Betsy Seals and Deb Devereaux, MBA, RPh, explain what motivated them to start a managed care consulting business; how COVID-19 shifted things into hyperdrive; and the keys to success in the rapidly evolving Medicare Advantage space.
On February 3, 2020, health care industry veterans Betsy Seals and Debra Devereaux, MBA, RPh, launched Rebellis Group, a government programs consulting firm. They saw an opportunity to meet the unique needs of managed care stakeholders in a rapidly-changing health care landscape. Little did they know how rapidly change would come. Within several weeks of their launch, cases of COVID-19 would surge in the United States. How did Ms Seals and Ms Devereaux step up to meet the challenge? By applying the same skills that motived them to launch Rebellis in the first place.
We recently sat down with Rebellis’ co-principal consultants and cofounders to discuss their motivations to launch a business, how the pandemic has shifted health care into hyperdrive, and the key issues that are impacting the Medicare
Advantage space—particularly social determinants of health and technologic advancements.
The obvious way to begin this interview is to ask how COVID-19 is impacting your new business and your clients. But before that, I’d like to first ask what were the driving factors that caused you to team up and help managed care stakeholders?
Ms Seals: First of all, Deb and I have worked together for close to 15 years. We really enjoy working with one another, as well as the other team members who are part of the Rebellis Group. But much bigger than that, we saw a fundamental shift occurring, particularly around social determinants of health and how these determinants are impacting beneficiaries and the industry. In this we saw an opportunity to combine our extensive expertise in regulatory requirements, as well as plan operations, with a modern twist on the technology to make a difference on both the vendor side and the health plan side.
Ms Devereaux: When Betsy and I first started off in the Medicare Advantage space, everybody was just trying to keep the lights on. Some of our first applications were manual and time consuming. It took 3 months of 12-hour days for three or four of us to get the work done. Now, we’ve advanced from keeping the lights on and rudimentary kinds of compliance to sophisticated operations—with a focus on members and health outcomes.
It used to be that we were just trying to get members to the right provider, or the right pharmacy to get a prescription filled. Now, we care about which prescription for which member with what condition. What else is going on in their life that is keeping them from being healthy? It’s an entirely different mindset.
How should managed care stakeholders be adapting to these trends?
Ms Seals: Even before the COVID 19 pandemic hit the US, the health care industry—and Medicare Advantage specifically—was in the midst of a shift that requires response from stakeholders.
I can point to a few examples. Regulations that allow special supplemental benefits for the chronically ill subset went into effect for the first time in 2020. New innovations are emerging to predict health outcomes. Even before the pandemic there was a shift to home health care services—caring for beneficiaries where they are vs in provider offices. The industry was shifting already, but COVID-19 has catapulted us possibly years forward in the evolution of health care because, all of a sudden, innovation isn’t an option, it’s a matter of survival.
And what, in your view, is the key to survival?
Ms Seals: Health plan innovation in terms of member acquisition, retention, and medical intervention is key. And in order to innovate, organizations must understand data—both the internal data you hold within related to your specific your membership, and external factors data, such as social determinants of health, that impacts your members and the Medicare Advantage population at large.
What other changes are you seeing with Medicare Advantage?
Ms Seals: For many years there was a feeling that Medicare Advantage lagged behind in innovation. But now it is catching up very rapidly and CMS [the Centers for Medicare and Medicaid Services] is now at the forefront of the innovation. They’re loosening the guardrails and allowing us to do what is needed to impact the lives of the population we serve.
What are the consequences of not adapting to these trends?
Ms Seals: Beneficiary experience and health outcomes have such a tremendous impact not only on beneficiaries, but on health plan star ratings, risk adjustment, on all the different parts of a health plan. In order to be a healthy organization, you have to be bold and agile. This is especially true during an unprecedented pandemic. For example, organizations who put themselves in a position pre-pandemic to adapt quickly have been able to roll out telehealth benefits in real time—a benefit that was not universally available through many of the health plans serving the of previously for the Medicare Advantage population. And, as you can imagine, the ability to do that during current circumstances is absolutely critical.
We saw from beginning of March to beginning of April roughly a 50% decrease in members seeking routine care. If you don’t have the ability to roll out telehealth benefits, that is going to have a massive impact on your beneficiary health status and also the health of your organization.
Ms Devereaux: The health plans most acutely focused on data and automation are in the best position to survive and thrive. It is gratifying for me to witness. There was a time when some Medicare organizations looked at the emergence and proliferation of data and simply folded their tents. But others were not intimidated. They dug in and have made things better for their members.
What was it like to hang your shingle at roughly the same time as the COVID-19 outbreak?
Ms Devereaux: Our first conversations were about the science of COVID-19 and how much of an issue it was it going to be. Once we saw that its impact was going to be significant, we started to see the how we could make a difference quickly. We’re perfectly positioned because the world is transitioning to a virtual workforce, and we are used to working in this way.
We started by reaching out to our closest clients, not to sell our services, but just to check in, find out how they were doing, and get their thoughts on the emerging crisis. We wanted to make sure to hear them.
Ms Seals: Our firm was developed and positioned precisely for this environment where technology and innovation are moving into hyperdrive. We’re going into the trenches with our managed care knowledge and technological expertise.
It sounds as if there was not much stress about it.
Ms Seals: Of course there were many conversations with our executive team about how best to rapidly adapt our service offerings to meet current needs—but my only moment of real panic was when I realized that I was going to have to homeschool for the rest of the year [laughs].
How have you had to adapt your business because of COVID-19?
Ms Seals: Consultants typically build relationships in onsite meetings, particularly during a project kickoff. That hasn’t been an option. But, like everyone else, we have adapted, using virtual meeting platforms such as Zoom. We’d much prefer to be onsite, but we have been able to acclimate.
How has your advice to clients changed in light of the pandemic?
Ms Seals: Telehealth capabilities have moved to the forefront. We are also looking at how we’re going to do broker sales in the upcoming annual enrollment period. Those things have changed because the landscape has changed. We are providing advice and helping with implementation. We are also advising on how to enhance benefits mid-year with the allowances that CMS provided. Ultimately, of course, it’s the health plan’s choice. We straddle that line between providing advice and letting the plan decide. We’re there to provide counsel.
Data-driven operations are key, now more than ever. For example, if you manage your population of diabetes patients very well, how can you enhance those benefits and advertise those programs to beneficiaries with diabetes? It’s a matter of looking at what you do well and growing upon it.
Ms Devereaux: To amplify Betsy’s points, it is important for clients to know how they will design benefits to: (A) Keep members; and (B) attract new members, particularly to a treatment or a care where you excel.
Beyond that, it is important to think about what your competition is doing, and either meet or go beyond that. Think about tiers in a formulary or utilization management—what are going to be barriers to enrollment, and what is going to enhance your opportunities to increase member enrollment?
Many of the organizations that were innovative at the onset of COVID have the potential to be behemoths this upcoming open enrollment season.
Your website notes that Rebellis brings “a modern experience marked by flexibility, hands-on expert assistance, technological expertise, and tangible results.” Can you talk more about the unique qualities your of your firm?
Ms Seals: We saw an opportunity to apply our deep knowledge of Medicare Advantage and managed care programs, with a focus on operations and technology. There are many experts in the industry, but this is our niche where we know we excel. We have an ability to connect the dots between all the different functional areas of the health plan and identify operations and technology innovation that is going to have a significant impact on the beneficiary experience, the delivery of care, and, ultimately, the bottom line of the health plan.
You’ve touched on social determinants of health. Do you have anything to add about the implications as this area grows in importance?
Ms Devereaux: I think of it this way. We have treatment guidelines, based on research-backed evidence, for an array of diseases and conditions. Guideline recommendations are best applied after they are overlaid onto what actually is happening in the member’s life. It’s very difficult to tell a person who has diabetes that this is your meal plan when that person lives in a food desert, with no grocery stores and fast food is the only option. There are a lot of factors in people’s lives that make the health plan unable to get at the really important treatment for specific pockets of chronic conditions, particularly if things are done in the traditional way.
You’re never going to be successful unless you address the holistic view of the member and their life. I think that’s become a realization in the industry. People with diabetes or heart failure are part of large groups, but their treatment has to be customized individually. Every person’s situation is different and a successful outcome is largely dependent on the individualized treatment plans.
Ms Seals: This is something that has taken off in the last 3 to 5 years. There are new companies in the space that have amazing predictive analytic capabilities, all based on social determinants of health. When you marry those predictive analytics on the social determinant side with actual claims data, you end up with a very reliable predictor of adverse events and preventable hospital admissions. It gives you the ability to implement meaningful interventions.
What are the key trends in Medicare Part B operations that stakeholders need to consider, for instance, implementing step therapy?
Ms Devereaux: I have a fairly deep clinical background. I remember when Medicare Part B was considered the wild west because a lot of Part B decisions were made in doctors’ offices. Treatment guidelines were not always adhered to—it was whatever the provider ordered, even if it was the most expensive treatment option. But now health plans are applying rigor and utilization management criteria to the use of these therapies. It not only saves money but improves quality.
As the population ages, there is a need to manage patients with multiple chronic conditions. What are they keys to success here?
Ms Devereaux: Some of the conditions are interrelated. For example, people with diabetes are at risk for kidney problems and high blood pressure. So, when you address blood sugar issues by recommending exercise and other lifestyle changes, you can improve the other comorbid conditions.
Sometimes you might need to reach outside your organization for help. For instance, if your plan does not have a great track record managing patients with HIV, you should look for programs in your service area with that expertise. Contract with them to take care of your population with HIV.
Technology can also help. Health plans need to increasingly rely on wearable technologies, smart pill boxes, smart scales, and other innovations. For instance, a smart scale can alert you when a patient with heart failure put on five pounds of fluid overnight.
Ms Devereaux: The other thing that we’ve seen, especially with the polychronic population, is an increased effort to provide care in the home. This is particularly the case for what we call an institutional equivalent special needs plan—beneficiaries who need an institutional level of care, but they’re still living in their home or in the community. This model and plan type is even more important in light of COVID-19—keeping beneficiaries out of institutional settings where we can. We expect to see a shift as well, in general, to more care being provided in the home, but especially when treating multiple chronic conditions.
How has the emergence of artificial intelligence (AI) changed the industry? What are the keys to leveraging opportunity in this area?
Ms Devereaux: Some organizations are beginning to leverage artificial intelligence and machine-based learning. For instance, look at the coverage determination space, particularly now that we have added Part B determinations. It takes a lot of time for the systems to talk to each other, transpose information from one system to the other, and then go through multiple reviews. If an AI engine was able to scan and get the information into the system, and then make a decision based on criteria that was existing in the background, then all the plan would have to do is validate the decision. The plan might change the decision, but all of those steps leading up to that would have been done by AI. That’s going to be a huge step forward.
What are the key trends to be mindful of in the next 3 to 5 years?
Ms Seals: Ten years ago, no one would have imagined that the industry would be where it is now. That we would have the predictive analytic capabilities, the AI capabilities, and the technology solutions. Very few would have thought any of this would be possible so quickly. The important thing to keep in mind as we move forward, and especially as we fast forward, is that anything is possible. We should not discount ideas because those ideas can change the industry in ways that we never could have expected.
Ms Devereaux: As we noted previously, the laser-sharp focus on what the member needs is important—and will gain even more importance. That’s going to be one of the biggest drivers in health care. Additionally, CMS has become an agency of innovation. It has evolved from a system of compliance, auditing, and a “thou shalt not” mentality to a culture of “what are the possibilities? How can you take better care of the population you serve? Go ahead and try it.”
That’s huge. Those organizations that embrace this new culture are the ones that will succeed.