Why Diagnostics Need Payers?

Introduction to the Provider's Edge 0:00

What if healthcare waste is not coming from bad medicine, but from delayed decisions? Every extra handoff, prior authorization, and disconnected workflow can slow patients from getting the right treatment. Today, Dr. Julie Schultz, Physician Executive and VP of Product at Avalon Healthcare Solutions, breaks down how diagnostics Care partnerships and smarter workflow design are helping speed care, reduce waste, and make precision medicine actually actionable at scale. Healthcare entrepreneurs, are you ready to rewrite the rules for your business so you can have more time off, a great team, and more income while creating a positive social impact?

Then you are in the right place. Welcome to The Provider's Edge. I'm your host, Sabrina Rambach. I'm a provider and international peak performance keynote speaker and a best-selling author. Let's open the gateway to profitability for you today. My guests and I help healthcare entrepreneurs and startup founders like you break through barriers so you can control your business, control you life, and control the future. This is your defining moment to be a disruptor in healthcare. Hi everyone, we are back at health.

It's always exciting to be in the room full of thousands of people who are caring about innovation, care about pushing boundaries of what we can do in healthcare.

Avalonu2019s Precision Medicine Mission 1:32

And today we have Dr. Julie Schultz here with us from Avalon. So Julie, what truly brought you here this time? Every year is a little bit different. We're popping up with new innovation new pavilions. What's exciting for you this year? So we know every day there's 10 new genetic tests that get approved. And the number of tests, rather, the routine genetic precision medicine is just skyrocketing. And what are clinicians to do, right? How are they ever going to keep up with all of this information, with guidelines that change every three months?

So at Avalon, we're a lab benefits management and insights company. We're helping to kind of help providers, payers make sense of all that in a very evidence-based, data-driven way. Awesome. And I think for us in health care, mostly people are like, show me your data, right? And then I thing we're so entrained into how do we present data and understand data. You can have all the innovation out there. Solving a big problem is actually getting the engagement that we want, because we can build all these technologies, solutions.

But if people aren't using it, if we are not using our clinician, patients are using that, then what's the point of throwing millions of dollars in that? So with you guys testing and then focus on this data part, how do you see the adaption usability? You're right. The data is just one small part of it, right? Now, first of all, we have to have clinicians, data scientists, all the right people at the table to first of all, just design the models and make sense of it in a way that makes sense with good clinical medicine.

But then thinking about how do we make it actionable for providers? How do We engage payers?

Making Data Actionable in Clinical Workflow 3:10

how are we working with nurses, mid level providers, it's oftentimes the physicians kind of that last point of care. So we think about it as a PPO product, I think a lot about that workflow of how it all comes together in terms of making sure that the workflow is thinking about all those steps where things get lost and how we can make sure at the end of the day all the work we've done actually gets used. Because it's hard work, right? Building any business is not easy. And innovation, we have so many regulations, layers of people that need to get involved, approved.

So it is really crucial to say, what is that entire journey looks like? Who all have the hands in this process? And making sure that we feel good about the impact that can be created. getting to the point of what the result can be and I think sometimes it's also about like making it so simple that people can talk about it, so much easier, right? Also because genetic testing I, think people understand the importance of it but the application can't be so wide and then from the lineage testing when to match the dose of medic are you actually missing?

Y in your body and don't re So all of this, is there anything specific you guys are focusing on any specific disease process or any application in terms of we see that more of a direct-to-consumer or is more a clinician-led in smaller practice versus a system-wide? Yeah, let me walk you through an example in oncology. So again, you know, it's impossible for physicians and providers to keep up with all the guidelines, all with the evidence. We're working right now in non-small cell lung cancer, which is one of the few tumor types where there's an approved liquid biopsy that helps actually

Oncology Example: Faster Testing and Treatment 5:00

pick which treatment is going to be effective that matches the mutation to the drug. But again, it's also new. Physicians are treating many different tumor type. We see that only 18% of patients are actually having this test ordered, even though it is in the guidelines. And then when they actually get the results. only 44% of patients are actually on the drug that was recommended. So not only from a financial but also a clinical standpoint, that's just a huge opportunity to help them out. Here's what we're doing.

We're working with the payers and we are also trying to ease that prior authorization process so that there's that administrative burden, the headache that I think is part of why physicians aren't ordering the tests or aren t following the care pathways we know they should. We're trying to make that as easy as possible and so what we've found is not only by providing that decision support but again easing that administrative burden makes it easier for them just to do the right thing the first time.

They don't have to second-guess it and then we're able to bring the time from taking the test to getting the drug from 60 days down to 15. So I think it's a nice kind of tangible way that it brings together again like with all of the rights stakeholders at the table including the payers and really helping patients get the best possible care. yeah it's all about like everything we're looking at is like faster to treatment right or can we prevent something from progressing to the end stage so for you guys it really shortened that gap of delaying treatment because that the standard is the stander and then we didn't have any option until now and it is an exciting thing to go after the payers because they're already being identified triggering with the disease coding and things, so we actually can help narrow down the group.

So how many payer groups have you guys already been engaged with? So we're working with over 30 payers. We actually are not contracted for 90 million lives, one in four. Yeah, we are working a very broad swath of the the U.S. and lab spending is it's overlooked. It's less than five percent of overall spend but it has outsized influence. We know that 70 percent in the clinical decisions take into account some type of testing and we know the 50 percent visits incorporate some types of the lab.

Payer Partnerships and Lab Spend Impact 7:10

And so even though it is a small part of spend it affects so many downstream things and so making sure that again all the players at the table have the information that they need to in the right form, in a way it's actionable, is really powerful. Yeah, as you guys start seeing into next year, we're going to the last quarter and going into the next, what's the bigger picture for next that you hope to achieve? Oh gosh, you know, I'm going be overly optimistic as I am, but it has been a rough year for payers, right?

Healthcare expenditures have exceeded, even what most people were expecting. and everyone's looking for ways to save money now. Fortunately, we have one of our solutions that does that. It really helps to make sure that payers are only spending money on the most evidence-based, clinically-backed tests, and we can help them save more money tomorrow. But my hope is that we start thinking even longer term. So while we're doing that, how can we make that sure we've diagnosed our chronic disease patients who maybe aren't getting the care that they need?

How can you use analytics to ensure that our precious GLP-1 dollar that we're spending is going to the patients who need it the most. We see that in our data that, unfortunately, among diabetics, the healthier patients are three times more likely to get a GLp-one prescription, and among obese patients, healthier ones are 14 times less likely. So I really hope that you start looking at a longer-term view and finding ways that can really get that preventive care in the hands of patients and providers sooner.

right it's all about like finding the right people instead of just thinking oh this sounds good this is good let me just grab a prescription and start testing it right and then when those are really not at this pace even though they think it is part of their treatment plan and sometimes because some of these things are too readily available and not regulated enough and that's why we see that skew of oh everyone's on it Right? And like everyone's somehow just able to get it, but not having that holistic view of how medicine should be, right?

Taking into all the consideration of their family, their genetics, and their other comorbidities before making those decisions. So we're excited for you guys to be on this journey.

Long-Term Value, GLP-1s, and Preventive Care 9:20

I also always love to ask a fun question. If we give you a magic wand, the magic one grants you three wishes to help speed up the goal for the next year. How would you use the Magic Wand? oh gosh i just wish we were all incentivized for like just rather than like a two-year horizon maybe a five- year horizon would that be okay can we just you know optimize for patient's health in five years it's so hard right because we know these diseases take so long for us so i think that would be my way how can my wish how could we incentivize ourselves to take care of patients on you longer term and i'm just gonna have one one wish Now you gotta come back.

I don't wanna get greedy. Yeah, I think that's a principle of like the old school doc way of someone who take care of you, your family from pediatric all the way to senior years. And then now we're seeing so fractionalized. Even you go to the same practice, you might be seeing multiple different providers. So people feel like, oh, You have no idea what happened to me. Last time you barely reading my chart. There's no vision provider relationship anymore, right? So there's the friction that we have built to create lack of trust in the pathway.

And then you also have the multiple layer of people just can't get care, right? Certain diseases, certain specialties are just not available, and then people are locked into certain states, even if there is available outside state, then they have a high premium. So the more that we can figure out, from the payer side, from allowing the public to understand the options and then not just say that more options is a good option, right? Then it's analysis paralysis and also connected what you meant by the nurses, the care providers, all the way to the patients that become caregivers.

Let's do. The number of times I've spoken to, you know, a nephrologist in a PCP and they're like, well, who's responsible for their diabetes? I thought it was you. Exactly. People start bouncing, right? And it's different in different markets. Correct. And I think there's never going to be a right question. It's always a big, how can we have an open enough dialogue on closed-loop communication and not just chart it? Oh, there is my plan, hoping someone will just pick it up, Right?

Closing Care Gaps with Better Communication 11:30

How can get back into that? oh, I can actually message, call, or a different automated way to actually trigger the care plan so things are actually following up. We have CRM system, we have all these tools. Let's do it better, right? It's not like back in the day that you bump into your clinician on the hallway and be like, hey, let me psych her console you and before you go see that person, and we all have these tool. So I think the more interoperability start coming into play, the people like you guys that are actively, specially identifying these subgroups will have more solutions.

It's exciting to be in this space right now. We have a lot of hope. Now it's just like, okay, there's a lotta ideas. Who are the strategists to help us plan it? Who the next level of people who actually implement it, and who are there true champions to talk more about these things? so we can get them educated to all of it in the proper way, right? I think that's so true. We have fancy tools, but at the end of the day, it's people thinking about patients, working with one another, trying to solve problems.

And that the hardest part, the technology is actually easy. So as you guys are expanding, are you hoping to continue to expand to the payer market, more on the lung cancer detection, say, or you are starting to already go down other pathways? So like I said, we work with a lot of health plans. What we found is that, it's interesting, Medicare Advantage has actually gotten a little further in terms of value-based care than I think the commercial and self-funded market. And so now we're starting to work a bit more with employers, brokers, to help out the self funded space because a lotta times, because they've taken on that additional risk, their provider ecosystem, in term of their TPAs, all of the different building blocks they're bringing together to make that helpline.

They're so fragmented, but it's actually a lot harder to do a long of that value based care. So it is an interesting opportunity. And I think employers are actually the ones who are incentivized for longer term wellness of their employees. I'm really excited about that. Yeah, and I actually recently met someone who specializes in tax reduction. for the employers, so they can have the money to use for health plans and incentivize. I'm like, wow, more people should know about that because one of the questions is going to be like how do we understand retention is valuable,

Expanding to Employers and Self-Funded Plans 13:40

keeping your employee happy, right? Healthy is good, but where is that allocation of fun coming from? So I think that more can merge together for these resources. Now we can really do something a lot bigger and in all different facets of support. So I thank you so much for being here chatting. It's exciting for everything that you guys have already built and then can't wait to have more follow through to see how you are planning out next year. How can people best to continue this conversation with you?

So I'd love for people to read our lab trend report. That gives all the nuggets and the information and insights that you need to know to get smarter on labs and diagnostics. Where the different costs are in terms of site of care, where it's growing, what's not. So Avalon Healthcare Solutions, our Lab Trend Report is a great place to learn more. perfect. So for anybody else who's watching, who is listening, if you're already in a diagnostic space, we would love to hear what are the some things that you guys have built to speed up the path to being identified.

Because at the end of the day, the faster we can get to a result, as faster as we catch up for the next phase of treatment, and the options that can be discussed. And for anyone who really wants to look into those data, go to the start reading those reports and reach out to Dr.

Lab Trend Report and Final Takeaways 15:00

Chun and to have those open dialogue. Many of us are very active on LinkedIn so we can't wait to see what you guys are already been doing out there so the more collaboration can be happening. Awesome! Thank you for listening. Remember, the positive change we're seeking starts right here with me and you. If you're a fan of the show or if you are just having struggles or success that you've either experienced in the past or are experiencing now in healthcare industry, these matter to all of us. I want to hear from you!

Visit sabrinarumbag.com forward slash connect and send me a direct message. Talk soon!