Our Response to COVID-19 →
Employers and health payers need data to improve the healthcare outcomes of their members and also save costs. However, they've faced a major challenge in accessing these data. This has subsequently formed a huge barrier in employee benefits design and execution. Leveraging digital solutions, experts have created a way out of this misaligned space, creating a toolbox that points employers and health payers to the right data and the right network of partners and programs.
Jonathan Edelheit, Chairman and Co-Founder of Global Healthcare Resources (the organizer of Healthcare Revolution), spoke with Daniel Reber, Director of Corporate Employee Benefits at Prudential Financial, about what this means for the future of employee benefits. 
My name is Dan Reber. I'm a Director of Benefits at Prudential. I'm responsible for the program, design, strategy, and communications of our benefits programs, including our health programs and retirement program.
I'm passionate about the healthcare industry in general. We know that the system is currently broken, so I enjoy not accepting the status quo and trying to make changes, whether incremental or major changes, that ultimately make a difference in the lives of our employees and the broader health ecosystem.
The status quo, for me, is accepting some of the misaligned incentives in the system that exist today. For instance, we know the fee-for-service model is not the most efficient, where you're paying for more services, and they're not necessarily the appropriate services. And we also know that they're not necessarily priced and paid for correctly. So, as an employer, we don't want just to accept that current system. We want to try to make changes to move away from that fee-for-service model by creating a more affordable and simpler experience for employees while also creating an ecosystem where people are getting the same quality of care.
Absolutely. For me, the bad guys are those tied to that status quo. They're tied to those misaligned incentives in the marketplace, such as shared savings for out-of-network adjudication of claims. So eliminating this wasteful spending and the bad guys in the system is what we are focused on as an employer. The good guys, I'd say, are more transparent in their fee structures in terms of how they establish a relationship with an employer as well as charging for services on a utilization basis rather than on, say, a PEPM (Per Employee Per Month) basis.
There are, unfortunately, a lot of examples of this. We work with companies like Smart Light that have uncovered a lot of fraud, especially with COVID testing, where providers bill whatever they like just to profiteer from the system. A lot of these providers know that, for example, self-insured employers pay 100 percent of the costs of some of these services that have now been federally mandated.  
The balance of cost, quality, and affordability has been a major problem. People tend to think that you can't get high quality at a low price, for instance, but we do think that this is possible by driving people towards the highest value providers. We are doing that by breaking down the healthcare ecosystem as it exists today in the delivery models and partnering with networks of providers that we know are delivering high-quality care at a lower cost than a traditional provider network. That is part of our focus at Prudential, creating those high-value providers within our ecosystem and allowing our members easy access to those providers.
A lot of big vendors, big PBMs, or big medical insurance companies believe that some of the data is proprietary to their organization, even though it's our members that are incurring those claims, and it's our checkbook that is paying those claims. For example, PBMs are notorious for not sharing rebate information. Thankfully, Prudential has banded together with other employers in the Health Transformation Alliance (HTA), where we've been able to negotiate stronger contracts with some of these organizations to get more transparency and more access to those data.
Yes, of course. As an employer, we should have access to every line of those claims data, including the different revenue streams, so that we know what we are paying for as part of those claims.
We did that by partnering with organizations, such as Abett, which serves as a data repository where we work with vendors to share medical data. So, for instance, pharmacy data goes into the Abett lockbox, and now we have complete ownership of that data in terms of being able to release it to other partners in our vendor ecosystem and point solutions. This enables all parties to operate more efficiently and better engage our members using actual claims data.
So, for example, we partner with a company called Progeny, which provides infertility benefits to our members, and Progeny gets monthly claims data through Abett to identify members that have infertility or have had fertility treatments in the past. We also partner with Vita Health on the health-coaching side; they do diabetes prevention and chronic care condition management and offer behavioral health and therapy services.
So, these companies are sifting through our claims, reaching out to the right members who would benefit from a weight loss program or a diabetes program. We're able to do targeted outreach to those members and meet them where they are in their healthcare journey.
We also have a partnership with Carrum Health, which is a center of excellence for surgical procedures, including orthopedic, bariatric, and general surgical. They're also ingesting our claims data through Abett, doing targeted outreach to members to meet them further upstream in the process at a much lower cost. And we know that the quality of care provided is as good as or better than what they would receive outside the Carrum network.
Yes, exactly. So we now receive claims data from PBMs and medical vendors almost on a daily basis, which is incredible compared to what we have been able to do historically with traditional data warehouses. For instance, with these leveraged traditional data warehouses, claims data lagged for a significant period of time. For example, it's April here, and we're just getting our February claims data loaded into the system right now. This two-month lag time adds to the time lag between when the claim was submitted and when it is paid.
It is incredibly important. We wouldn't be able to implement these types of point solutions without access to that data. For instance, we found that we have high spending on behavioral health and mental health claims, and this heightened especially during the pandemic. So now, we are evaluating different solutions that could help meet the needs of our different demographics and the different challenges we're facing. We have leveraged Abett to do a deep-dive evaluation of some of the new vendors in the space that could help solve some of those problems.
I would say you really need to be persistent with the vendors. A lot of times, when we went to the vendors, they would say that they were only going to share certain data points and not all of them. But the more you push them, the higher your chances. This is one of the reasons it is important to have a contract that establishes that you could share data with other partners in the ecosystem, such as Abett. However, we know that we are on the right in terms of data ownership. Sometimes it takes a lot of convincing, but we do get there at the end of the day.
Certainly, at Prudential, our focus is on disaggregating the healthcare delivery model as it is set up today. So we've partnered with what we call an independent TPA to provide network access to our broad employee base across the country while also taking more control of things like utilization management. They help us answer key questions, such as: is this service medically necessary? How much should we be paying for this out-of-network claim? Is this an out-of-network claim, and should we even pay? So taking more control of what we're paying for is one step, and having access to that data at all times is a critical piece of it.
I have not seen any. Abett is unique in comparison with a traditional data warehouse, where once the data goes in, it's very difficult to export that data, say to another third party, whereas this is Abett's specialty. With Abett, you are able to move large amounts of data at break-neck speed for the healthcare industry standards. Abett is also able to create eligibility files, take in HR data and create complex files in a relatively simple way.
I'd say don't take no as an answer from a vendor; even if they say no the first time, you have to go back and try harder. With persistence, you could get them on board. It is important, however, to state that those data are employer data, so we have the right to own it. Another thing is that when you're evaluating vendors, ensure that philosophically they're on the same page as your organization. So ask yourself, are they out there to lower cost and create higher quality and value for our employees? This philosophical outlook of the vendors is something that we value even more than the financial ROI.
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