Unbundling the Healthcare Revolution … · Cofounder of Health Rosetta. What is Health Rosetta?...

Health RosettaUnbundling the Healthcare Revolution

Sean Schantzen

Cofounder ofHealth Rosetta

What is Health Rosetta?

ProductOpen Framework Ecosystem

Transparent Advisor Relationships

Value-Based Primary Care + Patient Stewardship

Independent, Active Plan Administration & Oversight

High-Performance Plan Design, Docs. & Risk Mgmt.

ENA

BLIN

G T

ECH

BIN

DS

CO

MPO

NEN

TS T

OG

ETH

ERTransparent Open Networks

Major Specialties & Outlier PatientsFocus on MSK, Oncology, Cardiometabolic and other high-cost areas

Transparent Pharmacy Benefits

Health Rosetta ComponentsModular Shipping Containers for High Performance Health Benefits Plans

20k+ in 16 months

BOOKS SOLD

How we source our insight Building a self-perpetuating movement & market intelligence

Hundreds ofcontributors

HEALTH ROSETTA

Plan sponsorsBenefits AdvisorsIndustry Experts

CliniciansTechnologists

40,000+ followers

TRADITIONAL & SOCIAL MEDIA REACH

65 articles in H2:18

3.7 million

LIVES OF CERTIFIED ADVISORS

110 advisors

37 states

Largelymid-market

100’s of sources

Broad goal is to drive decentralized, grassroots action

The ProductA Collective Intelligence platform for simplifying andaccelerating adoption of Health Rosetta-based plans

Architect

ImplementOptimize

CREATESVIRTUOUS CYCLE

OF IMPROVEMENT

Topics I’ll Cover

1. Healthcare’s effects on society2. Unbundling the Movement & Macro Trends3. Unbundling of the Plan4. Opportunities to Thrive

Rise of the “Functionally Uninsured”

20 years of wage stagnation & decline

60% of workforce <$20/hr

50%+ households → <$1k savings

50%+ workforce → $1k+ deductibles

Many Americans → One stubbed toe away from financial ruin

70% of those filing bankruptcy due to medical bills had

insurance

LARGEST GENERATION IN HISTORY (MILLENNIALS)SLATED TO SPEND > HALF OF LIFETIME EARNINGS ONHEALTHCARE

MEDICARE TAXES & PREMIUMSDEDUCTIBLES & OUT-OF-POCKET EXPENSESINSURANCE PREMIUMS

EMPLOYER PREMIUMSEMPLOYER MEDICAID TAXESFEDERAL & STATE TAXES

VISIBLEPAYMENTS

HIDDEN PAYMENTS

GRAND TOTAL

$.6M+

$1.3M

$1.9M

TOTAL LIFETIME EARNINGS $3.8M

America’s largest public

health crisis in 100 years

HEALTHCARE IS STEALING THE AMERICAN DREAMHERE’S HOW WE TAKE IT BACK

Pre-Reformation Indulgences

Emergence of the Reformation

The Effects on Society Are Driving Transformative Change

Relocalization

Fiduciary/Regulatory New Talent Flows

Decapitalization

Transformative Tech

Emerging Powerful Levers for Driving Black Swan Events

Disintermediation

Transformations of Other Complex Systems Have Many Similarities

Energy

Micro-credit Food

Financial Services

Fiefdoms of Mediocrity

Stacks of Excellence

Health plans are becoming increasingly unbundled.

Vendor

VendorVendor Vendor

Vendor

Vendor

VendorVendor

Vendor Vendor

Traditional fully bundled ASO

model

Traditional independent TPA model

Network

PBM

Stop loss

Basic DM, case mgmt.

The Promise of Unbundled Health Plans

Old World New WorldToday’s Transition

Macro Threats to Current Plan Admin Model

Exponentially Lower Barriers to Entry

Too Small to Pay Attention to Until It’s

Too Big to Ignore

Trojan Horses & Connecting Dots into

New Stacks

The Challenge of Unbundled Plans

The Logistics of Delivering Unbundled Plans Are Enormously Complex

More plan docs & vendorcontracting issues

More vendors to identify, vet, implement, measure, etc.

Cross-vendor operations

Dealing with data fluidity& new data sources

New underwriting needs

Building more varied plan sponsor experiences

Building member human & digital interfaces

More cross-vendormember referrals

More plan details to getto more stakeholders

Far more details tomanage for each plan

Increased opportunities for member confusion

Organizational & member change management

Transparent Advisor Relationships

Value-Based Primary Care + Patient Stewardship

Independent, Active Plan Administration & Oversight

High-Performance Plan Design, Docs. & Risk Mgmt.

ENA

BLIN

G T

ECH

BIN

DS

CO

MPO

NEN

TS T

OG

ETH

ERTransparent Open Networks

Major Specialties & Outlier PatientsFocus on MSK, Oncology, Cardiometabolic and other high-cost areas

Transparent Pharmacy Benefits

Health Rosetta ComponentsModular Shipping Containers for High Performance Health Benefits Plans

Transparent Advisor Relationships

Value-Based Primary Care + Patient Stewardship

Ind., Active Plan Administration & Oversight

High-Performance Plan Design, Docs. & Risk Mgmt.ENA

BLIN

G T

ECH

BIN

DS

CO

MPO

NEN

TS T

OG

ETH

ER

Transparent Open Networks

Major Specialties & Outlier Patients

Transparent Pharmacy Benefits

Transparent Advisor Relationships80’s Stockbroker → Modern Financial Advisor

Increasing Plan Sponsor Demand for More Aligned Incentives

Rapidly Expanding & Maturing Capabilities of Next-gen Advisors

Transparent Advisor Relationships

Value-Based Primary Care + Patient Stewardship

Ind., Active Plan Administration & Oversight

High-Performance Plan Design, Docs. & Risk Mgmt.ENA

BLIN

G T

ECH

BIN

DS

CO

MPO

NEN

TS T

OG

ETH

ER

Transparent Open Networks

Major Specialties & Outlier Patients

Transparent Pharmacy Benefits

Plan Design & Risk Mgmt.Plan Tailored Architecting + The Future of Risk Markets

Pre-bundled → N-of-group → N-of-one plan design & underwriting

Potential of more broadly diversified risk products & markets

Unpacking risk tranches

Individual members

Cross-risk-bearer geographic communities

Self-funded plan sponsor communities

Individual plan sponsors

Fluid cross-community risk markets Increasingly pooled risk products &

derivatives

Emergence of PaaS for TPA

Claims Processing → Tech-enabled Flow-of-Funds

Transparent Advisor Relationships

Value-Based Primary Care + Patient Stewardship

Ind., Active Plan Administration & Oversight

High-Performance Plan Design, Docs. & Risk Mgmt.ENA

BLIN

G T

ECH

BIN

DS

CO

MPO

NEN

TS T

OG

ETH

ER

Transparent Open Networks

Major Specialties & Outlier Patients

Transparent Pharmacy Benefits

Independent Plan AdministrationEmbracing a New Role + Building Plan Admin Stacks of Excellence

Unbundling of the Plan Admin Stack

Plan Architecting/Bundling/Docs

Network Access + Provider Contracting

Flow of Funds

Claims Adjudication

UM/UR//CM/DM/Pre-cert/Prior-Auth/etc.

Each Plan’s Human & Digital Interfaces

Various Other Services

Transparent Advisor Relationships

Value-Based Primary Care + Patient Stewardship

Ind., Active Plan Administration & Oversight

High-Performance Plan Design, Docs. & Risk Mgmt.ENA

BLIN

G T

ECH

BIN

DS

CO

MPO

NEN

TS T

OG

ETH

ER

Transparent Open Networks

Major Specialties & Outlier Patients

Transparent Pharmacy Benefits

Value-based Primary Care & Patient StewardsThe renaissance of trust and relationships

Trust- and relationship-enabled steerage

Interoperability with traditional admin roles, e.g., case mgmt, advocacy, UM, UR.

Transparent Advisor Relationships

Value-Based Primary Care + Patient Stewardship

Ind., Active Plan Administration & Oversight

High-Performance Plan Design, Docs. & Risk Mgmt.ENA

BLIN

G T

ECH

BIN

DS

CO

MPO

NEN

TS T

OG

ETH

ER

Transparent Open Networks

Major Specialties & Outlier Patients

Transparent Pharmacy Benefits

Transparent Open NetworksKnown Prices + Known Quality

Rise of the Clinical Value-Creators

Unbundling of the Concept of a Network

Relocalization of Contracting & Networks

Unbundling the Network

flow of funds & financial transactions

Relocalizing contract relationships

Standardized, transparent terms

Open performance auditing

Aggregating contracts + Clearinghouses

Administering contracts

Assessing care quality

Ways to Respond.Reshuffling of $100-125 PEPM

Build technological stacks of excellence

Capability to Thrivein Uncertainty

Standardization(Science + Art)

Leverage Market Levers in Your Favor Skunkworks projects Build operational

stacks of excellence

Some Useful Thought Exercises

1. Do your clients deeply understand how you get paid and what you get paid to do?

2. Be like Max from Paypal.

Useful Mental Models

Incentive Analysis& Game TheoryDistributed Systems Complexity Theory

Innovator’s Dilemma

Clayton Christensen

BoldPeter Diamandis

AntifragileNasim Taleb

A Couple Specific Books

Q&A