Silicon Valley is not only Google, Facebook or Apple, high-tech companies based on internet or correlated products. It is also insurance services, it is starting to focus on making the insurance market more efficient to better serve patients and hospitals. One new health technology upstart is betting that the combination of data and preventive care is the solution for creating a better insurance company.
A company which wants to make this real is Clover Health. Clover Health wants to use software and data to give seniors, particularly those who use the private versions of Medicare, a cheaper option. Generally a Medicare patient goes to a primary doctor’s office, goes to a cardiologist, goes to a hospital, there is no quarterback for that data but especially no one has the time or the data to guide that patient and coordinate all those interactions and make sure each provider gets the right info at the right time.
This is a tough unstructured data problem with all these reports coming to the company. It requires creating tools that are able to mesh all those different forms of data into a unified system that can then analyze whether or not a patient is at higher risk.
And the company has to figure out why that patient is at risk so it nows how to intervene. That’s why the company’s strength is its technology. The company’s technology is supposed to recognize when patients need medical treatment and then intervene in their care to save money for both the patient and the insurance company.
“We’re not just using [technology] to pay out claims,” says Vivek Garipalli, Clover’s co-founder and chief executive officer. “We’re building a learning machine, and we’re using it for health.”
HOW DOES IT WORK?
“We have one goal – to improve the quality of life of our members and physicians.”
It all starts with its insurance model. The company aligns with physicians by reducing friction and increasing transparency, leading to improved patient care. Its physicians are able to focus on people, not paperwork.
Clover is also partner in care, using patient-centered analytics and a dedicated care management team to identify potential risks and directly provide preventive care.
As an insurer, Clover pays all its members’ bills. This gives the company an evolving health profile for every customer. Since Medicare members visit doctors more frequently and have higher costs than anyone else in the country, Clover is amassing a huge volume of data. The company has trained its system to look for anomalies, such as missed doctor’s appointments, failures to pick up prescriptions or visits to the ER.
The company’s algorithms and software identify the most at-risk patients, and then its nurse practitioners visit patient’s homes, and coordinate necessary tests that may be missing in the patient’s profile. Clover Health also analyzes lab data to identify patients who are in danger of serious illness, such as diabetes.
“If we know something is on a 30-day refill and we haven’t seen a claim in 35 days, we know they aren’t taking it regularly,” Gale (Clover co-founder) said. “We can reach out — for example, maybe do they not understand how they’re supposed to be taking this — and intervene. This is info that’s available to us because we’re the payer. The doctor that prescribed gave them a piece of paper that’s now on them. The doctor doesn’t know if they’re getting that filled unless they’re asking them regularly. That’s part of the data advantage.”
ECONOMIC SIDE: Uncle Sam pays Clover a monthly fee for each Medicare Advantage customer the startup enrolls. The amount varies depending on where the person lives, but it averages $850 before adjusting for chronic conditions or healthy habits, the Medicare Rights Center says. Clover uses the money to pay members’ bills and generates almost all its revenue from whatever is left over after reimbursing doctors, hospitals, labs, pharmacies and other points of care. The company offers plans with no monthly premiums or ones that go as high as $225.
By law, Medicare Advantage providers must pay out 85 percent of premiums they get from the government. The goal of the Clover is to counsel them before they require costly treatments. In fact, helping patients avoid hospitalization saves the company an average of $10,000, so the potential savings nationally could be huge.
COMPETITIVE LANDSCAPE: Clover Health’s primary competition are the traditional Medicare insurance companies, such as United Healthcare. But those companies aren’t collecting the data from their patients in the same way Clover Health does.There are also other startups, too, that are also trying to re-invent the health insurance industry like Oscar Health, Bright Health and GoHealth. But the companies are targeting a very different demographic, and Clover Health’s selling point is the technology that powers it.
In conclusions, Silicon Valley has just given birth to a company which is “anusual” from the big corporations which stay there. Clover thought “How could we change something so traditional and expensive as Health Insurance in the USA?” I think is is doing it well because in the digital era informations are like “digital gold” and if you succeed using them well you can get a lot of money. However, in addition to this the company is using informations for an important goal: take care about people’s health and do it for a better price. This last point for american people is a very important topic and it could be a good solution for the american private health system. So, they make money, you have more care, you prevent diseases and pay less than before, I think everyone wins.
Enrico Di Stefano
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