00:00One point, of course, you have to run a business and, of course, make profits.
00:03On the other hand, you have a lot of pressure coming from the administration and from quite a few others
00:08looking to find ways to keep a lid on health care costs.
00:12Square that circle for us. Can we do both?
00:17Thanks, Romaine. I really appreciate being here.
00:19And we have to do both, to be quite honest, you know, for the health of the country,
00:24both from a financial perspective as well as an actual health perspective.
00:28We have opportunity, you know, as an industry to address a variety of factors together.
00:34And when I think about what are the things that are causing health care costs to rise today,
00:38I think about utilization. So as an example, I mean, our population is aging.
00:45So we have an older population. We tend to have folks with more chronic diseases.
00:48And so utilization is up. Additionally, some of our cost inputs are up,
00:53whether it's hospital costs or it's pharmaceutical costs, the cost of health insurance itself.
00:59And then we have regulatory changes. We have technology advances.
01:03And finally, there's fraud, waste and abuse. And I think, you know, we have to attack all aspects of this.
01:08Some are easier to attack than others. There's no silver bullet.
01:12But we're really, you know, committed to delivering affordability for our clients
01:17and just as much for the rest of the nation.
01:21I am curious that with regards to those elevated costs,
01:25and I know it's a confluence of a variety of costs that go into that,
01:28but is there any one thing that you think can be that low-hanging fruit
01:32that overall, collectively, we can address
01:35that would actually maybe make this a little bit more tenable?
01:39That's a great question. I mean, fraud, waste and abuse is definitely a place to be focused.
01:43And one of the areas that we are talking about,
01:47which you kind of mentioned at the beginning of this,
01:49is around the No Surprises Act and the independent dispute resolution process
01:53that is a part of the No Surprises Act.
01:55What we are experiencing, and I know others in the industry are as well,
01:59is an abuse of that independent dispute resolution process.
02:03The No Surprises Act was focused on taking patients
02:07who had not chosen a particular provider, think like an ER situation,
02:13out of the middle of arguments between health insurance companies like ours
02:18as well as providers on the other side who might not be in-network.
02:22And that No Surprises Act actually took the patient out of the middle
02:26with respect to what they would have to pay
02:29when there was a dispute between the insurer and the out-of-network provider.
02:33But what we're seeing now is those out-of-network providers,
02:36and it's a small portion of them, but a small portion of them
02:39are taking advantage of loopholes within the No Surprises Act
02:42that we would love to see closed.
02:44Those are driving costs that are not driving any improvements
02:47in outcomes or quality, and it's inflationary.
02:51And it hurts, first and foremost, our employer groups that we serve.
02:54We have a fiduciary responsibility to deliver to them affordable health care.
02:59And so closing loopholes like this is an opportunity for us
03:03to work with the administration and others around reducing that fraud and abuse.
03:09So, Catherine, yeah, I mean, the focus definitely on this arbitration process,
03:13as you mentioned in this particular loophole.
03:16Though given that the providers are winning the vast majority of arbitration cases,
03:20as we've seen, do you think that the problem really is that there is a loophole,
03:24or is there something more structural of an issue here,
03:28or perhaps is it an issue of issuers maybe underpaying in the first place?
03:31And is that something that can be found a solution to with what you're doing at Elevins?
03:38Well, that's a great question, Christine.
03:40And look, I think there's several opportunities with respect to the arbitration process
03:44of the independent dispute resolution process.
03:46Yes, it is a fact that health insurance companies are losing 80-plus percent of these cases,
03:54and the providers on the other side are actually winning these cases.
03:58Our concern with that is it's a completely opaque process.
04:02We have no transparency into why the arbiters are making the decisions that they are.
04:07I can say personally that we have done a lot of different pilots to test different amounts
04:13to offer providers in this independent dispute resolution process,
04:16and it really, frankly, hasn't moved the needle.
04:18We have real concerns with whether or not some of these arbiters are actually PE-backed.
04:24They have an incentive, frankly, to continue to drive volume into this process.
04:31That's how arbiters get paid.
04:32And since providers are the ones who are actually submitting these disputes to begin with,
04:39there's, frankly, a perverse incentive on the arbiter's side
04:41to find for providers to continue to drive that volume.
04:45So I do think that there are some structural opportunities here.
04:49We have shared some of those with the Centers for Medicare and Medicaid Services,
04:53who runs the No Surprises Act and the independent dispute resolution process.
04:59And I think, you know, there's some real opportunity for us to address this.
05:03All right, Catherine, we have to leave it there.
05:04Catherine Gaffigan, president of Health Solutions over at Elephants Health.
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