unbundling the healthcare revolution … · cofounder of health rosetta. what is health rosetta?...
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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
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MPO
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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