In this episode of "Healthcare on the Rocks: Employee Benefits with a Twist," co-hosts Brittany Hardaway and David Pittman sit down with Will Rumsey, Senior Vice President of Sales at Specialty Care Management (SCM). Will shares his journey in the healthcare industry and explains how SCM focuses on risk mitigation in the renal space. He discusses their two main solutions: chronic kidney disease (CKD) management and outpatient dialysis risk mitigation.
Will emphasizes the prevalence of kidney disease, noting that "90 percent of individuals with kidney disease don't realize they have it," and highlights the demographic disparities, stating, "For every one Caucasian, there can be three African American, Latino, or Hispanic individuals with kidney disease."
The conversation dives into the unique aspects of SCM's approach, including their budget certainty model and focus on member experience. Will explains their cost-saving potential, saying, "We went from having $2.7 million to just over $700,000, saving about 73% off of the paid charges."
He also discusses their renal risk assessment process, which provides precise data on kidney disease prevalence within a population. Will addresses the challenges in the healthcare market, particularly around data access and scalability. The episode concludes with Will encouraging listeners to reach out for a free renal risk assessment, stating, "Let us do, at no cost, that renal risk assessment exercise and show you what your exposure could be."
Key takeaways:
- SCM offers Chronic Kidney Disease (CKD) management and outpatient dialysis risk mitigation solutions
- Their programs can significantly reduce healthcare costs for employers
- Kidney disease is often undiagnosed and has demographic disparities
- SCM's approach provides budget certainty and improved member experience
- Data analytics and proactive strategies are crucial for future cost containment
Stay in Touch!
- Connect with Will Rumsey on LinkedIn
- Visit Specialty Care Management
- Learn more about the Springbuk Activate Partner Marketplace and get other related resources
- Get the complete 2024 Employee Health Trends report and other related resources
- Connect with our co-hosts Brittany Hardaway and David Pittman
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Episode Transcript
[00:00:00] David: Hello, and welcome once again to Healthcare on the Rocks: Employee Benefits with a Twist. I'm David Pittman, the head of marketing here at Springbuk. And today I'm welcoming my new co-host, Brittany Hardaway. She joined Springbuk at the end of May as our director of strategic partnerships. Brittany, welcome to the host seat.
Why don't you tell us a little bit about yourself?
[00:00:26] Brittany: Well, thanks, David. I am really excited to be here. I come to Springbuk with over 12 years of healthcare data analytics experience, including various customer success roles and product management positions. In my role here at Springbuk, I own the relationship with each of the Activate partners, really serving as their strategic advisor.
This also includes being the liaison between each of our partners and each constituent of the Springbuk organization.
[00:00:56] David: And I, for one, I'm thrilled to have you here because it means that I have to attend fewer meetings. So, thank you!
[00:01:03] Brittany: All right, today we will have the pleasure of speaking with Will Rumsey, senior vice president of sales at Specialty Care Management. Will, welcome to our show.
[00:01:13] Will Rumsey: Yeah, I appreciate it. So it's great to be here, Brittany, David. Springbuk's been a great partner up to this point and we're excited to move forward. So, excited to be part of the podcast.
[00:01:23] Brittany: Awesome. So let's start by getting to know you a little bit better. What's your background and how did you find your way to Specialty Care Management?
[00:01:31] Will Rumsey: Yeah, sure. So, originally from upstate New York and, after college relocated quite a bit, but, for the past 14 years or so have been, In some fashion within the healthcare industry, before Specialty Care Management, most recently for about seven years out, I was at a, telemedicine and virtual primary care firm, called First Stop Health.
And that was really my, introduction into employee benefits and the ancillary benefits for cost containment. And, after about six or seven years there, made the move to, Specialty Care Management where I've been here for about two years, leading the commercial team.
[00:02:05] Brittany: That's great. It's a really small world. I'm also from New York state, though not upstate, Western New York. So that's good to know. can you explain what Specialty Care Management does and then give us an overview of your main programs and solutions?
[00:02:19] Will Rumsey: Yeah, for sure. So, Specialty Care Management, it's a risk mitigation firm focused within the renal space. So, laser-focused in a world where prevalence tends to be very low, but financial impact within the cost containment side is very high. So we're, we're driven by data analytics. And we focus on two real solutions.
The first one is chronic kidney disease, CKD management. And that's summarized as a, one-to-one clinical program where we're identifying people through data with different comorbidities of kidney disease between diabetes, hypertension, obesity, and they're assigned a dedicated nurse coach to make a custom plan on how to slow down, pause, and ideally reverse the trends of kidney disease.
And it's really the, in the best case for the member and the plan to prevent people from progressing to dialysis. And our second solution is outpatient dialysis risk mitigation. So this is for individuals that have already progressed to dialysis or were on their way there. And the way that will work will be, we go through an underwriting process for each individual on dialysis and we come up with a case rate.
And the case rate is fixed and capitated. So it gives budget certainty for that particular claim for that member for the plan for a year. And on average, that savings is 82 percent off of bill charges, but more importantly, just over 54 percent off of paid charges for each claim. So it's a very substantial impact on the cost for that plan. And the idea is to save the integrity of the dollars allocated for the, for that plan, but also improve the member experience. Where similar to CKD, everyone on dialysis is assigned a nurse coach to help with all those confusing questions of starting dialysis. So member experience is increased while we're lowering the cost for the plan.
[00:04:12] David: You hit a lot there that we are going to dig into, so I'm looking forward to hearing more about several of those topics. But I'd like to start with, you talked about the prevalence, and so let's, let's just start there. Tell us a little bit more about the prevalence and the impact of chronic kidney disease.
[00:04:29] Will Rumsey: Yeah, for sure. So it's, it's, really everywhere. Any company you look at, there's never going to be a firm that is not impacted by kidney disease in any fashion. The prevalence does fluctuate based on a lot of variables, between, demographics or geographically, where are they located, industry is a big factor as well.
One example being, again, prevalence can be everywhere, but, it's a one-to-three ratio as far as with demographics. For every one Caucasian, there can be three African American, Latino, or Hispanic individuals with kidney disease. So, it's going to be everywhere, but there's some areas and some firms, if we had to choose to look into some firms over another, there's prevalence will be higher some places than others, but probably more important than the fact that it's everywhere, the silent aspect of it is really what takes people by surprise where 90 percent of individuals with kidney disease don't realize they have it.
They can be going and spending time with their PCP and saying, "Yeah, your blood pressure is a little high or, slightly overweight. We should try to work on your, your BMI." The reality is these are just the beginning stages for something that may already be very much an issue for the member with advanced kidney disease.
We do different analysis for different firms and sometimes it will show what they thought was just some comorbidities of some of those items I mentioned before. In reality, our advanced kidney disease people just aren't diagnosed, they don't realize they have it. They just think it's masked with some other very lighter health care issues.
[00:05:58] David: That's fascinating. I had heard previously about the discrepancy between races, but I had no idea it was that large. That's quite significant.
[00:06:08] Will Rumsey: Yeah, I mean, the, and there's a lot of leading factors to that, but the reality is that is the prevalence. So, when we're looking geographically around the country, certain pockets would be a better fit for us to make a more immediate impact. But the reality is even the, the on paper groups that would seem very healthy, there is kidney disease everywhere.
And again, even if they don't realize it, it is there. And it's just a matter of when, not really if it's going to make an impact.
[00:06:32] David: So let's talk about the costs associated with your program. So how do those line up and just what goes into that?
[00:06:40] Will Rumsey: Yeah, for sure. So, we're very conscious of, the integrity of budgets for groups because everyone wants to help improve the impact of their members. But, there's obviously financial restraints for firms based on who they are, where they are, and everything. So, we're very focused on that. So, for those, the three elements I spoke to, the data, CKD management, and our dialysis risk mitigation, there's no cost to our data.
So, we will review for prospects as well as clients quarterly review their data and give them the results of what is the, the disease impact within their population. As far as our CKD, Chronic Kidney Disease Management Program, once we review the data, it's essentially an opt-in program where we identify individuals with those comorbidities or diagnosed kidney disease.
And we, we, we call them. We outreach through a couple different mediums and say, "Do you want to work with us? We're here to help. Here's what we want to do." And if they opt in, there would be a monthly fee for that particular member.
And it depends on the group size. So there's a bit of a scale there. On our, dialysis risk mitigation, this is where we've really put a lot of focus into it to make sure we can lead the industry with this solution. So as far as the financial impact, there is no cost to this program. There's no fees for the legal review or drafting amendments to their plan language, implementation, onboarding. There's no fees to that. There is no PPM. And, and a big difference, there is no percentage of savings of what we can take away and save the group for the, for, against the claims.
So, one through that underwriting process I spoke to before, we come with that fixed capitated rate. And that's a, it's paid as a claim, not a premium. Which means if we're not actively contracting with the group, reducing the cost of that claim on average by 54%, then there are no fees associated with it. We're taking a pre-existing high claim, lowering it by more than a half. And within that claim, we're able to pay ourselves as well as the provider.
So it's all-inclusive. And there are no surprises where the group will know to a penny what they could pay up to in any year with no surprises at the end of the year.
[00:08:43] David: So it sounds like you are incented to help the employers reduce their own costs.
[00:08:48] Will Rumsey: Yeah, it's a simple methodology. If our clients aren't winning and saving money, then we shouldn't be paid. So that's our methodology. If we're making an impact, then it will work. If not, we're just going to be a silent partner reviewing data, waiting for prevalence to appear. Because prevalence is low, but again, when it comes, it's a substantial expense for the group.
[00:09:09] Brittany: Wow, that is really awesome information. So what about Specialty Care Management is unique?
[00:09:16] Will Rumsey: there's probably, I mean, a lengthy list here, but really the two main elements, what I spoke to a moment ago, as far as budget certainty, where again, everyone wants to do a better job for their employees and, and save money. By going into dialysis cost containment with our services, the group will know that it's very easy for a broker of record to say, yes, this is great.
And the plan sponsor, the CHRO to say yes, but the big impact is the CFO. The CFO in large part has to sign off on it. And if we can prepare and educate the entire company saying, this is a win-win-win, everyone's going to win here, and you will go into the next calendar year knowing what you were paying anywhere from $700,000 to a million dollars for that particular paid claim, we have a flat rate to the penny, you will know you will not pay more than this.
So budget certainty is where we really get to stand apart and say, this is where we can differentiate ourselves, as well as our, our member experience. So, as much as we focus on those claims, our clinical team led by Kimberly Langford, our VP of clinical services, she is second to none in the space to make sure the member is first.
If the member is having a better experience, then that is her key priority, and that is really what we have a laundry list of testimonials and members oftentimes say, I don't know what I would have done if I wasn't speaking to my nurse coach. And we can really make that, really enhance that experience for the members.
So knowing what it's going to cost to the penny and having every member that works with us have a better experience is where we get to separate ourselves.
[00:10:43] Brittany: Yeah, that is very much impactful. Just coming from a patient or a member perspective, having that personal touch of a nurse is extremely impactful to an overall, you know, health stance.
Going back to cost, I was just reading an article this morning that suggests that high cost claims are continuing to increase stop loss rates. How does Specialty Care Management impact stop loss?
[00:11:07] Will Rumsey: Yeah. It's a great question. And we've again, kind of made our program to make sure that the entire ecosystem is impacted in a positive way. And stop loss is very much a part of that. The idea being stop loss is concerned about catastrophic claims and, and that impact. When we are a part of ecosystem, we are taking that off the table.
We're taking a previously volatile claim, conservatively, $550,000 per one person on dialysis per year, conservatively. We've seen seven-figure claims often, and that's where stop loss is going to see that and going to say, okay, you have a high volume of kidney disease, but we're going to underwrite your premium as a stop loss provider to make sure we're not going to be out of pocket here with this group.
When we're part of the ecosystem, stop loss recognizes that. The prevalence is still there, but the cost of it is significantly lower. So stop loss is a huge fan of ours where we're taking a lot of liability from stop loss off the table. Also what we can oftentimes see is whether there's active dialysis or not, stop loss will reward the group by reducing premiums a few points because we're taking risk off the table.
As well as if there's a laser on an individual, we've seen lasers be reduced and sometimes eliminated altogether. Because again, we're taking that $700,000 claim and cutting that in more than in half. So stop loss wants to reward groups for taking away liabilities from them.
[00:12:31] David: Yeah, that's, that's pretty amazing savings there. I want to shift gears for a second. You covered so many items in we have a chance to touch on several of them. So let's go to the renal risk assessment. How does that process work?
[00:12:45] Will Rumsey: Yeah. So that's been, it's really transformed our commercial side in 2024, where up to, up to this point, we would work with a prospect and say, well, the national averages for kidney disease is X, and the prevalence of dialysis is Y. And it's good. It gives a good directional risk for the group. But, again, it's just directional risk.
So what we're able to do now with a renal risk assessment is ingest claims data. We go through a custom underwriting tool, and we're able to pinpoint within a population exactly the prevalence of the different levels of kidney disease as well as dialysis. So, instead of a broker of record going to a group and saying, yeah, you, statistically, you might have this exposure.
We have a vetted document that says there's exactly the exposure you have. And you have 27 people that are high risk with comorbidities, 17 people have CKD4, nine people CKD5. This is real plan exposure versus theoretical. And within this renal risk assessment, if dialysis is discovered, we can proactively go through an underwriting process and show, here's what your case rate would be, here's what you were paying, here's your savings, here's the percentage of savings, and by the way, we don't touch that, that's yours to keep
So it's not just a, a fun value to see, but it's actually true dollar savings, so the renal risk assessment has gone from theoretical risk to actual risk and action for a broker of record and a self funded plan, which again has really separated our process in 2024, where we're able to show the risk and show solution as well.
[00:14:14] David: Well, I'm going to ask you to pull out your crystal ball a little bit here. How do you see the future of cost containment solutions evolving? Costs are continuing to skyrocket. Everybody wants to try to get them under control as best they can, especially in the realm of some of these high cost dialysis claims.
[00:14:34] Will Rumsey: Yeah. The reality is that overall as a country, we're not necessarily getting healthier. So the prevalence of these comorbidities and how they're going to move into kidney disease and move into dialysis, those rates are not going in the right direction. So, it's really the actionable items that can take place.
So, the cost of avoidance, we really want to stress that to plan sponsors and brokers of record. What does it cost if you do nothing? And sitting back and waiting and hoping that these catastrophic claims don't exist. This isn't going to cut it because the prevalence is only on the rise. So investing in data analytics with a firm like Springbuk is the first step.
Then finding solutions that fit what your needs are is the next step. So taking a more proactive approach where there's plenty of phenomenal firms out there to help with cost containment. And we happen to be in a very specific niche, like I said before, but there's many, many options out there. So the future of cost containment has really got to be a more proactive approach and everything is driven by data.
That's no surprise to anybody, but picking the right data partner, picking the right vendor partners, and being proactive versus hoping and getting lucky is not really the case anymore. Maybe 20 years ago with prevalence being lower, you could get lucky and you could go through a career as a broker with a decent book of business and never get surprised with these catastrophic claims. Today, it's just not the case, and sitting back and hoping is not, not a solution. So being proactive is really the future, regardless of whatever the claim may be.
[00:16:00] David: Yeah, hoping and hiding, not a good strategy.
[00:16:03] Brittany: So it sounds like from your programs, what you've described that Specialty Care Management has a significant potential to be wildly successful in helping employers. Can you share a success story where Specialty Care Management made a significant impact on employers' healthcare costs and employee outcomes?
[00:16:22] Will Rumsey: Yeah, for sure. So there's two quick anecdotes. The first one was really getting back to the surprise where people didn't think they had an issue, and there's very much an issue. So through one of our renal risk assessment exercises, the HR head said, yeah, we have some diabetes within our population, but we don't have any kidney disease, and we're not trending towards dialysis.
We said, that's great. You're in a great position then. Let us do this renal risk analysis for you just to confirm it. What was discovered through that was that what she thought was low levels of diabetes happened to be four people at CKD stage 4, which is advanced kidney disease. So, CKD 5 would be the only level higher before you're progressing to end-stage renal disease, needing dialysis.
So, what was assumed to be a healthyish population was discovered to be very much at risk to have some pretty horrible surprises for a member experience with four members transitioning to dialysis. As well as, again, the plan integrity for the, for, benefits, there's going to be four dialysis claims that's going to destroy your stop loss premiums at renewal.
There's going to be potentially four lasers. And it's going to impact them significantly. So by the proactive approach there, that was one big surprise in a good way for the group. And another quick anecdote will be a group had come to us with three active dialysis members.
They're in a particularly expensive area of the country. And for the three members on dialysis, the paid claims was just over $2.7 million. So they were spending a significant amount for these three members on dialysis. We went through our underwriting process and we're able to lower that cost to just over $700,000, I think it was $734,000 in total for those three members. So we went from having $2.7 million to over, just over $700,000, saving about 73% off of the paid charges. And that also significantly impacted the renewal for stop loss. So, by doing nothing more than signing up for Specialty Care Management, we saved that group over $2 million.
And that $2 million, we do not charge a percentage savings, that is straight back to the pocket of the plan. So, I'm not sure, right, how big any group could be, but 2 million is 2 million. So to reinvest in other benefits and, and, and growing the company and new facilities, whatever they want, but, by doing nothing more than signing up, we're able to change the dynamic of that company.
And from the member experience there, we are provider agnostic. So the member, I think all three members are going to the same facility. We do not require them to change. They can continue to go to that facility. They can change to a different facility, anywhere they'd like to go, they could continue to go to, as well as that enhanced member experience where they were. All three were just educating themselves on how to live life on dialysis, where once they signed up with our company, they now were assigned a nurse coach and that nurse coach is there to help with.
The bureaucratic, clinical, administrative questions of how do I get on the transplant list? How do I enroll in Medicare? Even simple questions of what do I wear? What can I bring? I'm in a dialysis chair for four hours, should I bring food? These things that are seemingly very basic are very real, stressful questions for people that are on dialysis, so significantly enhancing the member experience, based off of just signing up with SCM.
[00:19:41] Brittany: Wow.
[00:19:42] David: I bet your organizations were happy, but the members were extraordinarily happy too.
[00:19:48] Will Rumsey: Absolutely. I mean, it truly is a, it's fun to have this part of the conversation where it's a win-win-win. We're a growing company. The broker of record is bringing great value to their company. The CHRO is bringing a great service to their employees. The CFO is saving a ton for their bottom line.
Everybody in this scenario wins by taking a volatile claim and lowering it.
[00:20:10] David: All right. Well that, thank you for those amazing, amazing results there. Congrats on those too. So we've talked about some of the good sides of things here. Let's look at what are some of the challenges that you're facing, especially Care Management. what about the broader current healthcare market and how are you addressing those?
[00:20:31] Will Rumsey: Yeah. So the, to no surprise where we're going in our, in our growth, it's all driven by data, where we're taking assumptions and thoughts out of it. And everything is data driven, as it should be. So the scalability of our data platform, as well as access to data is probably the, one of the bigger obstacles to overcome, which is why we're spoiled with Springbuk, where the ability to aggregate a massive pool of data and find the areas of where we can make an impact on groups that are not part of a platform like Springbuk, that's where we can have challenges.
Where if we're working with a regional broker and a regional TPA and access to data sometimes can be clunky, it can be time consuming, it can be frustrating because we know there's someone on dialysis, but we need the data to drive the underwriting, to drive the savings, to drive everything. That's a part of it.
So, I know we're not unique to that, but that is really where the world is going between AI, data analytics, and streamlined, efficient access to data is part of a daily conversation internally. And we're, we're always rapidly improving it, but that's something that's always top of mind on our side and something we're addressing as we're scaling as rapidly as we are.
[00:21:42] Brittany: It's all about the data. Well, this has been great. Thank you so much for sharing your insights with us. If people want to get more acquainted and learn more about Specialty Care Management, how can they get in touch with you?
[00:21:57] Will Rumsey: Yeah, for sure. And I would encourage everybody, if you're listening to this and you are a broker who has self-funded groups, or you are a self-funded group yourself, reach out to us. Let us do, at no cost, that renal risk assessment exercise and show you what your exposure could be. And by going to our website, SpecialtyCM.com, or emailing me directly at Wrumsey[@]SpecialtyCM[dot]com. I would love to have a conversation and go through that exercise with you.
[00:22:24] David: Yeah, I tell my wife all the time, don't cost nothing. So let's do it. Right.
[00:22:28] Will Rumsey: That's the goal. Yeah.
[00:22:30] David: All right, Will, thank you for joining us and thanks to our listeners for tuning in to another episode of Healthcare on the Rocks: Employee Benefits with a Twist. Before you leave, please be sure to subscribe and leave us a nice, juicy five-star rating or review.
[00:22:45] Brittany: And for more episodes and to stay updated, visit springbuk.com/podcast. Until next time, stay healthy and stay informed.
