If You Don't Know, Now You Know... DUOS

Brian Urban:
Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban, and today we went big time into the Medicare Advantage space, in particular with the chief strategy officer of DUOS, Jenn Kerfoot joining us today. Jenn, thank you so much for joining our show.

Jenn Kerfoot:
Thank you for having me, Brian.

Brian Urban:
This is going to be really exciting. I've tracked your career over the last year plus. So excited for you to have this executive rank at DUOS. This is just going to be such a monumental impact you're going to be having for this space. So with every episode, we like to have our guests introduce themselves and have our audience get to know you a little bit more. So let's go to Jenn Kerfoot before the executive titles here. Let's go back to who you are and how you got into this space.

Jenn Kerfoot:
Absolutely. Well, thank you so much for having me, Brian. Super excited to talk to you today. So a little bit about me before DUOS and before becoming the chief strategy officer. Well, I grew up in Oregon. My mom's a high school history teacher, and my dad worked at the VA. And before having an exciting career in managed care, I actually was a US Navy corpsman. I deployed to Afghanistan in support of Operation Enduring Freedom, so much different lifestyle than I have today sitting behind a desk.
All this to say, I think it's very rare in life to find a career that you truly find passion and fulfillment in. And I've been really lucky in that lightning really struck twice and that the work that I do today I find just as fulfilling and I'm just as passionate about. Granted, it's a little bit different, but I'm reminded what Teddy Roosevelt said, "Comparison is the thief of joy." And so I really try and reframe what does fulfillment look like, what does passion look like? And what used to be being in a helicopter is now helping health plans and other solution providers bring incredible solutions to meet the really growing needs of members throughout America.

Brian Urban:
I've always thought you're very calm and focused speaker as well. So obviously that goes back to your days flying helicopters, being on huge naval crafts across the world's oceans and also Happy Veterans Day.

Jenn Kerfoot:
[inaudible 00:02:44].

Brian Urban:
In our recording time here we've just passed this weekend is Veterans Day this past weekend. So happy Veterans' Day as well.

Jenn Kerfoot:
I appreciate that. I tell my team all the time, once you've been to war, nothing is on fire. No one's going to fly when we have everything that we need to solve a problem. And sometimes just taking a step back, one of my good friends and mentors, she always says, "Never underestimate the power of doing nothing. Sometimes you just need to be still." And even though I talk really fast and everyone who knows me always says, "You're always moving a mile a minute," I'll say, "I'm reminded, especially as I've taken an executive role, that sometimes the best thing I can do is to just be still."

Brian Urban:
Right there, starting off the show, not only with the Teddy Roosevelt quote, but wisdom as well. I think that's very difficult for a lot of executives in any corner of the healthcare ecosystem today is to literally do nothing or to say no or to pause. So that's a very, very good way to start the show.
So Jenn, it's interesting your background. You've been a part of a lot of really interesting organizations that have seen growth through early traction very quickly, and you were a part of a lot of that with DUOS in the last couple organizations you were with. So in the modern times here of being an executive at really a healthcare, tech-oriented startup in a lot of ways, looking back the last several years, I guess, what are the biggest barriers you've seen in really the niche place? Because you've been a lot of niche organizations, really a very particular service to a particular population. What have you seen the biggest barriers to getting to traction and then starting to scale and really make a meaningful impact for the lives that you've served? What are some of the biggest challenges you've seen going through some of these smaller startups that you've been a part of?

Jenn Kerfoot:
No, that's a great question. I think principally you want to make sure as a leadership team you're aligned. I say there's the horse, the jockey, and the track, and you need all three to be able to have a sustainable and thriving profitable business that really goes the distance. And I took a stab at writing for the first time, and in that article that I wrote, I like to compare startups in the world that we're in right now to the 1969 Apollo 11 moon landing. Innovation can take us to such great heights, but the same technology really contributed in 1983 to the Challenger explosion. Two really stark differences. And so I think principally as a leadership team, you really have to align to one, having that strong conviction in what you are building and who you are building it for and ignoring the shiny objects that want to distract you, but also making sure that you have a clear north star that you're guiding towards.
Because when you are growing and there's that excitement, it's almost like a drug. It'll keep you up at night, but it also just sustains you at the end of the day. You can kind of forget about some of the fundamentals. So right now, if we're looking at the industry at large, I would say from a national regulator level all the way down to individual compliance officers, there's a lot of concern about safety. And I think rightfully so.
So sometimes when a new company is taking a product to market, they get stuck in this whirlpool of just simply not knowing the regulatory guidance. There are no startups in managed care, CMS looks at them all the same. It doesn't matter if you've been doing this for 20 years, two years or two months, the expectation is uniform regardless. And so I think it's really important for new startups or even legacy based companies to be really evaluating, have they taken the foundational steps and gone the full distance rather than just lip service? And that's dedicating a full FTE, a budget investing in safety and compliance throughout their entire organization and building a culture around compliance and it's not just a footnote.
The other thing I think that is really critical when we think of these barriers is timing. If you're too slow off the block, unfortunately because of how quickly everything is innovating, you can be behind the curve or you can find yourself in a very oversaturated market where your value proposition that you started out with, that you have that really strong conviction in it might be diluted. And you're really struggling when there's only so many payers, only so many full risk providers to sell to being able to stand out.

Brian Urban:
Very good points. And obviously you've lived that. So it's not just something that you're looking at across the market. You've been through those particular experiences giving you this perspective. So I think the one thing that you said too, aside from the timing, is the building the culture around compliance. I think there's so many startups now that dial into a UI or dial into an app or data exchange, and they completely forget that CMS rules everything. And especially if you're touching data exchange that is at the individual level or it touches the patient in some sort of health service way or engagement way, a lot of places forget about that and they struggle entirely. So having a dedicated focus to that makes sense or else you can't really be in the market. And then timing, oh man, you're right. I think about all the different social care, technology players now, thinking about some of the social safety network closed loop referral players too.
It's saturated. It really is. And it's starting to move the needle in some way, but it seems like it is saturated. So you've been in this community for a while. I've always thought of you as an amazing Medicaid athlete. You know so much because you have to about CMS and some of the things in the past, some of the things going forward into regulation in that light too. So you've been a part of this community for a while, Jenn, so I'm curious, what emerging theme are you seeing right now that is helping spur new innovation or new companies coming into market?

Jenn Kerfoot:
I think that one, there's been a lot of support from the value-based healthcare community to invest not only capital, but also knowledge into these early-stage startups. My mom's a history teacher and she used to tell me, "History can be a really great teacher as to where we've been, what we've done wrong, so we know how to do it right." And I think that there's two kind of schools of thought: one is Silicon Valley tech, and they just kind of move fast and break stuff versus in healthcare, we just really need to be mindful, of course, about safety. And so I think there's been a lot of investment not only from venture and PE, but also health plans and their venture arms specifically, investing capital, but also explaining why things work the way they do. When I think about my career in the military, there's such a culture around institutional transfer of knowledge.
And what really surprised me in navigating a transition from being active-duty military to having a civilian career is when I'd show up to a new duty station in the Navy, someone would hand me a binder. They said, "This is how I did it. This is where you go, this is who you go to." And then I would take over and from the day that I started that new role, I would already be planning on how am I going to document what I'm doing and why I do it that way, to set up the next person for success. And you have to do it like that in the military because the nature of, especially in combat, someone could get injured, someone could unfortunately die, and someone's going to have to take their job. And what surprised me the most, especially when I was working at a Medicare Advantage Health Plan, is that I said, "Well, who knows this?" And they said, "Well, this one individual." I said, "Well, what happens if they retire or win the lottery?" They're like, "Well, we'll just kind of figure it out." And I'm like, "Well-"

Brian Urban:
It's a bad plan.

Jenn Kerfoot:
You can't go to school, say, "When I grow up, I want to work in Medicare Advantage." There's really no school. And it's a lot of institutional knowledge being passed down throughout the ranks.
And so I think it's really an emerging theme that I'm really seeing lately is more willingness to share that knowledge 'cause I think we're moving from a scarcity mentality where it's like, "I know this piece of information, so I know that chapter four, section 40 is where I go for OTC, and only I can know that because if someone else knows that, then I don't have job security," versus now we see there's a really interesting community that I'm part of called Out-of-Pocket Healthcare, which is a lot of millennials and new up and coming startup leaders and healthcare leaders that they quite literally have a Slack channel that said, "Can someone explain this to me?" And I'll see five or six people say, "Let me explain it to you." And it's something that I'm very passionate about in my career is it's not enough that maybe I know a piece of information we really need as a community to democratize that sharing of information. So that's another emerging trend that I've been seeing lately.

Brian Urban:
I love that. And two good plugs, and I didn't address it earlier, but you wrote a well seen article that was posted and shared multiple times through LinkedIn. We'll have that available as well. That's already something our audience can see off of this episode, but then also out of pocket. I'm glad you mentioned that because yeah, it's the dissemination of key information or insights today, it's a part of other communities across different industry, but healthcare, it has always been different, especially with a health plan in particular, how that works and how you have some contingency off of that if people move or leave or change careers, et cetera. I'm glad you said that. So this has been pretty vital and it seems like you never stop learning. That's another thing I think I've learned about your personality. You're constantly downloading more things to keep you up to date. Is this, I guess one of your big mechanisms for staying up to date, aside from various news outlets, I'm sure, but this sounds like it is an up-and-coming outlet to join a community and to share information and thoughts.

Jenn Kerfoot:
I think that one is that if you look at the individuals principally within managed care that are in leadership positions, it's no surprise looking at me versus them that there's a huge age gap. And I think that the millennial generation is like, "One, I don't know how to make connections. How do I get in the room where people are explaining things." And then vice versa of saying, "I don't understand." I was just telling someone the other day I was having a conversation with a Gen Z and they said about 15 different words, and I understood each word individually, but as a collective sentence, I was so profoundly confused. And so I think the disconnect generationally between how you learn and how information is shared. So I think there needs to be multiple avenues.
But I'll tell you what, Brian, one of the things when I'm at conferences, people will come up to me and say, "Jenn, it's lonely being in my department. I might be a department of one on a quality team. Where do I go to meet people that are having the same struggles that I do?" And I think one of the things I really love to do, either through LinkedIn or in person, is say, "Hey, you both are having the same role, same struggles. You should know each other."
And I think it's so important to be able to build that professional network, especially speaking to maybe a younger generation where connectivity has been in large part on the internet, it hasn't been in Masonic lodges or joining the Rotary and that community engagement. And so going out in the wild in real life as the younger kids would say, and making those connections, I think is critically important. And the RISE Conference community has been so giving to me in the sense of investing, in teaching me things, connecting me with people that can help me both professionally and personally. So I think it's something really important for all of us to be doing.

Brian Urban:
Good examples by the way, the Elk Lodge drop there, the Rotary Club. Yeah, generationally, it's changed so much in terms of networking and also sharing information too. Each generation should get better than the past ones. So I love where you're going and yeah, I agree with you. I think talking to younger generations or even a couple above, there's no Rosetta Stone in business language or even in social language. So that's a really good example, and I think you have a great following in terms of the various conferences that you speak at on a quarterly basis, let alone annual basis. So it's good to hear that.
I've skipped over this from the beginning, but let's get to know DUOS, a little bit more younger growing organization out of the upper Midwest. So what are you all about and what are some of the big tools and tech that you're deploying today that helps really with member engagement? And I think a lot of it, I see your opportunity is helping get some of those Medicare Advantage stars back in the hands of Medicare Advantage plans that maybe lost one last year, which there's been a ton, but I'm getting ahead of myself. Tell me more about DUOS, what you all are doing right now.

Jenn Kerfoot:
Absolutely. At DUOS, we're re-imagining the future of aging, really that technology we always see in LinkedIn or maybe in our newsfeed. Everything is tech, tech, tech, AI, AI, AI. I think there's a new company every 30 seconds. There's probably been a new company created since you and I've been talking. But at the end of the day, while technology has really optimized our day-to-Day, where we now have an entire universe of information at our fingertips, information's kind of like space. It's really vast and can be very overwhelming. So really principally, and at our core, what we do is digital and as well as telephonic care navigation, we organize all of that information, that sea of goodwill, and that's siloed in a way that's accessible and understandable. A really great article from Lisa Fitzpatrick, she's a doctor in DC. She wrote a great article where it says, "If I don't understand you, I can't trust you."
When we talk about engaging people in their health, trust is so fundamental to that. But if people don't and our members don't understand, health literacy is a massive component of not only influencing health outcomes, but also building better relationships with members. Where we get away from that transactional basis is super critical.
So what we've done at DUOS is we've taken in all of the resources that their health plan has as a member, but not only that, the community-based organizations and resources, we built a very, very broad nationwide network as well as connecting members to the federal and state and VA resources that exist to support them. Why this is important, because even with the increase of these new classes, supplemental benefits, a health plan was never supposed to do it all. It wasn't, and it shouldn't be. It's not sustainable for a health plan and especially as a Medicare Advantage plan to provide all these services. It's there to support members maybe for acute needs or post-acute needs or around their chronic conditions. But it was never meant to sustain that member the entire year for all of those needs. But there are other programs that do exist. And so what DUOS has done is in our B2B2C model, brought in all of those things into one place where members not only understand what they have at their fingertips, but also are prompted on key actions that health plans are trying to get members to do.

Brian Urban:
I see. That's the key fit right there, is all things in one place, and then the actual engagement trigger. And I love how you go way back before that, "I can't engage with you if I don't trust you," is paraphrasing what you said there. And I think that goes so much deeper than cultural competencies. It goes into trust as a currency and how outcomes can be based off of that if someone is willing to engage with you and whatever modality or for whatever particular subject. And I think that's, so it's fascinating. Your one-of-a-kind organization in doing this, and I think I look back at 2019, I believe 20... late 2018, it went into effect 2019, I think you can correct me on this one. I know you keep up to date far more than I, but the CMS came out and said, "Medicare Advantage plans, you can now have SDOH address social determinants of health addressed through an expansion of services that are supplemental as a part of your medical coverage plan."
So that includes rides, medically tailored meals, I believe in even first aid, durable equipment for hygiene as well, other things like that. So it seems like every conference I've been to lately, there's a ton of SafeRide, Rideshare programs, food programs, and it seems like we're really covering all the domains, but are we now looking at this supplemental benefit package that's going out here more and more? I want to get your opinion. Are we getting to be more personalized or is there just more stuff for people to have to navigate? It's what it seems like there's just more stuff.

Jenn Kerfoot:
Well, it's really timely that you asked this question because on the sixth of this month, and we can link it definitely in the podcast, CMS gave us proposed rule for plan year '25. It's actually a bit early this year. What was interesting in the 486 pages, it has a lot to do with what you're referencing, which is special supplemental benefits for the chronically ill, which was enacted 2019 under the CHRONIC Act for plan year 2020. And that includes all of these benefits that are, they're called non primarily health related benefits. And if anyone ever has a question about them, they can either look at ATI, that's a great resource to learn more about these or feel free to find me on LinkedIn. And I'm happy to always [inaudible 00:21:41]-

Brian Urban:
Oh, they're going to find you, all right. Yeah.

Jenn Kerfoot:
But really I think to your question of, "Is that more stuff?" Well, within the proposed rule, CMS acknowledges that there's a lot of these new types of benefits, but the question is are they being utilized? The GAO did a great report on supplemental benefits and the idea is are these plans paying for these benefits? But are they actually getting utilized by members? And there hasn't been a lot of transparency into that utilization. And so what CMS is proposing is there's greater transparency into that utilization, but also are these benefits, are they serving a greater purpose of improving health outcomes or is it just stuff for the sake of stuff? And while we might not have that exact answer yet, because the programs and the upswing of these benefits hasn't been for more than about four years, I think what it is clear is, and really why DUOS exists, is there's a lot of confusion around the benefits.
So a great example of this is when you're filing these benefits on the plan side into your bid SSBCI, there's 15 chronic conditions and you have to file them with what chronic conditions make a member eligible to get, for example, a food benefit, not meals, but actually food and grocery. And the member might not necessarily say, "I have diabetes, so I know I'm eligible." There's a lot of confusion in how that benefit is actually adjudicated in real time. What is very clear in an Excel spreadsheet is not clear to a member.
I had a member say once to me, "I left my local plan," and this was when I was at a conference in New Orleans, I was talking to my Uber driver. She said, "I left my health plan that I've been with for a long time because this other health plan, a large national plan offered utility support. They can actually pay for my power bill. But I was really upset when I went to go swipe that card to pay for my utility bill and it declined. I was upset. This is why I changed from a plan that I really liked because I also really needed this utility support and they didn't offer it." And then when I was having that conversation with her, I explained to her how SSPCI worked, and she goes, "Are you telling me that because I don't have this chronic condition, I'm not going to get this benefit?" I said, "Well, how the benefit works and it's filed. Yeah." She goes, "Well, they lied to me and I really want to index on that. They lied to me." All that hope. All that excitement was instantly broken.
And I think just a lot of this abrasion can be mitigated by just being a lot more clear in how we talk about these benefits. And CMS and the White House have been talking about all these predatory marketing schemes around Medicare Advantage and AEP, which we're in right now. I think all of this is really aimed at A, protecting beneficiaries, but B, holding plans and service providers accountable for the services that they're delivering as stewards of the taxpayer's dollars.

Brian Urban:
Yeah, what a beautiful example, a terrible experience on this individual's end here, but just a really good example of the words we use, I guess the route of communication that we're restricted to in terms of explaining supplemental benefits for Medicare advantage beneficiaries and dual eligibles, even Medicaid for other instances. There's too much confusion, there's too much, there's a lot of restriction. It's best we have a navigator. It really, really is. It's so interesting that we're in the youngest part that we could be in, even though if you look back, we should have been here maybe 20, 30 years ago, but looking out a couple years from now into '25, it seems that'll be very promising. We'll have more evidence to say, "Here's what we can do to get better with explaining things and with having one-on-one navigators in communities or in a digital format."
What's really interesting is going off what you're saying, Jenn, there's another proposed rule. I don't think they're tied together, but this was something that came out, I believe last week in a pretty interesting Becker's article. They reflected upon this from CMSs proposal of having a new health equity-based change into prior authorizations. So I found this to be very interesting. It's pointed at Medicare Advantage plans. Want to get your perspective on this because the focus of it is trying to clean up the denials or delays of care that prior authorizations have historically done as a stage gate in between care services being referred to or coordinated.
And they in particular broke down three things that Medicare Advantage payers are going to have to be required to have a health equity expert on a utilization team as a committee. And then that committee's going to have to conduct annual analysis to examine the impact of prior authorizations on enrollees that have economic vulnerabilities or disadvantaged in a variety of ways versus those that don't. So they actually have to look at two cohorts here, do an analysis, and then the last thing is they have to report this back out publicly through domains that they might own, which is digital on their website. I don't know if it's actually public printed press, but they'll have to make it available. So this is a big move. I think it's aggressive in the right way. What are your thoughts on this?

Jenn Kerfoot:
I would say that it's not just utilization management. I'd say overall, CMS is pulling all the levers within its authority to make sure that at health plans, they're not making siloed efforts to achieve health equity. It's really another way to weave in considerations to reduce these health disparities throughout organizations at large. Interesting study that came out from the World Economic Forum, and they estimate that the US health inequities cost about $320 billion annually. Now, when it comes to how these teams are going to assess and determine the impact, it's really, really hard to say at an individual level, what is one day of delaying based on a prior auth, the quality of care.
But I think that across all things that CMS is doing, for example, the change of reward factor in star ratings to this new health equity index, they're tying ways to measure how well do you take care of individuals who are duals, LIS, disabled, NCQA through their stratified HEDIS measures, as well as we see this in the new SNSE measure that's really looking at housing insecurity, transportation insecurity, food insecurity, and then at CMS at large, having the universal foundations having a new HHAs measure proposed saying, "Not only did you screen positive and you were given an intervention, but how did you feel about the intervention that you were given?"
So I think across the entire ecosystem, looking at isolation, just utilization management, obviously that's something that is important, but I think what's more important is the totality of all the changes over the past three years that have been really looking at specifically how is it that the totality of the services are we providing for members? Is that addressing these disparities? And I think one of the things that I love most about working at DUOS is that not only are we connecting members to those interventions, to those resources that they need provided by their health plan or another service, but we ensure that we have that closed loop feedback to ensure are those resources that we're offering, was that useful? Was it culturally and linguistically appropriate? Did it meet you in your time of need, or do we need to go back and look for a better resource that can take you all the way?

Brian Urban:
I love that comment right there, because you're not just a thing in a point of time. It's the follow through and then the cycle back to how does it get better or refined? That speaks a lot to DUOS. I think maybe more culturally too, not just of what you actually deploy as well.
The other thing I thought was really interesting, what you said right there, Jenn, is it's not just the utilization management, which you can obviously tie a hard business case to in terms of what CMS is trying to do here, but it's everything beyond that, and I love that you mentioned NCQA, what they've done the last decade plus has been phenomenal. They're now in the front pocket of CMS having all these other measures adopted, woven into existing HEDIS measures, and I think the social needs screening. The next step from there, I think in 2025, is the actual social connection. So a referral and the actual action of what you've captured and you're applying it to actually measure how you're helping, and then you have to ask those questions on the very backend. So I just think so many great examples there. You obviously know your stuff, Jenn, so I got to ask you to look into your crystal ball now. Let's go down the road two, three plus years. What is the greatest contribution you believe DUOS will have to the broader healthcare ecosystem?

Jenn Kerfoot:
Yeah, that's a really open-end question. I think it's really at our core, bringing it back to what we do, it's that there's not a single individual that doesn't seek care because they don't understand or know the resources that they have at their disposal to support them. And that even in a small way, we've built greater trust in healthcare and the healthcare ecosystem at large, and that people feel empowered and honestly, I think hopeful about the future, about the future of their health, because I think, honestly, Brian, we are all of us, you, me, our listeners right now, we're the architects of a system that we will ultimately inherit. Is this something that we want to inherit ourselves, our loved ones? That's something that our leadership team is constantly thinking about. Is this a service that I'd want for my loved ones and for my kids to inherit ultimately?

Brian Urban:
I am so thankful for that comment, your time, Jenn, and you being a future architect of what is put out into the rest of this ecosystem. I'm blown away. You're just so wise beyond your years for sure. I think a lot of our audience can hear that, and I'm just excited to see what your impact's going to continue to be, what DUOS will continue to evolve into. Thank you again so much for joining our little show here.

Jenn Kerfoot:
Well, thank you so much for having me, Brian. Really appreciate it.

Brian Urban:
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