The U.S. healthcare system is procedure-focused and fragmented. A patient should be viewed as a whole person including mental, physical, and social health. The self-directed care management system contributes to our isolationist medicine. A robust, dual-purpose primary care system could help connect all the dots including mental health.
As a part of my interview series with leaders in healthcare, I had the pleasure to interview Den Bishop, President of Holmes Murphy and a member of the company’s Executive Committee leading the Employee Benefits practice. He’s also the co-founder of ACAP HealthWorks, an innovation and consulting subsidiary focused on clinical solutions. Den is a recognized industry leader, a member of the Council of Employee Benefits Experts, serves on the Board of C2 Solutions, and is a member of the Dallas Regional Chamber. He’s also a recognized speaker on the subject of economic implications of the Affordable Care Act, the author of “The Book on Healthcare Reform,” and has a new book coming out in the summer titled “The Voter’s Guide to Healthcare.” A graduate of Southern Methodist University, Den earned his degree in Business Administration while also earning All American and National Senior Player of the Year honors in tennis. In his free time, Den enjoys spending time with his family, riding his bike, and trying to fix America’s healthcare system.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
I was a two-time All-American tennis player in college. However, I lacked the talent to make tennis a career. I chose to go the health insurance sales route and, subsequently, consulting because I loved the competition and intellectual puzzle the business provided.
Can you share the most interesting story that happened to you since you began leading your company?
In 2005, my business partner, Wally Gomaa, and I determined that activity-based wellness programs were going to frustrate our customers’ financial officers because they lacked specific financial and clinical measures. We decided to apply the clinical risk cluster known as metabolic syndrome to health benefits. The presence of metabolic syndrome in a person’s body increases their risk for diabetes, heart attacks, strokes, many types of cancer, and a series of other unwanted diseases and conditions.
To the best of our knowledge, no one had previously applied this clinical risk measure to health benefits. At the time, a pharmaceutical manufacturer, Sanofi Aventis, was developing a drug that would reverse metabolic syndrome by suppressing appetite and food cravings. The drug was permanently shelved after a number of suicides in the clinical trials in Europe.
Following this tragedy, we began searching for a behavior-based program that could help people lose weight and reverse metabolic syndrome. This search led us to form a partnership with a nurse practitioner, Marcia Upson, who was teaching a program called Naturally Slim in churches and to a few local employers. A decade later, our partnership with Marcia has helped almost one million in their quest to slow the production of disease through the reversal of metabolic syndrome.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
In my first year in sales, I was called to an immediate meeting with a broker and prospect to explain an insurance financial product I had quoted. I had not yet been trained on the program, and I had to go immediately to the meeting or I would lose the potential sale. I was not able to answer any of their in-depth questions. Needless to say, I did not get the sale. That was 30 years ago, and I haven’t been unprepared for any meeting since. My dad had a saying on his desk when I was growing up, “If you fail to prepare, you prepare to fail.” How true!
What do you think makes your company stand out? Can you share a story?
Our tagline is “Thinking Ahead.” Insurance is about positively influencing risk to lower cost over time. You cannot buy insurance for something that has already happened. Our company does not sell insurance…insurance companies sell insurance. We sell our cumulative knowledge and experience that make health insurance work better and cost less.
Several years ago, an executive from United Healthcare (UHC) came to us asking for ideas for how we could mutually grow our businesses. I believed our customers outperformed their other customers because we challenged our customers to evaluate their role in the health of their employees. UHC pooled all of our Texas-based customers together to produce a report comparing the cost and health metrics to their book of business. On a geographically and demographically adjusted basis, our customers produced 26 percent lower medical and pharmacy claims than UHC’s similarly adjusted book of business.
We believe the secret to improved outcomes and lower cost over time is employer engagement in health, and this study proves it.
What advice would you give to other healthcare leaders to help their team to thrive?
We know healthcare financing and population risk. Our slice of the healthcare industry must focus on removing obstacles for patients to access high quality care and on lowering the cost of healthcare for everyone. If we don’t solve our quality, access, and cost problems as an industry then the government will be forced to solve the problems for us.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
Life expectancy is often used as a measure of the quality of the U.S. healthcare system. This is a blunt measurement at best. Factors like obesity, gun violence deaths, and drug overdoses impact mortality but have little to do with the quality of care available. However, one measure has haunted me since I first understood it. This measure is mortality amenable to healthcare. It measures the rate at which people die from conditions that could have been cured with available diagnosis and treatment within the healthcare system. In other words, the cure was available but the person died anyway. According to the latest Commonwealth Fund study, the death rate from these curable conditions was 58 percent higher in the U.S. than the average of other economically developed countries.
This doesn’t mean we don’t have great hospitals and great doctors. It means people are dying because they can’t connect with the care available within the system. I refer to it as the “T-Rex Effect.” Think of a short-armed Tyrannosaurus Rex. Imagine there is a survival button positioned just above the T-Rex’s head. If he can reach the button, he survives. Unfortunately, the poor dinosaur cannot reach the survival button…leading to his death and ultimate extinction.
Our complicated and expensive healthcare system today suffers from the T-Rex effect. The survival button is there for hundreds of thousands of people who die needlessly in the U.S. every year because they cannot reach the care that is available.
So, what causes our T-Rex effect? It is the combination of the most complicated consumer industry in the world with the highest cost healthcare system in the economically developed world. A few contributors to this cost and complexity crisis are as follows:
- Complicated insurance enrollment — Half of the nation’s uninsured population is eligible for either free coverage through Medicaid or heavily subsidized marketplace coverage, but these individuals have still not connected with insurance available to them.
- Complicated plan design — Americans don’t understand our complicated system of deductibles, coinsurance, and in- and out-of-network care. This lack of understanding and fear of economic surprises leads to poor care compliance.
- Unaffordable and unpredictable out-of-pocket cost — Deductibles and out-of-pocket maximums have skyrocketed since the signing of the ACA. It has created a class of underinsured Americans who have health insurance but cannot afford the cost-sharing provisions if they need care.
- Lack of consistent cost baseline or index — Private insurance pays hospitals approximately double what Medicare pays for the same services. This hidden tax renders cost transparency attempts fruitless and contributes greatly to the high cost of health insurance.
- Procedure-based rather than primary care-based system — The lower cost and better performing Canadian healthcare system is built on dual-purpose primary care system where your family doctor is the first line of treatment and your navigator for more complex care needs. A physician in Canada is more than four times more likely to be primary care. Patients trust their doctor and not their insurance company to be their care navigator. We could learn a lot from our northern neighbors.
You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
I believe there are three essential guideposts in improving the U.S. healthcare system from my perspective. Remember, my experience is in the financing of care and is not clinical. The three guideposts are: lower cost, protect access, and sustain Medicare.
1. Lower cost — The ACA regulates and limits the profitability of health insurance companies through its medical loss ratio provisions. However, there is no regulation of the underlying cost of the actual healthcare services. According to the Congressional Budget Office (CBO), the average commercial insurance plan pays hospitals almost double what Medicare pays for the same services. This discriminatory cost shifting dramatically increases the cost of insurance. Medicare should be used as the benchmark with all pricing indexed to what Medicare pays.
2. Protect access — this comes in 3 parts
- Protect access, part 1 — The ACA guarantees that individuals will not have their health insurance availability or cost influenced by their health status or pre-existing conditions. This insurance provision provides great peace of mind to Americans and should be protected.
- Protect Access, part 2 — The ACA protections guarantee access to health insurance without regard to health status and provide financial support based on household income. In spite of this guaranteed right to insurance, there are almost 30 million people in the U.S. who still lack health insurance. The right to health insurance is guaranteed by the ACA, but there is no meaningful provision for the individual responsibility to have health insurance. The individual choice to not have health insurance creates additional financial burden on those who do have health insurance. I have always believed that one person’s rights end where another person’s rights begin. One person’s choice to go uninsured should not create a financial burden on someone else, but it does as hospitals and other medical providers are forced to spread the cost of care for the uninsured to others. The IRS should collect for access to a public care program for those who choose to be uninsured.
- Protect access, part 3 — Access to health insurance is important, but actual access to care is infinitely more important. Insurance is good and fine, but insurance is of no value if there are no doctors and hospitals available to treat you when you are sick. The average hospital in the U.S. loses almost 10 percent on treating Medicare patients and even more when treating Medicaid patients. The actual cost to deliver the care is more than the government is reimbursing. The private insurance system makes up for the government underfunding and provides all of the money for profit. I fear that a radical change in the financing, like Medicare for All, would immediately pull too much money out of the healthcare system resulting in a dramatic reduction in access to providers. Yes, Medicare for All reimbursement strategy would lower insurance premiums, but they might also lower access to essential medical services through hospital closures and medical job losses. I would legislatively link all payments to a Medicare index to lower the cost of insurance, but the indexing would evolve over time allowing hospitals and other medical providers time to adjust to a new economic reality rather than popping the economic healthcare balloon.
3. Sustain Medicare — Medicare is the primary framework of the American healthcare financing system. Everything else is built off its foundation. According to Medicare’s Trustees, the Medicare hospital insurance trust fund has less than a decade of solvency remaining. An aging of America has the ratio of people paying into Medicare while working compared to those receiving Medicare coverage dropping dramatically. This demographic shift will crush Medicare financing without change. We need more money to fund this essential program. Expanding Medicare availability is one idea that could create more revenue, but it also expands risk and cost. The federal government’s track record on understanding risk and cost from the ACA is not pretty. Indexing reimbursements in private insurance to Medicare will dramatically lower costs and does not create any increase in risk or expense for Medicare. I recommend the introduction of a network access fee paid to Medicare for the economic advantage of indexing prices to Medicare. The access fee would be paid by every person and insurance plan that benefits from the indexing — which would be everyone. Think of it as a shared savings program to sustain Medicare and to lower your cost of insurance.
Ok, its very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
Individuals — The best thing an individual can do is vote. Health insurance is the №1 federal government expenditure. It will be the №1 topic of the 2020 presidential election. We must improve the interaction between the public insurance systems, Medicare and Medicaid, and the private health insurance system.
Corporations — Corporations should simplify plan design and demand transparent Medicare indexing from insurance companies. Sustainable cost saving and health quality improvement cannot occur in today’s complicated, opaque system where most patients have a difficult time understanding the true cost and quality of healthcare.
Communities — Communities step in as a safety net when government and private insurance fail. An appropriate connection between the public and private system that guaranteed that every person had health insurance and that lowered the cost for everyone would remove this burden from community resources allowing them to focus on other essential services.
Leaders — Leaders must stop blaming others for our cost, access, and quality problems. Insurance companies blame hospitals. Hospitals blame insurance companies. Republicans blame Democrats. Democrats blame Republicans. The real enemy is disease. It is disease that is robbing and killing people. Strong leaders should focus on removing cost, complexity, and quality barriers so that at-risk people can connect with the care they need.
As a mental health professional myself, im particularly interested in the interplay between the general healthcare system and the mental health system. Right now we have two parallel tracks mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?
The U.S. healthcare system is procedure-focused and fragmented. A patient should be viewed as a whole person including mental, physical, and social health. The self-directed care management system contributes to our isolationist medicine. A robust, dual-purpose primary care system could help connect all the dots including mental health.
How would you define an “excellent healthcare provider”?
Something or somebody who measurably helps people get better. As an insurance person, I don’t necessarily understand why diabetic patients with one physician group are more compliant and have fewer complications than similar patients with a different provider group, but I do know the outcome differentials are measurable, sustainable, and real. The excellent healthcare providers simply provide measurable, sustainable, and real results that are better than others.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“If you fail to prepare, you prepare to fail.” Successful businesses and successful people are intentional in their preparation. Great preparation is immensely more valuable than great potential. I learned this lesson from my dad.
Are you working on any exciting new projects now? How do you think that will help people?
We are working on a health plan optimization platform called SimplyPay Health. SimplePay transforms the healthcare financial transaction to make it immensely more efficient for both the patient and the provider. With SimplePay Health, patients know exactly how much care will cost them by provider, and they also know the provider’s quality ratings. Rather than sorting through Explanations of Benefits and bills from providers, the patient receives a monthly statement much like their credit card. The providers receive 100 percent of their negotiated reimbursement directly from the claims administrator. Providers no longer collect money from patients and no longer have to deal with patient bad debt. If successful, the concept will simplify the healthcare transaction for both providers and patients. A less complicated transaction means fewer barriers for people to get the care they need.
Additionally, coming this summer, I’ll be releasing my newest book — “The Voter’s Guide to Healthcare”. The intent of it isn’t to pretend to solve America’s healthcare cost, coverage, and complexity issues. It’s also not intended to sway readers to either the left or the right politically. The healthcare issue is neither blue nor red. It’s purple! It’s an all-in combination of blue and red because it impacts each and every one of us without regard to race, religion, income, gender, or politics. I view healthcare as one of our most challenging social justice issues and as, far and away, the greatest economic challenge facing our country. My goal with this upcoming book is to simplify and educate so you won’t be swayed, moved, or manipulated by fake news or truth-twisting campaign promises.
Why has healthcare become so political? Can’t we just get the government out of healthcare? Can’t the government just give us all free healthcare? Opinions on the government’s role in healthcare are kind of like navels…everybody has one! I’ll be tackling all of these issues so voters are more informed as they head to the polls in the 2020 election.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
I pay immense attention to the Congressional Budget Office (CBO), Medpac, and the Medicare Trustees. These may not be the most exciting sources, but the cost and quality of the private healthcare system are a secondary outcome of the actions of the public healthcare system. An intimate understanding of the pressures of the public healthcare system will help you understand the coming challenges and opportunities within the private healthcare system.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
It would be the Simple Movement. The greatest good of health insurance is to proactively connect at-risk patients to the medical providers or programs that give them the best chance of getting better. Accomplishing this is too complicated in today’s system. Health insurance must stop being an impediment that creates the T-Rex effect and should become a proactive ramp that lifts people to the care they need.
How can our readers follow you on social media?
You can follow me on:
· Twitter: @DenBishopHM
· LinkedIn: https://www.linkedin.com/in/denbishophm/
Thank you so much for these insights! This was so inspiring!
About the Author:
Originally from Israel, Limor Weinstein has been anorexic and bulimic, a “nanny spy” to the rich and famous and a Commander in the Israeli Army. Her personal recovery from an eating disorder led her to commit herself to a life of helping others, and along the way she picked up two Master’s Degrees in Psychology from Columbia University and City College as well as a Post-Graduate Certificate in Eating Disorder Treatment from the Institute for Contemporary Psychotherapy.
Upon settling in New York, Limor quickly became known as the “go to” person for families struggling with mental health issues, in part because her openness about her own mental health challenges paved the way for open exchanges. She understood the difficulties many have in finding the right treatment, as well as the stigma that remains so prevalent towards those who are struggling with mental health issues. She realized that most families are quietly struggling with a problem they’re not comfortable talking about, and that discomfort makes it much less likely that they will get the help they need for their loved ones. She discovered that being open and honest about her own mental health challenges took the fear out of the conversations. Her mission became to research and guide those families to the highest-quality treatment available. Helping others became part of her DNA, as has a commitment to supporting and assisting organizations that perform research and treatment in the mental health arena.
After years of helping families by helping connect them to the right treatment and wellness services, Limor realized that the only way to ensure that they are receiving appropriate, coordinated and evidence-based care would be to stay in control of the entire treatment process. That realization led her to create Bespoke Wellness Partners, which employs over 100 of the best clinicians and wellness providers in New York and provides confidential treatment and wellness services throughout the city. Bespoke has built its reputation on strong relationships, personalized, confidential service and a commitment to ensuring that all clients find the right treatment for their particular issues.
In addition to her role at Bespoke Wellness Partners, Limor is the Co-Chair of the Academy of Eating Disorders. She lives with her husband, three daughters and their dog Rex in Manhattan.
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