When employees face a serious medical condition, the impact on their health and financial well-being can be devastating. These cases are also driving a significant share of rising healthcare costs for employers—yet many solutions still rely on fragmented, one-size-fits-all care. How can you prioritize personalized, expert-driven healthcare that delivers better health outcomes and financial savings for your company? In this session, Ropes and Gray LLP and Private Health Management (PHM) share learnings from their partnership, revealing how advanced care navigation provides employees with faster access to top specialists, reduces unnecessary treatments, and improves overall well-being. Attendees will gain actionable insights into how two organizations collaborated to introduce an innovative, next-generation benefit that transforms employee health. This case study will explore a cutting-edge model for improving clinical outcomes and the collaborative process for implementation and engagement, and it will demonstrate how personalized medicine reduces high-cost claims while offering employees the best of what's possible in healthcare.
Key Takeaways:
- Gain insights into how precision medicine and expert navigation accelerate diagnoses, improve treatment effectiveness, and enhance employee health.
- Discover how reducing misdiagnosis and unnecessary treatments significantly lowers high-cost claims and medical spend.
- See how tailored, concierge-level support boosts employee engagement, reduces stress, and promotes long-term well-being.
Transcription:
Alyssa Place (00:10):
So today we're going to be talking about turning high-cost claims into high-value care, a guide to effectively navigating the most serious and expensive medical conditions. I'm so excited to have our speakers here today, Julie Blume and Natalya Gertsik, and we have a lot to cover today. I wanted to briefly introduce both Julie and Natalya. Julie is a Total Rewards Expert with decades of experience designing and implementing benefit programs that are comprehensive, easily understood, and highly valued by employees. Natalya works with clients to manage health risks, improve cancer outcomes, and reduce wasteful medical spend. She also advises on topics such as precision medicine adoption and case management approaches. This topic is obviously top of mind for benefit managers and leaders today as high-cost medical conditions can have an outsized impact on health, wellbeing, and financial wellness for employees and are a major driver of spend for employers. Today we're going to learn about innovative ways to navigate these complex challenges, dive into the partnership between PHM and Ropes and Gray, and discover how employers can save on healthcare without sacrificing high-value care. We will have a Q and A at the end of our conversation, so please hold any comments and questions until that time. Julie and Natalya, I will pass it off to you to get started. Thank you so much.
Natalya Gertsik, PhD (01:29):
I just first thank you all for being here, and I want to introduce PHM, if this clicker would work, which it is not.
Alyssa Place (01:41):
The clicker is not working.
Natalya Gertsik, PhD (01:44):
Can everybody hear me okay while we work on the technical difficulties? Okay, good. So I'm going to start without the slides. PHM has been around for 18 years doing the work of improving clinical outcomes for complex conditions. This is not something we dreamed of over the past five years in response to the growing high-cost payment problem. It's something we have deep expertise in, and what it requires is depth of clinical sophistication. We have PhD research scientists and advanced practice clinicians guiding members to the best of what's possible in medicine. The types of conditions that we manage fall into two broad categories. One is cancer, 40% of our business is cancer because cancer is serious and complex by nature. The other looks like your high-cost claimants report. You've got your musculoskeletal, cardiovascular, neurological, immune related, pediatric rare conditions, diagnostic dilemmas, and lots of other things. What we're really talking about... Do we have a new clicker?
Julie D. Blume (02:56):
She took it away.
Natalya Gertsik, PhD (02:57):
I did not have it. Well, someone's advancing through the slides for me, so that's great. If we can go to the next one. Yep. Next one more. There we go. What we're really talking about is the 5% of the population driving 60% of healthcare spend. You may remember just a few years ago it was 5% driving 50%. Now it's 5% driving 60%. So what that's telling you is these cases are becoming more and more expensive, and this is the reason you have stop-loss. This is the reason you have double-digit trend increases and the reason that employers are expecting a 9% increase going into 2026. If you try to apply the same resources, solutions, tools to this 5% as you do to the 95% of your population, you're going to fall short. The reason for that is that in order to really move the needle clinically and financially for these very serious and complex cases, you need a different care model.
(04:06):
These people, they're not just numbers on a bar chart. They're your employees, their families, their children, their spouses navigating a fragmented healthcare system and experiencing all of the obstacles and gaps in that system while going through the darkest time in their lives. So what are some of the gaps that these folks are experiencing when they're embarking on that journey, and how do we go about addressing them? The first is doctors often don't have enough information about the clinical issue. When they walk into a room with a patient, they're not reading hundreds of pages of medical records. There's no reimbursement code for that. What we do is not only do we distribute medical records across all the different providers, we also generate clinical timelines and clinical summaries, which are at-a-glance documents that give providers everything they need to know about a case so that they can make an informed recommendation to the patient.
(05:07):
The second is docs aren't spending enough time with patients. I mean, 15 minutes might be enough for me to scroll my TikTok feed; it is not enough time for a provider to be spending with a stage three cancer patient. We wrap every member with a clinical SWAT team: a PhD research scientist, an advanced practice clinician, and a care coordinator. That team interfaces with the rest of the healthcare system on behalf of the member. We answer questions no matter how big or how small, and we'll spend any amount of time necessary with that patient to drive them to the best possible clinical outcome. Oh, this is moving on its own now. Okay, here we go. There's a ghost. The third is that there have been enormous advancements in biomedicine over the past two decades. In fact, there's been a paradigm shift in the way we treat cancer and other conditions.
(06:04):
The traditional healthcare system has not kept up. The care that is here, that is available today, that is FDA approved, is not being delivered to your members with serious and complex conditions. To bridge that, we have a team of PhD scientists whose job it is to deliver the best of precision medicine to our members. The fourth is that these serious cases may require 6, 8, 10 different providers to work in lockstep with each other. Let's be honest, that's not happening in our healthcare system, which is part of why you may see a patient getting multiple scripts from multiple docs. Turns out some of the drugs they're taking are contraindicated because the left hand doesn't know what the right hand is doing. That would never happen to a PHM patient because we're taking care of the whole person. No one's doing that in the traditional healthcare system. No one is looking at the whole person. We're making sure that all of the providers are working in coordination with each other towards the best possible outcomes for this patient. And the fifth is when you're sick, it's actually really hard to find yourself a doctor, to find yourself the right doctor, because it requires you to understand the biology of your condition and the subspecialty expertise of the provider, and then to match those two things.
(07:19):
You then are expected to make a timely appointment for yourself in a provider shortage environment where the next available with a good doctor may not be until 2026. So we take all of that off the plate of the patient. We will identify the exact right provider for the patient within their constraints. What are some examples of constraints? Network constraints, right? Most members will want to be in-network, and geographical constraints. Most members want to stay close to home when they're going through one of the hardest times in their lives, and there's no need for them to travel if we can identify the exact right provider with the right specialty expertise in their home, because few things are as important to your overall clinical outcome as identifying the right teams of providers. So I'm going to go ahead and turn it over to Julie Blume, who is a tenacious and innovative benefits leader. Julie identified a gap in their benefits plan, and she went about bridging that gap. Over to Julie.
Julie D. Blume (08:17):
Thanks, Natalya. So Alyssa did say decades. I know all of you are shocked that I've been in the benefits arena for decades, right? I look so young, but yes, it's very true. So thanks for having me here. As many of you here, eight years ago, I never heard of Ropes and Gray. What the heck is Ropes and Gray? We are a prestigious global law firm. We have over 3,200 lawyers and benefit support team members around the world, across the US and Europe and in Asia. We pride ourselves on pro bono work and also reaching the top of the A-list many years, which is an award that we're really proud of. Over the past 15 years, we've been able to be at the top. So that's who Ropes and Gray is. Next, I'm going to talk to you about some challenges that we were looking to solve.
(09:17):
Our lawyers. You hear the term time is money. That is so true with our lawyers. They bill in six-minute increments. So anytime they spend searching for the best treatment for a diagnosis that they received or trying to understand their diagnosis, that's time taken away from their billable hours. Another one is our firm. We call it a firm. At our firm, our people are assets. So we really need to be seen as paternalistic, really helping to support our members as they're going through a serious or complex issue. Finally, our high-cost claimants. That's why we're here. How do we mitigate these high-cost claimants and that volatility? Who here has gotten a call from their finance group like, "Oh my gosh, I didn't know that this huge claim was going to hit. Did you have any idea?" We've all gotten those calls from finance.
(10:25):
So we really want to be able to mitigate that volatility within our plan. Just to give you a little bit of insight, our plan covers 4,200 lives. I came from before Ropes and Gray, I came from a big athletic retailer where we covered many more lives, but it's the same whether you're dealing with 4,200 lives, 20,000 lives, or 1,000 lives, your issues are the same. We have 4,200 lives. When digging into our data, we saw that approximately 2%—exactly what Natalya was talking about—approximately 2% of our population was accounting for 40% of our plan spend, right? That is crazy. Digging down a layer deeper, you want to go ahead. Digging down a layer deeper, we had the top 20 claimants, as we went through with our partner Quantum Health on a quarterly basis, looking at our top high-cost claimants. The top 20 were accounting for 20% of our plan spend, which is crazy.
(11:35):
So the value that we found that PHM is able to give to our colleagues is what Natalya said before. It's clinically driven, right? We hear all the time, "Who are you going to for your oncology or for your hip replacement?" "Oh, my brother-in-law just had their cancer, or their neighbor had this kind of cancer, I'm going to their oncologist." That's not necessarily the right place for your members to go, right? As Natalya said, there's so much detail that goes into finding the right provider for each one of these diagnoses. So the clinical depth, the independent guidance. What I love about PHM is that they are not tied to a hospital system, a medical plan. They have free reign across the top providers. Then of course, that access to those top providers. They've been able to get my members in to see a provider next day, which has been crazy.
(12:39):
One of my members has their own provider. They weren't able to get in for, I think, another week. PHM made a phone call. They were able to get them into their provider that next day, which is mind-blowing. I don't know how they do it. I don't ask questions, but they do it. And also the research-driven going through those pages and pages of research to see where's the best clinical trial. If you go to an oncologist, that oncologist most likely just has access to the clinical trial in their hospital. PHM is able to work alongside of that member's oncologist and say, "Hey, do you know what? Down the street or across the river, there's a clinical trial going on that can really help you, that your provider may not have known about." So that's what we love and the support that our members really feel with PHM.
(13:37):
The value to our firm is really our people are feeling like they're being taken care of. Also, the high colleague satisfaction. Benefits people in here, do you ever hear any good news? Right? No. "No news is good news," right? That's my motto. I cannot tell you, from inception, the emails and calls that I've received from tough customers telling me, "Wow, PHM is such a great benefit." This is something that Natalya and I talked about. "My brother-in-law has this issue. Can I use PHM for them? Or my parents?" This is something we'll talk about a little later. "Can I use PHM for them?" They can. They'll have to pay for it separately. But that's how the offering of PHM is so valued by our population. Moreover, the interventions, the unnecessary interventions, which you don't want to have to do a service or a surgery that's not needed.
(14:35):
And also the extra cost to our plan. So we benefit so much from it, our colleagues as well as our firm. Next, we'll talk about our partnership timeline. I first heard about PHM at a benefits conference in 2023. Soon after, we had many conversations. As you can imagine, we decided to do a pilot at the end of 2024, just focusing on cancer care. We have so many high-cost claimants that were around cancer. So we did our soft launch with cancer. It proved so well that we launched the beginning of this year, January of 2025, as full cancer within our medical plan. Now starting January 1st, 2026, we got approval from our leadership. It wasn't even a fight. They know how much value PHM is bringing to our plan members. I didn't even have to talk about it.
(15:36):
I sent them the deck. That was one of the things that they easily approved was offering PHM for all serious and complex issues starting January 1st, 2026. So as Natalya mentioned, for musculoskeletal, for cardiovascular, all of those illnesses. You'll see up there, we have Health Advisory, which is another service that we could talk to you about if you visit our booth or visit their booth. We have 370 partners. Think of them as your C-suite, like your high-level executives who you have to handhold. It's a benefit that we provide for them globally, regardless of them being enrolled in a medical plan. If you have any interest in that, it's a fabulous program.
Natalya Gertsik, PhD (16:20):
I'll just add the serious and complex is our bread and butter. It's what we do. It's what we've been doing for over 18 years. Lots of peer-reviewed publications about how we're improving clinical outcomes, helping people live longer than they otherwise might. But in addition to that, we've had clients like Ropes and Gray and many others, particularly in consulting, law firms, financial, that were like, "Well, what about if you don't have a serious need? I just need a doctor for my kid who just got hurt playing soccer, and it's urgent, right? My kid's in pain. It's not so serious, but it is urgent. Maybe I need to find a provider for myself. I don't have a good PCP. I can't find somebody that's been good for me." Those kinds of more day-to-day needs that we all have, and the entire population has, is this Health Advisory service that Julie is describing that typically we make available to—most of the time it's not the whole population—it's some subset of the population.
(17:18):
So we'll talk a little bit about utilization. Ropes and Gray utilization, Q1. I know Q1 feels like it was eons ago, but it's interesting because their utilization matches our book of business exactly: 40% cancer, 60% non-cancer. You may be asking yourself, "How could you have any non-cancer here when you just said that in 2025 you did cancer only, and you're only expanding to all serious and complex in 2026?" That's true. The reason is because the cancer pilot was going well, Julie and her team were receiving positive feedback. When a member came to them with a non-cancer condition and asked, "Can you help me?" in Julie's words, she said, "How can I say no?" Right? So they were softly making this program available to people who emerged as having other serious issues. Of course, the formal launch of all serious and complex will be in 2026.
(18:09):
These are some examples of conditions that we managed in Q1. On the cancer side, you'll see breast cancer is one that's very common in the working-age population. Pancreatic obviously very deadly, and then some liquid tumors as well. But one of the things I'm really proud of is we actually served people who didn't have cancer at all. They were high risk for cancer. So they either had a genetic mutation or a family history that increased their predisposition to having cancer in their lifetime. This is the holy grail, right? The ability to get to a person before they ever get cancer and put the right surveillance plan in place so that if the cancer ever does happen, you're catching it at its earliest possible stage when it's curable for the member. Stage one cancers are five times less expensive to the plan than stage four. So this is something that I'm really proud of, and we're going to continue to do going into 2026. That's preventive.
(19:09):
When we identify the right segments of the population, we know we're going to have a profound clinical impact. We change diagnoses 30% of the time. Sometimes it's because it was misdiagnosed. Other times it's because it was underdiagnosed. There's not enough information about the clinical issue to make good treatment decisions. Right or wrong, a diagnosis determines everything that follows, and the worst treatment is treatment for the wrong disease. So it's incredibly important to get this part right. We change treatment plans 70% of the time. The statistic I really want to highlight is we have a two to fourfold improvement in overall survival for late-stage cancers. That means that a patient who comes to PHM is going to live two to four times longer on average than the patients in the general US population. If I could put that in a pill and bottle it up, you all would be paying hundreds of thousands of dollars for it and doing so very happily, right?
(20:11):
There's no FDA-approved drug today that has this kind of profound impact. What it's really getting at is that when you deploy precision medicine accurately and consistently, you can have a profound impact on survival and quality of life. Better care costs less for all the reasons Julie described: avoidance of unnecessary care. I can talk for hours about the types of care we've prevented from happening, and as a result, there's a financial return. Of course, the feedback, right? As HR professionals, I mean, I think that's the thing that really gets you excited is for your members to be happy. This is a program that helps them live longer, stronger, healthier lives.
(20:57):
I want to bring us to a close, at least for the presentation part of this before we start taking questions, with a story. Hannah was 32 years old when she was diagnosed with hormone-positive breast cancer. She came to PHM shortly after. She had a decision to make at the very outset of her care: chemo first or surgery first? She had five different consultations with five different oncologists. Two said surgery first; three said chemo first. They were split pretty much down the middle, as when you survey five doctors, I think you would expect, right? So PHM's role was to guide her to the right clinical decision. How did we do that? We ordered a molecular diagnostic test that showed that this patient was high risk and highly susceptible to chemotherapy. Now, that isn't always true for hormone-positive breast cancer, but it was true for Hannah.
(21:52):
Beyond a reasonable doubt, this told us that she should do chemo first. The chemo would wipe out the chemo-sensitive disease, leading to a smaller tumor burden, and that's exactly what happened. The chemo shrunk her tumor, and she was able to have a less aggressive surgery as a result, better for the plan and much better for Hannah. They were also able to spare her lymph nodes in surgery, therefore reducing the risk of lymphedema. That's a chronic condition, much better for Hannah to avoid the risk of chronic lifelong lymphedema, and much better for the plan to avoid the spend associated with another chronic condition. None of the five providers that Hannah went to for these second opinions recommended this molecular diagnostic test. She would not have received it without PHM, and she just as likely would have had surgery first as she would have had chemo first.
(22:45):
It was a flip of a coin at that point, but there was only ever one right choice here. Another way that we optimized her care was in her maintenance phase. We sequenced her tumor and found that she had a fusion subclone that was resistant to hormone therapy. This patient had hormone-positive breast cancer. She needed to be on hormone therapy for five to ten years, and here we get this information that hormone therapy wasn't going to cut it. Well, there was some early data that a class of drugs called CDK4/6 inhibitors had very promising results in patients just like Hannah. Only one problem: they were not FDA approved, and they were not commercially available. So we found her a clinical trial, and we enrolled her on that trial. So she was able to access CDK4/6 inhibitors before they were ever commercially available.
(23:36):
Clinical trials are great for the patient. They can be life-saving. They're also great for the plan because the investigational agent is covered by the trial sponsor. At the peak of her life, when Hannah received this devastating diagnosis, she was able to do everything in her power to reduce the risk of this cancer ever coming back. All of these decisions—the decision to do chemo first, the ability to have a less aggressive surgery, to spare her lymph nodes, to use the right targeted therapy (that's CDK4/6) when traditional modalities like hormone therapy fell short—all of those decisions hinged on one thing: our ability to deploy precision medicine. As a result, Hannah is cancer-free today.
Julie D. Blume (24:22):
That's so amazing, Natalya. Hearing stories like that is what really sold me on PHM services. They really do make a difference. You hear about some services that come in and just do a part of it, where PHM really looks at the patient as a whole, right? That clinical research is amazing. We had a patient who, during our soft launch at the end of 2024, she was diagnosed. She had a cancer diagnosis, and it came to me. Somebody told her word of mouth—as we said before, your coworkers are always the ones who are like, "Oh, you should do this." Somebody told them to come to me and talk to me, and I'm so glad they did. She went to our healthcare lawyers, our healthcare partners, trying to find the right provider for her with this initial diagnosis. I said, "Wait, time out, time out.
(25:22):
Come here." We put her in touch with PHM. She was able to get the right diagnosis, the right treatment. She is cancer-free today. She goes for checkups every six months to make sure that nothing is changing in her diagnosis. But the best part of it is she wrote me a six-paragraph email thanking me so much for this and offering to be a testimonial case. She said, "Anybody that has any doubt about PHM within the firm, please send them to her," because she will tell her story about how they helped her from beginning and not only supporting her medical journey but her emotional journey as well, right? Everybody goes on to Google and does the research. They'll tell you to stop. They'll do all the research and share that research with you as a member so you can understand things as well. They're not expecting you to understand all the information that Natalya as a former researcher knows, but they will give you all that information and help support you and your family members. So that's a story that touched me as well, is that member, that plan member who really has a great outcome now thanks to PHM.
Alyssa Place (26:42):
Great. Well, that was really incredible. I mean, it's unbelievable, the ability of modern medicine, and just hearing these real-person stories, it's really inspiring. Obviously, many people are affected by some of these cancers and other diseases, and to have you both on the front lines is really wonderful work. Julie, you did mention the storytelling. You said that that really made an impact on you. I wanted to ask about that decision-making process for working with PHM over other solutions. Was it that personalized approach? What went into the choice to partner with PHM?
Julie D. Blume (27:18):
Yeah, that's a great question. We were working with another provider before, and what we were really looking for was a partner that not only works with their provider or the providers but works with the member as well. Like I said, that support, being able to provide that support to the members and their family members is so key. That's one of the main things why we decided to go with PHM, is the outcomes. Not necessarily—Natalya mentioned how the diagnosis changed 30% of the time, treatment changes 70% of the time—that doesn't mean that a member needs to change their provider. PHM works alongside with the provider. That's a question that we had. We were like, "People like their providers. What happens if PHM comes in and says one thing, the provider says another thing? How does that work?" Most of the time, the provider is really grateful for PHM to have that information, and they do change course with PHM support. So that was a huge reason why we decided to move with PHM.
Alyssa Place (28:26):
We heard so many success stories, but of course, with any benefit, there's going to be some learning curves. I would love to hear from both of you what challenges you may have faced during the implementation or the very early months of partnering together.
Natalya Gertsik, PhD (28:39):
I'll start just by saying that the very first challenge was contracting with a law firm.
Julie D. Blume (28:46):
Yes, that took—
Natalya Gertsik, PhD (28:48):
A very long time.
Julie D. Blume (28:48):
We're still working on it. We're still working on it, right?
Natalya Gertsik, PhD (28:51):
Across three services. We didn't talk in detail about all three. Most of the time we talked about serious and complex, but you heard about Health Advisory. We also have Corporate Advisory, which is we are actually a consultant to Julie and her team. If you have questions about that, come stop by our booth, but we can also be a consultant to you on the health and benefits space. Yes, enough said there about the contracting. They are a tough, tough crowd. Yes.
Julie D. Blume (29:14):
Very true. Very true. I would say from our side, it's managing members' expectations, right? They call PHM. Some of them want an answer right away, but they can't give an answer right away. So really managing members' expectations. Also, the way that we communicate to our population, right? When PHM scrubs our data from our insurer and decides which members to reach out to, should we reach out via email, phone call? What's the right way? As we heard before, that's always a challenge. So finding the right way to communicate with our members.
Natalya Gertsik, PhD (29:52):
For sure. We worked a lot together on that. I expect we're going to continue to work on the communication piece. There was a lot said about that in the prior session too. One of the things is also being able to support Ropes and doing it in their voice in the way that their population is going to be familiar with. We actually did roadshows to all of their offices last year, all the US offices. We did webinars.
Julie D. Blume (30:12):
And London. They went to London as well. Yes.
Natalya Gertsik, PhD (30:14):
We did webinars with Asia on their timeline. So we serve internationally. That's the other piece of it that I think Ropes really appreciates because they are an international firm.
Julie D. Blume (30:25):
Yeah, I got to fly out to our Tokyo and Hong Kong offices, thanks to PHM, right? I had to talk to the partners in person and tell them about this, the great benefit. So
Alyssa Place (30:36):
Yeah, I mean, I think it's really interesting to hear all these different engagement strategies. Now that the program has been in place for over a year, what sort of successes are you seeing, and how have those engagement strategies really paid off for you?
Natalya Gertsik, PhD (30:50):
I'll say, look, the first biggest success is the member feedback. There are not many programs that I'm sure you all put in place that you actually get people coming to thank you for it. This is something that's really unique. I use PHM myself. It's something you want for yourself. So I think for Julie, that member feedback is really incredible and probably why it was such an easy decision to expand in 2026.
Julie D. Blume (31:16):
I'll interrupt you for a second. Our chairwoman, we have a chairwoman. She's like a CEO at a firm. She is a tough cookie. She is hard, right? She works like a dog. Super hard to please. All of a sudden, I get a call from her. She's saying, "Can you give me somebody at PHM because I want to refer them over to one of our peer firms, one of our competitors," because she is so enamored by PHM and all the feedback that she's received from our members on how great they are. She was giving PHM over to one of our other peer firms. That is a huge endorsement for her. She's very hard to please, trust me. I've presented to her, very hard to please.
Natalya Gertsik, PhD (31:59):
The other thing I'll just add is the financial side of it. It does take about a year. So we're working through. We started the program this year. By the end of the year, we'll really look at the trend. On average, we see about a twofold improvement from when we started managing these cases to where we are today. You want to look at trend year over year and really be able to do some apples-to-apples comparisons among breast cancer, the stage, how advanced it is, and compare that to the general population versus your population. Hopefully, year over year, start to see a trend decrease, which is what we are starting to see with some of the clients that have started with us about two years ago. But it does take a couple of years of data.
Alyssa Place (32:41):
We only have about a minute left. I always like to finish these presentations where people can really walk away with that nugget of advice that they can walk out with. I wanted to ask what your top guidance is for tackling these high-cost claims and supporting employees facing serious medical conditions. Obviously, one would be to partner with PHM, but is there any other advice you'd like to offer to the people sitting here today?
Julie D. Blume (33:04):
I would say meet the members where they are. Of course, we plaster information all over about PHM, but until they really need it, then they're like, "Wait, where is this information?" So really work with your partners. We work with Quantum Health, we work with all of our other partners to make sure that everybody's aware of PHM to really try to get the word out, figuring any point where the member might reach out looking for some help. We make sure that we get in front of those people with the information.
Natalya Gertsik, PhD (33:39):
I'll just add one thing, which is you need to think differently if you're going to solve your high-cost claimant problem, because the answer to that is going to be different from the other 95% of your population. So I'll just leave you all with that. There are obviously some other considerations there. Feel free to stop by booth 19. We can chat about it.
Alyssa Place (33:57):
Great. Do we have time for questions? Does anyone have any questions? We'll take one question.
Julie D. Blume (34:06):
Have you ever had a—
Alyssa Place (34:07):
Provider—
Julie D. Blume (34:07):
Push back and not want to cooperate? The question is, have you ever had a provider push back and not cooperate with the process? That was one of the main questions that we had.
Natalya Gertsik, PhD (34:21):
Yeah, we actually had multiple capabilities calls with Ropes and Gray answering that one question, so several hours, because it is a complex question. The answer is yes, there is a spectrum. Most providers are generally favorable to it because we're giving them resources. They get a PhD scientist, which they don't usually have, spoon-feeding them data. There's a clinician that they're used to working with, and then we also have a care coordinator that schedules the appointments on behalf of the patient. We make sure that the patient is aligned with doctor's orders, so there are things that they appreciate. Doctors know that they are not in the position of success. They don't want to be spending 15 minutes with a patient; they want to spend more. That's not what they went to medical school for, but they are in this situation they find themselves in. So most providers are happy with the extra support because of that.
(35:03):
Moving down the spectrum, some providers are not very collaborative. In cases where a provider doesn't really want to work with us, but they're generally a good provider, what we do is we arm the patient to be their own best advocate. I'll give you an example of how we do it. For example, they'll walk into the room with their doctor for a consult. We're going to give them a question list, and they may have five questions on it, but these are very specific questions. For example, "Hey doctor, can you weigh in on this particular clinical trial for me?" and there's a link to the clinical trial. "Is this a good fit? We think it's a good fit." We're giving it to the doctor to weigh in on. Another question: "Doctor, I have hand-foot syndrome from the chemotherapy that I'm on.
(35:39):
It's really interfering with my quality of life. Can we reduce my chemo dosing to metronomic dosing? Here's the new regimen that we're going to provide in that document. Can you please weigh in on this?" Right? So these are very specific questions. Other times, we're able to give members the data they need to convince their provider to order a certain test for them, for example, circulating tumor DNA. We've been very successful for members actually being able to sway their providers to do that. Now, moving all the way to the other side of the spectrum, where a provider is not collaborative and they're also making bad clinical decisions. In that case, we're going to recommend the member make a change, and we will give them a couple of options for providers.
Alyssa Place (36:17):
All right, thank you, Julia and Natalya, and again, appreciate your time. I think we're going to bring Ed back up to.