Misc. Questions Flashcards
Blanket Provider Approval
-Allows an employer to specify a set of providers that approved for Garner reimbursement, regardless if a member finds them through the app
-Common request among healthcare groups
Note: This is an MVP solution, use best judgement
How does Garner work with level-funded groups?
We quote them the same way as fully insured
How does Garner work with HMO’s?
If the HMO requires a referral before seeing a specialist, we don’t recommend adding Garner
We can technically support it, but it can create a confusing member experience
-they might find a doc using Garner, but then don’t get that referral so they’re stuck
How are you ingesting the hospital transparency data?
We actually built our own engine to ingest that information
How do we know if someone is up-charging for visits?
Site infection at Mayo Clinic: What about the nurse that does the stitches? Couldn’t they cause the infection?
These doctors are using the same operating rooms, same support staff
-They’re working down the hall from one another
-There’s a constant here, it’s the doctor
-Hence why the infection is tied back to the doc
Maybe the doctor is giving better instruction to the team, or even the patient on how to take care of themselves at home
Garner’s Closed Data set perks
Able to track members across different carrier networks
-Ex: Someone is with UHC one year, and moves to Cigna the following year
-Means, UHC loses track of patient
-If Joe gets a knee surgery with UHC, then the carrier switch happens, UHC doesn’t know about infections, complications, or revisions
Garner however, can follow that patient
-much more accurate into the quality of that surgeon
How do you compare to Surest?
Disruption - HSA - Data
Similar philosophy, getting employees to higher quality care. 3 major differences:
- Surest is more disruptive, ID card says Surest
- Can’t have Surest on a HSA plan
-Fully copay-driven plan, employers have to toss HSA strategy
-Garner actually sees higher engagement with HSA plans - Most importantly, Surest is based on different data
-Episode groupers, not effective at identifying higher quality doctors
-Garner has much more data, take a bottoms-up approach
-Does the network matter in your recommendations?
Yes, we only make recommendations for in-network doctors
Also take into account network discounts
-Ingesting health plan transparency data helps us know how cost varies from doc to doc, or plan to plan
Network discounts do impact cost of care, so it’s factored into our recommendation
Ex for Practice:
-$1000 with Dr. Smith
-UHC has 20% discount
-Cigna has 25% discount
How does Garner work with Tiered networks and domestic steerage?
We have experience working with large hospital systems
-Mercy works with Garner to understand how their doctors perform
We can help with domestic leakage, steering folks to high-quality doctors when they looks outside hospital system
What is the HRA Funding Fee?
This is in place because we’re guaranteeing the cost of the program for 12 months
However, those dollars are budgeted to be used by the HRA
-expect to pay those dollars out as reimbursements, and not meant to be additional rev. for Garner
-Main thing to know: These dollars are not eligible for the return via the 80% settlement if there’s lower utilization
If higher than expected utilization happens, Garner is on the hook to cover any overages
-So this is how we balance the financial elements
How is HRA Funding calculated?
How do you reconcile the Performance Guarantee at the end the year?
Start by saying we think we’re going to save you X % on your claims spend, say 10%
-Of that 10%, we’re going to guarantee a portion, maybe 5.5%, 6% for example
-If we don’t hit the guaranteed savings target, we refund up to 3x our admin fees to make you whole
How do we reconcile that? At the end of the year:
-Take your historical claims spend to figure out what your expected claims spend would be in the upcoming plan year if you renewed as it
-Then, look at the claim spend in the year with Garner after you cap for high-cost claimants ($50k)
NEEDS MORE WORK
What’s the communication campaign look like for Garner?
Can see we’re heavily invested in marketing Garner to employees, especially since we’re putting our money on the table to hit a certain savings target
Make sure that not only employees know they have Garner
-But how it works, how to take advantage of it
-In the end, we only hit our savings target if people use the program
OE support includes:
-One pagers, email and text campaigns, direct mailers, videos
-Designated AM team is tasked with figuring out best comms strategy for each population
-we understand each group is a little different
Performance Guarantee % for Overlay, Increased, Enhanced
we guarantee 1% Overlay, 5% Increased, 9% Enhanced
Continuation of Care - what it is and examples
Continuity of care
Be careful when you’re presenting this, it’s not black and white
Case-by-case exception
If folks are undergoing for an ongoing treatment for an active condition, we may or may not cover that existing doctor even though they’re not recommended as a TP
Ex: Employee is going through chemo with a specific oncologist, currently undergoing active treatment. We’ll continue to cover that doctor
But, if employee has been in remission for 3 years, and going for 6 month check up and isn’t actively being treated, probably an instance where Garner wouldn’t cover that doctor relationship
CoC is much more stringent
“Know this sounds like a cop out. We really shy away from making broad generalizations on the continuity of care policy”
Get member-facing language for CoC from Jake (from training with Rob and Rick)
Short answer: It depends
What does Garner define as an emergency? (Asked when Garner is covering ER care)
We define emergency as: Does the underlying medical plan define it as a true emergency
Ex: Sniffles and go into the ER, Garner is not going to cover it either
Deferring to the medical carrier to determine what emergent is
How many doctors in any given network are identified as Top Providers?
Usually 20% - 30% within an existing network
What is a Disruption Report?
(Main Answer)
Analysis of a prospect’s specific claims and network to show:
-% of providers visited by members that are top doctors
-estimated savings if all members visited top doctors
Details
% if top provider metric:
-Ranges from 20%-35%
-we expect higher % in rural areas b/c proportion of top providers is greater there
Estimated Savings:
-Take every non-top doc, calc. avg. % cost diff. with TP’s in that specialty and region
-multiply % by claims amount, sum differences to arrive at total
What’s required to run a Disruption Report?
What doctors were visited in the last few years and what $ amount was spent on that doctor
-Rendering provider NPI’s required
What’s a Geoaccess report?
Analysis showing % of employees in a given region that will have access to top doctors available for Garner reimbursement
Report Standards:
-Ensure that all recommended providers are within an acceptable distance from the employee
-Drive time based on where the employee lives, and the volume of that speciality
What’s required to run a Geoaccess report?
-Full census of employees with zip codes
-Network name
What is broker commission?
What is Garner’s admin fees PEPM?
What reporting does Garner offer to customers?
We provide quarterly reports showing:
-what folks are searching for
-who’s signing up
-the amount of Claims $’s being reimbursed
Can also provide that reporting ad hoc if requested
How long does implementation typically take?
What data are you using to find the best performing doctors? (Succinct response)
We’ve aggregated medical claims from pretty much every source out there
-From insurance companies, clearinghouses, HT data
-As well as 3rd party partners
These sources stitched together give us largest claims database in the country, over 310 million patient records
Then we use in-house quality metrics to rank doctors
How does your PEPM change for single vs. with dependents?
Garner’s fees are tired depending on enrollment
What is Garner’s minimum incentive amount?
$1,000
How long does it take for an employees to get reimbursed?
With claims feed: 7 weeks from date of service
Member-initiated claim: check or direct deposit 3 weeks from when they submit claim to Garner
Does a member have to pay the claim before they can get reimbursed from Garner?
No, it’s up to the member if they want to:
-Pay their bill first and get reimbursed from Garner
OR
-Get money from Garner and use that to pay the bill
When you get pushback on Garner, why are clients saying no?
Unique to self-funded world
-Not wanting to make investment upfront to see ROI on the backend
-It’s more: I have to wait until end of the year to see impact on claims
-With fully insured, they get savings from plan change usually
Communication and how we’re going to get engagement
-Particularly for demographics who tend to struggle with benefits (blue collar, dispersed)
-Oftentime where the client will say:
I don’t know if I’m going to get 45% engagement”
Garner does a lot when it comes to communicating the program: Email and text campaign, direct mailers, recorded webinars, comms throughout year
Self-funded quote (concise answer)
We request 24 months of claims experience (Med & Rx spend)
-Then, we do a projection based on their claims spend, plan design, and what we anticipate engagement to be to determine Garner’s impact
This savings analysis will show:
-Reduction in claims spend from Garner
-Fixed cost of the program
-Finally, net savings
Will also show plan design with Garner in place
Does the Garner HRA amount impact the max amount someone can contribute to their HSA?
No, they can continue to fund the max IRS limit, regardless of how much is in their Garner incentive
When is Garner usually rolled out?
Typically, goal is to have it running by OE
-Even though reimbursement doesn’t start until new plan year
-Get folks familiar, allow them to chat with concierge, learn about program
Typically need 2 weeks to get ready for OE
Is the HRA funding prorated for new hires depending on when they start?
No, they get the full incentive amount
-The total resets at the beginning of the new plan year
How does Garner work with embedded deductibles?
If the plan has an HSA, we just need to make sure the Garner HRA doesn’t pay out until at least $3,200 (in 2025) is met in aggregate by the family
Ex: Bob has spent $3,1999, Mary spends $2, we reimburse $1
-Don’t need Mary to meet her individual embedded deductible, it’s combined between the two
Issues with hospital transparency data not being as accurate, etc…
No strict guidelines on how hospital data is reported, so not as useful at scale
However, health plan transparency helps Garner understand negotiated rates between diff. carriers and hospitals
How do you measure the plan savings of 12% in your slide deck?
12% is blend of our BoB, depends on group’s funding arrangement:
-SF: historical claims spend compared to actual year with Garner, net of our fees
-FI: compares as is renewal vs. plans they implemented w/ Garner + cost of our program
How do you determine the top 25% doctors? Is is just a total cost?
Look for doctors who are better than average:
-On quality
-Total cost of care
What specifically do you mean by 310 million records in your dataset?
-310 million patients
-60 billion encounters overall
How do you know you’re not duplicating a lot of your data, especially with so many sources?
Probably 1% or less is duplicates
We do thorough de-duplication based on:
-Who’s the member
-Who’s the provider
-Date of service
-Procedure
What’s the clearinghouse in your dataset?
Basically where providers send their claims en route to the carrier
-Ex: Change Healthcare
When you say you have 75% of all claims, are you talking about unique people or total claims?
75% of all claims
-got over 90% of all patients that have gone through healthcare system
Where do you get your average trend number from?
Aon’s trend data, and also use Kaiser
What happens if someone messages the concierge outside of operating hours?
-Essentially get an away message
-Our team works 8-8 weekdays, so we’ll be back in touch on the next business day
How is Garner made available to employees?
Does an employee have to “select” Garner during enrollment?
It’s available to everyone
-Members will still be covered by underlying plan
From there, you can decide to use the program or not
-and when you do, the financial incentive kicks in
Who owns Garner?
Private equity backed
-In the end, we’re a private company
-The employees are the owners
How does your network steerage work? Is it agnostic?
Garner is an independent 3rd party with our own proprietary algorithm
-We gather the data and come up with performance-based metrics which include:
-care appropriateness
-patient outcomes
-cost of care
When a client comes on board, we’re only making recommendations within their network
When employees are reimbursed through Garner, does it still apply as credit toward their deductible?
Yes, even when reimbursed you still get credit for it on the plan
Ex: $1,500 deductible
$200 OOP expense is reimbursed thru Garner
$1300 now left for member deductible
How does reimbursement work?
2 ways:
1. Claims feed
-receive info from TPA/carrier
-file is post-adjudication, telling us what the member responsibility is
-reimburse them via check or direct deposition
2. Manual submission
-Client snaps picture of bill/EOB
45% engagement, you’re saying the majority of people don’t use Garner when have the option on their plan?
45% factors in all members on the health plans
When you think about a population on a health plan:
-% don’t even use the plan at all
-Others that use it only for a wellness checkup, fill a script, aren’t really seeing specialists
If we remove those folks, the % of members using Garner would be much higher
How are you lowering OOP expense for members?
Mix of access to incentive dollars and better-quality care
Garner has an engagement-based HRA, meaning:
-when they take our recommendation and see a top doctor, they unlock dollars they can use for their OOP expenses
Also, Garner top doctors generate 27% savings, so cost of care is lower too
There are instances where the carrier might reject certain procedures. Does Garner have any part in that process?
We typically follow the underlying plan design
However, our continuation of care policy is case-by-case
How are you assuring these top providers have patient availability? (Short Answer)
- In our data, we can see which doctors are billing for new patients
- Have a call center reaching out to Dr. offices to confirm upcoming appointment availability
- If a member needs more support, or is looking for care more immediately
-Our concierge team will actually call recommended doctors’ offices to get that member in
What if someone doesn’t hit the IRS minimum deductible where they can use the Garner HRA?
Member still has access to the search function
-could restructure it to kick in first dollar
For clients who keep that HSA
-The financial incentive may not kick in
-But would still get great care from doctors who generate 27% savings, which also helps the plan run better
Why don’t the carriers just do this?
Contractually, they’re not allowed to steer within their network
-The hospitals and providers have so much negotiating power, so they have to take all the docs into the network
Explanation of putting 3x Garner’s admin fees at risk
Take your historical claims spend:
-to figure out what your expected claims spend would be in the upcoming plan year if you renewed as is
Then, we anticipate what Garner’s impact on claims will be
-Allows us to say, “We think we’re going to save you 6% net of Garner’s fees”
From there, we guarantee a portion of that savings by putting up to 3x our admin fees
-in scenario where we don’t hit a certain level of savings to make you whole
On proposals, what are expected net savings based on?
Savings are off expected claims spend based on prior years
There’s a big delta between the HRA exposure and what Garner is capping it at. Walk me through that
We know basic healthcare utilization:
-half of members may not even use the plan
-others may do a wellness visit, fill a script here or there
Then there’s those high utilizers
-folks seeing specialists regularly, spend a lot more OOP
-That group needs to be accounted for when setting the incentive cap
Also, the Garner HRA has to be spent at top doctors
-generates 27% saving per episode of care
That’s generally how we think about it
I imagine Garner’s data would have significant overlap with say, a Center of Excellence? Perhaps the same high rating for the same doctors?
Fundamentally, the biggest difference is Garner will tell you who within the COE you should see
-we believe there are top doctors within most centers
Done exercise in the past, particularly where a COE is tied to a specific procedure
-Run search in that zip code
-Out of top 15 docs in that are, 3-4 are from COE
We get very specific on type of care. Ex:
-If you’re looking for an orthopedist, is it for wrist? Hand? Knee?
-Let’s get you to the doc who does more knees
We can always put in a new solution, but how do we actually steer them to use the program?
It’s a combo of those incentive dollars and the robust marketing campaign
Incentive Dollars:
-Folks really understand that if they use the tool, they’re going to get a substantial part of their OOP expenses covered
Marketing campaign:
-Dedicated resources to craft a marketing strategy dependent on how you all like to communicate to your employees
Speak to a case where you’ve put groups on super high deductibles with first dollar coverage
Some of our best performing groups have $5k deductible, $5k incentive at first dollar
-$0 OOP expense for the employee
-Get around 85% utilization
-Basically every claims going through a high-quality doc
Drastically reduces plan spend, even net of funding the HRA
Who administers the HRA?
Garner is the administrator of the HRA
-the client doesn’t have to do any of that
Are these stats, 12%, 80%, 45% (in the mid-market broker deck) from year 1, or over multiple? And how much of this is consistent? For example, does utilization taper off after the first year?
These are first year results
-We’ve seen ability to drive higher engagement in Year 2 and beyond
Word of mouth spreads, maybe a group implements different plans with Garner
-our clients see Garner as a multi-year strategy
What if everyone starts going to Garner doctors and they lose availability?
We think about that situation
-We’d have to be very heavy adoption in a geographic location
-Which at this point hasn’t been an issue
What we do right now, via the data, AI tools, and call center is:
-We’re kind of obsessed with the provider directory data (phone number address)
-Most importantly, are they accepting new patients
-Struggles on carrier site where they’re showing docs who have no openings
-If a provider isn’t accepting new patients, they’re removed from our recommendation
The data vs. the demand for providers aren’t always aligned
-Ex: There are providers who have full panels b/c they’re associated with Mayo Clinic, but they’re not really docs you’d want to see
-So that public perception is still quite strong for those who aren’t using Garner
So do you have an affiliation with UHG?
Full transparency, we did take an investment from Optum Ventures, which is the venture capital arm of Optum, but we’re not affiliated
We’re owned by employees at the board level
-no contractual relationship there
Are there any specialties that you don’t cover?
No, it’s one of the key things about getting engagement from our side
-It’s for all episodes of care from PCP to strange conditions you probably haven’t heard of
From a member standpoint:
-They can come to Garner for anything they’re experiencing, which includes mental health too
Tell me about the concierge team: Where are folks located, when are they available, how many people do you stock up when you get spikes?
We have concierge members all throughout the country:
-predominantly work from home
Hours of operation:
8 am - 8m ET M-F
Total team: About 50-ish folks
-we also monitor activity to make sure people aren’t waiting for responses, we’re staffed appropriated, etc
Where are you hiring those concierge folks from? Are you looking for experience with health plans?
Looking more at a social worker-type background
-Healthcare is pretty personal, and we want folks to feel like they’re being taken care of
-Vs. feeling like they’re being rushed off the phone
The team also has clinical support:
-Nurses, MD’s to help with provider identification and answering questions
-So if they have a symptom but don’t know who to see, we can help them
How are you different from HealthJoy?
Answer from Jo in UNICO conversation
Does Garner compare all doctors within a given area, or just those in the members network?
For territories, do we focus on where the broker office is OR the client addess?
Broker office
-Ex: Broker is out of Nebraska, client is in Illinois, that falls under my (JB) territory
What % of clients are fully insured vs. self funded?
60% clients are fully insured
40% self funded
However, membership is flipped b/c self funded groups are larger:
40% fully insured membership
60% self funded membership
Why would a doctor not show up in search results at all?
we have an HRA in place today that isn’t used that much. Why would they use Garner if you’re administering the same thing?
How accurate is Garner’s directory?
