One of the few remaining universal truths is that healthcare costs are too high. Insurance companies are bucking under the pressure from the Affordable Care Act (ACA), and they are willing to try almost anything if it means reducing costs.
NextHealth’s pitch to insurance companies is very similar to OPower’s pitch to utility companies. If you can target customers most likely to be overspending, you can generate efficiencies that make the entire ecosystem money. Whereas OPower’s rise was fueled by the regulatory environment, NextHealth is being supported by both the failings of the ACA and the innate properties of the insurance industry.
The company is using a mix of behavioral science and predictive analytics to project out specific customers, in a post-ACA world, that could save a lot on healthcare with just a few relatively simple lifestyle changes. While a dramatic drop has occurred in the rate of uninsured Americans, the new customers have broken many traditional models of predictive analytics in the insurance space.
“Insurers were very surprised by the staggering losses from new members because they were uninsured before,” said Casper de Clercq, General Partner at Norwest Venture Partners.
Fortunately, new patient behavior follows identifiable patterns. For example, a 2007 New England Healthcare Institute report estimated that U.S. patients waste nearly $38 billion dollars every year on unnecessary emergency room visits. That’s almost enough money to give one Chipotle burrito bowl to every man, woman, and child on the planet. NextHealth wants to nudge these people into more sustainable care habits.
To solve the problem, NextHealth’s has to combine effective targeting with smart applications of existing data-sets. The platform parses through membership data, demographic data, lifestyle data, and geospatial data to pick out specific individuals with a likelihood of successful targeted outreach. For example, a young mother might have little experience with the emergency room. She may have heard about long wait times, but feel that the ER is the only option for after hours support.
Next, a case-specific campaign is developed that can involve a telephone call, email, letter, and even refrigerator magnet with information about location-specific healthcare options like telemedicine and urgent care. To ensure intervention accuracy, NextHealth regularly performs statistical analysis against control groups. To date, 25 percent of patients targeted have accepted the nudge and abandoned the ER for all but critical needs.
“We can use machine learning to know what worked and easily turn off what isn’t working,” said Eric Grossman, CEO of NextHealth.
Common sense would tell us that every dollar of reduction in claims means a dollar of additional profit for insurers, but it doesn’t quite work like that. Insurers are required to spend 85 percent of revenue on claims and are limited to 15 percent to cover administrative overhead and generate profit. However, because NextHealth is considered an operational expense, it is counted in the first 85 percent bucket for regulators.
Once a partnership starts, insurers have two options. They can use NextHealth as a standalone service, or they can fork over full turn key access to member outreach using insurer branding.
NextHealth is currently working with eight insurance companies and half have opted to give the company marketing power in exchange for a promise to return fees at 2.5X. The company puts about half its fees at risk in the process and gains when insurers gain.
While the platform already monitors about 2 million members, Grossman is brainstorming new use cases, like targeted outreach to remind people to get cancer screenings.