What does it take to really understand population health?
In this episode of Bite the Orange, we have the privilege of having Gretchen Shanofsky on the show. She is an independent consultant that collaborates with organizations to develop programs and services that improve healthcare costs and outcomes in vulnerable populations. She explains what population health is and what it entails in our industry. Considering social determinants of health, population health can be a proactive way to address the care required by some. Gretchen also reflects on innovation and the role of several stakeholders in it, the adoption of technology by the senior population, and newer health services that rose from the pandemic. Healthcare’s on its way to evolving into something more personalized, and that’s exciting!
Tune in to this short and sweet episode about population health; we know you’ll enjoy it!
FULL EPISODE
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Emmanuel Fombu:
Welcome to Bite the Orange. Through our conversations, we create a roadmap for the future of health with the most impactful leaders in the space. This is your host, Dr. Manny Fombu. Let's make the future of healthcare a reality together.
Emmanuel Fombu:
Thanks, everyone, for taking the day or night of today to listen to this great conversation. Today we have a wonderful guest and her name is Gretchen Shanofsky, did I say that correctly?
Gretchen Shanofsky:
Yes, that's correct.
Emmanuel Fombu:
Excellent. Perfect. So why don't you tell us about yourself?
Gretchen Shanofsky:
I have spent really my entire career working in healthcare, focusing on vulnerable populations. My canned joke is that I've had every job you can have in the healthcare delivery system without a license. So I've never been a clinician or an actuary, but I have really done every aspect of healthcare operations from customer service, claims, regulatory, provider network management, I have a special interest in population health and also 12 years of experience at United healthcare in their retiree division, helping to manage their portfolio of Medicare products for large employers.
Emmanuel Fombu:
That's fantastic because I do believe, as a clinician, that teamwork makes the gym work, right? So, right, so we do definitely, I think your role is just as important as is a clinician or anyone else in healthcare, right? And I'm a big advocate for value-based healthcare. And value-based healthcare is driven mostly by payers, right? Because all the checkbook determines what happens, who pays for it, basically, that's what it comes down to. I am particularly interested in your experience from a population health perspective. First of all, how do you define population health?
Gretchen Shanofsky:
Well, population health is really about marrying kind of that public and private sphere. And I would say also it is about addressing determinants of health in a proactive way, whereas our healthcare delivery system is really designed to be reactive, waiting for people to show up in the doctor's office before we really do anything. This is about trying to understand the health status of a person, there are social determinants of health and how, how kind of the entire population can benefit from interventions and thinking about risk strata within that population and then identifying strategies for each risk strata within your population.
Emmanuel Fombu:
Which is also very interesting. And this is, that's why I was looking forward to our conversation, because I think it's a very unique perspective coming from the payer site, right? So coming from that insurance side, what is most important to the payer?
Gretchen Shanofsky:
Well, I think it's interesting. You know, actuaries know that a very small percentage of patients spend most of the money on claim's. Most expensive patients are going in and out of the emergency room, in and out of the hospital, they have very complex needs. And if you look at the pyramid of who is spending the most money, you have a very small percentage spending roughly half of the dollars in Medicare, like the top 2, 3, 4% are spending about 50% of the dollars that go towards healthcare services in the Medicare population. At the bottom of the pyramid, the healthiest people, so the bottom half of your pyramid is really only spending 10 to 12, maybe 15% of the total Medicare dollars. And then we're the biggest area of opportunity is, are those people in between, so we call those the rising risk populations. So these are people who might have a chronic condition or two or, or perhaps they are skirting, you know, pre-diabetes or some of these other conditions that may lead them into the high-risk category. But the idea is that you can alter the trajectory of their healthcare pathway by intervening early enough before the one or two chronic conditions become eight, chronic conditions that require a lot of money and support to keep the patient going.
Emmanuel Fombu:
And that's great insights. And just to add to that, so we mentioned Medicare, people that understand what Medicare is, right? Or you ... to the US, you do understand the market. So Medicare is more for elderly, correct? I remember medical school the ....
Gretchen Shanofsky:
Medicare's for people who are 65 and older or who qualify because they have a disability. So it could be for a younger population if you become fully disabled, there's a two year waiting period and then you can become eligible for Medicare. And also there's a few, few different criteria depending on your work history in addition. But generally, everyone who has qualified for Social Security benefits, there's people pay into Medicare when they work. If you're over 65 and a citizen of the United States then you become eligible for Medicare when you turn 65.
Emmanuel Fombu:
And what about Medicaid?
Gretchen Shanofsky:
Medicaid is for people who are low income. These are state administered programs, and each state has different criteria and different benefits for people in Medicaid. And those are often administered even at a county level. In California, where I live, the county, each, each county has a different approach to how they administer Medicaid benefits. And then there are also people who are dual eligible, so they qualify for Medicare and Medicaid. And in those cases, Medicare is primary and Medicaid secondary.
Emmanuel Fombu:
Gotcha. That's a very good insights, I guess, for our listeners. And there's something I found interesting. I mean, doing research on your background about some of the firsts, you've been involved in, right? For example, you know, we're involved in the first national PPO, Medicare Advantage plan, the first roll out the virtual visits for the Medicare population, first House calls, visit programs, the first population health. I remember those initiatives among many other firsts, which is very difficult to come across in the healthcare ecosystem, right, in general. So do you think from the payers side that the payers are more proactively involved in innovation compared to, let's say, health systems or life science companies or any other stakeholders in the industry?
Gretchen Shanofsky:
I think there's a lot of innovation happening all over the place and it's certainly a complex world out there with a lot of stakeholders and I've seen a lot of approaches to kind of healing the healthcare system. Some of them focus on the provider side, so like value-based care that you mentioned, that's really about aligning incentives for the provider, whether it's the physician, the hospital, the integrated delivery system, depending on where you are in the country, there's different types of relationships. There are other innovations that are happening really around member engagement. So trying to get people to be more active in their own healthcare journey and taking care of their own health. And then I've seen some that are combining that. I think the locus of care is changing quite significantly to the home, especially in these COVID days, you've got a much higher utilization of telehealth type of services. And then I would also highlight that there's a big explosion in the mental healthcare space of trying to address social isolation and mental healthcare issues, Alzheimer's, etc., in the Medicare population as well.
Emmanuel Fombu:
That's very interesting. And just to follow up on that piece, being the first in rolling out some of the solutions, I know COVID, with the pandemic, I think people had no choice, kind of. So telemedicine luckily was there and you have remote patient monitoring that kind of fit what the market looked like. And even today, I hear people asking questions like, are we going to go back to the old days? Which makes no sense because I think everyone has realized how convenient it is to have telemedicine, right? Like I'm in New York, you're in California right now and we can have a conversation, right? And I think that makes it more feasible for us to adopt. So what are some of the challenges that you faced, you know, being rolling out some of the first innovations out in the market?
Gretchen Shanofsky:
Yeah! Well, I think just the technology itself can be a challenge. Anyone who's been on a Zoom call knows how frustrating it is to have lags, people are on mute and they don't realize it, the camera doesn't work. There are a lot of seniors that aren't really familiar with using that technology, they may not be paying for Internet access in their home, or if there, may be just a barrier to them being able to afford that monthly bill. And so just having access to a tablet or some other device that is Internet-connected, enabled having technology, that's simple enough for a senior to use. Some seniors are very sophisticated in their use of technology, others are newer adopters. So being able to make sure that everyone has equal access is definitely a concern, especially as you're offering different cost sharing for telehealth versus an in-person visit. You want everyone to be able to access those telehealth benefits. And so health plans think about how to enable that. And all the ways that things go wrong, if you've got a scheduled call, you want both people to be able to fully participate in that call.
Emmanuel Fombu:
And so clearly, Gretchen, you have a wealth of knowledge and expertise and in my day to day work, as I engage with a lot of early stage entrepreneurs and startups, one of the biggest challenges they have is how to engage with a payer, right? And how do they sell your services to payer? What exactly is the payer looking for in the solution? And so what is your current role right now? I know you're an independent consultant. What's one of the services that you provide right now? And, and who are some of the clients that you have in terms of, not to say names, but some of the services and benefits that you can provide to some of these, some of our audience?
Gretchen Shanofsky:
Sure. So I have like say, an independent consulting role. I work with a whole array of companies. Some of them are digitally focused, trying to develop requirements for products that they hope that health plans will be interested in purchasing, trying to help prove out ROI, return on investment, what's the actuarial model of this benefit, how might we price it, what are the features and benefits that we offer that health plans may be interested in? How can we articulate our message in a way that is going to attract the kinds of sales that we're looking to get? I also work with health plans, helping them to select services that they may be looking for to solve particular problems. And so I have a number of relationships with folks at different health plans, helping them to find people who can help solve problems for them.
Emmanuel Fombu:
Excellent. So if you are an early stage startup, you want to, let's say, sell your solution to a payer, what do you need to have? Do you need to have some kind of evidence or you just need a great slide deck and a great idea?
Gretchen Shanofsky:
I think many of the solutions that I've seen are very niche. They solve sort of a very narrow problem, and some of these problems that they are solving are problems that maybe the payer is not aware that they should be paying attention to. And so some of the advice I often am giving out is that sometimes you have to sell your problem before you sell the solution to that problem. I think sometimes companies can be a little bit more effective explaining why this problem needs money thrown at it to solve. So that's definitely my first piece of advice.
Emmanuel Fombu:
How do insurance companies go about identifying solutions? Is it random? Is it, is it like a process? Or how do you go about that and find solutions yourself?
Gretchen Shanofsky:
Like I say, I think it's really having a deep understanding of what exactly are we trying to solve? What have we tried in the past that has or has not worked, and why didn't that work? Or what might we have looked at that we didn't at that time? What are the array of solutions in the marketplace today? What's kind of the high expensive with all the bells and whistles solution? What's the minimum viable product, cheapest possible solution, and then what's sort of in the middle, and how does that relate to what I already have in place? So if, for example, I know that I'm really strong in telephonic solutions, but maybe not so strong with my app or digital solutions, then that might be an area where I'm thinking, oh, well, I need to make more investment here, but I want to make sure that I'm not degrading what I already have in place. So those are some of the thought processes. And then also as you're thinking about the benefits, what is this solution going to get me in terms of improving retention of my members or reducing churn, reducing complaints, also avoiding unnecessary care, like emergency room visits and hospitalizations, closing gaps in care and achieving quality metrics is always first and foremost, as well as consumer assessments of the health plans services, so the CAP survey, which is basically member satisfaction and their perception of the quality of the care that they're receiving.
Emmanuel Fombu:
Excellent. So what would you say as we wrap up here? What do you think healthcare will look like in the next five years, now?
Gretchen Shanofsky:
I think it's going to be more personalized. People have really complex health needs, and when you get I think historically the health plans have had care pathways for kind of large diagnoses, like here's our diabetes solution, here's our heart failure solution, here's our solution for people with cancer or people with ESRD, and I think as we get more sophisticated, the algorithms will be able to use more data. So not just claims data, but lab data, electronic health record data, publicly available demographic information, social vulnerability index. There's a whole lot of data points that I think will become more integrated and we'll develop a more personalized experience in terms of being able to determine care pathways for individuals and then aligning benefits that meet the needs of those individuals, whether that's in the form of rewards and incentives or care programs, disease, case management programs, or even formularies and authorizations.
Emmanuel Fombu:
And of course all of this is driven by reimbursement, so do you, are you bullish on the idea that payers and CMS has done a great job, you know, in terms of reimbursements for remote patient monitoring kind of solutions which actually have made the industry actually spark and grow more, semi-telemedicine. So do you see that trend continuing down the road?
Gretchen Shanofsky:
I definitely do. I think the pendulum swings back and forth in the value-based care world. There's a whole spectrum of solutions from fully capitated delegated systems all the way to report cards for performance, bundled payments, rated payments, there's a lot of different creative ways to align incentives across the care continuum. I definitely see refinement of those relationships to make sure that we are really addressing the problems that we're trying to solve and not creating unintended consequences that come from having contractual relationships that are not well thought out.
Emmanuel Fombu:
That's fantastic. So if someone was to reach you now, what was the best way for any of the audience members to contact you and what would get you out of bed to actually work with someone?
Gretchen Shanofsky:
I am available through LinkedIn, I think that's probably the best way to get in touch with me right now. And I would be really excited to talk to anyone who is looking for, kind of getting to that next level of how do we make sure that we are solving the right problems for the right reasons and getting the right results from the solutions that we're putting in place.
Emmanuel Fombu:
But that's great, Gretchen, because this podcast is actually sponsored by Marche Health, which is the world's largest digital health marketplace and community, right? And so you have all the setups that are there as incubator space and we'll also have a link to the podcast with your contact information there to make sure that any of the startups in this space can reach out to you. Definitely, of course, I think you have a wealth of knowledge on this and I know we're running out of time today that, but I would love to also bring you back for part two if you are available very soon. That'd be fantastic.
Gretchen Shanofsky:
My pleasure.
Emmanuel Fombu:
Thank you very much, Gretchen. And it was great having you, and I'll be in touch.
Emmanuel Fombu:
Thank you for listening to Bite the Orange. If you want to change healthcare with us, please contact us at info@emmanuelfombu.com, or you can visit us at EmmanuelFombu.com or BiteTheOrange.com. If you like this episode and want more information about us, you can also visit us at EmmanuelFombu.com.
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About Gretchen Shanofsky:
Gretchen Shanofsky is an independent consultant, collaborating with organizations looking to develop programs and services to improve health care cost and service outcomes.
With extensive experience in health tech and insured products, she has held executive positions at Clover Health, Oscar Health, Satellite Healthcare, and United Healthcare. She is a population health enthusiast with interests in systems thinking, behavioral economics, and solutions to address inequities in the health system, and in her spare time enjoys playing classical piano and crossfit workouts.
Gretchen earned her Master of Applied Science degree in Population Health Management from The Johns Hopkins University Bloomberg School of Public Health and her Bachelor of Arts Degree in English and Science, Technology and Society from Pitzer College in Claremont, California.
Things You’ll Learn:
Population health is the marriage between the public and the private spheres of care.
Population health also takes into account any determinant of health, may it be social, political, or economic.
If the one or two chronic conditions a patient has were addressed on time, it could save a lot of money, time, and resources before those conditions multiply or evolve.
Medicare is available for the 65+ American population.
Medicaid is for the low-income population.
The Medicaid programs work differently in every State, and they may work differently in each county.
With the rise of the COVID-19 pandemic, there was also a rise in Telehealth services.
Resources:
Connect and follow Gretchen on LinkedIn.