Richard Jacobs:  Hello, this is Richard Jacobs with the future tech and future tech health podcast. I have Louise Short. She’s the National Clinical Director for Strategic Benefit Advisors (SBA). They are owned by Brown & Brown, which is their parent company. So, Louise thanks for coming. How are you doing today?

Louise Short:  I’m doing great. Thank you, how about you Richard?

Richard Jacobs:  Yeah, glad to talk to you. So, tell me about Strategic BA. What’s the premise of the company?

Louise Short: Yeah. Great. So happy to, strategic benefit advisors is really peak health and benefits, brokerage and consulting firm. We are located in Southborough, Mass and our book of business is mostly in the northeast. We are part of Brown and Brown, which is a $2 billion company in the property and casualty and employee benefits space. And as a company the larger, broader around, we provide employee benefits, brokerage and consulting services to all markets. So from less than 50 employees up to jumbo employers, including the largest fortune 100 companies in the country. And I’m currently working to build out a national practice of clinicians and well-being specialists and we’re focused on population health, so we’re assisting employers and improving health outcomes, member experience, the process of care, medical costs, productivity. We also have a new health innovation hub and we currently accumulating a lot of knowledge on digital health solutions in several categories and figuring out how we can best help our clients, understand that faith and really leverage some of these solutions in their strategies. And we recently became a member of the National Business Group on Health Innovation Forum.

Richard Jacobs:  Alright so for employers, what kind of issues are they facing and how are these changing, you know, in the less 10 so years, what are you noticing?

Louise Short: Yep. So employers are facing escalating healthcare costs at a rapid rate and for every employer, you know, the pain points are kind of similar, varies a little bit by employer size and by industry, but what we’re finding is high-cost claimants are a big concern, the cost of specialty pharmacy drugs. The ability to engage employees in anything including work or health or anything in the workplace is a huge challenge for them. The war for talent, very big, especially in certain sectors like healthcare and tech and then chronic disease, which is really just kind of escalating these healthcare costs and literally, you know, killing the American workforce and then I guess I didn’t mention access is also a very big issue. So the idea of digital health is to address a lot of the pain points that employers have today. And digital health is doing that in a few ways. One is it’s addressing access and availability of healthcare, the second is it’s addressing high costs and chronic conditions and then the third is if it’s addressing employee engagement and through different sorts of modalities, programs and emphasis.

Richard Jacobs:  Alright so what does that mean? What does accessibility mean instead of a health care plan? What things are accessible or not accessible, and what gets in the way of people getting the healthcare they need when they went up employers plan?

Louise Short: Yeah, great question. So, we know today that there is an access issue, by 2025, there’s going to be a 250,000 nurse shortage and a 93,000 physician shortage. And so even today we have long ways for primary care, behavioral health, and specialist. And so in order to solve for that problem, digital health has enabled telemedicine. That’s one of the sorts of biggest manifestations of digital health. And so what we’re seeing now is a lot of virtual visits and that has increased the scalability and access to care. And initially, the virtual visits started off as being more like, I’ll call it semi-urgent care like I’ve got a cold, I’ve got a sore throat, you know, I’ve got a cough, something like that. What we’re seeing now is the evolution of virtual care and greater acceptance and utilization of virtual care both by physicians as well as by patient. So, what’s happening is we’re seeing virtual care move now into behavioral health, not just for a console, but for ongoing therapy. We’re seeing virtual physical therapy and I believe soon it’s coming. We will see virtual chronic care. And, you know, I was at a conference where it was kind of futuristic that I really think it’s coming around the corner. The woman who was watching a soap opera and her doctor interrupted and said, sorry to interrupt your programming, but I just need to ask you these five questions and check if you are taking your medications. That actually is going to start happening. I mean, it’s already happening in some sense and it’s going to start happening a lot more. So that access is expanding tremendously. And we know the uptake by physicians of telemedicine has increased 340% from 2015 to 2019. And there are some early studies showing that virtual care is actually getting better outcomes for people with chronic disease, Intermountain healthcare, and some other organizations had done some recent studies. So I think there’s starting to be evidence that virtual care is going to be more and more the way that consumers are going to relate to caring. There also been studies on consumer behavior, because Deloitte does a study every year and what they found is that millennials and generation z expects to be interacting virtually or with tech-enabled practices, meaning online scheduling, e-prescribing, being able to text back and forth or interacts through an app and not having to come in to get things like lab values and things like that. So what we’re seeing is that the younger generations are demanding virtual care or virtually and enabled care and that, they’re going to go more for the convenience care. Their expectations of the primary care relationship are also very different from older generations. They’re not so interested in that long term relationship as much as getting their care when they need it, how they need it and kind of being done with it.

Richard Jacobs: Well if you have a chronic condition, that kind of rings counting intuitive too, being done with it because in a chronic condition you need primary care I think and a follow up in order to manage your condition better than you normally would.

Louise Short:  You’re absolutely right. So someone has a chronic condition, they’re going to need ongoing care. But again, that ongoing care could be delivered virtually. And so, it’s like not having to leave work. Even if you are working at home or working in an office, go to the doctor’s office, wait there, I mean, could be a half a day or you know, a fair or more if you have a chronic condition, many different appointments with specialists, but instead being able to do virtual visits from your home with a variety of different practitioners or from your workplace in a secure area. So there’s just a different way of thinking about it. They don’t need to necessarily be there, cancel on in front of the doctor.

Richard Jacobs:  Yeah if I understand what telemedicine, you know, you have to visit the practitioner in person the first time and then you have what like a year to be able to do telemedicine or virtual conferencing with them.

Louise Short:  I’m not sure what you’re referring to. I mean, as far as I understand, you can always go back to, you know, have another encounter with the physician it’s that telemedicine benefit is provided to your healthcare plan. You can always have another encounter. So, is there some specific program you’re referring to?

Richard Jacobs:  No, I know you can do as much telemedicine follow-ups as you want. I just thought the first time you see somebody that you have to see them in person and after that, we are able to do telemedicine visits. I don’t know right off the bat and you could just, all right, I need to see an endocrinologist. And the first time I ever interact with them, it’s through telemedicine and not in person.

Louise Short: It kind of depends on how the program is set up. So if it’s for example, a sub urgent care like I’ve got a sore throat or something like that, you can just, you know, do tell the medicine. Some physicians who are specialists or deal with more chronic patients are going to see it the first time until this and you’re right. So it just kind of depends on what condition you have and the provider group that you’re interacting. But what’s interesting today also is that there’s chat-bots and that, there are a couple of companies that are using chat-bots that actually refer people into the right type of care. So you can go on chat with the chat-box, which is program has clinical algorithms behind it and it will kind of direct you to the right care for your first encounter and the healthcare system like, suggest you see, you know, go to the ER right away or sounds like you need to see an endocrinologist here’s the way you can go. This interesting sort of access points, if you will, some of which are more automated.

Richard Jacobs: Alright so access I see, a big benefit would be telemedicine, doing these virtually texting, that kind of thing. What about the care itself? Is there any way to get better outcomes, you know, using all the technology from just the digital health versus the way it’s done now? Or is that not really a part of the digital health mission?

Louise Short: It definitely is and I think what digital health is enabling and will enable more is more remote monitoring and also more use of social connectedness to change behaviors. I’ll give you an example, the diabetes prevention program, which is a program that is scientifically proven to prevent people from progressing from pre-diabetes to diabetes, 57% decrease in risk if you can change modifiable risk factors. Basically, people who are overweight or have high blood pressure or high cholesterol and high glucose. So, this program was always delivered brick and mortar that the YMCA had a national program where they would deliver classes and diabetes prevention program. Probably about 10 years ago, a group of smart people got together and said, how can we scale this veteran delivered to more people? And they decided to put it on a platform, you know, a digital platform and have virtual coaching in groups. And what they found was that this virtual diabetes prevention program actually was incredibly effective and they have shown and demonstrated amazing outcomes in terms of weight loss, reversal metabolic syndrome. And they even have a government contract now to deliver this and there have been a lot of other programs using the diabetes prevention program that have come up that utilize the same principles. So there are two to four companies that are doing this now, but that is an example of getting the better outcome, leveraging science because we know that diabetes prevention program works and technology and social connectedness and virtual coaching groups.

Richard Jacobs: You said there are virtual coaching groups for what? For people that are dealing with diabetes or other chronic conditions?

Louise Short: Yes, pre-diabetes and other chronic conditions, hypertension and others.

Richard Jacobs:  How does this work? I mean are they led by physicians or are they just peer-to-peer group and how are people able to connect without violating HIPAA?

Louise Short:  Yes, so, it kind of depends on which company and which program. But generally these are led by trained coaches who usually have some kind of degree, might be an exercise physiologist and nutritionist, whatever, depending on the clinical condition and they’re able to do it by not violating HIPAA because they have everybody sign appropriate releases, all of their technologies, HIPAA compliant. They have all the certifications that they need and people agree to be in these virtual coaching groups. Yeah. A lot of times people can opt, they can say, I want to work one on one with a coach or I want to work in a group, I want to work in a group, but I don’t want to show my identity so I just want to be anonymous in the group or they can actually be in the group and had their identity. It’s totally up to the individual.

Richard Jacobs:  So how does the health insurers themselves and employers, how they react to the new demands of digital health and benefits and the tradeoffs? What is the feedback from them?

Louise Short: It’s a really good question. So I guess I’ll start with employers. So employers are kind of confused. There are literally hundreds of different digital solutions, maybe thousands at this point, and there are new ones coming every day and they’re in every clinical area. Behavioral health, women’s health, advocacy, and navigation, you know, helping people get around the healthcare system, diagnosis of disease, genomics-23 and you know all of those kinds of companies, virtual care you name it, it’s got a solution today. And so, some of these digital solutions started out direct to consumer and some still have direct to consumer apps, but they have extended their services through employer-sponsored programs. So a challenge for employers is kind of making sense of this landscape and that’s, that’s part of what we do as consultants, that’s what strategic benefit advisors does. It’s a very complex market and so we encourage our employers that we work with to really look at these digital health solutions in the context of their broader workforce strategy, not just their health strategy, that their workforce strategy. So high visual solutions fit in with their overall business objectives and goals, particularly related to health and performance and well-being. And so, you know, employers need to look at their data and medical cost drivers, chronic conditions, employee talent, and turnover and satisfaction and figure out where is it that they want to invest and what makes sense for them, where will they get it all rely on their business. And then also what resources do they have? Because they’re a small employer and they’re fully insured, they’re not going to be able to probably implement a lot of these solutions. If they’re self-insured, they’ve got more options, but still, if they’re a smaller employer, it will be hard from an administrative point of view to manage all of these different vendors. They may not have a lot of staff to do that and it takes a lot of internal resources to manage vendors. So, you know, they have to figure out what’s right for them. And then when you implement these digital health solutions which we tend in the industry to call point solutions, they have to figure out how to integrate it with their benefits strategy and other parts of their health management program. For example, if they have a care management program, let’s say with the carrier and they’ve implemented a behavioral health solution, let’s just say they implement some kind of cognitive behavioral therapy online, their carrier needs to know that they can refer people to that solution. So it all has to be integrated and work together. And that’s really, really important because I’ve seen a lot of employers implement great solutions, but no one ever uses them no one has engaged and they don’t know about it. They don’t know about it at the right point in time. So there’s a lot of communications and integration efforts that need to go along with these solutions. So I think in general, the majority of the employers, and this has been shown there was a survey last year by the National Business Group on health and the Blue Cross Blue Shield Association. Majority of employers want these digital health point solutions that have proven to be effective in the marketplace. They want data, which I’ll talk about in a minute because there isn’t that much data. The payment mechanism is important. So some of these solutions are like a PM-PM basis and most important now are saying, no I want to pay for this through my medical claims. They want these vendors to get set up so that they can be paid in that way. So they have to have a code and that code needs to be reimbursed on the claims side or they want to pay for performance. If you engage a certain number of people, if you get certain outcomes, you know, then we’ll pay you x. So, these are some of the issues for employers also struggle to integrate some of these solutions from an IP perspective and they want to be sure that they have the right messaging, analytics, whatever it is, multi-modal communication channels that the vendor does to actually kind of target and engage people. So, what we’re finding is a lot of enforce would rather go through their health plan because a lot of the health plans had figured out, oh, they better catch up and partner with these digital points solutions so that they can add more value to their clients because otherwise their business, the carrier’s business is getting chopped up, it’s harder for them to work with these different solutions that create more work for their staff, more costs. So basically, now in the last several years, all of them, major carriers, so should be called the BUCAS. So the Blues, the United Healthcare, CIGNA, Aetna, they’re all partnering with different points solution. And the advantage to employers is they don’t need to contract directly with the point solution. They don’t need to negotiate, they don’t need to integrate. So all that is done for them, but they can’t customize as a point solution. So there’s pluses and minuses to both approaches. And some of the carriers have just outright bought point solution. Now some of the carriers also though are building their own. For example, I mentioned the diabetes prevention program. Well, two or three of the major carriers are building their own digital life program. It’s very similar. So they’re also doing meuthes if you will or trying to develop an original solution for, you know, for which there aren’t competitive point solutions out there. But it’s hard to find that niche right now because every clinical area has a point solution.

Richard Jacobs: Yeah it’s tough because the carrier wants to do their own stuff and keep it in a walled garden. How’s it supposed to participate when employers are looking to choose carriers and plans? If they don’t integrate? They have all their own stuff. I know it captures them once they’re in with them, but I think it doesn’t seem to serve anyone to do that. What is the most advanced comprehensive or you know, most of the vacations plan you’ve seen out there, what are some of the elements of it and I’m not asking you to name names but what are some of the like best plans you’ve seen out there? What do they have?

Louise Short:  A health plan or the point solutions?

Richard Jacobs:  The health plans because it’s more expansive than the little point solutions.

Louise Short: I would say that the best top health plans, in my mind, really, they have virtual care options, really critical, they have robots, chronic disease care management and the longitudinal care management of members of chronic disease really focus on those members, incorporating some elements of virtual monitoring if you will and then they have options for other types of programs that have to do with, for example, diabetes monitoring and glucose monitoring or behavioral health. Some of the plants now actually are integrating with nontraditional partners. So Cigna just announced a partnership with Amazon Alexa, and one of the other big carriers did as well and right now it’s just like information like Alexa can answer, help questions. But to be honest in the future, what’s going to happen is that Alexa is going to be, you know, knowing the treatment plan. Alexa is going to be reminding people to take their medications or Google, depending on whatever the personal assistant is. There’s going to be a lot in that space. And the health plans I think are getting out in the head in terms of partnering with those nontraditional groups, that are not necessarily point-solutions.

Richard Jacobs:  What are some of the most interesting point solutions you’ve seen? Just curious what some of those would be?

Louise Short: Yup. So tell you what some of the best-funded areas by venture capital had been and this, just to give you some perspective, in the past seven years have been almost 30 billion in Venture Capital (VC) funding alone for additional health and that does not include the Amazon, Google, Apples of the world. So it’s a huge area. I think 10% of all VC coming in 2018 was going towards digital health solutions. And it’s not leveled off. We thought we would see in 2018 that the funding had decreased but actually increased in 2018 and what we found that there are 8.1 billion in funding in 2018 for digital health, with 368 deals. So, in terms of, some of the more creative things that I think I’ve seen out in the park marketplace, or most importantly, a lot of this solutions are really aimed towards big cost drivers or significant issues in employer populations. And it makes sense because when you think about it, employers are covering a huge number of lives, right, in the United States. So what’s happening is that a lot of solutions are aimed there, many of these solutions started out direct to consumer and realized very quickly, no, that’s not where the market is. The market is the employer market. So if we look at what’s driving medical costs? One of the big things driving medical costs is behavioral health. So 5% of claims, but up to 20 to 40% of spin can be related to behavioral health, particularly those people who have medical issues and behavioral health, co-morbidity. So, because there are a lot of access issues and behavioral health, we’ve seen virtual visits that started as a console. And now moving into ongoing therapies, we’ve seen also online cognitive behavioral therapy, peer support programs, new work life support and EAP models, programs for families with autism and developmental disabilities, resilience training and resiliency has become a big issue. It’s about making sure that people have coping skills and getting to them before they get stressed out. So instead of stress management, it’s like prevention of stress. So I think behavioral health has been one of the areas that’s had sort of the biggest innovation in terms of that sort of intellectual capital and money that’s gone in there. We’re also seeing a lot of musculoskeletal solution for a muscular-skeletal drive a lot of concert employers, back pain, hip pain, knee pain. Many of those people do need some type of intervention, but, many can be managed at least initially, conservatively with physical therapy and other interventions until we’re seeing virtual PT where we have companies that have built devices that they send to members and then the member can have a virtual visit with a physical therapist and physical therapist can monitor their motion. So, I think that’s really amazing, great solution.I mentioned the pre-diabetes, those virtual coaching solutions have shown great results, sort of across the board that you have different groups, you know, different companies, but all pretty good results. Women’s health and infertility, that’s been a big area of focus for employers in terms of retaining talent. And we’ve seen some carved out solutions, meaning carved out from the health plan and infertility, that are virtual including new types of benefits that are administered, narrow networks and quality monitoring and coaching that includes behavioral health because that’s a very stressful time for people, but that has shown, cost savings, decreased multiples, which is really critical in terms of, you know, decreasing risks to the individual as well as the babies, right and then, of course, decreased Constance, you don’t have multiples because people don’t end up in the ICU as much and things like that. So those have been great solutions. I think, there are also a lot of solutions that apply only to this sort of providers side, right? Like teleradiology, telepathology, virtual monitoring device to use all of those types of solutions I think have improved efficiency for a physician. There are solutions that are in the expert medical opinion area that I think is critically important where people can get a second opinion or an expert opinion on what’s going on with either themselves or a family member, virtually. And these solutions I think are among the best that I’ve seen in the industry in terms of actually really helping people get high-quality care and the best care many times the diagnosis is wrong or the treatment path isn’t optimized. And so these types of solutions and vendors are able to help members tremendously. And then, one of the central heights of solutions that have come about in the last, I want to say really 10 years is the sole idea of advocacy, navigation, both digital and human. So using analytics to get people where they need to go, holding their hand through the episodes of care, giving them, you know, sort of personalized attention, very different than traditional health plan customer service where they can understand what’s going on. And be helped to get the right care and the best care at the right time. So this is kind of a smorgasbord, but you know, again, addressing the problem of the healthcare system is too complex and people can’t get to where they need to be or they don’t understand where they need to be and that leads to poor outcomes for quality of care. So, and I think these advocacy navigation solutions also address health literacy and helping to educate people and make them understand more what they’re going to and what kinds of questions they should be asking and educate them on the choices that they have going forward.

Richard Jacobs:  One last question for you, you’ve talked about a lot of areas. But is there anything you haven’t covered that isn’t the future of digital health? Any new exciting things that are coming? And yet, I know you touched on a lot of things.

Louise Short:  Yeah, I think that we’re sort of at an inflection point. You know, every day we would customize or open up and some are what I would call revolutionary. We haven’t really talked about new therapies to cure disease cause that’s not really so much digital, although some of it is and then, you know, there’s sort of new ways of doing things that have been done before, like my example of the diabetes prevention program, some of it’s improving with technology out what we already have, like ultrasound and imaging. But I think the thing that impresses me is that the pace and speed to market and innovation, it’s unlike any error in the past. So what we’re going to see, I think it’s a lot more virtual care. When I show my daughter a photo, about 10 years ago, my youngest daughter, and there was a record player and the federal and she had no idea what the record player was and to me, that’s where we’re going in medicine. I think 10 years from now or 20 years from now when we show kids pictures of hospitals, they may not know what that is because the idea of inpatient medicine is going to be reserved basically for people who are enormously ill or need some major surgical procedure because a lot of the surgical procedures, even hip replacements, and knee replacements are being done outpatient now. It’s amazing. So I think that we’re really going to see a very big change in how healthcare is delivered and where it is delivered. It started already and it’s sort of, we’re just at the brink of a very big, I think evolution or maybe even at revolution and how that care is going to get delivered. I think we sort of live in a, I’ll call it an age of a mutating edge, but like not the cutting edge, but the mutating edge, like things are changing but not in a cancerous way that they’re changing radically and we’re pushing the envelope every single day. I think the other thing to think about also is that I talked a lot about employers, but I am a consultant for employers, large self-insured employers but we need to see the quality in the application of the solution. Everybody in this country really needs to have a basic level of coverage that includes preventive services. And we need for everyone to have health literacy or be able to have access to all of these wonderful solutions and technologies that can improve the quality of care and health outcomes. We don’t want this to be, something that is only for those who can afford it. Only for those who are employed and many of these solutions now are being utilized by Medicare and Medicaid. And hopefully, we’ll see more of that as time goes on.

Richard Jacobs:  Well very good. So what’s the best way for people to get in touch to find out about your services, whether they’re an employer or a carrier insurance company, etc?

Louise Short:  Absolutely. So, they can reach me at Louise.short@strategicba.com.

Richard Jacobs:  Well very good. So, Louise, thanks for coming on the podcast. I appreciate it.

Louise Short:  Thank you so much. I appreciate you having me today and I’m delighted to be here and hope that I will hear from some of the people who listen to this podcast because it’s just an area that I feel really passionate and excited about.

Richard Jacobs:  Excellent.