at a granular enough level to make sense, we're still going to be fighting hand to hand combat. And if we really want to move the needle in a meaningful way, there has to be some sort of industry pressure. And while a lot of that will come for employers, I think it will come better and faster and more consistently if we can have at least some basic rules of the road on how we're going to engage regarding data. And it's coming. I think the pbm, um, bill that passed is the first step. So I think that's an important step. We still have more steps to take, but it's a good sign that we're starting to at least shed light on these issues.

Speaker A: Well, let's end with the role that employers can play in helping accelerate this change as, uh, kind of the policy and legislation roles. I know you're on the road a lot. You're on an airplane next to a cfo. CFO says, oh, so interesting. You're in benefits. Ours are going up 10% a year. I've had CFOs tell me the only time I feel stupid is when talking about benefits because it just feels like a foreign language. Hey, doctor, help, uh, me understand, like, what questions should I be asking my benefits team? What do you tell that cfo?

Speaker B: Yep. The first thing is I'm asking what data are we getting and who's managing the data? Right. I want to know who's helping us get the insights. Secondly, I want to know who our partners are and who, which of those partners are making a difference for us and which or not, unfortunately, it's a, it's an interesting, um, eye of the needle to thread where we have to hold partners accountable to provide us the information we need and to deliver on the solutions that they have brought forward and that we're paying for. On the flip side, if we're switching partners every year or every other year, we don't have enough Runway to then become getting a deeper, um, relationship and to be collaborating on what's the next step? Right. We want partners that not only are delivering on what they said they were going to do today, but who are willing to say, I see that you have a problem. Let's figure out together how we're going to solve this. Right. So as a CFO or a CEO, I'm saying, first of all, I want to know exactly why our costs are going up. And I don't expect my benefits team to know that. I expect them to point me to the right partner who could tell me the answer to that question. Secondly, I want to know who all is supposed to be helping with this, this, and are they making a difference or are they not? And if not, why not? And then we're going to go and say we're going to build some deep relationships with partners that actually do what they say, who are willing to look forward to the future and are going to build solutions with us that make a difference.

Speaker A: And I think to that point, none of this is easy. So you got to have the right partners in the trenches or foxhole with you that, uh, you want to fight the battle with. So now flip that conversation another way as you talk to him to, let's say, benefits teams who are saying, man, I just wish I could have a better communication with my executive team to tell them what's going on, ask for help. How do you encourage them to have that conversation?

Speaker B: You know, that's so interesting you should ask that. I actually recently spoke to a group of employers at a coalition meeting. And uh, we at the end of the meeting went round robin, they had tabletop discussions for last part and then we did report outs and the very first table said their to do item on their list was to ask me to present to all their CEOs and CFOs. And I said sign me up. So don't be afraid to ask for help. I get it. It can be very hard because I mean frankly I went through this as a physician and moving into the business and finance side of, of healthcare as well, where I was told things like don't bring me your doctor math. So you know, we docs have that problem too. We get it. You have to find people that actually can be a uh, translator of sorts, know what the, what the thing you're the receiving end is going to be looking for and the things that matter to them and that will catch their attention. Right. And so you know, creating regular touch points. First of all, leadership don't tend to like surprises. So I would say creating those natural like periodic touch points so there aren't big surprises or at least fewer. And then don't be afraid to ask whether it's your administrator or pbm, um, your consultant, a vendor partner. If you're having a hard time with that messaging to your leadership, see if you can set up a conversation where you can all be on the phone and get some clinicians on there or some really good claims experts to really dive in deep and help answer their questions right, you know, right there and then so you get all on the same page.

Speaker A: Um, let's end by talking about the future a little bit. What is one part of healthcare that you wish was moving faster and you feel like is still daunting thing. On the flip side, what's making you optimistic that things are pointing in the right direction?

Speaker B: Well, let me start with the what what I wish would move faster. Honestly, that linking of the, the full member information and also pulling out. If there's one piece of advice I can give people today, please start asking for your autoimmune claims to be pulled out from the 15 different specialties that it's buried in today. It is often amongst the top three or four drivers of large claims and rising clients cost. And you can't see it because it's buried in a whole bunch of different specialties. That was, I walked into this role in January and day one I was like, let's go build this report. So we actually have, um, now built our first prototype of that report so that I wish would move faster. I wish we would actually create a specialty for autoimmune like we have for cancer. It's the same drugs. Often people like me have multiple autoimmune conditions. So sometimes it's even the same people. And it is an opportunity to both not only improve the care, but improve all of the things, things trigger, prevent triggers and things stress, diet, lack of sleep. Right. That, that could be mitigated. And, and then the other thing I wish we could do more of is creative solutioning. Right? Again, not only on the addressing the problem that exists. Let's talk about the lead application, the work comp, but also on things like, gee, if we know that certain foods or additives are inflammatory, why when we host a conference, do we have those snacks as the only options? Right. We need to think more holistically and walk the walk. We can't just tell people like in your spare time, you know, here's some mental health benefits when the reason that some of these people are very stressed is because they have toxic managers and we aren't doing anything about it. Right? So we have to couple that, you know, dealing with the issue at hand with then really going back to, you know, we call it in healthcare root cause analysis, where you go back and back and back and you keep saying, well, why did that happen? Why that that happen? Why'd that happen? Until you finally arrive at some of the things that were the, the sort of progenitor of the whole situation and say, we gotta tackle it right now, but let's not keep. That's the definition of insanity is just keeping doing the same thing, expecting a different outcome. Right. We have to actually get back to the root cause and start to solve those in creative ways. Now what makes me excited is we do have capabilities now, right? We have AI that we can bring to bear that's allowing even groups like mine to hotspot faster. What are some of those things that aren't working? Whether it's being billed incorrectly, whether it's members that need assistance. We have the technology coming to help us with these things and to help us connect dots between all these different data sources in a way that we've never been able to do before or that would require very costly resources. So the technology is coming to help us. We're starting to move the needle on awareness of the issues and even some of the legislation, um, and just conversations at a high level. So the, the opportunities are now becoming greater to get unstuck we just have to stop accepting our old way of doing things and be committed to doing something different.

Speaker A: Well, uh, in the spirit of doing something different, you. You gave an open invitation to speak to the nation's CEOs and CFOs.

Speaker B: That's right.

Speaker A: If, if folks want to reach out to you, what's the best way to get in contact with you?

Speaker B: Hit me up on LinkedIn. Christine Hale. And I think my maiden name is in there, too. Morehouse, spelled in the German way, so you can't miss it. It you can message me there. My email and phone number in there as well. Please don't hesitate to reach out if you have a question or want to follow up.

Speaker A: Well, Dr. Yale, thank you for the conversation today. Thank you for the energy, thank you for the passion, and thank you for helping to push everyone where they need to be.

Speaker B: Thanks for the opportunity. I appreciate it.

Speaker A: If you're enjoying the benefits playbook, uh, we'd love your support. Take a moment to rate interview the show wherever you listen. It really helps others discuss. Russ and join the conversation. And while you're there, don't forget to hit subscribe so you never miss an episode. If you know a colleague or friend who'd enjoyed the conversation, share it with them too. Thanks so much for listening, and we'll see you next time.

Speaker B: This podcast is brought to you by Collective Health. In health benefits, conventional wisdom says you have to choose better care or lower costs. We give you both as the leading independent TPA with over 800,000 members and counting. We unify plan administration, cost management, and a member experience your employees will actually love. Uh, all in one place. If you're an HR leader or consultant ready for a more transparent benefit strategy, get in touch@giveivehealth.com playbook.