Access to Healthcare Simplified | with Ryan Coplon

This video provides an in-depth exploration of simplifying access to healthcare and optimizing employer-sponsored health plans, featuring Ryan Coplon, co-founder of HealthWallet. The discussion begins by establishing HealthWallet as a "member experience as a service" company, functioning as a benefits aggregation and engagement platform. Its core purpose is to consolidate disparate healthcare services and use this centralized "chassis" to communicate and engage effectively with members, thereby reducing fragmentation in the healthcare experience for employees. The conversation highlights the critical need to improve member engagement to reduce health plan expenses, ensure employees understand their healthcare options, and ultimately design more effective health plans.

Coplon details his journey from a benefits broker to a technology founder, identifying a significant market problem: while employers were increasingly unbundling self-funded plans and adding innovative point solutions, employees often failed to utilize them due to confusion, lack of awareness, and poor accessibility. This underutilization not only negated the intended benefits but also contributed to unnecessary plan expenses. HealthWallet was initially developed to address this within Coplon's own brokerage programs, demonstrating the power of solving a personal problem that resonated with a broader market need. The platform's success led to its external market launch, driven by demand from TPA partners who recognized its value in their own client portfolios.

A key aspect of HealthWallet's approach is its flexibility and vendor-agnostic "platform as a service" model. Instead of curating a fixed suite of vendors, HealthWallet integrates third-party point solutions (e.g., virtual care, pharmacy benefits, EAP) at the request of its partners, perpetuating the "strategist's strategy." This modularity allows for highly customized member experiences, where two HealthWallet implementations might be functionally unrecognizable from each other. The platform aims to simplify complex health plans by providing a consistent "front door" for members, regardless of the underlying carriers or point solutions. It also significantly reduces the burden of high-volume, low-complexity service requests (like "where's my ID card?") from member-facing service units, allowing them to focus on higher-complexity care navigation. The discussion culminates in a theoretical exercise of designing a "perfect" self-funded plan, emphasizing reference-based pricing, value-based primary care, robust care coordination, and strategic bill review to achieve optimal outcomes and cost efficiency.

Key Takeaways:

• Fragmentation is a Major Problem: The unbundling of self-funded health plans, while offering potential cost savings and specialized solutions, often leads to a fragmented member experience, causing confusion and underutilization of valuable benefits.
• Engagement Drives Utilization and Savings: Effective communication and easy accessibility are paramount to ensuring members understand and use their health plan benefits. Improved engagement directly correlates with better health outcomes and reduced overall health plan expenses.
• Benefits Aggregation Platforms are Essential: Solutions like HealthWallet centralize disparate healthcare services and information (accumulators, plan designs, virtual care, PBMs) into a single, user-friendly platform, simplifying the member journey.
• Vendor Agnosticism Enhances Scalability: A platform-as-a-service model that integrates third-party solutions by request allows for greater flexibility and scalability, enabling partners (TPAs, brokers, payers) to maintain their preferred vendor ecosystems while still providing a unified member experience.
• Relieve Service Burden with Self-Service: Mobile platforms can automate responses to high-volume, low-complexity member inquiries (e.g., ID cards, deductibles), freeing up care navigation teams to focus on complex, high-value cases.
• Timely, Actionable Communication is Key: Leveraging automation logic for instance-based engagements (e.g., push notifications for pre-op/pre-cert, allergy season reminders) ensures members receive relevant information at critical moments, driving behavior change.
• Incentivize Member Behavior: Plan designs should be structured to financially incentivize members to choose optimal care paths (e.g., free care at direct contract facilities, waived deductibles for centers of excellence), making the beneficial choice the obvious and easiest one.
• Digital Fulfillment Reduces Costs: Transitioning from physical to digital ID cards and EOBs can lead to significant cost savings for TPAs and health plans, with some clients seeing over 90% reduction in print and mail expenses.
• The "Perfect" Plan Foundation: An ideal self-funded plan often includes a reference-based pricing chassis for catch-all, a blend of direct primary care and value-based provider arrangements, and a mandatory pre-op/pre-cert process managed by a dedicated care coordination unit.
• Strategic Care Navigation: The care navigation unit should act as the "brain trust" of the plan, executing on the plan-level strategy, guiding members through the healthcare journey, and alleviating the "onus of consumerism" from the individual.
• Long-Term Strategy Over 12-Month Cycles: Employers should shift their mental paradigm from a 12-month insurance purchase to a long-term healthcare purchasing strategy, recognizing that sustainable cost reduction and quality improvement require a multi-year horizon.
• Market Shift to Self-Funding: The benefits of self-funding are increasingly accessible to smaller employers, leading to a flattening of growth in the fully-insured market and a potential "adverse selection" scenario where fully-insured pools retain higher-risk populations.
• Regulatory Scrutiny on PBMs and Vertical Integration: There's growing attention on the lack of transparency and potential conflicts of interest in the PBM sector and the vertical integration of insurers owning providers, suggesting potential future regulatory changes.

Key Concepts:

• Member Experience as a Service (MXaaS): A business model focused on providing platforms and services to enhance how members interact with and utilize their health benefits.
• Benefits Aggregation and Engagement Platform: A centralized digital tool that consolidates information about various health benefits and point solutions, making them easily accessible and promoting member interaction.
• Self-Funded Plan: An employer-sponsored health plan where the employer directly assumes the financial risk for providing healthcare benefits to its employees, rather than paying a fixed premium to an insurance carrier.
• Captive: A type of self-funded arrangement where multiple employers pool their risks together, often gaining more control and potential savings than traditional self-funding.
• Reference-Based Pricing (RBP): A payment methodology where healthcare providers are reimbursed based on a reference price (e.g., a percentage above Medicare rates) rather than negotiated rates with traditional networks.
• Value-Based Care: A healthcare delivery model where providers are paid based on patient health outcomes rather than the volume of services provided, incentivizing quality and efficiency.
• Care Coordination/Navigation: Services that help guide members through the complex healthcare system, assisting with appointments, referrals, understanding benefits, and finding high-quality, cost-effective care.
• Digital Fulfillment: The electronic delivery of documents and services (e.g., ID cards, Explanation of Benefits) that traditionally would have been physical, reducing print and mail costs.

Examples/Case Studies:

• Aha Moment for HealthWallet: The realization at a group captive member meeting that cool, shiny point solutions were underutilized due to ineffective communication and lack of accessibility, leading to "egg on the face" of consultants and increased expense ratios.
• Micro Member Experience for Optimal Care Paths: A TPA client with a reference-based chassis and direct contracts offers totally free care at specific facilities. HealthWallet created a micro-experience with "free healthcare" messaging, prompting members to choose this option or watch an explainer video if unsure, thereby steering them to optimal, cost-free care.
• Digital ID Card Savings: A 300,000-life Mech plan client saved 90% on print and mail costs by offering digital ID cards and EOBs as the default, with less than 10% opting for physical copies.
• Personal Experience with Emergency Care: Ryan Coplon, despite being a benefits navigation expert, defaulted to an expensive, private equity-owned urgent care for a motorcycle injury, highlighting that consumerism often fails in emergent situations.