Medicare Advantage Changes: From PPO's to Value-Based Care | Insurance 360 Ep. 31

In this episode of Insurance 360, Dr. Shannon Decker joins hosts Bob and Rob to discuss the evolving landscape of value-based care in the healthcare industry. The conversation covers the importance of compliance, the impact of risk adjustment and quality measures, and how technological advances like AI are shaping the future. Dr. Decker also highlights the role of telehealth, chronic condition management, and the ongoing shift towards more specialized Medicare plans. Don't miss this deep dive into value-based care, its benefits for physicians and patients, and what the future holds.

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Transcript

Bob: Hey, good afternoon everybody. Welcome to another episode. Insurance 360. There we go, right?

Rob: Cheers it up, man.

Bob: There you go.

Rob: That was uh,

Bob: In case you didn't see: Insurance 360. Get your mugs here.

Rob: Yeah, my face is on it--it's the only mug that my face has ever been on, which is pretty cool. Gotta say.

Bob: Yeah. Well, whatcha gonna do? We have been blowing through the summer. It's end of August. 

Rob: That's crazy. 

Bob: First looks are coming out. We're doing meetings, certifications. I mean, if you're an agent and you haven't looked at your certifications yet, it's that's the time

Rob: You're pushing the limits. You're pushing the limits. 

Bob: It's starting to get a little, little hairy, right? And if you haven't contracted with all the carriers yet, man, you want to get on that now because they start getting a little backed up, you know, come. September, October beginning. It's gonna be tough to pick up any companies, especially if you wanna add something like hospital indemnity cancer, so many additional plans that are out there.

Rob: Or if you want supplies. 

Bob: Yes! 

Rob: I know paper's a little outdated. Yeah. But, uh...

Bob: You can still get paper apps!

Rob: Yeah.

Bob: I mean it does, it does still happen. Just so you know, we have an enrollment room, one of the few agencies that still. You can fax us apps. We'll take 'em.

Rob: Yeah. We have a couple different fax lines.

Bob: Yeah. Yeah. We have encrypted service. You can send an encrypted email. We, we have all the good stuff.

Rob: Well, it's weird though. Most companies, they want you to send a paper app if it's a PPO now, right? It's the only way that you can even get paid now.

Bob: "Only way," yeah, well... PPO's...

Rob: But that's a whole other story!,

Bob: We're gonna talk a little bit about that as well, but cool episode.

The ecosystem. We'll call Medicare, the ecosystem. There's been so many changes over the last couple of years, and then we have the new administration come in, which really, that's a big change. 

Rob: Yeah. 

Bob: But I think one of the things we're seeing as an industry is a really strong push to doing things the right way, compliantly.

Making sure that everything's done above board, making sure that marketing's being done the right way, but I think even from a carrier standpoint, the way that even the star ratings work, right?

Rob: Yeah.

Bob: We're looking at big changes with the push to value-based care and physician groups. So we really thought it was appropriate to have an expert in the value-based care arena join us today because there's a lot going on with value-based care and it's growing and it's everywhere now. We're working with a ton of groups.

Rob: Yeah. Honestly, when did it really start? Maybe like six, seven years ago?

Bob: Something was coming down,

Rob: It's like floating, 

Bob: Nobody really knew what it was.

Rob: But now it's like every other day you're seeing new groups and you're seeing other physician groups. I mean, just, the other day I went to my dermatologist and they partnered with a larger dermatologist and they probably were bought out. Let's, you know, be honest, but now they're totally different dermatology firm because they connected with another dermatology.

Bob: Right.

Rob: And I think that's, you're seeing a lot of consolidation in the market now, so value-based care is just kind of growing. And I mean, before you know it, who knows what it's gonna look like, right?

Bob: Yeah. So... so excited: we have with us Dr. Shannon Decker. Now if you've gone to any industry events, Shannon is there speaking all the time at the RISE events, and I think you were just at one, if I'm not mistaken. Didn't they just have one? Was it the Vegas one or is it a different one that just happened? 

Dr. Shannon: I was just in Chicago,

Bob: Chicago

Dr. Shannon: And Vegas will be, uh, I'll be there on Sunday, so it'll be early next week.

Bob: Yeah. And there's tons of events out there in the industry right now and a lot of them are geared towards certain segments of the population. So if you're looking at, say, a Medicarians, it's really geared towards the agent. RISE seems to be a little bit of a hybrid because I seem to feel like there's that operations part of the RISE meeting where it's compliance and marketing and a lot going on there. The value pace, care conversations, industry executives from the carriers and different groups are there and then we are also seeing agents attend those, as well.

What are you seeing as far as. Listen, you've been in the healthcare industry and I think you should give a little background for everybody that's, that's joining us today, but you've been in this so doing it a long time, so you've been through the changes.

So first off: let's give a little five minutes what, where you're from, what you're seeing, and what you're doing these days. 

Dr. Shannon: Sure. Thank you so much and thanks for having me on. Looking forward to the conversation.

I've worked in healthcare for more than 20 years. I was an expert in adult learning and motivation and had an opportunity to go and work for a large national health plan. Worked on some various programs with them, did a lot of needs assessments around their products and actually got to work a lot with the brokers that they worked with and so rolling out new products, sharing with them the things that they needed to know about those products, who they were most appropriate for.

That quickly segued into, and you're right, you talk about value-based care. When I think about value-based care, I think of it as an umbrella and it really started with this idea of risk adjustment in taking risk on patients. And what that means is you're being reimbursed for the conditions that those patients have because we know that they're going to require more healthcare. So, for that large national health plan, I started managing end-to-end risk adjustment for them across the country through various markets.

Did about, I wouldn't say seven or eight years there in that role and then moved into working with several large organizations, medical groups across the country. Optum and others, managing end-to-end risk adjustment for them. And did my corporate career, as a vice president for clinical performance for a large, organization where I managed risk adjustment quality, and all the other things that you would need to measure around how a group might be performing clinically.

Did that for Medicare Advantage, Commercial, Medicaid, ACO clients as well and in '22 moved out onto my own and started my own consulting firm. So currently today, we have about 45 consultants that work with us and we provide fractional operational support to medical groups. So if you are taking risk and you need help with your quality programs or you need help putting together your files for risk adjustment or doing chart review, documentation training for physicians.

We also work with small to moderate health plans too, helping them with their operational work. Anything around operations to be successful in value-based care is what we've worked on.

So 26 years now have been doing this work and have definitely seen, as you said, a lot of development over the years, on how things have changed in the industry around that work.

Bob: We're talking about this a little bit, but we're, we're the "insurance geeks" here we call ourselves in the office because I love the "why."

The plans change every year, the carriers. There's so much turmoil and there's always the "why:" what's causing all this behind the scenes, the moving parts and the mechanisms that go into it.

I think we like to bring that to the agents because one day they're gonna, it's gonna be 2026 AEP, and it's gonna be, here's the plan and here's why it, here's how it changed and I think knowing what's going on behind the scenes just makes the agent so much more valuable because to your point, value-based care has, has grown a ton.

We've worked with so many groups over the years, but let's talk about the star ratings a little bit I mean, CMS is making an effort. They're saying value-based care matters because they're putting it big into star rating. So it started really last year. Did you feel like last year was the big push too? Where it just kind of like big shift or maybe the year before, but I feel like last year it just like went crazy with the value-based care. 

Dr. Shannon: I think the intent, I'll take it back a couple steps, if you don't mind. I think, you know, you said about what's the "why" and the why really is we know that there are more folks in this country, today that are living longer, but not necessarily healthier.

I actually just gave a talk on this in Chicago. When we look at the 1980 census and hopefully you can see in the camera here, it looks like this with the wider ban there being your 20 and 30 year olds. Well, in 2020, the census now looks like this and so we know we have more individuals that are 60 and over on the planet than we do under 5. We know that folks are living longer and not necessarily healthier.

The thinking is with advent of the GLP-1's and other medicines out there, that actually the mortality rate is going to increase some folks are saying that we may enjoy life, very "healthfully", if you will, and I'll put quotes around "healthy," until our 130's and that, that is, is truly possible, within our lifetime, that we'll get to see that.

But again, people are living longer but not necessarily healthier, right? So it's not because they've adopted different habits in their life that are leading them to be healthier, it's because medicine has gotten so much better and the challenge is, is that we know we have a PCP shortage in this country, so there aren't enough physicians to take care of those patients.

So, in my mind, when I think about value-based care and the "why," the thinking really is: " how can we get people to be healthier?"

In addition to living longer, live that life healthier. And I'll just throw a statistic out there to you too. We know there was a study that was done in 2018: 51.8% of Americans have at least one chronic condition.

So we're thinking about things like diabetes, CKD, CHF, COPD, depression, right? All of these conditions are highly prevalent in the population and again, we need a way to take care of people.

So, value-based care, in my mind, the movement started where the risk adjustment, the idea was let's capture the chronicity of the patient so by documenting the conditions that the patient has, the doctor submits that on a claim or in a chart note, and then the government looks at those codes and can provide monies back to the health plans, which then gets shared oftentimes in different ways with the physician groups, but the intent is, is that someone with diabetes costs more to take care of than someone without.

But the challenge was, that really wasn't moving the needle on making folks healthier. So then quality was a focus. And I think of quality in two buckets:

Preventive: how can we prevent people from getting sicker?

And then Prescriptive: you may have a disease, but how can we get you to control that so you don't have the typical exacerbations that one might see.

For example, with diabetes: we know usually within the first three years of being diagnosed with diabetes complications occur, you may have challenges with your vision, with your cardiovascular system, with your kidney function so if we can do things to get you to manage your A1C and to take your medication, there are opportunities for you to slow the progression of that disease down and potentially change, or perhaps not develop, the complications that we would typically see in an unmanaged case.

So when we think about quality measures, that's what I think about is "How can we get people to live healthier?"

So if we can diagnose cancer earlier, if we can make sure people are taking their blood pressure medicine, all of these things can help us keep folks that maybe could control their conditions and not necessarily have to see a doctor.

Not that we wanna prevent people from seeing a doctor when they need to. When they need to, they need to, but if there's things that they can take on and advocate for their own health, it's an opportunity to, better manage the system.

And this is the other thing with healthcare and, and when we talk about value-based care. The intent is to push for what we call now, the 'Quintuple Aim.' It started as a triple aim, went to the quadruple, we're now up to five, but it's right care, right time, at the right place. So making sure people aren't going to the emergency room if you can go to your PCP office.

If we can advocate for that, making sure, and I'll give you the other two pieces of the Quintuple Aim.

It's not to burn out doctors and then to make sure folks have equal or have equitable, I should say, access to healthcare.

The thinking around the quality measures is how can we help people, have a better quality of life by advocating for themselves and doing those preventative and prescriptive things that we know are going to improve their outcomes.

And then the other part of value-based care, that's a relatively, it's not that it hasn't been attended to, but I think it's starting to get more attention, especially as and I, I think we may get into the discussion around V28 and some of the more recent changes, but this idea of total cost of care.

So can our primary care physicians do things like basic biopsies in the office as opposed to getting the referral to the dermatologist? How can we make sure that folks are going to the urgent care or to their PCP calling the after hours line as opposed to going to the emergency room when they're not feeling well? And it's not a condition that really qualifies an as an emergency.

When I think about value-based care: risk adjustment, quality, very important. And now something else that we've been talking about, this total cost of care, but if we can manage those things, again, we can help folks that are living longer, hopefully they're going to live healthier as well and not overburden the healthcare system, especially when we don't have enough physicians to be able to care for all these folks. 

Rob: Living to 130

Bob: I, yeah.

Rob: Could you imagine?

Bob: I, I'm just trying to, yeah, I'm trying to visualize that...

Rob: I hurt myself in my sleep and I'm not even 40 yet, but I did see an interesting TikTok 'cause you know, you were talking about the science, I love Neil deGrasse Tyson.

Bob: Oh, okay. Sure.

Rob: And he had a whole stance on this, and he was talking about how science, it's not that people are living longer because we're just, we adapted to it. So from the first sign of humans up until 1840, you know, humans only lived to 30, right? And then within a short span from like the 1700s to 1800s, it was 35, but then once you start to hit the middle of the 1800s and on as we develop medicine we've more than doubled our life expectancy.

So it's all about the science, you know, whether it's risk adjustment through numbers, developing new medicines to help people live longer or whatever the case is.

And you know, you mentioned GLP-1's and there's a lot going on, I think recently with the GLP-1's with Ozempic getting sued and was it Neuro? I forget the name of the other company is it does Zepbound, but they're getting sued for people going blind permanently and some stuff they didn't disclose to people, which is kind of crazy, but it's a wild thing.

Bob: It's jumping pretty fast and you're probably seeing it as well, like, listen, CMS is obviously looking at it for a win-win situation, right?

Rob: Yeah.

Bob: They see the cost of care and everybody, and your statistics are staggering, right? With the people with chronic conditions. Obesity is a big player in all of this so how do we get individuals that are seeing the doctor getting better care? Costs for CMS, they're looking to lower dose costs. The win-win is that individuals be healthier for a longer period of time, living better so it's in everybody's best interest for people to live healthier, live longer lives.

Rob: "MAHA", right?

Bob: See the doctor? Yeah, see the doctor on a regular basis actually make sense when you look at. From everybody's perspective. That's, that's what we all want, right? 

Rob: Yeah. And I mean, I do think a lot of it does boil down to, and maybe you would have a response to this, Doctor, but, uh, you know, a lot of this stuff with all the synthetic dyes and all these things that since the seventies we've been consuming, I think we're paying the price now.

Right. You're starting to see a lot of this stuff come to fruition and thankfully you've had a couple of the major companies come out and say they're gonna start to pull those synthetic dyes like Red 40. I mean, these are things that are banned everywhere.

Bob: Except the US.

Rob: Except the US and it's killing us, not just us, though. We're giving it to our children. I don't have kids, but I'm sure my dog's dogfood is not very good for them either, right? But you know, any thoughts on that?

Dr. Shannon: So I'm a PhD, not an MD, but it is something that's important to me, especially working in healthcare for as long as I have and I do think that there's something to it, and I definitely support the opportunity to get back to more natural foods, one ingredient foods, less processed foods, and definitely think that there's something to be said about how we've adulterated our environment and our food sources and how that's changed, right?

So yes, definitely a believer in more natural foods again.

Politics aside, some of the recommendations that are coming out around, you know, being healthier, exercising, staying away from preservatives and a lot of processed foods, and getting back to, those more natural sources. And then, like you said too, to talk about healthcare, it's a mind shift. We always thought about healthcare and this is the thing and it's slowly happening, not everybody is there yet.

This thought of being reactive in medicine, you know you're sick, you make an appointment, you go to the doctor, they prescribe drugs for the symptoms, you go home, hopefully it works, and you go about your business and if you don't, then it's referrals or seeing the doctor again; whereas in the value-based care system, the intent really is to be preventative and prescriptive or proactive, if you will, as opposed to reactive and that you're going in and you're getting your screenings and so we know we can do a lot more if breast cancer is caught early, if colorectal cancer is caught early. There's treatments and things that can be brought to bear that, to your point weren't available years ago but, are making a difference in the lives of Americans today. 

Bob: Now are you seeing with the, so you're working with the physician groups, they're obviously seeing the shift in a lot of this, the same way that we are. So with the senior population, I know it's really got 2020 COVID, but the telehealth side of things, is that also playing a big part? I mean, are are seniors still? I know they had '20, '21, '22. Nobody was getting things done, right? Yeah. They weren't going to the hospital. They didn't, they weren't doing what they were supposed to be doing and healthcare, paid the price for the next couple of years 'cause everybody went out and got everything done after that.

So, do we still see telehealth in the same way that it's still being utilized by the seniors? They've adopted it at this point? 

Dr. Shannon: I think there's a blend. That's a great question and it's something that I've been tracking it's, and I actually started a telehealth program during the pandemic. We stood one up in four days at a medical group that I was a part of, in the Bay Area, so that we could see patients and provide care to them.

We still see, and I think it depends on the geographies, I also got an opportunity to, be in DC and work with some folks that were part of CMS and HHS and some of the government agencies and we talked about telehealth and the importance of it to healthcare. And so it's a great benefit. I think it provides a lot of access for patients and so if you have seniors or even, you have caretakers, folks that are taking care of elderly parents or a spouse that can't leave the home so telehealth even provides them an opportunity, to see their physician. I think it makes for a faster visit sometimes so when we're talking about the burden on our healthcare providers, there's opportunities there.

There's also some new rules too, around state licensure. And so you have the opportunity for some practitioners, to practice across before they used to be constrained to their state. You don't have those requirements any longer so you have the opportunity to provide greater access.

But for some patients, they still require to go in and see a doctor. They still may require to have someone lay hands on them so I do think that telehealth is an important component, I definitely think that it was a boon, that came out of the pandemic. Amazing that we were able to get that up and going, and I think it's a great opportunity to provide access to healthcare.

But just like everything , I think everything is within moderation. So while it's a great benefit, it wouldn't be the only way in which we would want folks to access healthcare, but when I think about the shortage of physicians, rural communities maybe that don't have access to healthcare, it definitely gives you the opportunity to see a specialist maybe that you couldn't see before because the travel was prohibitive. It allows you to open up office hours too so that folks can see doctors late in the evening if they need to and get greater access to care.

Bob: Yeah, it makes a ton of sense because even think about it, if something small was to happen, a lot of times you're like, ah, I'm fine, whatever. 

Rob: Yeah.

Bob: Then it's four months later you're like, "all right, this is still bugging me," but now it's four months, you haven't done anything, maybe you can just do a quick telehealth visit and the doctor can say, "ah, you're fine, rub some dirt on it," or. "Hey, you better come in and get this checked out."

Rob: Or if you're my step-dad, you'd cut your thumb and then instead of going to get it, you know, sewed up, you just duct tape it together.

Bob: Yeah.

Rob: And be like, ah, it's fine.

Bob: It's all good. So I think that's the direction.

I mean, I think that at the end of the day. We know the costs of healthcare, and CMS definitely knows what the costs are. So they're gonna look from a couple different points of view, and I think it makes sense that the value-based care is gonna give better outcomes and you've been involved in this, as well. The physician groups, they get audited, right? So they're scrutinized from their perspective, so they've gotta meet certain care and their model has to have certain costs, you know, and they've gotta do certain things that are also going to lead to the better outcome for the patient, but also better cost for CMS, which everybody wins.

So how does that work? What kind of pressure is CMS putting on the value-based care and the physician groups? 

Dr. Shannon: So, the announcement was made in the former administration, and I believe that it will continue today is that everyone will be in a value-based care arrangement by 2030 that's not many years away and so now physician groups have an opportunity, they can either contract with health plans, or they're contracting directly with CMS, through the ACO structure, and through other types of contracts that they have there and my group actually was brought on, as an, an educator for groups that were working directly with CMS to work with better documentation.

But that's been the, you know, the push is physician groups too are on the hook for this and not just about audits. I mean, they need to stand behind the documentation. But the message that I think I've heard, and you know, we mentioned about the conferences. When I'm in Vegas next week, I'll get to hear OIG speak, it's one of my favorite sessions when they come and CMS, but one of the things that they've been talking about the last couple of years is the emphasis on follow-up visits. If a patient is documented, and this is where I started talking about risk adjustment and you mentioned quality.

Risk adjustment is still important in Medicare Advantage, but with some of the changes the reimbursement maybe isn't the same. We know certain conditions were taken out of that V28 model. We know that some of the reimbursement values have changed and now , or not now, but rightfully so, there's been a little more focus again on quality like we talked about, and then this total cost of care, so having the access to follow up. One of the things that CMS is looking at is if you've written down in the medical record that this patient has diabetes, we should see multiple visits 'cause we know, and there's a statistic out there that to manage a senior patient should be seeing the physician five to nine times a year. On average. So we can look over the claims and we know what patients are going in and if you go in to the physician and you're diagnosed with diabetes, we would expect you to go in for follow-up care to be getting your A1C's checked. To having your eyes checked and all these other types of things.

That's where I think CMS has put the pressure on physicians, things like that. Other things that we've seen come out in addition to looking for evidence of follow-up and actual care provided for those conditions, other things that CMS is looking at, and there's lots of different measures, but I think the two that stand out to me the most are readmission rates.

So if you have a patient that's been in the hospital, if they're readmitted before 30 days are up, there's something there that maybe they shouldn't have been released from the hospital or they didn't get the appropriate follow-up care.

They didn't understand the medications that they needed to take when they left the hospital. That's another thing that CMS is looking at and then one of the other things that I think is important in addition to those quality measures is if you know a patient has particular conditions, we should be able to manage them so that they don't end up in the hospital.

I'll just share with you again some additional statistics.

Of the conditions that are most prevalent that are probably the most taxing to the healthcare community, but also have the greatest cost are going to be diabetes, CKD, CHF, COPD, and then more recently, we've added depression and morbid obesity.

When I look at conditions that are under reported that are going to lead to the highest healthcare costs, it's those four that I mentioned.

With COPD, what we find is 30% of the population over the age of 60, has a diagnosis of COPD, and of that percentage of the population, it's 29% will have at least a one night hospital stay because of their condition and on average. They stay about six days and we know that gets to be pretty cost prohibitive and pretty expensive.

So if we have the opportunity to, because we know that they're going to have those exacerbations if we can provide for after hours lines. In-home care nurses that come in, because a lot of times it's there's been an exacerbation in the middle of the night. They can't breathe, they go to the emergency room, they end up getting admitted. There's other types of care protocols that can be put in place instead of that so that the patient knows where to go and how to control those conditions.

Especially those, there's about 10 actually that are on those lists, but we know that those four are big, that we know if they have them, they're more likely to go to the hospital, they're more likely to need greater care, but if you can enact, be more prescriptive, preventive, proactive, you can probably stave off, some of those more critical visits when they could have been cared for early on and prevented. 

Bob: It makes sense, and as you're talking I'm thinking about this: Rob does all of our training and we've seen the carriers a big push this year towards the CSNP plans, which are the chronic plans and it makes sense based on what you're saying now, these individuals are getting in an appropriate plan. It is going to monitor them. I know you're spending so much time training on the CSNPs. 

Rob: Yes. 

Bob: Which, what you're saying just makes sense for that and the agents are gonna be selling CSNPs big time in '26. 

Rob: I think this year we're gonna see the most CSNPs sold ever. It was kind of like that, what, a couple years ago with the DSNPs. 

Bob: Yes. 

Rob: Because you had a lot of people start to say, "Hey, you know what? We need to start marketing these DSNPs." They made the plan so robust. You know, you're talking four or five, $6,000 in dental and if you can qualify, why wouldn't you, right?

Bob: Yeah, sure.

Rob: Well, since they're starting to tailor back on all of those extra benefits with some of the new rules and regulations. You're gonna see, I think that outflow go right into the CSNPs.

And you know what? In some cases it might make the most sense because if you have someone that's got diabetes and they're on a plan that's tailored to diabetes...

Bob: Right.

Rob: ...it's gonna, I think, really help them with their care and their future, hospital trips that hopefully won't happen, you know?

Bob: Yeah, it makes sense. So, at the RISE event are there conversations around this, as well? Are they seeing the CSNP plans are becoming that hot topic?

Dr. Shannon: Absolutely. In fact, I would absolutely agree with you and there is, there's a RISE conference, that is based around special needs plans. It's called the Special Needs Plan Summit and I've chaired it, I've chaired it a couple of years now, but it was just a few months ago. They usually hold it in the early spring and there's been a lot of talk around that and would agree with you.

When there were some changes that were made, especially around V28, and that's Version 28 of the Risk Adjustment Model, health plans basically made a couple of different decisions and if you've been following the headlines too, you can see it, where you know they're reporting less earnings and that is because there's less risk revenue, but they have to manage their quality and we know that's been a challenge, with how star ratings are going out and then also too, they have to manage spend, and that's the total cost of care component that I talked about.

So when V28 came out, meaning that they weren't going to get as much reimbursement from risk adjustment and it forced them that they really had to, not that they weren't before, but they really had to double down on 'cause risk adjustment wasn't gonna save the day, they had to double down on really managing those quality and total cost of care programs.

They basically made two decisions. One was they threw in every benefit that was possible and the intent was to enroll as many people as possible and figure it out. And then the other was to become. I guess you would say more distinct and differentiated and provide more special plans. And we have seen a proliferation of these special need plans 'cause if you think about it, you can tailor it, right? Specifically that population, you have the opportunity to get drugs and the formulary right and at the right prices.

So I think we'll see even more and more of that as time goes on, I know that, I think it was it Aetna or Elevance? Someone I read just the other day is getting rid of like 990 plans, but as you read the article, it was all PPO plans that they were getting rid of. So you will see some consolidation to your point, but definitely think it's going to be more tailored around specific chronic conditions and that you're going to see these more maybe narrow networks, very prescriptive formularies, that are specifically addressing these particular populations within our communities. 

Rob: Not a good day to be a PPO, by the way.

Bob: Yeah.

Rob: Not a good day to be a PPO.

Bob: We know what's happening there.

Rob: They're in the the bullseye view there, unfortunately.

Bob: Yeah, first looks are coming out... it's not looking rosy for the PPOs, but...

Rob: Not good for PPOs or PDPs, those are the two that are not looking good.

Bob: Yeah, exactly. So, I think we talked a lot about it, but I think, as we posed the question, where are we going? I think we're going to a point where CMS is making a shift in the model for cost reasons, benefits, for better outcomes for the clients. I think it's gonna continue to go, it only makes sense. I mean, the costs become outrageous, you know?

Rob: Yeah.

Bob: For the Medicare system. So I think that's the direction we're gonna go in. Is there anything else that you're feeling like, "Hey, this is where we're gonna see ourselves 2, 3, 4 years from now" like, you know, this is the shift. 

Dr. Shannon: I think we're gonna see more of this. When I think about, your listenership, too, it's helping patients getting to the right plans, and getting them connected early and helping, because I often think that the relationship with healthcare really starts with the broker and the brokers really build that trust with the patient first, so getting them into the right plan that will suit them best, and then helping them to the extent possible, and even if it's a handoff to the physician, but making sure that they're utilizing their benefits. Getting their annual wellness exams if there's opportunities for telehealth, using that and being able to access their health in a way that is advantageous to income, revenue, or, expense is definitely part of it, but just knowing that we want better outcomes, we don't want people waiting to see the physician if they don't need to see the physician, especially knowing that we don't have enough physicians or other aspects of healthcare that aren't available, to patients. We want folks accessing healthcare in a way that's appropriate given what their health concerns or health needs are so I definitely think we'll see more of that.

I also think that we'll, see more around, technology, in the space so do expect to see more standardization of data, and then definitely opportunities for AI to improve engagement and to improve the member experience, so that we're interacting, and getting patients to take up healthcare, their own healthcare, advocate for their own healthcare needs, in a way that makes sense, for the conditions that they have.

Bob: Yeah. No, that makes sense. I think that was a record though. We went like 30 minutes and didn't say didn't say AI, in our day. I think that was the first time it came up.

Rob: It might be.

Bob: I was timing it. We got to like 30 minutes before we said AI.

Rob: Well, think about it. Think about it, right? What was it 5, 10 years ago? It was the the smart watches, right? So every plan they give you smart watches. Mark my words. I'm gonna come back in 10 years. 10 years from now, it's gonna be AI robots that help people in the plans. 

You want a robot? You contact us, we'll hook you up. And it's personalized-- it's gonna happen. Exactly. It's gonna happen. That's all I'm saying. 

Dr. Shannon: If you go to the RISE shows they do have, every once in a while you'll see robots, there is a company that has a robotic dog, but I have seen those things, so , I definitely think it's...

Rob: It's close. 

Bob: It's coming, the robots are coming. 

Rob: And look, all I'm saying is when I ask ChatGPT to do something I say, "please" every time. And I know that, that's silly and I know it costs. OpenAI, A lot of money I think they said they lose millions.

Bob: Yeah, don't say please and thank you according to Sam Altman, but...

Rob: But when they take over... hopefully I'm on the good list. That's all that matters, all right?

Bob: Exactly, yeah. But, uh, Dr. Decker , a lot of great information, I think there's a big shift happening, which is gonna impact, I like to just say the ecosystem, right? It impacts everybody. It's going to, you know, from the government down to the beneficiary, there's a lot of changes. Technology's gonna be a big driver of it, but I think how care is received, the way the plans are built, everything's gonna be shifting a little bit and it's gonna be more of the norm, and I think to the agent's point of view, I think the agents would rather not have to move people around if there is a little bit of standardization, it doesn't benefit the agent to have to move from plan A to plan B every year for half their clients that they probably like to have some of that as well.

I think they said up to 60% in the next couple years we'll be in an MA plan. I think that we're over, we're like 54 now or so, but I think we're gonna hit 60 here in the next two years or so.

Rob: Yeah. 'cause we haven't even seen the price inflation as much on the Med Supps as we there.

Bob: It's coming.

Rob: It's, it's been there. I think this is the first time I've ever seen United Healthcare have like a 15% increase.

Bob: Yeah, exactly.

Rob: And they're a industry standard when it comes to holding rates. So if they're going up 15, you're gonna see probably 30s, which I've never seen before since doing this. 

Bob: It's coming, it's coming. Yeah, but thank you again. Appreciate your time. A lot of great information. If we live to 130 means we're gonna be doing the show for the next how many years? So, we'll be on every, we will be on for a while, so we'll definitely hook up again and have you on for whatever changes are down the road that we're seeing. 

Rob: 0% chance. I'm gonna have my real hips and knees by then, but we'll see. We'll see what makes it to it. 

Bob: Exactly, yeah.

Rob: Thank you.

Bob: Thank you again though. Have a great rest of your day. Everybody: great rest of your day. Any questions? Call Rob. 

Rob: Call me, and follow us on our socials. Check out all the useful content that we have. Yeah, absolutely. It's coming and going every day. 

Yeah.

Yeah. 

Thank you again. Thank you.