Shawn Rutledge is the President of Sales for Edison Healthcare. He has been in the business of healthcare innovation for more than 25 years and is now leading the charge through Edison’s Network of SmartCare Centers. Over the last 8 years, Edison has built a private network of 17 Smart Care Centers across the country. Shawn assists employers in addressing the dramatic misdiagnosis and overutilization rates throughout healthcare.
You work with employers to help them reduce the financial burden associated with high-cost claimants in their populations. How do you advise them to think about and approach this issue?
It’s really important when you look at a self-funded health plan that the employer is really focusing on the high-cost claimants. Six percent of the enrollees on that health plan are spending the bulk of the plan dollars—and what is that? That’s the knees, hips, spine, cancer, heart transplants, bariatric, and complex pediatric care; that’s what’s driving the cost. It logically would conclude anybody to ask: “why in the world are we not micro-managing the six percent?”
Edison healthcare helps manage that. We have an epidemic of misdiagnosis, overutilization, and inappropriate care in America. We show employers how to manage that through a centers of excellence solution, or what we call SmartCare, and direct those members to the best places in the world that are not doing things inappropriately.
What are examples of surgical or disease pathways that are commonly misdiagnosed?
Of that six percent of the plan members spending all the money, we know that 20% will be completely misdiagnosed, and another 40% will have wrong or suboptimal treatment plans, which is a misdiagnosis in its own right. It’s harming members and costing the employer a fortune for things they should never pay for.
What does that translate to?
6 out of 10 spine surgeries are completely inappropriate.
35% of all cancer is misdiagnosed. I never thought in a million years I’d have this story hundreds of times over: you’ve been diagnosed with cancer in your local market, maybe you even started treatment for it. Then you go through our program, and you find out you don’t even have cancer.
4 out of 10 cardiac stents are inappropriate.
6 out of 10 bypasses are inappropriate.
3 out of 10 solid organ transplants should not happen.
The list goes on and on. It’s insane what’s going on in healthcare in America. It’s cool to see these employers finally waking up and realizing we have got to be better.
What other burdens besides financial ones does misdiagnosis & overutilization present to individuals, employers, and the health system?
The burden is you are harming members by overtreating and doing unnecessary surgeries. I mean, who wants a spinal fusion that doesn’t need it? I can’t tell you the countless stories we’ve got of people being told they need a fusion in their local market: it’s incredibly invasive, incredibly expensive, and they go through our program and find out they only need physical therapy, or they only need a minimally invasive laminectomy that costs $8,000.
The most important burden is that members are being harmed, and that must stop. These doctors are paid to cut. They are paid to prescribe one medication over another. That’s how they make their money; it’s human nature. So, you’ve got to change that mechanism or it’s never going to improve, and that’s where we are uniquely different as an organization.
Has Covid-19 exaggerated these issues? What has the pandemic taught us about managing rampant misdiagnosis & overutilization?
COVID obviously made things pretty stagnant for a while. They weren’t allowing elective surgeries. The impact that it’s had now that things are picking up again, we’re seeing massive increases in claims spent because people are getting all their stuff done now. We’re going to see a massive uptick in the dollars on these self-funded health plans so again, micromanage your high-cost claims because they’re just going to go up.
It has also taught us that we need to be more flexible in the laws in this country around remote consults. When COVID hit, they allowed any doctor whether they were licensed in that state or otherwise, to do video consults with those members to make sure that if they absolutely had to travel, if they needed to go to the center, it was determined remotely first and then they pulled the trigger. As COVID started lightening up and everything opened up again the laws got tough again. Now doctors have to be licensed in the state to do these consults, but COVID has taught us that is an area that is deeply flawed for us in this country. We’ve got to allow these doctors, if they’re licensed professionals, to be able to do consults wherever someone is.
If the current pattern continues, what will the future of employer healthcare look like?
It’s just going to be the continued status quo. It’s going to be overutilization, inappropriate care, the cowboy doctor; you’re going to continue seeing massive increases in cost. We’re going to continue seeing Medicare squeezing these centers which causes them to overutilize because when you lower the price of something, they’re just going to do more of it to make up the difference. That’s where it’s going if nothing just changes holistically, without an Edison, you’re going to continue seeing and experiencing the same thing.
We provide a study from Dartmouth correlating stent and death. Who would have thought over-stenting and death were synonymous? It’s insane the amount of people that have 9, 10, 11 stents in their heart: it’s mind-blowing and we do a lot to intercede in that area around pharmacogenomics and different things like that.
What strategies do you advise to help employers change this trajectory?
The Proactive MD solution is huge for Edison healthcare because not only is the employer saying: ‘we’re going to manage people at the beginning of a potential issue,’ but then we have Care Beyond the Walls™ in an Edison healthcare where we can get them to the best centers, best providers in the world that are not going to misdiagnose, not overutilize. We will check the price box and will do it all in a case rate or a bundle that will blow the carrier pricing out of the water.
I think if I were advising an employer from entire plan perspective, I would say add a Proactive MD so you can micromanage your members early in a diagnosis, then embed a center of excellence solution alongside of it to protect it when those high-cost claims come up.
What results or ROI have you seen employers experience from implementing these strategies?
The ROI is through the roof. One of the cool things about us is we have a proprietary validated ROI calculator so I can tell an employer of any size, if they have 100 employees or 100,000, how much they will save by going through Edison versus their standard carrier pathway.
So yes, it’s a price for price comparison, but the ultimate ROI is in what you’re not paying for. When you think about it from a reinsurance perspective, and you know a lot of employers have to pay for stop loss, having an Edison type of thing embedded allows those stop loss carriers to offer significant discounts for obvious reasons: check the price box in a case rate or a bundle but you’re telling me you’re avoiding 60% of spine surgeries? I mean, it’s a pretty good deal.
What other message would you like to get across that we didn’t cover in the interview?
Self-funded employers out there: you have control of your plan, whether you have 100 employees or 100,000. You have control. Don’t let all the carriers, these insurance entities, or these healthcare entities tell you what you can and can’t do. You have control. We have proven it at Edison healthcare over and over again with the sheer volume of employers that we have and their varying sizes. That would be my message to employers: take control of your plan, micromanage the 6%, and win every time.