Ep. 4 | Renown Rounds: High Quality & Affordable Care

Hi everyone, this is Mike Higden, the owner of Mike Higden's Storytelling Studio. We're here with another renowned rounds podcast episode. And today we're talking about the strategic plan, specifically how to ensure access to high quality and affordable care. I'm here with Dr. Elling who you saw in the first episode, and Bethany Sexton, the CEO of Home Town Health. And I'd like you to introduce yourself a little bit more for everyone. Sure, thanks for having me. I have been with the renowned health for the past 11 years, and many different roles. And then about three years ago, moved over to the health plan, arm of renowned health, which is Home Town Health. We have about 70,000 members across the community, across many different product lines. So we ensure folks from small groups to individuals, as well as those with Medicare Advantage. And we love working with our community and making sure that they have high quality health plan offerings. Awesome. And Dr. Elling, I hope you introduce yourself for any new people who are joining the team. Yeah, Brian Elling, I'm the president, CEO of renowned health. I started in November of 2022. Our strategic plan was formulated in 2024 as we talked about in the first episode. And I excited to share some detail on this pillar. Awesome. So whoever wants to take this question, help us break down what ensuring access to high quality and affordable care means. Well, I'll kick it off. So we talked a lot about all of the advanced care that we are bringing to our community, that we've really focused on, ensuring, trying to provide the kind of care that will keep as much care local as possible. So that includes some, our kidney transplant, which we actually just had our first kidney transplant, includes some high-end ICU care, trauma care, stroke care, all of those things. And then also in partnership with you and our school of medicine, as well as the school of nursing, all of the training that we provide to our community. And when you look at that, you could take a step back and that, and there are health systems across the country that we have very good examples of that have provided that expensive type of care, but have also driven the cost of care up. So as part of our strategic plan, we are very focused on, we want to keep the cost of care appropriate for our community. So we did a study and looked at Reno. And Reno is actually, if you compare it to all the other municipalities around the country, we run a little bit below the median when it comes to cost of healthcare per capita. We thought that was a pretty good place to be and we wanted to really make sure that we weren't driving the cost of care up. So we created a pillar that was around delivering value for our community, for the purchases of healthcare, which includes families and individuals, employers, and that sort of thing, as well as ensuring that we were focused on providing the best outcomes, as well as access points for our community, both primary care and specialty care. The big part of this is our health plan and the work that our health plan is doing under Bethany's leadership and hence the reason she's joining us here today. Yeah, I love that. And as a health insurance CEO, what we think about pretty much all day long is making sure that our members do have that access to amazing high quality care and that it's sustainable and affordable. And so I love that from a renowned perspective, we're thinking that way more broadly about the community as well. And we really lead out on that from our health plan. So we start with our members that we have the ability to really navigate their care for them and make sure that we're doing everything we can to manage that cost over time. And so this pillar and the tactics underneath it are really about driving that forward. Awesome. So I've always been curious how hometown health and renowned like interact is it the same company as separate company? Is it a partnership? I don't know if I actually understand how that works. Maybe I can give a little bit of detail there. So the health plan is wholly owned by renowned health. We are not for profit health insurer in the state of Nevada. We offer actually we have two sub companies within hometown health. So we offer PPO's and HMO's. We're licensed to offer both of those in the state. And as a health insurer, basically we collect premium dollars. So whether you're an individual or an employer, you pay a premium each month for having that coverage. And then all of the care that you might need, whether that's pharmacy prescription drugs or going to see a doctor. And if you have to end up in the hospital for some some reason, all of that care is paid for by the health plan out of that premium. Gotcha. Okay. That helps make a lot of sense for me now. Can someone get hometown health who is going to other hospitals also or out of state? Yeah. So for hometown health, our primary network here in area is all of the renowned network. So all the renowned hospitals, renowned doctors. We also do have a very broad doctor network beyond just the renowned doctors. So we partner with community providers across many different specialties. And a fun fact that maybe a lot of people don't necessarily know we actually hold a network of providers across the entire state. So that means we directly contract with as an example hospitals in Las Vegas and providers in Las Vegas. And so any of our membership that ends up anywhere across the state, even out into some of the rural communities we hold contracts, we can make sure that we're delivering that care for them and have those relationships with those providers. When our members go out of state, we actually use a wrap, what's called a wrap network. And so today we partner with SIGNA on that and that enables us to use the SIGNA network, which is a national network. If our members need out of area care for any particular reason or if they happen to be traveling and find themselves in need of care. Gotcha. Okay. So then, okay. So now that I understand how all the inner workings, how does hometown health kind of participate in that strategic plan mission of making sure there's high quality access? Yeah. So in a number of ways. One, we've really been focused on quality and driving quality forward. We work really closely with the medical group providers within renowned medical group. And so we have done a number of efforts for our members to just make sure one that they're receiving preventative care, two that they actually have a relationship with a primary care doctor. We find that to be a really great way of ensuring that people get care when they need it and also that they're navigating to the right level of care. So when you have that primary care doctor kind of in that quarterback position, that physician can help you navigate the care that you might need. And then to within the health plan, we have wrapped around a lot of services. So some of our membership may have chronic disease or components that they have had over a long period of time or maybe navigating a specific disease state, like a new diagnosis of cancer or something like that. And so we have a lot of wrap around services. We have chronic care managers, we have community health workers, we have social workers and others that are actually hometown health resources that we can partner with our members to make sure that they have they kind of wrap our arms around them, make sure that they get the right medications at the right time that they can navigate the health care system, which can often be very confusing and sometimes hard. We also have supplemental benefits like things like Uber rides for those who might need to get to a deployment or things like that. That sometimes people don't necessarily know all the resources that we can bring to bear to make sure that they get the care they need. That's really cool. There was a phrase that I was reading about in insurance that is it value based network or. Value based care care value based care. What is that and how is there other versions of that? Is that different than other insurance? Start with what's most common around the country, which is. Beefers care. Beefers care. Most health systems do not own an insurance company, the vast majority. And you'll hear the term provider and provider refers to both, it's a very generic term, both physicians, nurse practitioners, patients, people who provide care but also health systems that have hospitals and clinics are providers. Home town health is a provider sponsored health plan. So we own home town health to deliver this service for our community. Beefers service is exactly what it sounds like. You do something, you build an insurance company or an individual and you get paid for that service. And that is one of the greater flaws in the US health care system is that is based tremendously on beefers service. So you have, you know, the more you do, the more, so people want to do more because that's how you generate a living or whatever drive your business results. That's not always the best thing for people. So value based care is a focus on doing high value things. So, you know, care that is going to affect outcomes. And there's a lot of study and a lot of research that goes into what's the best, you know, what's the best care protocols and pathways to ensure that, you know, I'll just give you a random example. If you have back pain in your show, but your doctor that you don't automatically get an MRI and a surgical consult that you're maybe, maybe it's a plain x-ray. If that's even warranted based on an algorithm and you get physical therapy and maybe some pain injections or something like that. So much more high value care that may have the same outcome or better outcome than too much care. So we, you know, the US system is based on fee for service so you cannot turn your back on it. It is how the whole system works. But we felt that it's very important to also have a value based care part of our organization that can help us work towards the results that are in the best interest of our community. Would you add to that? The only ad is that. for us as also having a health plan, it enables us to do that right from the get go. So I think when I think about a health system like renown, often it takes being in that position of having those premium dollars to actually be able to do that model of care. And so for many health systems across the US, they have to partner with a health plan because the health plan is the one that holds the premium. And so in our scenario, we can start and really drive what Dr. Elling talked about in terms of a value-based care model with our membership as the starting point. Now, I think from a renowned perspective, we want this type of methodology for our broader community, but this enables us to really start with our membership. And so all of those hometown health members that we talked about, whether they're on a Medicare Advantage plan, our Senior Care Plus plan, or they're an individual or through their employer sponsored plan, we have the ability to then move into this type of model right from the get go as a part of the strategic plan. So from a patient point of view, are you able to give an example of how that would look or feel different? I mean, you started to give an example, but if I'm a patient, how would my experience be different in those two value-based versus fee-first service? Yeah, so I think, again, starts with that primary care experience. So a lot of times, just sort of your average member, if you will, that is navigating on their own the health care system, they may or may not actually have a primary care doctor. So I think for us, as we think about managing the population, first setting up that relationship with primary care is super important. And so we can help drive that through the health plan. We actually can set up many of our plans to require that kind of relationship where we want to make sure you have told us, this is who I'm seeing for primary care, and then we'll follow that up and I'll actually look for, did you go and see them, did you not? And so that, to me, is first and foremost, is making sure that relationship exists. And then I think as you navigate care, there are some folks that are very healthy in any given year, right? And then there are others that require a lot of health care throughout any given year. And so from a health plan perspective, we are going to focus some of those extra resources on those that need it the most. And we're going to make sure that we're watching for any signs that you might be arising risk. So health indicators, maybe you didn't, or haven't gotten some of your preventative care done. We're going to be looking for those kinds of scenarios so that we can reach out. And make sure that we begin to engage you in what we think is probably a great path in terms of prevention and other things. And for your general average member who isn't engaged in this kind of a model, that just doesn't exist. You're kind of navigating on your own. And really that health plan relationship is likely not happening in the same way. Yeah, I can speak from experience of probably being in the fee base that it's basically just kind of me going shopping for health and then getting stuff done that's recommended or not or, oh, I think I need to see a physical therapist because I injured myself during sports. Maybe I should go call one. So there's no one who's really guiding me. It sounds like. Yeah, exactly. You're kind of navigating it all on your own. And if your provider is being reimbursed in a fee for service kind of way, they don't have any incentive to help you with that process. Good example. It's 4.30 and you call your doctor and say, hey, I have this problem. I say, you know what? Just go to the emergency department. We're closing up. In a value-based care, that was the last thing. Now if you're having an emergency, I'm an ER doc. Go to the ER. But that's usually not the case in those phone calls. And so we want to get you to an after hours clinic, which is with a low price point for you. And that'll get you the best results and avoid a necessary care. Yeah. That was part of my question too, is how is it different for providers? So I think you gave a hint in terms of is almost like an incentive or is it actually an incentive to have them navigate with people or does it work differently for them? Yeah. So one of the things that we're working on, again, from a health plan perspective, is having some dedicated sites of care because it is a different model. I mean, so Dr. Rilling has really talked about the fact that in a fee for service world, which by the way, we still live in that here in Reno today, right? Like much of what we do every single day is fee for service. So we as a health plan will have dedicated sites of care where those providers really can focus on this model. And so when you think about aligning the model, it also incorporates thinking about how that provider is paid. So that provider isn't necessarily paid in the same transactional, I do more, and then get paid more. The value-based model actually has different incentives around quality outcomes and some of those prevention measures and other things like that. And by doing that and having some of those dedicated sites of care, the care that's delivered within that primary care office as an example for a health plan members can look different and can actually feel different. And to the point about the 430 call, those providers likely will also have additional resources like nurses within the clinic, potentially social workers, pharmacy, support and other things that enable them to get some of that support and help in those minutes and hours that they need it. And then also they can make different decisions about, hey, let me fit you into my last 20-minute appointment of the day to make sure I see you and get you taken care of before we roll into the weekend and so nothing else happens. And I think that alignment of those incentives changes the dynamic there. Interesting. So many thoughts around this. I guess my first thought would be, so if you're a provider, let's pretend I'm a doctor and I kind of have to navigate insurance coverage through fee-based and insurance coverage through hometown health, how do you, as a provider, balance, this is kind of a potentially a better service that I can treat my patients differently and this one is just kind of sending in bills for a day. >> Yeah, that's a great question and we never want to create that choice for a provider. We don't want someone to have to look and say, is this a hometown patient or is this a, whatever their insurance coverage is. So we always just want to do the right thing. But what you have to do is align the incentives for the providers with the plan and with what you're trying to accomplish. So it is a different way of thinking. It is a different way of, it's different algorithms and care delivery pathways. It's a different, it's a different formula for drugs that you'll prescribe based on what we have contracted with hometown, for example. And so all of that is better handled in focused areas where the whole model is value-based care with all the wraparound services. >> Gotcha. >> And I think a really important part of this is also thinking about that broader care team, right? So I'm talking about dedicated primary care sites that are in this value-based model. But those primary care doctors can't handle 100% of the care, right? They have to connect to broader specialist community, if they need that referral out. And I think we will begin to see over time is that the dynamic for those providers in primary care is that they do want to manage the care and they want to handle as much as they possibly can in primary care. And then when it's the right time where they really do need that specialist, that's when they do the handoff. And then the specialist can focus on that member just like they would any other member. Because that level care is truly needed and they're working in their office just like they would with any other member. So that's where we've really started the focus around primary care. >> Gotcha. What's really interesting to me is thinking about my own business, which is very different than medical. It's storytelling and photography. But I think about clients who call and just want, just come show up and take pictures so they're treating like a service provider versus even you guys bringing in and say, let's plan this podcast series together. That feels like that's more like what you guys do is let's all come in together and kind of figure out the best way to create good outcomes versus just having someone click a button for you. >> Yeah, no. The big caveat for us is that any way you slice it, this is insurance. And insurance is something that is inherently involves actuaries and risk management and things like that. And one of our challenges since the pandemic is that we're at a total membership prior to COVID of around 150,000. Now we're down into the low 70s,000. And that has been one of our bigger challenges with hometown health and the model is that you need volume to help offset risk. You can imagine we can have one or two cases that are really expensive, that really disrupted. So you got to be able to, so that's been one of our challenges that we've been experiencing and it has been forcing us to sort of ask what is, what do we need to do next? The other one is around, we're a small regional health insurance company. And we don't have the resources or the technology and some of the other software, things like that that can help us manage our patients in a way that like some of the big players. So it becomes more difficult to compete when you're a small regional player like hometown health is. Everybody's hearts in the right place. We're doing great care, but you need to be bigger. And that's led us actually to a big piece of our strategic pillar, which if you look at the tactics underneath that, one of those was to look at ways that we can partner differently to take hometown health to the next level. So what did you guys come up with? We I'll back it up. I will say that we started almost two and a half years ago, Iish, with this exercise of is the value-based care in the health insurance space important for us? Or do we do it a lot of health systems have done and just focus on being a provider, contract with insurance companies? We really think that it is important for our community. We want to deliver value. We want to make sure that our employers and people that purchase health insurance are getting high value and keeping that a small part of their expenses as we can possibly provide. So we said, yes, this is something we want to do. So we actually went through a significant process. We engaged our payer community, we said, and said who would like to make a proposal to join us and to partner with hometown health? We focused only on payer providers, only not for profit, only other companies that were like-minded and mission-oriented, like we were and cared about our community and wanted to do this for our community. And we went through a two-year process and we have landed on a partner that's going to join us in the future of hometown health. Pretty excited about it, actually. The loser's going to be. You have to keep the suspense going. I know. I don't have an album cover to pull out or anything like that. But it is really exciting. We'll be partnering with Kaiser Permanente, actually. So probably a lot of your listeners have heard of them before, maybe once or twice. And the reason being, they cover about 12 million lives nationally. And so they're a major payer nationally. They're in eight different markets. And they hit on all of the things that we've talked about. So their primary focus is value-based care. They focus every single day on delivering high quality outcomes. They have some of the best quality outcomes, in fact, nationally in terms of when you look at different disease states. And so if you can't tell, I'm just a little bit excited. Because I think it really is going to help us as a regional player to go to the next level. It will bring technology that we have not had as hometown health previously. They have worked out for many decades. In fact, the kinds of protocols that we're talking about, they have really refined that whole process. And so as we think about working with our provider community, as we think about setting up-- and I think we've talked a little bit about some of these dedicated sites of care. As we set those up for our health plan members, they will be able to bring a lot of that backdrop to that care model. And it's a really exciting opportunity. And Bethany announced that as a CEO of hometown health, because it is hometown health. That is partnering with Kaiser Permanente. There is-- that transaction is a transaction. We are selling roughly half of the health plan to Kaiser to form a joint venture that will be for the entire state of Nevada. And we're excited to be in a partnership with them. Nothing is happening on the renowned side of things. So I want to be really clear, because there's always room or control. And what does this mean? Kaiser is not purchasing renown or anything like that. We will be contracted with the joint venture, just like we're contracted with hometown health. So that is a wonderful partnership that we look forward to growing into the future. But this is a health plan partnership that we're excited to announce for our community. Yeah, that's a huge deal. So that helps answer some of the questions. Selling half to Kaiser Permanente. What does that look like for you and your team and the offices and all the kind of logistical-- like I'm an employee and I'm listening to this and I'm like, oh my god, what's happening? Was it really mean for me? Well, they better not hear for the first time on this podcast. OK. But you're right. They'll look around like, did you guys know? But I hope that we can answer some questions that might be in people's minds. OK. Yeah. As a health plan, again, scale is super important. So when we think about things that are behind the scenes that nobody really even cares about, but like claims processing and call center services and a whole host of components, having scale really, really matters. The kind of amazing part of where we are today, even compared to pre-pandemic, is so much of this work is actually done remotely. And so we're really excited because our presence is in Nevada for our employees and so forth. And that will remain the same. We will have a lot of employees that are here in the state and will continue to service our membership. As we move into 2026, our plan year is already defined. So the plans that we have filed and that we will be putting out into the market, there is no disruption to any of those plans. So I think from a member perspective, it only gets better from here. We strive every single day to provide amazing service to our members. I think we deliver on that almost every single day. And none of that is changing. And I think we'll be able to bring new technology, additional services and capabilities for our membership that they will be super excited about, honestly, from an experience perspective. So I think that that part is really great. We also, I think, will be able through this partnership to take advantage of things that we haven't necessarily been able to. So what that means for members is lower costs. And that is something that's a part of this equation that we were trying to drive. So that part is really exciting. And then I think our employees, part of this whole pillar is for us to grow. So Dr. Elling talked about this partnership being not only here in Northern Nevada, but statewide. We also know that we have a lot of opportunity to grow even in Northern Nevada. And we want to be able to create this differentiated experience for more and more membership over time. And so as we work through this transition, a big part of that is working on how do we continue to grow. And so I'm excited for employees, because I think that also creates a lot of opportunity for them. Oh, that's cool. Like in terms of just as the company gets larger, there is maybe more mobility, whether it's sideways or upwards, whatever people are interested in. Yeah, and this is a very a new model. Kaiser's never done anything like this. There's actually not a lot of health systems in the country that have done anything like this, where we've truly partnered in a way that will bring all these capabilities of a really big company, but keeping it local for our local community. And the mantra through the whole experience has been, well, this is a new type of joint venture that hasn't been done before. But how do we ensure that the patient and the customer experience is just A+? Because this truly is going to be a Kaiser-like experience like they have in a lot of the markets, which is outstanding right next to the renowned experience. And so we want that to be very seamless for folks and have a really excited about what it's going to bring to the community. Yeah, that's pretty cool. I think there's definitely a lot of possibilities that folks will unravel as it happens. So we'll probably see a lot of that and maybe talk about it more. How does that affect-- so is it going to be like a renowned hometown health Kaiser at the table kind of thing? Is it like thirds or something? Nothing's changing with renowns. How does that-- your connection? Yeah, so we'll have a-- the joint venture will be branded Kaiser permanent day. We'll be, like I said, roughly 50% owners of that. And then we'll have contracts-- that joint venture, as Kaiser Nevada, will have contracts with renown to provide the care. We'll have joint clinical committees to help ensure that all the clinical protocols are in place, both in the clinic level, all the way through the hospital level so that we can get those outcomes that Kaiser has been known to achieve, which is really, really good, strong quality and outcomes. And the leadership of the joint venture will be absolutely tasked with leading out on our member experience, making sure that we're driving all of those quality outcomes. So they'll be bringing-- the leadership of the joint venture will be bringing the best of what Kaiser has nationally to the market, and then also working directly with renown to create that seamless experience. Gotcha. So there'll be a lot to unpack, but maybe hopefully from the members' point of view, they'll have some better technologies and faster things. But for the most part, it'll just feel a little bit beefed up. Yeah, I think maybe a couple other just tangible examples. So we talked about our national network that we use today through hometownist SIGNA. As we move through integration, and I guess I also I'll just put out there because I know a lot of people would want me to say this. All of this requires regulatory review and approval. And so all of these things that we're talking about are the goals and ambitions that we have in bringing this joint venture together. And so once we have all of that regulatory approval and then can actually work through the joint venture, we're really excited about things like the national network that Kaiser has, right? It creates a much broader network. And that was also, frankly, a challenge being a small regional player. And especially when you're talking to employers that maybe have offices in northern California, Southern California, Vegas here. And we're really focused. We're really headquartered here. And most of our operations at Reno. So this brings just huge scale and access for all of the patients and customers. That's really cool. Yeah. So we're rounding out on our 30 minutes. Is there anything that you guys haven't gotten to mention yet that we have-- that you're really burning to talk about. Did I say I was excited? Yeah, I'm not sure. I think Dr. Eileen told you said that you were excited. I am. We're really excited. I think that we see this, honestly, as the future for renown and for health care in northern Nevada, if not all of Nevada. So we're really excited. And we're excited to prove a concept that I think has application for other health systems that maybe are struggling. A lot of provider sponsored health plans are either shutting down or scaling way back. And they're a valuable part of the health care ecosystem. So we're excited to demonstrate a new model. Yeah. I think for me, being able to take what we have worked on over the past three years and take it to the next level, that's the exciting part. And I think this partnership absolutely will do that. And I think just reiterating that for our members, it's what we come to work every single day to make sure that we're providing what they need as members. And none of that changes from today forward. And we're so excited about the amazing things that we're going to bring to the table for them as well. Yeah, that's really cool. Our renown health employees will be part of this. Myself and my family will be part of this and get our care through this new venture. And I'm extremely excited about it. It's going to be better for everyone. That's cool. I'll have to see if I'm able to look into new insurance in maybe a couple of months. Also, I'm right now on a different planet. I'll have to check that out when you guys watch. We'd love to have you. Thank you. Well, that should be the end of this episode. So I think we have a couple more points than the strategic plan to go over up until this point. And then possibly another episode after this. So I hope everyone enjoyed this talk today. Thank you so much. Thank you. [MUSIC PLAYING]