Part of my attitude relates to an experience I had. And this was within a single HIS. I wanted to…
Russ Thomas, JD is CEO of Availity of Jacksonville, FL.
Tell me about yourself and the company.
Availity is the largest network in all of healthcare, connecting 2 million providers and every health plan in the country and transacting 13 billion healthcare transactions a year. We have a broad scope and broad scale in driving a lot of cool impact in the transformation of healthcare. I’ve been the CEO since 2012 and have loved every minute of it.
To what degree do you see EDI, networks, and clearinghouses still being innovative and vital for digital transformation?
My buddy Sean Wieland, the analyst at Piper Sandler, told me a few years back that he would love to see how we make clearinghouses sexy again. I kind of laughed, saying, “I’m not sure clearinghouses were ever sexy, Sean, but I’ll do my best.” You have to be transformational and innovative. Otherwise, it’s a commoditized business where you are selling essentially transactions at fractions of a penny. If you don’t innovate and evolve, then you become irrelevant pretty quickly. That’s where we’ve been super successful. We have always focused on real time. The company was started as a real-time network.
When you say EDI, I think batch and days in transaction processing and transfer versus milliseconds. That’s a real opportunity for businesses like ours, to take what today is a large network of very important transactional activity and evolve it into a network of interactions between providers and health plans and make sure that, on a real-time basis, you’re serving up content. We’re in the information business. We have to be able to serve up content to the right provider, right time, right patient in ways that can meaningfully improve that patient experience. I think that 21st century clearinghouses and networks like ours have to be able to do that and demonstrate that value in order to thrive.
Your most recent investment was from Novo Holdings, which has life sciences connections. Do you see an opportunity to expand into real-world clinical research data?
That’s not where we’re headed, to be candid with you. We are in such a trusted place with our customers — our health plans, providers and ultimately the members and patients that they serve — that I don’t think we need to go there. Just being a data broker isn’t particularly exciting to me. What’s exciting to me is this evolution of transactional relationship between providers and health plans to an interaction, meaningfully moving to digital engagement, digital platform between providers and health plans.
Today we live in this pretty siloed transaction environment where you run an eligibility check and you get a response to that. It may tell you to do something else. You run an authorization, you get a response to that. Then down the road, you submit a claim, you get a response to that. That’s not how healthcare gets practiced. Physicians are practicing in real time, and they are making real-time clinical decisions about how best to treat their patients.
The administrative networks haven’t kept up with, or at least haven’t advanced, to support that type of real-world relationship between providers and patients. That’s where we are focused, moving to this intelligent network that discerns information from the very first encounter between a provider and a health plan around the patient and helps that provider think forward to what they need to know during the patient visit and when they are making the referral. We need to follow the trajectory of the patient visit more than some sort of made-up transactional flow that has persisted for decades and doesn’t support the workflow in the provider’s office.
Where do you see the line between provider and payer blurring and what are the transactional needs that are involved?
There’s this opacity in healthcare between providers and payers, between providers and their patients, and between payers and their members that just has to get fixed. Payers clearly have to continue to demonstrate value in that, for lack of a better term, the clinical decision process. But that ultimately is a provider’s responsibility as the professional who makes the decision about what’s best for the patient. Where I think we can help, and I don’t have the ultimate answer, is to be able to move that decision-making process to something that feels more like a real-time, intelligent workflow. That would be a great start.
We know from our providers and even our payers that authorizations are the bane of their existence. No matter how big of a smile you put on it, it’s still just seen as a brute force utilization management tool. But payers have information about a member that might not be readily available to a provider, and when that is served up in the context of a real-time workflow process — whether that’s an authorization or referral or whatever it may be – it can drive a ton of value in that overall patient experience. That’s where we are focused.
One of the things I’ve always said about Availity is that we’re not an arms dealer. We are not provider centric. We are not payer centric. We are solution centric, and f we can create more transparency in those complex workflows where both the provider and the payer are bringing value to the table, then there’s a lot of upside for us and a lot of growth potential.
We can start to knock down some of these walls between providers and payers around who is bringing value and at what point in the cycle. Providers would say that, by and large, payers don’t bring a lot of value in a clinical review process. The payers would say they need to keep a close eye on these providers because in the absence of utilization management processes, you get a significant overutilization and abuse of the healthcare system. I don’t know that I believe that either one of those is true. Value can be delivered on both sides of the equation.
To what extent are providers using clinical information that they can get only from a payer?
Our model is that we sell products and solutions to payers and we sell products and solutions to providers. We sit in a unique place where we are able to grow our business through our relationship with both sides of the equation. The answer to your question is that is growing. We are seeing more utilization of clinical data going both ways. We are seeing more clinical data being served up to our provider network from our payers to help close gaps in care, particularly in the Medicare Advantage space to get to the right utilization for HEDIS and other scoring purposes. We are seeing more and more data flow to the providers and then come back.
We’ve done a lot of integrations into provider systems to be able to pull out clinical data, attachments, charts, other things that are then consumed within a payer’s system to try to help come to a better and faster solution to an authorization workflow, for example. We are doing real-time, automated authorization workflows where we are reaching into the provider system, extracting clinical data in the provider context, translating that to payer-speak, and using that to help automate the authorization workflow within the payer systems. That is a big area of growth in the market and for us.
What challenges remain with building a network and integrating with EHRs?
You have to look at the endpoints on the network, which in healthcare are its users. We have solved a lot of the core administrative network issues, getting to the right person within the billing office, the front office, or other places where historically the adoption of technology has been pretty high. But we are still not nearly 100% penetrated into the parts of the provider organization where clinical decision-making is being done. We’re not penetrated into the clinical coordinators, the nurse practitioners, and the folks that all day, every day are trying to help manage these more complex clinical workflows with unstructured data and that sort of thing.
As a company, we have 2 million connected providers into our network, but we haven’t gone deep and created connectivity to the right users in all of those offices and all those facilities. There’s a real focus on expanding the use of Availity within a provider organization to make sure that we are bringing value not just to the scheduling person, billing person, or front desk intake, but also to those clinically oriented professionals within the organization.To a large degree, we have only scratched the surface of the value proposition there.
I think you build that all from a single network. There’s no reason to have a clinical network, an administrative network, and a financial network. When you do that, you create silos that then create more opacity in the process. But there’s work to be done to get to that nirvana state of a true holistic network.
What is driving investor interest in companies that offer patient payments technology?
We’re pretty small in that space right now. We help a physician collect a deductible upfront, but it’s not a big piece of our business. The interest comes from the right place. What we’ve done over decades is fairly completely disconnected the consumer from the provider. It’s the only section of the economy where we’ve done it quite so thoroughly.You and I as consumers of healthcare are still mostly ignorant to what a service costs, what the options are, and what is being billed versus what is being collected. We’ll do $2.5 trillion of billed claims through our network this year, of which 50 or 60% actually gets reimbursed. Where did the other trillion dollars go? You and I as consumers certainly don’t know where it went.
The desire to move into the patient billing and patient reimbursement space comes from the right place of saying that to drive the demand-side healthcare economy, you’ve got to connect the consumer with the provider of a service and the cost of that service. Strategically, I think that’s where these companies are trying to go. I’m not sure that anyone has completely figured out the timeline the process to get there. But it comes from the right place, even if it’s just to create awareness with a consumer that even though my responsibility for the services is only $50 or $100, I want to know what it really cost and what the options are, because there may be an option where I don’t have any deductible or there may be a higher quality option. Today, it’s just so difficult for us to get any visibility into those choices.
What will the company’s focus be in the next few years?
We’ve built a great culture here as a company. By and large, people really like working here. We have a revitalized leadership team with some great new leaders who joined us over over the last year. One of the things we’ve learned is that COVID has changed the way we work, changed our business, and changed the way we run the business. I’ve been in healthcare tech for over two decades and the energy around change and faster evolutionary processes is higher than I’ve ever seen it. It has to be.
The move to digital should be user experience driven, not technology driven. This move to a digital platform and a digital experience for our users is going to be our top area of focus. Moving to this interaction-based workflow within both our products and the way that we serve up data to our B2B customers is a great place for us to be as a company and a place where we can both grow and bring a lot of healthcare system. As we sit here today, we transact, by our estimates, half or so of all the healthcare transactions in the country. We sit in a pretty interesting place to be impactful if we try. We are going to give it a hell of a try.