Modernizing Benefits Consulting - Genesys Health - Matt Monahan

This video provides an in-depth exploration of modernizing benefits consulting, focusing on the strategic implementation of Population Health Management (PHM) and leveraging data systems to drive cost savings and improve employee health outcomes. Matt Monahan, Chief Strategy Officer of Genesys Health, details his firm's approach, which moves beyond traditional wellness programs to clinically manage employee health. The core strategy revolves around using data warehousing to identify and intervene with high-risk populations suffering from controllable chronic conditions such as hypertension, diabetes, and hyperlipidemia.

Genesys Health emphasizes that systems are the future of the business, utilizing platforms like Deerwalk for data warehousing. This allows them to take claims reporting out of the hands of carriers and gain granular control, enabling monthly analysis of year-over-year performance for specific disease states. This data-driven approach facilitates targeted outreach to individuals identified with "gaps in care" (e.g., those with hypertension who are not adhering to medication), allowing the consultant to proactively engage employees before issues escalate into catastrophic claims. Monahan stresses the importance of convenience and cost removal in driving behavioral change, arguing that doing something, even if the ROI is initially unclear, is far less risky than doing nothing.

The firm implements a "care spectrum" designed to simplify access to medical providers. This spectrum includes virtual primary care, on-site clinics, and Direct Primary Care (DPC). DPC is highlighted as a powerful tool because it provides consistent access to a familiar medical provider, removes the financial barrier of co-pays for primary care visits, and eliminates the perverse incentives of the fee-for-service model. By controlling primary care costs and establishing a predictable bucket of expense, the employer can then focus on steering employees who need specialty care or procedures toward high-quality facilities with better cost structures, thereby improving outcomes and reducing complications like septic claims. Monahan concludes by noting that his experience in the carrier world (Aetna) revealed significant internal innovation often stifled by red tape and contract restrictions, positioning independent consultants like Genesys to implement these high-impact, data-driven solutions with greater speed and autonomy.

Key Takeaways: • Data-Driven Population Health: Effective Population Health Management requires leveraging data warehousing (like Deerwalk) to analyze claims, identify specific risk pools (hypertension, diabetes, hyperlipidemia), and track gaps in care on a monthly basis, moving beyond generic, ineffective wellness programs. • The Care Spectrum Model: Implementing a comprehensive care spectrum (on-site clinics, DPC, virtual primary care) simplifies access and removes cost barriers for employees, which is essential for driving preventative care and behavioral change. • Direct Primary Care (DPC) as a Cost Control: DPC is a critical strategy because it isolates primary care costs into a predictable, fixed bucket, eliminates the fee-for-service incentive for unnecessary testing, and fosters a stronger, more consistent patient-physician relationship. • Scaling DPC: For DPC to be viable, critical mass is necessary (approximately 100 lives per location). Smaller offices should be layered with a cohesive virtual primary care model to ensure consistency and access across the entire employee population. • Strategic Use of Technology: Consultants must adopt technology (e.g., PlanSite for RFPs) to automate administrative tasks and eliminate reliance on error-prone spreadsheets, allowing high-value strategists to focus their time on strategic initiatives like PHM and systems integration. • Intervention ROI: While the ROI of PHM interventions can be challenging to measure immediately, proactively addressing gaps in care for high-risk individuals can prevent catastrophic claims, making intervention the less risky financial and ethical choice. • Carrier Constraints vs. Consultant Autonomy: Carriers often possess significant internal innovation, but external consultants have the autonomy to implement high-performing network solutions, DPC models, and direct contracting strategies without being constrained by existing volume agreements or regulatory red tape. • Steering to Quality: A key benefit of controlling the primary care relationship is the ability to guide employees needing specialty care toward high-quality facilities and providers known for better outcomes, lower complication rates, and favorable cost structures. • Future of Data Flow: The healthcare industry desperately needs technology to improve the consistency and flow of medical data, moving away from self-reported clipboards to give providers Amazon-like access to a patient’s complete, integrated health history. • Marketplace Disruption: Regulatory shifts (e.g., PBM regulation, transparency rules) and the rise of cash-based payment models are creating opportunities for innovative solutions, including the acquisition of outpatient surgery centers to drive down costs for common procedures.

Tools/Resources Mentioned:

• Deerwalk: A data warehouse platform used for claims reporting and detailed population health analysis.
• PlanSite: A technology platform for employee benefits brokers to efficiently manage the RFP process.

Key Concepts:

• Population Health Management (PHM): A data-driven strategy focused on improving the health outcomes of a group of individuals (the employee population) by identifying risks and intervening with clinical management.
• Direct Primary Care (DPC): A healthcare model where patients pay a flat monthly membership fee directly to their primary care provider, bypassing insurance claims for routine care, thus improving access and removing cost barriers.
• Gaps in Care: Instances where an individual with a known chronic condition (e.g., hypertension, diabetes) is not adhering to recommended treatment or medication protocols, identified via claims data analysis.
• Care Spectrum: A range of accessible primary care options (virtual, on-site, DPC) offered to employees to ensure convenience and meet diverse needs.