About the Episode
Welcome back to HealthTech Remedy! In this episode, your hosts, three physicians who transitioned from academic medical centers to leadership in health technology, dive into a topic familiar to every healthcare professional: Prior Authorization. This system, often viewed as a messy, inefficient, and burdensome process riddled with friction – yes, including faxes! – is Cohere Health's target for transformation.
We explore how Cohere Health, founded in 2019 by serial entrepreneur Siva Nam Saviyam, is tackling this massive problem head-on using technology and intelligent design. Joining us is Dr. Brian Covino, Cohere Health's Chief Medical Officer and an orthopedic surgeon by training, who shares his fascinating journey from clinical practice to leading change in the health tech industry.
Learn about Cohere's approach to bringing coherence to utilization management, moving beyond the frustrations of the current system which, while sometimes necessary to curb inappropriate care, imposes significant administrative burden and contributes to physician burnout.
We discuss Cohere's rapid scale, impressive customer base (including major health plans like Humana, Geisinger, and others), and their unique "right to win". Discover their distinct method of "green lighting" high-value providers for automatic approvals while maintaining oversight, a potentially better approach than simply "gold carding".
Find out how Cohere incorporates behavioral economics through "intelligent nudges" in the workflow, guiding providers towards guideline-compliant care by suggesting alternatives or requesting missing documentation before submission. We highlight the crucial point that nudges are designed to educate and streamline, not obstruct.
A key part of Cohere's innovation lies in their responsible use of machine learning and AI. We explain how their platform reads clinical documents to speed up approvals for appropriate care, reducing reliance on error-prone manual forms. Importantly, Cohere uses AI ONLY to accelerate approvals; any denial of care is ALWAYS made by a physician.
Dr. Covino shares powerful data showing how Cohere's platform is reducing administrative burden for both provider practices (upwards of 30-40%) and health plans, freeing up staff time and helping to mitigate burnout. He also offers valuable advice for physicians interested in leveraging their unique perspective to make a broader impact in the health technology industry.
Join us for an insightful conversation on improving healthcare operations, reducing friction, and the potential for technology to transform areas like Prior Authorization.
Transcript
[00:05] Tim: It's good to see you guys.
[00:06] Trevor: Hey guys.
[00:06] Paul: Good evening.
[00:07] Trevor: I'm wearing my puffball jacket. I just came in from outside putting up Christmas lights with three children under eight. I do not recommend it.
[00:15] Paul: Yeah, I don't recommend having three children under eight either.
[00:18] Trevor: It's not getting easier when they're team.
[00:20] Tim: Wait for that.
[00:21] Paul: Should we hop in?
[00:22] Tim: Let's drop the hammer.
[00:24] Paul: Really? Is that our catch phrase? town. Come on.
[00:33] Paul: Welcome to Health Tech Remedy. Physician stories from the Health Technology industry. This is a podcast hosted by three physicians who cut their teeth in academic medical centers and later found themselves as leaders in the health technology industry. We tell the stories of early stage tech companies seeking to improve healthcare.
[00:49] Technological innovation and healthcare don't always mix well. We review companies' early journeys and the physician and patient perspectives are shared and reflect on the challenges and successes of these companies.
[00:59] We also have fun together as friends, storytellers, and lifelong learners. Join us on a journey through the arcane interface of healthcare and technology and the human experience.
[01:14] Tim: So today we're going to talk about Cohere Health.
[01:18] This is one that came across my radar a while ago, uh just because I really love what they're doing in prior authorization. I think they're really using technology to solve for problems.
[01:30]To research this,we listened to podcasts with the founder, the COO, Chief Medical Officer, read every press release we could possibly get. I also saw a lot of press during 2024 because they were named a top five LinkedIn startup and they also won”Best AI Story” at Health 2024.
[01:52] Fun fact, my company was also nominated for that, Artera and lost to Cohere Health. So I think this is very dignified to lick my wounds and investigate this company.
[02:04] We've also had the chance to meet Brian Covino, who'll check in with us later. He's the chief medical officer. He's an orthopedic surgeon by training. He's got a fantastic story of being in clinical practice and then finding his way as being a change leader at Cohere Health.
[02:20] So, a little bit about the company. It was founded in 2019, so it's been around for several years now. Uh the concept for Cohere Health was developed essentially in response to some needs to implement electronic capabilities and technology on prior authorization. Their first big customer in likely thought partner was Humana. So that was their first big contract for prior authorization.
[02:46] They initially focused on the musculo skeletal prior authorization work, which is I'm sure how Brian Covino got involved as ultimately as chief medical officer. And that's where they're they were focused in 2019 with Humana initially. And then they expanded in 2021 to include diagnostic imaging and sleep solutions.
[03:04] They went from about 10 employees in 2020 to over 700 employees in 2024. So they've obviously scaled relatively quickly. CohereThey currently serve five health plans and I'm told they process five and a half million intelligent prior authorizations annually for more than 15 million uh health plan members and 425,000 HCPs nationally. So obviously they're they're building quite a bit of scale and it'll be interesting to see, you know, sort of how they got there and and where we think they're going over time.
[03:34] Trevor: This is like such a huge problem in medicine. The CEO and the founder is uh Siva Nam Saviyam. And he's a serial entrepreneur, so this isn't his first rodeo. I think Cohere Health is his third venture and he was a founding partner of SCIO Health Analytics, which served Fortune 500 healthcare organizations. So this was kind of like a natural extension into a lot of that work.
[03:56] I think he's known mainly as a technologist, a businessman with a focus on health care. He's been around for over 20 years. He has a master's in computer science and an MBA.
[04:05] Tim: It's pretty amazing, Trevor, like just looking at his background because he I I see where the technology comes in and the business and he's obviously just picked up health care along the way, but it's pretty impressive. It seems like he's been essentially committed to health care, you know, since he got into his career.
[04:19] Trevor: It's so great to have someone with his business mind and identifying these inefficiencies in health care and applying it in health care. We need more guys like this.
[04:27] So in terms of fundraising, just as an overview, they've raised a total of $106 million since they're founding a 2021 series B of $36 million led by Polaris partners along with Longitude Capital, Deerfield Management, Flair Capital partners, and then Defined Ventures. And then in 2024 and another funding of 50 million led by Deerfield this time with some other participants.
[04:51] And maybe before we like dive into the meat here, Paul, if you want to tell us a little bit about prior authorization and utilization management sort of broadly and then kind of what problem these guys are solving for. You're probably best positioned to to cover that than any of us.
[05:03] Paul: I mean, you guys have lived through prior authorization yourself as fellow physicians, but utilization management, prior authorization, the I mean it can be a bit of a of a messy inCohererent world, but it is necessary or at least can be viewed as necessary to make sure that patients get the right care and that payers are not paying for the inappropriate care to the wrong patients.
[05:28] And the current system has a lot of friction in it. It's documentation has to find its way to the payer. In a lot of cases that documentation is, you know, transmitted, I don't know, even via facts.
[05:41] Tim: The only industry that's still using. Amazing.
[05:43] Paul: And and sometimes things like peer-to-peer uh discussion is sometimes required, which can't be done asynchronously, so that can cause scheduling difficulties.
[05:51] So what Cohere Health has tried to do is to try to reduce some of that friction which is associated with efficiencies, costs and just generally headaches and aggravation on the part of providers. And honestly, I think a little bit on the part of payers too.
[06:07] The other thing to mention here is that from a broader policy perspective, we are seeing interest in requiring the pipes to be built so to speak for more efficient utilization management.
[06:21] So as part of the 2024 CMS interoperability and prior authorization final rule, there was a requirement for implementation of three additional APIs, a provider access API, a payer-to-payer API and a prior authorization API.
[06:39] Now, obviously Cohere Health was a little bit ahead of the game in terms of this, but I think really what it shows is that they're a leader in terms of something that a lot of people have had a lot of interest in for a while now and I think they're going to be well positioned as everybody starts to become interested in doing this.
[06:54] Tim: We should ask Brian if they still use faxes. I bet they still do. Maybe they built a faster fax.
[07:00] Trevor: You know, you know there's an opportunity for disruption if you're still using the fax machine. Come on in guys.
[07:07] A couple of like quick reflections on prior authorization, I guess and hopefully these guys can figure this out. But like, you know, there's this big bucket of utilization management strategies, one of which is prior authorization. And there are all these other ways to restrict how much health care practices use or providers use and prior authorization being one.
[07:24] But like I I feel like prior authorization has taken on a life of its own a little bit. Like pretty much every specialty society that I can think of, at least in our own practices like Asco and Astro, have had these massive campaigns in the last sort of five years, basically championing against or trying to improve a lot of these prior authorization.
[07:41] But, you know, there is sort of a necessary evil there, um, where you need some check in the system so that you're not using too much healthcare.
[07:49] Tim: I've done some clinical advisory for one of the legacy groups and when you look closer and you sort of see what they deal with, like there are like I'm almost tempted to label them as like knucklehead physicians. There's some people that are doing things that just feel maybe a little like profit motivated and but certainly at least inappropriate. So they certainly have that. And then you know like even the greatest doctor you know sometimes has an off day. So it's certainly possible that people aren't really, you know, thinking clearly they put orders in.
[08:18] So, you know, I think honestly, we're all three docs, but, you know, if we're honest, we're not all perfect, you know, I mean, Trevor, you might be, but um, but the rest of us not as much. So I kind of see the point of like, you know, making sure that even even the non- knucklehead docs are are making consistently for every single patient, you know, doing the right thing. So it makes a lot of sense to me.
[08:38] Trevor: Yeah, just to kind of pull this thread a little bit further, like clearly the pendulum can go too far where you don't want everything that you do as a doc to need a prior authorization. Like it's an inefficient process. And so if there entities that can come in and make it more efficient, like boy, what an amazing opportunity.
[08:52] I mean, just to give you an example, you know, I've been on some prior authorizations for radiation oncology services where, you know, it's taken several days to get it scheduled. You're totally at their mercy of the scheduling. You know, your busy clinic doesn't necessarily come into play.
[09:07] And then you might get a psychiatrist on the other end of the line who's signing off on a proposed radiation oncology plan. And like, you know, I don't want to be put in a position where I'm telling him or her what anti-psychotics to prescribe. And like, hopefully they're not comfortable telling me how many fractions to give for a radiation treatment. So there's just a lot of opportunity here and I think there's frustration on both ends.
[09:26] Tim: So, you know, Paul, you mentioned the current prior off feels a little inCohererent, so I think that's where they got their name. They're trying to add some Cohererence here.
[09:33] So maybe it's a good point to talk about like who's buying in in terms of their customers. So I did ask Cohere Health who their customers bases are. And essentially, you know, their market segment for folks they work with are either insurance companies or other like a risk bearing medical group.
[09:51] Publicly, they were able to disclose that that list of customers currently includes Humana, Geisinger Health Plan, Mutual of Omaha, BCBS of South Carolina, your home state, Paul. Health partners of Minnesota, Avera in South Dakota, Highmark and Oak Street Health and I'm sure there are there are others that are coming down the pipe. So they've clearly gotten a fair amount of traction. And I think they've been able to show that they're improving outcomes from the perspective of the payers and providers along the way. So, you know, I expected they'll continue to grow.
[10:27] Trevor: I mean, that's a pretty impressive list of customers. Those are some huge, you know, systems that's working with them and I think at this point, you know, they're developing this credibility with payers where they're no longer the startup tech company that is an unknown entity.
[10:43] Paul, you want to break down the revenue for us?
[10:45] Paul: Yeah, so it's primarily from the payers and the risk bearing medical groups. And the reason that they, you know, make money and I guess they're right to win so to speak is one, doctors love efficiency and doctors are not known for loving insurers, but I'm sure if uh doctors can have more efficient ways of interacting with payers, uh they're certainly going to like that. Maybe love will be a strong word, but at least like.
[11:11] It's, you know, driving change with technology, automating things that can be automated. The other thing here is that this is scalable. You know, one of the big costs of utilization management is that if there's twice as much documentation to be transmitted and reviewed, you have to multiply your staff traditionally by a factor two. This is, you know, going to be a much lower cost solution. So the more documentation that has to be reviewed, it's not necessarily going to scale your cost that much.
[11:39] Trevor: Kind of wrapping us up here. Any final thoughts in terms of, you know, what we like about this, what we don't, or what are we worried about?
[11:47] Tim: I like it. I'm team Cohere Health. Doctors love efficiency. I like seeing some technology and advanced analytics to transform this area. I think it's a win-win, right? You know, there's been a lot obviously in the press about utilization management and I do think that companies like this that are doing something to make the process faster is a win for payers, for patients and for providers. I think people feel like they're being listened to.
[12:14] I think the overall approach to focusing on the patient journey and thinking beyond just that immediate service that's being provided is pretty obvious and I'm glad somebody's doing it.
[12:26] And what I don't like, my only like lingering concern about this field is I just wonder what the long-term need is. Like will we always need utilization management? And, you know, I'm just wondering like will alternative payment models take care of this in the future? It just seems like a very fee for service specific problem that our healthcare systems created and there's something about it that just seems like it, you know, it's fixing a really important problem and and unmet need, but it just feels like it doesn't get to the root of the issue. So that that's my my only sort of thing that I'm left uh feeling slightly dissatisfied about, but I'll say overall, I think they're on to the right strategy to deal with this particular problem as it stands.
[13:11] Paul: I think I like all the same things about it Tim does. I guess the one thing I'm going to say is if you're in the shoes of a payer, especially if they start to branch out into new areas, there's a lot of uncertainty in this. And if you're an insurance company, you know, you kind of have to be conservative. I mean, you can't run out of money if people are looking at you to pay for things. And so if you implement some new process with wide sweeping potential impacts, it can be a little bit risky that it has unintended effects. And even if the risk is low, insurance companies they take only very small risks or at least distributed risks. Makes sense. I think that would be the one thing I'm I'm a little bit hesitant on.
[13:51] Trevor: Yeah, I think Tim, you put it really well. Like you cannot understate how big of a pain prior authorization is for providers and like how much it has really kind of captured the national attention particularly, you know, recently.
[14:04] And this is like a perfect place for a health technology company to insert itself and make it just better. But I'm paraphrasing you Tim, but keep me honest, but the fact that we need to solve for this is a shame a little bit. And it would be great if we had a system where we didn't have to, but it's the reality of it and they are making that better and I'm all for these guys. I hope they figure it out and continue to succeed and do well.
[14:26] Tim: It's good catching up with you guys. You know, next time we meet, I think we'll have a chance to ask Brian some of these lasting questions.
[14:33] Paul: Let's do it again soon, guys.
[14:34] Tim: All right, man.
[14:35] Trevor: Great, looking forward to it.
[14:56] Tim: We are joined today by Dr. Brian Covino from Cohere Health. Brian, welcome to Health Tech Remedy.
[15:02] Brian: Thank you, Tim. glad to be here.
[15:03] Tim: We're really happy to have you. I was really fascinated when we talked before about your transition from clinical practice into being an industry leader in prior authorization. Can you tell us a little bit about your background and sort of what brought you from full-time clinical practice to your role at Cohere Health?
[15:20] Brian: I got involved in a project that actually became Coherere health. It was with a health plan. At the time, as an orthopedic surgeon, we were involved in some value-based care arrangements with that health plan. They asked me to consult on this project. The project became a company, became Coherere health, which became independent in 2019. I consulted with them for a short time.
[15:39] Then in 2020, we all know what happened in March of 2020, third week, COVID raised its appearance and as an elective joint replacement surgeon, I was essentially out of business because you were not allowed to do elective surgery at that time.
[15:51] After having really not much to do for several weeks and after having practiced for almost 30 years, I decided that maybe this was a time to make a change. Serendipitously, Coherer Health was looking for their first full-time medical director at that time. So I was able to make that transition out of clinical practice into the other side of healthcare. So again, the pandemic had an influence on lots of people, but that was its influence on me.
[16:12] Tim: That's such an amazing story. And I think the thing that I remember from that time is it always felt like clinical practice was like perfectly secure forever. And like you, I think we all saw in our hospitals that we were just a few weeks of elective surgeries away from being in a much weaker financial position. So it's pretty interesting and it's amazing that you like turned this into such a positive impact for the field.
[16:35] Trevor: It's so true, like you always talk about medicine as being totally recession proof and then like boom, overnight, clinics were shut down, outpatient procedures were down. We're radiation oncologists, like my clinic was totally shut down. It was wild.
[16:47] Brian: Yeah, we had not invested in telehealth or anything like that. so we're not set up to do that. So we really were somewhat behind the eight balls as many physicians were in how do you manage patients and again, the only ones we really were allowed to manage were those that had urgent problems and as I say my role is doing mostly elective surgery, there wasn't much of that to do.
[17:04] Trevor: And what was your practice like? Tell us a little bit about what your day-to-day was like at the practice.
[17:08] Brian: I essentially did lower extremity joint replacements, the hip and knee replacements. and that was 90 plus percent of my practice. Earlier in my career when I was taking call, I was doing fracture work, but later didn't have to do that. So as I said, having done that for as I said almost 30 years, I could said I had enough of clinical practice. It was ready. I was ready for it. It was a good transition for me.
[17:30] Paul: You made it longer than me. I was in for less than 10 years before I transitioned out.
[17:34] Trevor: I'm curious, Tim and Paul, if you feel the same way, but one thing that I hear a lot from practicing docs that are interested in industry or alternative careers beyond clinical practice is that industry is a black box and they don't even know where to start. You know, industry is such a big world, a big broad word with so many different types of roles and positions for physicians.
[17:52] And I mean, we'd love to hear a little bit more about how your experience as a practicing doc translated until like this just incredible company doing really innovative stuff. And, you know, we're all docs on this call and it's like a great success story. How do you think that skill set translated?
[18:06] Brian: Well, you know, I think one of the cornerstones that attracted me to Coherere in the first place was the concept was it had to appeal to physicians. We had to listen to physicians. The people providing the care had to be quarterbacks. So we had to align with how they think. So again, from clinical practice that was relevant for me.
[18:23] And then again, we had to have experienced the burdens of thezation, utilization management process ourselves to understand how it went. So even when I was consulting and I was working more so with my UM team in my practice to find out what was their day like? What were the obstacles that they faced? And so that perspective was helpful. and a lot of the research we did early early in the company was actually going and sitting in doctor's offices and watching their UM teams function and see what the impediments were and try to improve it.
[18:50] Trevor: And when you interacted with those practices, did you find that they were more receptive? I imagine they would be, but to you as being a physician, you know, being sort of one of them.
[18:59] Brian: No, exactly. and that was as I said part of the reason we wanted clinicians, physicians involved in the beginning was it did give you that credibility. You said I've been through this, I know what it's like, we're trying to make it better. And we've done that throughout the company. In fact one of the things we've done is try to partner with medical societies. MSK or Musculo skeletal medicine was our first clinical area that we went into and so we part have a partnership with the American Academy of orthopedic surgeons to leverage their guidelines, but also to go to meetings, talk to physicians about what we're trying to do, tell them that there is somebody out there trying to improve this whole process for you that's listening to you and it's working.
[19:34] Paul: I wanted to ask, you know, you obviously lived it and I think all the rest of us have lived it. physicians in general would welcome an intelligent and streamlined prior authorization process. You know, now that you've been at this for a couple of years, have you started to hear feedback and what's it been?
[19:48] Brian: So the feedback, I would say is very positive. When we have to understand that the process really in a physician's office is their staff that's doing this work. Physicians would love it if they had nothing to do with this process. And what I would say to them is the best thing they can do is learn how to document appropriately. If they document appropriately, the whole process becomes very easy.
[20:06] But what we hear from the staff in their offices is, and we've got data on this because we survey them quarterly, is that 93% of the practices that we work with are pleased with the platform. Anybody to actually recommend a par off platform must be a little crazy to begin with, but they do. And that translates to a net promoter score of 65, which in healthcare is pretty high. So, again, thanks to the people that designed our platform made it very user-friendly. We're getting good feedback from the provider practices when they use it.
[20:37] Tim: That's amazing and it seems like it's such an area where you're probably getting a lot of enthusiastic physicians and UM staff because people really just want a better product and a better process.
[20:49] I enjoyed reading a lot about how Cohere is approaching it. And some of the terms I read were about green lighting versus gold carding. And I wonder if you can explain for us why it may be that green lighting is actually a better approach than gold carding. And maybe you could first define those for us just so we understand.
[21:08] Brian: Well, I'll go back to again the early days when one of the cornerstones in development was, we have to have the ability to treat different provider groups and individual physicians differently because we know if you're looking at the data that 90 plus percent to use around number of physicians provide excellent care for the patients. And so we have to create a system that gets out of their way. Let's them take care of the patients and for health plans the members.
[21:33] And then focus on those that need education. And how can we educate those that seem to practice outside the bounds at times. And so that's where this whole concept of gold carding green lighting came along. So gold carding, that's when a health plan essentially tells a practice, you no longer have to submit any information. It's a nice carrot to give to somebody. If the plan has identified as a high quality group, high value group, that's great.
[21:56] A lot of state legislation now is around gold carding saying that if a provider has obtained 90% approval for a certain procedure over the last six months, they shouldn't have to submit anymore. Firstly, I don't think 90% is a great number. To me that means you're allowing one out of 10 cases is unwarranted. That's a fair point. Yeah. But uh we'll leave that to the legislature to debate.
[22:16] Trevor: That's the state level?
[22:17] Brian: There's about 25 states that now legislation to that effect right now. Wow. And others that are pending. So to comply with that legislation, plans would have to just shut the program off. So what we say is, okay, have them submit the information takes a few minutes. They automatically in real time get approved if they're in that status. But then we monitor. So then we can audit and see because typically what happens when you shut the program off is utilization goes up.
[22:43] So that way we can monitor over the next period of time and make sure that utilization isn't going up significantly and that audit specific cases and make sure that they're still meeting appropriate criteria for quality care. And so that is really what green lighting is. It's again, giving automatic approval, not delaying care for high value providers, but having the ability to monitor it on the back end.
[23:03] Paul: One of the interesting things you talked about here was providers providing, you know, high quality care and also the importance of documentation in noting the high quality care and the rationale for some of these costly procedures that get prior authorization. But I guess, you know, one of the other questions here is there's a lot of guidelines out there and as practice evolves, if doctors are not practicing in line with the current guidelines, you know, are there ways that you are providing nudges to help improve the use of guideline compliant care?
[23:34] Brian: Yeah, so the whole concept of nudges, which is borrowed from behavioral economics is, can we make suggestions in the workflow for alternatives? And will they accept those if the sort of the carrot of an automatic approval is there as well. And it's also an education piece basically saying, you know, based on the criteria for this procedure and the policies that are out there, this would be more appropriate and would allow you to get an approval for your patient.
[23:59] And so those come in different flavors. I think one of the simplest ones is a big problem inzation is the lack of information. So in our model, when the provider submits information electronically, we use machine learning models to read it. And if there's an element that's missing in that record, for example, your P&R physician Paul. If they want to have an injection, we don't see that therapy's been done, we can't find that. We can ask, we can nudge and say, Gee, we've got all your information, but we don't see any notes on physical therapy. Could you send us those?
[24:30] So we try to nudge them for what's missing in their documentation so they could submit it to us before they hit the submit button, before the clock starts running. And so then you also on the back end don't have to tie up a physician when a peer-to-peer call to say, did this patient do physical therapy? like, of course they did. Was unfortunately, you didn't send me the records that it. So, again, trying to solve folks's problems. So that's one example of a nudge is just, hey, this is information we need, we don't see it.
[24:55] Second might be unit-based and again, going back to your world, physical therapy. You know, if we say based on national data that for somebody with, you know, acute low back pain, eight visits is probably the appropriate initial recommendation, you're ordering 15, if you take eight, we can approve it right now. So you can sort of do unit base reduction based on national data for benchmarks for visit count.
[25:19] Another one is side of service, which is obviously post Covid, it was heading that that direction anyway is so much more now can be done in the outpatient world. And even whether it's hospital patient department or an ASC for the appropriate patient, can we suggest this case can be done as an outpatient? And again, those are intelligent nudges. We don't suggest that for everybody. You know if a patient had a lot of comorbid conditions, we would not present that nudge. but if we see the patient's healthy and they could have that total need on ASC, we might suggest that as an opportunity. Again, it doesn't stop the process, nobody has to accept them, but trying to get them to change some things that are to higher quality, hopefully less cost at the beginning of the process, not tying up the physician to answer those questions.
[26:02] Paul: And I guess as a follow-up question, you know, the example you gave with the injection, uh, asks about physical therapy and of course, the doc can only provide the documentation on physical therapy if that's already been done. But, you know, I can imagine you do get cases where it's not just a matter of missing documentation. It's maybe the physician isn't doing something that is in line with the current generally accepted guidelines. Do you have any experience with educating physicians on updates in clinical practice, which seem to be becoming more and more rapidly now?
[26:33] Brian: Yeah, so as you said, one of those is these nudges that we can present like saying, it doesn't appear you've done therapy. If you haven't, that really is recommended as first first line treatment. And if so, we can approve that now. So that's the first step. The second step is obviously in the system they can link out to policy so they can read the policy and see what the recommendations are.
[26:51] And the final step if it does get to peer-to-peer conversation, we like to have same specially physicians in the pain space, we have pain management physicians talking with other payment physicians that are requesting things. And that's the other opportunity to educate is to say, you know, this is what the policy is, hey, this is what guidelines and have an interactive conversation of somebody with the same specialty to talk about those things and try to educate so that going down the road, they know the steps that you have to go through before requesting the procedure.
[27:19] Trevor: That is music to my ears. We were kind of joking last time uh the three of us got together about how through our own prior experiences and there've been a number of times where I've spoken to a pediatrician or you know, psychiatrist about, you know, fairly complicated oncology regimens and it just seems like it would make sense that, you know, appear to appear would be sort of specialty specific.
[27:39] Brian: Yeah, exactly. I had some very nice conversations with obstetricians and pediatricians about complex joint replacement cases which Yeah, yeah. it was educational for them. Yeah.
[27:48] Trevor: I've actually I got to say I've never actually as a radiation oncologist, I've always had another radiation oncologist for a peer-to-peer. That's good.
[27:55] You know, I think all the time about that chart in healthcare where it shows the number of people in healthcare over time and that it's just exploding, but the number of physicians is like relatively flat and it's like administrative staff that's like really gone exponentially up over time. And to me, this is like a way to like bring that curve down of like the administrative burden. And I'm really curious on the practice level, have you seen that? Like impactful through your platform, decrease the administrative burden? Have they been able to reduce head count and get some of this, you know, out of the system?
[28:26] Brian: So all along the way we've messaged that is instead of going to somebody and saying, hey, you can, you know, release 10 of your employees, we say, you can repurpose them for patient facing tasks. And so, but yes, we have seen upwards of 30 to 40% reduction in administrative burden for practices and for health plans. which for practices again has allowed them to repurpose staff and for health plans, it's allowed them to do many things. One is they can actually expand their coverage of prior authorization into other areas they wanted to get into if need be.
[29:01] And some health plans, that's really the first thing they're looking for is simply administrative savings. You know, ultimately some of the plans that we work with obviously are looking at medical spend savings, which is tied to quality of care and patient safety. But for a lot, the first step is, you know, can this decrease my administrative burden? I have a staff of X number of nurses and physicians doing utilization management reviews. If I can automate 50% of it and not have it get to a clinician because it's an easy approval, I've got time to do other things. So, absolutely we've seen administrative burden reduced on both the providers and the health plans.
[29:33] Trevor: I see that, you know, on the practice level. I guess on the physician level, a lot of the professional societies now highlight things like Prith or utilization management as contributors to this burnout epidemic. What are your thoughts on the individual physician burnout level and how this can sort of mitigate some of that or maybe not curious your thoughts there.
[29:52] Brian: Yeah, no, I I think it definitely has a role there. You know, obviously physician burnout is multi-factorial. This is a part of it. I'm probably a little bit biased as a specialty physician. I wasn't directly involved in this. We had a large enough group that we had a team of UM staff that did most of this work for us, but a lot of primary care physicians and smaller groups are stuck doing this themselves and it absolutely leads to a lot of hours spent outside of patient care.
[30:15] And so again, one of the goals of the company was, how can we reduce the abrasion on the provider staff? Get them back to taking care of their patients and make this an much easier process for them. And we have seen that, which is good. A lot of the practices, again, even even the staff that submit their requests, we can do timestamp analysis and so they're spending less time. They're spending three, four, five minutes less per submission to submit the case.
[30:37] And then we can get, you know, approvals for appropriate care, 80 90% in real time depending on the specialty. So again, they're not on the phone back and forth, they're not going back and forth with the fax machine. And so we've seen lots of reductions in time spent on these administrative tasks.
[30:54] Paul: If you can just minimize the amount of time we spend on a fax machine, that's already a huge victory for the.
[30:58] Brian: Yeah, that's a huge technology win. And you know, I I keep saying we're trying to retire the fax machine, but it doesn't seem to be going anywhere and you have we have plans that we've worked with that literally were 100% facts for this entire process. And within two to four weeks had gotten them converted to over 90% using a digital platform. You know, again, the people that working in the offices and nowadays, they're looking for technology, they understand how to use technology. Just make it user-friendly and then they'll adopt it quickly. Nobody likes to stand next to the fax machine.
[31:27] Paul: So you've talked about a lot of exciting things that Cohere is doing. You know, I guess if you had to sum it up in your own words, uh, what do you think is the case for Cohere to win? Uh, what's Cohere's right to win so to speak? We have our own ideas probably, but we'd love to hear your take on it.
[31:43] Brian: I'll talk about two things and I think the first is that Cohere has a platform which we call Unify, but we have a singular platform that can be used in two different ways. And this is unique in this marketplace. Traditionally, you'll have a platform and a vendor will come in and then they'll have their own clinical staff reviewing cases that don't approve. So we do that model, a delegated model.
[32:05] We also have the platform as a platform as a service model where a health plan can keep their clinicians in house doing reviews, put our platform in the front end, again, auto approve a significant portion of cases and then if any case does not auto approve goes to their clinicians for review. So having those two options is unique in the marketplace. And so that's one thing that we've seen is sort of a win and that plans will start with one and go to the other and they have the opportunity to meet the plan where they are in terms of their process.
[32:34] That's one I think the unique thing about us. And the second thing is the use of of AI. Obviously everybody throws that term around, but you know, we are actually using AI and truly it's machine learning and data analysis that we're using. We call it AI where we actually do use machine learning to read the documents that are provided to us. So typically that's either done manually or the other form that's been used and sort of the the standard in the industry now is there'll be a form that a staff person fills out answering clinical questions.
[33:04] Based on those answers, you get approval or not. What we've done away with most of the clinical questions and instead use the machine learning models to read the documents and try to satisfy the criteria that way. So it's more accurate. We saw that with the assessment question forms, the error rates could be up to about 30% where the answers to the questions were not supported in the clinical documentation.
[33:24] And so I think those two things, again, responsible use of AI, what we call the twin engine model and having is unique in the industry. and I will mention that again, AI is used to speed up approval for appropriate care and is never used to deny care. Any denial of care goes to a physician. And physicians are the only ones that ever do that.
[33:45] Tim: That's great. I mean, I will say I've been very impressed learning about the company and how technology is being used in a like really purpose fit way and like under physician guidance as well in in terms of making an impact on patient care and costs and quality and maybe physician burnout and I think there's a lot of advantages. I think it's a very physician-friendly approach, which I think we all love to see.
[34:09] I thought we could close out with one last question that I know that Paul and Trevor and I all always get, you know, reach outs from physicians who are interested in doing something beyond clinical practice. And I'm sure you do as well. And I'd be curious to know what advice you have for physicians who may be interested in following your example to make an impact within industry, you know, a little larger impact on healthcare. So I'm just curious to hear your thoughts there.
[34:35] Brian: Yeah, I think a couple of things. And first is not to be afraid to take that first step even when you're in practice to get involved with activities outside. You know, at some time we've all thought that health plans were our adversaries. They have their their pluses and minuses, but get to know them and because there are good people there that really are interested in making sure that the members get good care.
[34:55] So whether it's health plans or other industry, don't be afraid to get involved and learn what's going on outside because there are so many opportunities outside of clinical practice. It was amazing to me when I got into this to see how many physicians are out there on the, you know, I call the business side of health care. So make that first step, you know, get your foot in the door, do something just to learn about it.
[35:14] The other thing that's impressed me with the physicians that I've met outside of clinical practice is they enjoyed clinical practice, but they felt like when they got into some of these other roles, they were actually able to impact a larger number of patients in a shorter period of time. You know, when we practice, we have a very good effect on one patient at a time. And that's rewarding and it's very meaningful and very important. But a lot of folks feel that once they're beyond their clinical days, they can have a greater impact on a larger number of patients in some of these roles that we've talked about.
[35:44] It's a black box. I don't have an MBA. There are physician MBA programs you can get to. It's on the job training and trust me. Everybody in industry and healthcare, if they're not doctors, they do not know what we do. We have, we have that unique perspective of we've been there treating patients and really only ones that have that perspective and it's valuable.
[36:04] Paul: Dr. Brian Covino from Cohere Health. Thanks for joining us on Health Tech Remedy.
[36:07] Brian: Thank you guys. Enjoy it.
