Turning FinTech Innovations into Medicare Advantage Success

Brian Urban:
Yes, this is the Healthcare Rethink podcast. I'm your host `Brian Urban, and today we're bringing in the CEO from Alivi Health, Magdiel Rodriguez to our show to talk a little bit about how in impacting SDOH supplemental benefits is going to be the new wave of the future for engaging a lot of the lives being served in this space. Magdiel, welcome to our little show.

Magdiel Rodriguez:
Hey Brian, nice to be here. Thank you for the invite.

Brian Urban: 
This is going to be a lot of fun, especially because we haven't had too much time to get to know each other. So a lot of the things that we're going to uncover is going to be a little bit of a surprise to me, but that's part of the fun on being on podcast here, so this should be exciting.

Brian Urban:                                           
So with every episode, we'd love to have our audience get familiar with our guests. So let's go back to your youth here if you'd like, all the way back, but definitely before the CEO title of Alivi Health. So who is Magdiel Rodriguez and how did you get into this expanding space of supplemental benefits and being able to really make an impact in Medicare Advantage lives? Take us back through it.

Magdiel Rodriguez:                                    
Oh boy. So that goes a long ways back, man. I don't know how much time you got. But anyway, so my career didn't really start in healthcare, I was not in healthcare. My career started in the transaction processing FinTech world, in the credit card world. So I spent basically my adult career working, building out large-scale credit card transaction processing environments globally. So I spent a lot of time doing that and really it was fantastic. Back when I started in the space, it was really a brand new space. It was growing leaps and bounds. Innovation was all over the place. Technology was all over the place. We were able to try so many new things and it was really an exciting time to be in that space. Today they call that FinTech. And I think it's still as fascinating as it was 25 years ago, 30 years ago when I was in the space.
And something really interesting happened to me back in 2016, 17 or so, I really got together with a colleague, a friend of mine that was in the healthcare space. He actually was the chief operating officer of a third-party administrator. And we started working and thinking of, what are some of the interesting things that are going on in healthcare at the time? And the more I spoke with him, I realized healthcare from a technology innovation perspective seemed to be years behind FinTech. There was so much innovation on the FinTech side, on the banking world, on the transaction processing world, I immediately gravitated towards healthcare. And again, you heard the quote from Bill Gates that, "If you're a hammer, everything looks like a nail." So being a technology guy, to me it was like, "Man, I think we can fix everything with technology." And we saw the tremendous opportunity. A lot of regulation, very similar to the finance world.
And in the transaction processing world, in the credit card world, which was my space, there were so many similarities that you would never think existed with healthcare. For example, in healthcare today you have a payer, well, in the transaction, in the credit card world, you have issuing banks, you have a member in healthcare, and in the credit card world, you have a cardholder, and then you have a merchant that you have to accept that card at a merchant's location, which are your providers in healthcare. And then everything in between are the different networks, the different gateways, the different payment processors, everything in between.
But at the end of the day, the concept is still very similar. You have a member or a cardholder that needs to access their benefits or their funds, and then you have the payer, your health plans on the other spectrum, which is the one that pays for these services for the members. So when I started to look at this, I realized there's a lot of things we can learn from other industries, incorporate those things in healthcare, and this is kind of where we are today, is just building tech-centric healthcare solutions for payers, which is pretty much the same thing we were doing just in a completely different space.

Brian Urban:                                           
I like how you simplified that because the overlay you just provided us is really almost a mirror in a lot of ways, and there's a lot of regulations in between the two different industries, but I actually never knew that that was part of your background in the FinTech world. So it makes sense that one of the biggest benefits that you offer in your engagement model is card-based as well. So the payment integrity world of healthcare in the way that your world was in FinTech is I can see how they merge together in terms of the strategy you're putting out there. So in thinking about that, there's a lot of different, I'd say, emerging innovations in the Medicare advantage space. So what are some of the trends that you're seeing that are occurring and what are some of the things that Alivi Health is starting to integrate there in the MA benefit design space, particularly the SDOH supplemental benefit space that a lot of your services connect into?

Magdiel Rodriguez:                                    
Sure. So a lot of our clients are in the MA space, the Medicare Advantage place, and there's an interesting thing that's going on in the industry today. Those payers are facing tremendous headwinds from CMS in where the revenue is decreasing and it's going to be a 2025, '26 timeframe, and where the revenue coming into the payers are going to be decreasing as a result of some new benchmarks that they're doing from a V28 perspective. So it's increasingly becoming a lot more difficult for payers to achieve certain star ratings and certain quality scores. However, that creates a really interesting trend for the payers because it puts the payers in a very difficult position where now they have less revenue coming in, but that revenue traditionally was used to create and to fund some of these supplemental benefits that we see. However, that creates a tremendous amount of pressure on them because in conjunction with them reducing their MLR or medical expenses and at the same time increasing quality, you're kind of creating a disequilibrium between revenue, increasing pressure from cutting certain supplemental benefits while at the same time increasing quality.
And one of the trends that we're seeing in this space is that a lot of companies from a payer perspective are using these supplemental benefits as part of their ability to either retain new members or maintain the members that they have, and that's the only place they can really compete is in the supplemental space benefit. However, if they need to cut those, where are the cuts coming from and how are they going to differentiate their benefits between one plan and the other? So one of the things that we are seeing is, again, from a trend perspective, is a tremendous amount of pressure on the health plans to continue to provide and enhance those supplemental benefits while at the same time reducing the cost of them. And I think that's going to be an interesting next couple of years that we're going to see in this space.

Brian Urban:                                           
Yeah, that is interesting. And I'm excited to break down Alivi Health a little bit more into how you all play into helping the health plans. But it is crazy, I think this year so many Medicare Advantage health plans have lost a star part or wholly due in part to CAPS ratings, the experience surveys that a lot of the members fill out, and that takes away a lot of top-line revenue opportunity for Medicare Advantage plans to be able to reutilize in programs. So it seems like right now is a great opportunity for healthcare technology firms like yourself to step in and be able to provide aid not only to members, but to the health plans themselves going forward.
 So I want to break down Alivi Health, with that said. So I know that you have transportation, you also have payment cards for non-medical needs, so it's really social health-based, what you're addressing as well. But I want to hear more about Alivi Health because I have a bunch of questions, but I want you to break it down a little bit more for me and so some of the services that you all supply and some of the progress you're making with health plans in deploying these things.

Magdiel Rodriguez:                                    
Absolutely, absolutely. So we're a tech-centric organization, so background is technology-centric and everything we do and all of the solutions we build our focus around technology, number one. And number two, how do we build certain flexibility, number one, for our health plans and make it really easy for them to use? From an engagement perspective, we wanted to make it really easy for the health plans to work with us, but really on the other side of that coin is, we're always looking at the member experience in place. How does the member experience take into account when we're building technology solutions?
Now, you rightfully said, so we're a third-party administrator in where we manage the entire benefit from the design perspective to the actual engineering of the benefit and deployment of the benefit and administrating the benefit end-to-end. So we manage everything ourselves. One of the things that we do in that pillar and one of the pillars is transportation. So transportation, it's a huge component of being able to deliver a certain level of care, going back to social determinants of health and health equity. If members need transportation, chances are they're going to need some of these other benefits that are supplemental to that. So we do transportation.
The other thing that we do is on the card side is we believe the card is a tremendous mechanism from a delivery channel perspective to be able to deliver a lot of these benefits. And then the other area that we focus on is on the ancillary side. And on the ancillary side, we have a number of different benefit networks in place. Physical therapy is one of those networks that we provide. We put out podiatry, acupuncture, chiropractic. So there's a number of these benefits that are on the ancillary side that now we combine them together in a single platform.
 So from a technology perspective, if you look at it with a single pane of glass and you're the member, now you have multiple benefits that you're accessing on a single platform. And then on the member side you have exactly the same thing, you have a member with a super app that may have access to all of these different benefits on a single app, that just facilitates everything from a customer interaction, from the flexibility and scalability to engage with members, the ability to create engagement programs with members. The members are really now very accustomed to calling and understanding what are some of the benefits that they're doing. And we're able to help the health plans really identify with data and analytics, what are some of these benefits that really the members are more interested in.
And we believe that from a health plan perspective, and even also from a member perspective, they love the ability to be able to go to one single vendor to provide all of the services and solutions in one single place. And one of the things that we're really looking at is going back to a user experience on the card side, your credit card, you're not thinking if that card's going to work or not. When you go to a merchant location you know that card's going to work and the provider is not thinking, "Man, am I going to get paid or not?" We want to emulate the same user experience that we are accustomed in other industries, and we would believe that integrating all of these products on a single platform, whether it's a card, addresses a lot of the possibilities and a lot of the benefits that the plans are actually looking forward to.

Brian Urban:                                           
That's really helpful, especially the singular platform. I think we are so inundated as consumers, as health plans, everyone in between with so many brand heavy siloed experiences that aren't well-connected or coordinated in terms of information sharing. So a single platform that's like a one voice for someone to look to get guidance from or to choose from as a menu, I think that is very attractive from a user perspective for Alivi Health.
And I'm interested on something that you did say, Magdiel is, when I first saw in 2019 that SDOH supplemental benefits, that non-clinical benefits health plans are allowed to build and deploy for their members, coming from CMS. I thought, "Wow, finally. This should have existed like 20, 50 years ago." But now it seems like everyone was starting to build stuff, health plans themselves too. I saw United and Cigna, they were all in, but making too much, not necessarily too fast, but just too much and it looked really confusing, at least just looking from a historical perspective to now in the short timeframe. And it seems like it's becoming maybe more personalized. And I'm curious, do you see it becoming more personalized? I think Alivi Health is one of the leaders in making it more personalized and not just a bunch of stuff someone has to figure out what to choose from. Do you see this as the next wave in the trend of SDOH supplemental benefit design being more personalized?

Magdiel Rodriguez:                                    
The short answer is yes. And you actually hit on something really interesting, back in 2019 when CMS released the notices for nonclinical stuff, prior to that we were working with health plans, an I'm going to share something interesting with you, around that time frame there was always a struggle within the medical directors of these payers and these health plans because they really wanted to provide non-skilled, non-clinical services to people. And they wanted to provide non-skilled non-clinical services to clinical type of care for certain patients, especially during either a post-discharge from a hospital. However, they were not really permitted to be able to do that because they were not clinically labeled or within the system. So basically it wasn't until CMS kind of kicked off SSBCI, from a chronically ill perspective, supplemental benefits for chronically ill.
And where really something interesting happened is that at that point then the health plans were permitted to target certain chronically ill members with certain things such as food or social services, social work or financial assistance. And it was very effective at the time, and the payers were able to really fund it in a way that it was affordable to them. And then they realized, "Wait a second, there's something to this." And then what happened was the traditional model to manage those SSBCI benefits, and we actually have a whole function around managing SSBCI benefits for some of our payers. One of the things that really became obvious during the SSBCI projects were it really required a lot of hands-on, really it was up to the caregiver or a caseworker or a case manager at the health plan to be able to manually administer all of these things. However, what happened then with CMS, they started to realize, "Wait a second, there's a good opportunity here to expand this outside of these chronically ill members." And they became really creative.
So naturally, going back to your point, naturally, it's expanding. And naturally it's become a little bit more user-friendly and more selective as to what are the products that could be used. However, the burden that we see today, and it's kind of what I mentioned before, is as these cuts are taking place, where are these cuts going to be felt the most and what supplemental benefits will they cut first?
So one of the things that we're looking at is, as the health plans are facing these pressures from a financial perspective, we're looking at leveraging the technology, levering that card as a delivery mechanism. It's very scalable. Number one, we know it's scalable. Number two, it's not labor-intensive. You don't need to hire an army of people to be able to do that. And then one of the things that we're looking at is managing that through different technologies, whether it's customizable marketplaces for certain conditions where the member now, or the care manager or the caregiver has complete access to what are those products and services that are allowed to be able to use. So now it's not really a guessing game, now it's more deliberate in providing the right solution for the right member and understanding that not every health plan is going to have the same benefit package, or no two members are going to look exactly the same. So one of the things that we're trying to do is build more of a customized approach based on certain conditions and certain value propositions that the health plan's looking for.

Brian Urban:                                           
And that's where I'm hoping we get to, is that's the customized, personalized place, or exactly what you said, Magdiel, is we are getting to what a person wants when they want it, and what's most suitable for them to help them live a healthier life and be able to downstream control or to mitigate unnecessary healthcare utilization. So I think, I'm really hopeful we're getting there with a lot of great companies like yourself, but how's that done? I mean, are you looking at different data to ingest into your platforms to be able to help health plans to become more precise in what they offer individual members or I guess groups of members that share certain characteristics, or is it data modeling? I guess what's the strategy there? What do you see unfolding in that type of data strategy that might be very non-clinical. You can't take claims data necessarily and do this type of work, but I guess what do you see happening there? What is Alivi Health doing in that space?

Magdiel Rodriguez:                                   
 Well, funny you said claims data, and you're spot on, it is, historically when CMS made these changes, it allowed for a certain level of flexibility, but it didn't really fit in the traditional data governance model that existed. So from a data structure, data governance model, it really didn't fit into a drop-down box when you were filing for the benefit, whereas traditionally it was very clean, this is the benefit, and all the health plans were looking across all of the benefits that they provided, and they were very consistent across the board. However, what happened with this new outside-the-box thinking, it really started... We had to start looking at the problem slightly in a different way, and it became very difficult to start looking at analyzing the data for the effectiveness of that specific population, which is the population that needs it the most and that it was intended for, there was really not enough data to be able to say, "Okay, this particular plan or benefit, this is the desired outcome and this is the achieved outcome." So the structured data wasn't available.
Now, one of the things that, the way that we at Alivi look at data, again going back to our background, is we need to make sure that there's a data portability management of the data and the power of collecting clean data points. Now, one of the things that we do there is we love to administer custom solutions, like I said, for the health plans, but we look at their data and we analyze that data and we look at their data and how concise is the data and how do we measure the data, and then how do we model that data from a member perspective and a payer perspective? Once we have all that data, we have to synthesize it and kind of normalize the data. Once we do that, we look at how is this plan going to achieve its desired effectiveness of outcome for the health plan?
Now, health plans may have different outcomes. One may be just to reduce total cost of ownership for that benefit, one is to increase certain quality measures or certain health outcomes. At the end of the day, we come from the old school of knowledge that data is king and data is gold. So the more meaningful data that we have in order to make rational decisions to us, it's really powerful. And fortunately, CMS has now done a decent job kind of going in that space in where there's new coding standards, you're talking about social determinants of health. There's new coding standards for SODH, there's health equity, the health equity index component. There's going to be new coding standards. But back in the day, and I shouldn't say back in the day, just two years ago, a year ago when we were looking at modeling this data, there was really no codes around grocery delivery. How do you codify grocery delivery, or how do you codify the life cycle of some of these benefits?
 Now, the beauty of the space and the excitement of the space that we're in is that although there's financial data and medical data, two very separate data contexts and data models, in the financial services world, there's very clear industry standards from a transaction perspective. It's very well understood, and every player, every player in the industry that plays in that space has to abide by some of those protocols or standards In the data component. We believe that there's enough in the technology stack that we can leverage some of those rails to be able to incorporate some of the medical data as well.
 So we're looking at different ways to leverage the data, we're looking at different ways to report it, and we're looking at different ways to analyze it based on the utilization and the impact of the desired outcome that the health plan wants. So it's a long answer to an exciting problem, but it is an exciting problem, and you can tell we kind of gravitate towards these problems because we think we can make a big difference, even if we're able to just manage it, synthesize it, and at some point increase quality and reduce the unit costs for the health plans.

Brian Urban:                                           
I like Alivi Health's approach because you're coming at it from a FinTech perspective. You're not a traditional healthcare, you're in the muck, you're going through all the phases of regulation and how you're trying to meet those standards. You're coming from FinTech, which is a different industry, has faced similar regulations, but also is a far more, I think, creative user, consumer focused type of solutions than tech that have come out of it. I mean, there's so many examples across the board of all these innovation companies that jus made things less clicks, more seamless, more well-coordinated, more easy to use. So I'm excited to see the impact that Alivi Health continues to make across the Medicare Advantage space and beyond.
And thinking about how Alivi has broken into this in a very thoughtful way, do you think you continue to see more healthcare tech startups like yourselves come in, or do you think there's too much of a barrier right now? There's a lot of players that are starting to establish their space, establish their value proposition, is there's just a lot of regulatory barriers? I guess, what does a healthcare tech startup have to do to become an Alivi Health? I mean, is it too difficult in this time? What do you think? What's your take on just people coming into the space?

Magdiel Rodriguez:                                    
I would love to see more people coming into the space. I think the more innovation we see, the more people we see gravitating into it, I think it's going to create a much better space down the road. So anytime I speak with someone that is asking, how do I get into it or what are the things they should do, I'm all for it because I do believe there's a tremendous amount of room for a lot more innovation and more players in this space.
 Now, with that being said, it is a challenging space to get into. And you're right. I mean, if you're looking at it from a technology perspective, there's a lot of technology barriers that we see in this space, number one. Number two, the financial ability to be able to have the staying power in the space, I think is a challenge. But really I think the biggest challenge there is, is having someone with the ability to take on a certain amount of risk and a certain amount of grit to be able to get into this supplemental benefit space. The space is highly unpredictable in the utilization patterns. We don't know from one year to the next what utilization is going to look like. We don't know from one year to the next what membership is going to look like. Is membership going gravitate from one plan to the other? What are the states doing, depending on if it's a state model?
So there's so much fluidity in the utilization patterns, which also creates a challenge on the reimbursement model from the payers. For example, certain payers want to go straight capitation, others want a fee-for-service model. Others want a risk corridor with an upside-downside risk corridor. Other ones, administrative services only. Other ones, cost-plus model. There's so many different models, and they're all unique based on what the health plan is looking for.
 There's a lot of companies out there today, it's somewhat of a crowded space today in certain areas. And I think from a health plan perspective, sometimes they get overwhelmed with so many different options. And then when you add the lengthy sales cycle on the MA space where it could be anywhere between 12 months, 18 months to even two years or longer from a sales cycle perspective, that's where I mean by companies have to have a certain lasting power because you may put a lot of effort into something and not really be able to sign a contract for the next 18 to 24 months.
 So when you factor all of these unknowns where you're not really able to control, it really boils down to having the right people in place. It's all about people, process and technology. You have to have the right people in place. I think a good healthy mix is good solid technology folks, but really you also need folks that understand the healthcare ecosystem, understand the payer landscape, understand where, directionally, the trends are, as you asked early on, where's the trends? I think it's important to have the right mix of people. They can't all be technology folks. They can't all be just healthcare guys because whatever solutions they put in place, at the end of the day, they have to be actuarially sound from an actuarial perspective for the health plan. If not, it doesn't do anyone any good. So I think there's a challenge there.
Then the challenge is you have to have the right people with that right innovation mindset in place in order for them to start thinking outside the cliche, the traditional outside the box. But in this space more than any other space, what's going to set someone apart from a startup perspective. And then once you start building the systems and the technology, build systems that don't have boundaries in the sense that, build an open architecture, build somewhere that other people can type into your API, I think the more interoperability that we see, I think the more open we become, it's going to create a lot and spur up a lot more innovation down the road. And it's somewhat different to what we've historically seen as where everybody kind of just wants to play in their own little sandbox, and I don't want to share data, I don't want to let anybody in. I'm completely the opposite, I will interface, I will talk to any one of these platforms that are willing to talk to us because I do believe that it's going to improve the overall quality and reduce the costs down the road.

Brian Urban:                                           
And I love... We need more CEOs like Magdiel Rodriguez, I'll tell you that right now. And there are a lot out there. A lot of them are on [inaudible 00:31:35] podcast.

Magdiel Rodriguez:                                    
[inaudible 00:31:36].

Brian Urban:                                           
A lot of them are on our podcast. But that approach that it's not a self-centered square box, our business model fits here, fits there, and that's it and we can't work with you, we can't work with you because of X, Y, Z. The open philosophy of if we work better together and we find ways to collaborate and innovate, that lifts up the whole healthcare economy in terms of technology, data exchange, innovation. So I just absolutely love to hear that. And with that philosophy in mind, what's Alivi Health going to be in five years from now? I mean, what's your biggest contribution to the ecosystem? What are you going to turn into? Are there more phases and iterations ahead that you can't share yet? Maybe, but you can give us a hint. What's Alivi Health going to be?

Magdiel Rodriguez:                                    
I think we're always looking at opportunities. And funny you asked for that, we love talking to our clients constantly and just asking them, "What keeps you guys up at night? What's your biggest pain point? What can we do together?" And I'm a firm believer, and I didn't come up with this actually, you said there's a lot of great CEOs out there, nothing I do is original, I steal from everybody. And I have no shame, no shame in admitting that I just learned so much from such great people that are out there. And one of my ex-bosses said, "Hey, we don't dictate what the market wants. We don't dictate the product that the market wants. The markets are the one that dictates what we want." So we basically listen to the market, we listen to the payers, we look at CMS, we even listen to our members. And we just love to look at, what is it that they want us to build? And we go back to our cave and start coming up with ideas.
But I think the next three to five years for Alivi are really, really awesome in the sense that we're looking for efficiency. We want to create as much efficiency in everything that we do. Everything we do has to have a component of quality. Are we making a difference for either the member or are we making a difference for the payer? Is it easy to use? We always have the member journey in mind in everything we do. And then really kind of one of the things we're always looking at is, what is the total cost of care? Where can we start managing, containing or reducing total cost of ownership across the board, from a total cost of ownership. I think it's important to start measuring unit cost in everything that we do.
We believe from a future perspective, it's really important in the future to look at those things and look at what's worked in the past. There's a lot of vendors that are doing transportation today. There's a lot of vendors that are providing the networks, the ancillary networks that we're providing. There's a lot of vendors that are doing marketplaces, OTC. There's a lot of vendors that are doing payment cards, and they're all doing amazing things. They're really doing really, really amazing things. One of the things that I'm hoping for from an Alivi perspective is that we started looking at what the health plans want from a value perspective. Although we can do a lot of these things, well, what are the things that we can do to start administering these benefits in a way that it makes it easier for the members to engage in? That's number one.
 And number two, we're always looking at scalability. How do we scale what we do? How do we make the health plans take value in all of these different benefits and services and combine them in one place? And for us, that could look very different today than what it's going to be in five years. We could be nothing more than a platform just engaging all of these different vendors in what they do best, and we just serve it on a platter, whether it's on a technology platter, on a technology stack, whether it's an omnichannel approach, we're very big on building platforms that are omnichannel across the board. So again, it could be very different to where we are today, but with one constant in place, it has to add value to the payer, and it has to increase that member engagement. At the end of the day, it boils down to one thing, the member. And that's what we're looking after.

Brian Urban:                                           
That vision in mind, if it's all about the member, all things will probably come together and fall in place. I love that your philosophy to innovation is wide open. It's also very thoughtful at the same time. I've just enjoyed the knowledge you've dropped on our little podcast here today. Alivi Health CEO, Magdiel Rodriguez. Thank you so much for joining our show. This has been a pleasure.

Magdiel Rodriguez:                                    
Brian, thank you so much. It was absolutely my pleasure. Really had a lot of fun, I enjoyed it. Thank you so much. And next time you're in my neck of the town, so let me know and we'll get together.

Brian Urban:                                           
Absolutely will. And you're already on my mental calendar. Thank you so much for that. And for more exciting insights and excerpts, please visit us at finthrive.com.