June 3, 2025 • 28 mins
In Part 2 of our powerful conversation with David Contorno, president and founder of ePowered Benefits, we go beyond the strategies and structures of health plan design—diving into the real-life struggles that are shaping smarter, more compassionate solutions.
Host David A. Saltzman and David Contorno discuss the realities of scaling direct primary care, creative ways to bridge care gaps, and the challenges of educating employers and advisors about fiduciary responsibility. But the heart of this episode is personal: David shares how his own battles with chronic pain and mental health have transformed his perspective—and the way he builds health plans.
The conversation uncovers the hidden crisis of mental health in the workforce, the need for more accessible and innovative care models, and the legacy that disruption can leave when leaders dare to do things differently.
If you missed Part 1, catch it now for the story of smart plan solutions and shifting structures.
🎧 Listen to Part 1 now: https://www.buzzsprout.com/2045524/episodes/17232879
📺 Watch Part 1 on YouTube: https://youtu.be/rYP7-z8WD0A
🔑 Key Takeaways from This Episode
- Direct Primary Care & Beyond: How scaling DPC and innovative provider relationships are breaking down care deserts.
- Cash Pay Pathways: Why starting with cash pay—and embedding it into employer plans—can dramatically change access and cost.
- Fiduciary Responsibility: Why ignoring smarter plan options is a risk for employers, and what needs to change for true accountability.
- Educating for Change: How complexity and legacy promises are barriers, and what it really takes to shift mindsets.
- The Mental Health Undercurrent: David’s raw account of dealing with chronic pain, mental health stigma, and his personal journey toward healing—including non-traditional therapies like virtual support and psychedelic treatment.
- A Legacy of Empathy: Why the next wave of health plan design must address the whole person—physically and mentally—and how employer-sponsored plans can help lead the way.
⏱️ In This Episode
00:00 Introduction and Guest Welcome
00:54 Scaling Direct Primary Care (DPC)
01:33 Challenges and Solutions in DPC
03:19 Employer and Provider Perspectives
07:50 Cash Pay and Reference-Based Pricing
17:47 Mental Health and Innovative Solutions
25:56 Closing Thoughts and Personal Reflections
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Plan design has evolved beyond things like
reference-based pricing andother first-generation
alternatives.
What's new, what's coming downthe pike, and how has a personal
experience informed one of ourindustry's foremost disruptors?
We'll find out on this episodeof Shift Shapers.
Speaker 2 (00:18):
Change either energizes or paralyzes.
The choice is yours.
Energizes or paralyzes, thechoice is yours.
This is the Shift Shaperspodcast, bringing the employee
benefits industry interviewswith individuals and companies
who are shaping the industryshifts.
And now here's your host, DavidSaltzman.
Speaker 1 (00:40):
And to help us answer that question, we've invited
David Contarno, president andfounder of ePower Benefits.
Welcome, david.
Hi, david, thanks for having me.
Oh, it's our pleasure.
Thanks for being on the podcast.
Speaker 3 (00:51):
I'm honored.
Thanks for having me.
Speaker 1 (00:53):
It's our pleasure.
We've talked a lot and frequentlisteners to the program know
that I'm a huge advocate fordirect primary care.
I think I may have written myfirst column about it 15 years
or more ago in Life InsuranceSelling Magazine, which doesn't
exist any longer.
How do you scale that?
Because we have a paucity ofDPC practices, although the docs
(01:15):
who are in it and do it welllove it, because that's why they
went to medical school was topractice that way, not to deal
with all the malarkey of theinsurance carriers.
But we also have DPC desertsand lots of them.
So how as attractive as thatsounds and as much sense as it
makes and it certainly makessense how do you scale it?
Speaker 3 (01:34):
Well, I will tell you , those deserts are getting
smaller and far, far lessfrequent than they used to be.
As a matter of fact, I wouldargue, the only place where we
truly from a reasonablestandpoint and listen, some
employees' expectations are justnot reasonable, and I'll
explain what I mean by that in asecond was in Grand Forks,
(01:55):
north Dakota.
There was nobody for hundredsof miles, and there are some
really fantastic either mobileunits or virtual DPC options
that are almost as good as thein-person, and I want to
segregate that from telemedicine.
Virtual DPC is you're going toestablish a relationship with a
doctor.
(02:15):
You're going to reach the samedoctor every time, and when
something needs to be done inperson, like they need to listen
to your chest or they need todraw blood, they're going to
coordinate with someone locallyon your behalf to get that part
done.
It's not ideal.
For a lot of people, especiallymy generation and older, they
prefer that in person, but it'sactually relatively rare.
So let's talk about there areless DPCs than there are
(02:38):
traditional primary care doctors.
For sure.
One of the things that I neversaw occurring in my career that
brings me a lot of satisfactionis when I happen to come across
an employer that has enoughemployees or patients in an area
where I can convert afee-for-service provider and
help them open their own DPCpractice.
And now I'm actually improvingthe lives of doctors, which is
(03:00):
not anything I ever foresaw asbeing part of my career in this
industry.
Speaker 1 (03:03):
Well, and that's a back to the future thing, I mean
, if you go all the way back toplaces like Kaiser, it was
onsite and nearsite.
It was clinic-based, which Iguess is probably a distant
cousin to direct primary care.
Speaker 3 (03:14):
Yeah, and listen.
There are some brokers outthere that regularly work with
employers that can do onsiteclinics.
We've done a few Most of myemployers.
They can't justify it.
They either maybe share aclinic if there are a few
employers in the area or it'sjust not an option for them.
But let's pretend for a minutethat their traditional primary
care doctor is 10 minutes downthe road and the closest DPC is
(03:36):
an hour away.
Well, you have an 11 o'clockappointment with your primary
care doctor.
Now let's assume that youcalled because you were sick.
It's what.
An average of 17, 18, 19 daysto even get that appointment.
So you're waiting two to threeweeks before you even get that
appointment.
But you show up for your 11o'clock appointment and what
happens?
You're there for, let's say, aurinary tract infection, but
(03:57):
you're sitting in a waiting roomfull of sick people and it's 45
minutes past your appointmenttime.
You're 45 minutes past yourappointment time.
You finally get called into theexam room.
You wait in the exam room foranother 10 or 15 minutes.
The door opens and who walks in?
Not your doctor, but a nursepractitioner, a physician's
assistant.
They do the intake, then theytake it, they go out, and then
now, an hour and a half pastyour appointment time, if you're
lucky, your doctor finallywalks in.
(04:18):
You get 7 to 11 minutes andthen you're out the door.
So it's a total, includingtravel time, of a two, two and a
half hour process and you'vespent seven to 11 minutes with
your doctor.
Versus a direct primary careoffice that's an hour away.
You spend an hour driving therealthough you'll have to
physically go there far lessoften than you would a
traditional primary care doctorbut you spend the hour getting
(04:38):
there.
You don't sit in the waitingroom at all.
You get brought right back intothe exam room, you get as much
time as you need with yourdoctor and then you drive back.
You're probably back to theoffice in almost the same amount
of time as you were before, butnow you've spent 30, 45 minutes
, maybe even an hour, with yourdoctor.
You've gotten real, genuinecare and, by the way, you've
paid no copay, no deductible,nothing out of your pocket.
Speaker 1 (05:00):
It's the real, genuine care piece that I think
really matters.
Not too many years ago I was upin New England and I had a
direct primary care doc in York,maine of all places who was
fantastic and who kept me fromhaving a huge medical procedure
called a Whipple procedurebecause the geniuses at MassGen,
even though there were nocancer cells, thought that I had
(05:22):
pancreatic cancer and Petersaid I don't know what you've
got, but I know your history.
I know it's not pancreaticcancer and it took him four
months to figure out what I hadand it was easily treated with
some long-term steroids.
If I had been in a regularphysician's or what we consider
a regular physician's office, Iwould have been on the operating
table at Mass General.
Speaker 3 (05:42):
Yep, well, and I want to say, none of what I just
said is either recent, new orgame-changing.
But when the doctor isdirecting the care from the
(06:04):
beginning and, more importantly,it's a provider that has more
time than traditionalfee-for-service providers and
more of an awareness of the paththey're sending the patient on
from a clinical and a financialperspective, that brings you an
opportunity to bring educationto that provider, to help direct
that patient down a path wherenot only are the clinical
outcomes better, but that cashpay environment exists.
(06:25):
And so we work with vendors,with partners within our plan
that are able to pay providerssame day, help us negotiate
bundled procedures in the eventthat we don't already have one.
So in the path of thismethodology and we can use it in
the traditional RBP environmenttoo.
(06:45):
It's just a little bit moreresistant and you don't get the
same uptick.
But imagine for a minute myback is hurting.
I go to my primary carephysician.
First thing is we try a coupleof things non-surgical.
But as soon as they determinethat, hey, it looks like surgery
is necessary and I'm not asurgeon, they're able to refer
me to a surgeon that we havegiven them, armed them with
(07:08):
technology in their hands.
That allows them to perhapsfind someone they're already
familiar with.
But if not, they can actuallylook up providers that are
operating in a high qualityenvironment where we can show
them what their outcomes arecompared to their peers in terms
of mortality, morbidity,readmission, reinfection rates
(07:30):
and, at the same time, havealready agreed to accept a cash
pay price bundle.
And then you pay them quickly.
You have to have a mechanism.
One of the mechanisms we use iswhere the member can actually
walk in with what appears to bea debit or credit card on their
phone and actually pay for theservice the same day.
(07:50):
From a reference-based pricingperspective, we have had
employees who are turned away atpoint of service.
I'm sure that every singleadvisor, if they're using
reference-based pricing, has hada provider where the patient
shows up and the billing officesays you're at a network with us
, we don't take plans that wedon't participate with.
So please go and have anothergood day.
(08:11):
But imagine for a minute ifthere was a way, even in the
reference-based pricing planwithout DPC because again some
employers are hesitant to forceemployees to change their
primary care physician If youwere able to go and say I need
to see an orthopedic surgeon.
Even I want to see thisspecific orthopedic surgeon.
(08:32):
And then you had a team ofpeople that immediately reach
out and say, hey, what's thebest cash pay price you can do
and can we schedule anappointment for this patient?
And what comes back, usuallywithin a day, to that patient is
hey, your appointment isscheduled with this provider
that you requested on the dateand time that you said you were
available.
When you go, please go showthis debit card.
And we're now paying on averagefor an office visit consult, a
(08:54):
hundred bucks total and the planpays a hundred percent.
The member pays nothing, butfrom the provider perspective,
they're getting paid cash sameday point of service, even at
the office visit level, whereasso much of my quote disruptive
time.
I was waiting to capture that atthe time of pre-cert of some
sort of significant procedure orimaging.
(09:15):
It's so much harder to changethe flow at that point.
And so my experience with mysurgery said hey, if you start
with cash pay from the beginning, if there's a way to do that,
but still embed it intoemployer's plan, you're going to
get people who get betteraccess to better care quicker,
for nothing out of their pocketand for less money, oftentimes
(09:36):
even than reference-basedpricing out of the plan's pocket
.
It's one of several things thatis rapidly evolving.
Cash pay has been there for awhile.
That's not what is differenthere.
It's one of several things thatis rapidly evolving.
Cash pay has been there for awhile.
That's not what is differenthere.
It's capturing that pathwayfrom the very beginning from the
office visit, consult or beforewhen it's being scheduled.
(09:56):
That's really what's startingto change this and still
allowing employees to havechoice.
Speaker 1 (10:02):
Well, and you raised an issue tangentially a little
while ago, and that is employersor plans, fiduciary duty.
One might argue that to not dosomething like this when
presented is a pretty you know,it's a pretty bad thing to do
straightforward breach of theirduty to the plan.
Speaker 3 (10:21):
It's much like the 401k.
I mean, imagine for a minute ifsome employer took a specific
Vanguard fund and agreed thattheir employees would pay a 5%
management fee when some otheremployer was using the same
exact Vanguard funds and payinga 1% management fee for their
employees.
There would be a breach offiduciary responsibility.
There they're getting the samething, but one employer's
(10:43):
employees are paying a lot morefor it than the other.
That's a breach of fiduciaryresponsibility.
But that happens in healthcareall the time, and let's not
forget the law that doesn'tallow that.
On the 401k side it's notsimilar to the law on the
healthcare side.
It is the exact identical lawand it's not being enforced.
That's the problem.
(11:04):
And so one of the things that Ihope and actually, interestingly
enough, just last night I wasat a small function with the
governor of North Carolina.
I'm pretty close with ourattorney general as well, and
we're looking to makeenforcement of this, or
revocation of nonprofit statusfor hospitals that aren't
embracing this, as well asenforcement at the employer
level, a much more real reality.
(11:27):
And that happened on the 401kside.
What was it now?
10, maybe 12 years ago?
And it radically changed boththe transparency and the fees
that employees are paying intheir 401ks.
It needs to just be enforced.
Nothing needs to change, itjust needs to be enforced and I
think it would bring that levelof responsibility and awareness
to employers.
How important it is.
Speaker 1 (11:45):
The thing that needs to change is perhaps more
difficult to change, which isgetting both advisors and I know
you work with a ton of advisorsgetting advisors to understand
this and understand themechanics of implementing it,
and then getting an employer whothinks, okay, anything new is
weird and this is like reallyweird because they already have
(12:06):
insurance.
Why would we get insurance?
Getting them able to explainthis so that mere mortals can
understand how do you do that?
Speaker 3 (12:17):
You know, I consider myself to be a pretty strong
communicator and orator, and yetI still struggle to condense
this down.
It has been, I think,intentionally made to seem
complex.
But if you really boil it downto what it is that we do in
almost every solution we bring,is we're really just changing
(12:41):
who's cutting the check and howthe amount of the check is
determined and who it'sdetermined to go to.
I mean, it's really that simple.
But getting employers tounderstand and, I think at the
HR level, getting them to helpemployees understand this even
more so this isn't being done tothem, this is being done for
them.
(13:01):
I think what's harder for me toovercome than the education that
needs to go around this is thislegacy of false promises that
both brokers like myself andcarriers have made over the
years that have not resulted inthe impact that they said it
would result in, whether it'swellness programs, hras, hsas,
consumer-driven health plans.
I mean programs, hras, hsas,consumer-driven health plans.
I mean the list goes on and onand on.
(13:23):
Icras now boggles my mindbecause, again, an ICRA is not
addressing the money coming outof the plan.
And even with the governor lastnight in North Carolina I said
and he's a Democrat.
So I used how Biden lowered thecost of insulin for seniors,
right, and I said let me tellyou Josh Stein is his name Biden
(13:43):
did not lower the cost ofinsulin.
What he did was he lowered theout-of-pocket that Medicare
beneficiaries pay.
But who picks up the rest ofthat?
Well, medicare, whichultimately is the taxpayers,
which ultimately is the verysame people that they're trying
to lower the out-of-pocket.
It's not about who's footingthe bill.
It's about why is the bill somuch?
(14:04):
And these politicians don't getthat, or at least they don't
think that's what's going tospeak to their constituency.
Speaker 1 (14:14):
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And now back to our conversation.
Uwe Reinhart talked about thisall the time when he was at
Princeton.
He called it hydraulic medicaleconomics and he said look, if
you've got a U-shaped tube andit's got water in it, it and you
put pressure on one side of thetube, the water is going to go
up the other side of the tube,but the amount of water in the
(16:08):
tube hasn't changed, it's justbeen redistributed.
And I think that that seems tome to be the hurdle that we've
got as an industry to get folksto understand.
Where you rightly came into thestory some time ago was what
should be insured.
That is to say, you know, I'man old TPA, so if I've said this
(16:28):
once, I've said it a zilliontimes there's only three things
you can do with risk you cantake it, you can share it or you
can give it away.
If you start with what riskshould be given away and what
risk should not, because each ofthose risks has a different
cost and different outcomes, youstand a chance.
I mean, is that the approachthat you guys take when you try
(16:49):
to educate folks?
Speaker 3 (16:50):
It has to be.
And then you also need toeducate them that paying less
for health care doesn't reducethe quality of care.
As a matter of fact, in manycases higher quality care costs
less money.
There's an inverse relationship, and that does require
education because it doesn'tapply in most other things.
You pay more for a car, youbetter get a better car.
You pay more for a house youget a better house.
But in healthcare we find themetric that drives both cost and
(17:13):
outcomes is frequency the morefrequently that they do a
particular procedure, the betterthey do it, the more
efficiently they do it.
And even within the specialties, we find subspecialties.
I mean I don't want to get handsurgery from an orthopedic
surgeon who mostly does feet andankles, and so there's a lot of
education that goes into it.
But helping employersunderstand not that they need to
(17:34):
personally be responsible forputting at least benefit design
that incentivizes those outcomes, but putting the right
resources in place and or rulesand regulations is a
responsibility and anopportunity that they have Now.
Having said all that and I knowwe're over time on your typical
podcast length there wasanother side effect of this that
(17:55):
really does not get addressed,and that was the mental health
side of things.
A lot of people struggle withmental health in general, but I
can tell you personally, whenyou're dealing with chronic pain
and major medical issues thatare either a direct or an
indirect result of that chronicpain, not only does that have
(18:17):
massive mental health effects,but every time I tried something
to solve that sciatic leg pain,I think, naturally I became
hopeful that it was going towork, and every time it didn't
work, there was thisdisappointment that I didn't
even understand was causing adegradation of my mental health.
(18:37):
It was impacting bothphysically and mentally, my
ability to run a business, to bea resource to my clients, to be
a husband to my wife, to be aparent to my children and even
under the best of circumstances,even with a plan that tries to
cover as much mental health aspossible….
Admitting, you need mentalhealth.
There's a stigma.
(18:59):
Accessing mental health issometimes even more difficult
than getting access totraditional medical
professionals and then gettingthe right level and the right
type of care and so anotherthing and when you implement
plans that fundamentally lowercosts for employers, it frees up
a lot of resources to put intoother things.
(19:20):
One of the things that I say toemployers they often ask me
about wellness programs becauseLord knows it's been spoken
about for so long, and I say tothem wellness program is not
going to save you money.
Just ask Al Lewis.
He's offered millions ofdollars to companies that can
prove it.
Not one has.
But if we can save you money,then you can use some of that
money to invest in the wellnessof your employees and I think
(19:44):
that's the way it should belooked at.
And when it comes to mentalhealth, most people think
there's two options there'sgoing to see a psychiatrist or
psychologist once a week orthere's going inpatient.
And those are the two options.
And getting to that outpatientmental health provider
especially if you have atraditional health plan and have
the thinking that the only wayI can get healthcare is by going
(20:04):
through the health plan, you'regoing to struggle to find a
provider that accepts it, isaccepting new patients and can
see you in any reasonable amountof time and, more importantly,
is well-educated andwell-trained.
No question reached out to alot of traditional types of care
(20:39):
and I don't want to speak tothose traditional types of care.
I want to speak to twonon-traditional types of care
for a minute.
The first and I'm going tomention this company by name
because I don't know of anyoneelse that does it, but I believe
there's a level of carenecessary that is somewhere
between doing nothing and seeinga psychiatrist or a
(21:02):
psychologist.
And there's a company out thereand I will disclose that I'm on
the advisory board because Ibelieve in it called Shoulder,
and it's spelt like a shoulderbut without the U, and they're
trained.
They're not psychiatrists orpsychologists trained, but they
are trained, not psychiatristsor psychologists trained, but
they are trained.
And it's that level of carewhich, believe it or not, is the
(21:24):
majority of care.
That is, sub-psychiatry, butabove, speaking to your friend
and you develop a relationshipwith this person, you speak with
them regularly.
It's virtual, no-transcriptHealth Parity Act, so they're
(22:12):
covering mental health now, butthis is a way that's more
accessible, more applicable tomore people and less expensive,
and so I would recommend maybeother solutions will develop,
but Shoulder out there, is agreat resource and I know they'd
be willing to speak to anyemployer or advisor who's
interested in finding out moreabout that.
Speaker 1 (22:31):
Well, I mean they have to cover it, but when you
start doing mental health parityreports, one of the things that
is the most predominant pointof failure is access to
providers.
Speaker 3 (22:41):
Yeah, and they may have a network which meets
network adequacy and they maycover it the same as they cover
a primary care physician'soffice.
It may meet all the rules ofmental health parity.
But if you can't get in to seethat provider, it's much like
when I say to oncologists whosay I shouldn't have to worry
about the cost of care, and Isay I completely disagree,
because if you prescribe atreatment to save someone's life
(23:03):
from cancer and they can'tafford it, why did you prescribe
it anyway?
There's no point.
And so, yeah, there's a lot ofreasons to do that.
Again, sharing a personal story,I try to access and I have
resources more more than many toaccess some of these more
traditional mental healthsolutions and while they
(23:24):
definitely had some benefit,there is a solution that is
being talked about but doesn'twork for everybody, more and
more.
But what I was surprised as Idid research, was the clinical
research that's already beendone behind this, including by
our own government, and that ispsychedelic therapy.
I am not a holistic frou-frouhippie, you know, make my own
(23:50):
dream catcher and have my ownwind chime guy.
That's not the type of personthat I am Watch it.
Speaker 1 (23:55):
Watch it junior.
That was my generation.
Speaker 3 (23:59):
But anyone listening to this.
I have undergone psychedelictreatment and it has changed my
life.
It has been a reset to a timeof brain processing that was
certainly pre the 18 months ofthis chronic pain and other
(24:21):
things that I went through, buteven addressed things that
existed earlier on that I didn'tknow about.
And there's a woman out there.
Her name is Sherry Race.
She owns a company calledEnthea that has programs to
bring this type of treatmentinto employer plans.
From a personal perspective, Iwas really struggling with
(24:43):
mental health issues over thelast year and a half and again I
did all the traditional stuffand it had some level of help.
I don't want to claim it didnothing, but for anyone, and I
think in particular anxiety,depression, substance abuse,
ptsd and even now Parkinson'sand dementia, there are
therapies out there that somepeople might consider fringe or
(25:04):
untested or unproven, some ofwhich are legal here in the US,
some of which are not quite yetapproved, and I just want to
make people more aware or atleast more willing to do some
research into some of thesepsychedelics, and there are ones
.
Just to name a few, there'spsilocybin, there's MDMA,
there's ketamine Ketamine is themost commonly used in the
(25:26):
United States, but there areother ones out there too that
aren't legal here in the US.
But it's something that I wantto be a part of making more
available to more people,especially through the employer
sponsored plan, putting theright people in place, making it
sure done in the right way, inan appropriate way, in a
clinical way, for the rightperson at the right time.
(25:47):
But it's something that wedon't.
We barely talk about mentalhealth, let alone some of these
other things, and I think wehave a mental health crisis.
It's not just in the US.
I think it's around the world.
I think it's particularly badin the US, but imagine for a
minute if you're able to createa health plan that is doctor-led
not carrier-led or TPA-led, butdoctor-led.
(26:08):
That incorporates better accessto a better variety of mental
health from an employerperspective.
(26:29):
So, from an employer perspective, think about what that does for
your employee, and it's easy tomeasure claims dollars spent on
an employee prescription,dollars spent on an employee,
days they've taken time off,that their finances are a mess.
They can't lose their job,right if they're under financial
pressure, which so manyAmericans are, so they're
desperate to show up every dayand be at that job, but how good
of an employee are they being?
And then, when they get home,how good of a parent or a spouse
(26:52):
are they being?
And this is something we justdon't talk.
We know it's the undercurrentthere, but we're so busy
addressing the most expensivedrugs on the drug list or the
most expensive procedures or themost expensive chronic
conditions we forget about notonly these other things that can
dramatically improve thequality of life but in many
(27:13):
cases can prevent the need forthose large things, and so I
encourage anyone listening tothis to, even if it's on their
own, explore their own mentalhealth options, recognize and
not be embarrassed.
I have struggled with mentalhealth.
Let me say that again.
I have really struggled withmental health and there is help
out there, and if we can bringthis into employer plans, that
(27:37):
might be the most game-changinglegacy I could possibly leave on
this industry, which is what Iwant to do.
Speaker 1 (27:43):
And that is an awesome place to leave our
conversation for today.
David Conterno, old friend,president and founder of ePower
Benefits.
David, thank you for yourinsight and for sharing your
personal stories with us.
Speaker 3 (27:54):
It was my pleasure.
And anyone that wants to reachout, even on a personal level,
it's easy to find me that wantsto reach out, even on a personal
level, it's easy to find me.
Speaker 1 (28:05):
I want to give a quick shout out to our sponsor
and our producer, hatcher Media.
Hey, if you need podcastproduction or professional
graphic design, josh Hatcher isthe expert to contact For more
information.
Visit him at hatchermedianet.
That's H-A-T-C-H-E-R Media dotnet.
Speaker 2 (28:23):
This Shift Shapers podcast is copyrighted content
and may not be reproduced inwhole or in part without the
express written permission ofShift Shapers Solutions LLC.
Copyright 2024.
Plan design has evolved beyond things like
reference-based pricing andother first-generation
alternatives.
What's new, what's coming downthe pike, and how has a personal
experience informed one of ourindustry's foremost disruptors?
We'll find out on this episodeof Shift Shapers.
Speaker 2 (00:18):
Change either energizes or paralyzes.
The choice is yours.
Energizes or paralyzes, thechoice is yours.
This is the Shift Shaperspodcast, bringing the employee
benefits industry interviewswith individuals and companies
who are shaping the industryshifts.
And now here's your host, DavidSaltzman.
Speaker 1 (00:40):
And to help us answer that question, we've invited
David Contarno, president andfounder of ePower Benefits.
Welcome, david.
Hi, david, thanks for having me.
Oh, it's our pleasure.
Thanks for being on the podcast.
Speaker 3 (00:51):
I'm honored.
Thanks for having me.
Speaker 1 (00:53):
It's our pleasure.
We've talked a lot and frequentlisteners to the program know
that I'm a huge advocate fordirect primary care.
I think I may have written myfirst column about it 15 years
or more ago in Life InsuranceSelling Magazine, which doesn't
exist any longer.
How do you scale that?
Because we have a paucity ofDPC practices, although the docs
(01:15):
who are in it and do it welllove it, because that's why they
went to medical school was topractice that way, not to deal
with all the malarkey of theinsurance carriers.
But we also have DPC desertsand lots of them.
So how as attractive as thatsounds and as much sense as it
makes and it certainly makessense how do you scale it?
Speaker 3 (01:34):
Well, I will tell you , those deserts are getting
smaller and far, far lessfrequent than they used to be.
As a matter of fact, I wouldargue, the only place where we
truly from a reasonablestandpoint and listen, some
employees' expectations are justnot reasonable, and I'll
explain what I mean by that in asecond was in Grand Forks,
(01:55):
north Dakota.
There was nobody for hundredsof miles, and there are some
really fantastic either mobileunits or virtual DPC options
that are almost as good as thein-person, and I want to
segregate that from telemedicine.
Virtual DPC is you're going toestablish a relationship with a
doctor.
(02:15):
You're going to reach the samedoctor every time, and when
something needs to be done inperson, like they need to listen
to your chest or they need todraw blood, they're going to
coordinate with someone locallyon your behalf to get that part
done.
It's not ideal.
For a lot of people, especiallymy generation and older, they
prefer that in person, but it'sactually relatively rare.
So let's talk about there areless DPCs than there are
(02:38):
traditional primary care doctors.
For sure.
One of the things that I neversaw occurring in my career that
brings me a lot of satisfactionis when I happen to come across
an employer that has enoughemployees or patients in an area
where I can convert afee-for-service provider and
help them open their own DPCpractice.
And now I'm actually improvingthe lives of doctors, which is
(03:00):
not anything I ever foresaw asbeing part of my career in this
industry.
Speaker 1 (03:03):
Well, and that's a back to the future thing, I mean
, if you go all the way back toplaces like Kaiser, it was
onsite and nearsite.
It was clinic-based, which Iguess is probably a distant
cousin to direct primary care.
Speaker 3 (03:14):
Yeah, and listen.
There are some brokers outthere that regularly work with
employers that can do onsiteclinics.
We've done a few Most of myemployers.
They can't justify it.
They either maybe share aclinic if there are a few
employers in the area or it'sjust not an option for them.
But let's pretend for a minutethat their traditional primary
care doctor is 10 minutes downthe road and the closest DPC is
(03:36):
an hour away.
Well, you have an 11 o'clockappointment with your primary
care doctor.
Now let's assume that youcalled because you were sick.
It's what.
An average of 17, 18, 19 daysto even get that appointment.
So you're waiting two to threeweeks before you even get that
appointment.
But you show up for your 11o'clock appointment and what
happens?
You're there for, let's say, aurinary tract infection, but
(03:57):
you're sitting in a waiting roomfull of sick people and it's 45
minutes past your appointmenttime.
You're 45 minutes past yourappointment time.
You finally get called into theexam room.
You wait in the exam room foranother 10 or 15 minutes.
The door opens and who walks in?
Not your doctor, but a nursepractitioner, a physician's
assistant.
They do the intake, then theytake it, they go out, and then
now, an hour and a half pastyour appointment time, if you're
lucky, your doctor finallywalks in.
(04:18):
You get 7 to 11 minutes andthen you're out the door.
So it's a total, includingtravel time, of a two, two and a
half hour process and you'vespent seven to 11 minutes with
your doctor.
Versus a direct primary careoffice that's an hour away.
You spend an hour driving therealthough you'll have to
physically go there far lessoften than you would a
traditional primary care doctorbut you spend the hour getting
(04:38):
there.
You don't sit in the waitingroom at all.
You get brought right back intothe exam room, you get as much
time as you need with yourdoctor and then you drive back.
You're probably back to theoffice in almost the same amount
of time as you were before, butnow you've spent 30, 45 minutes
, maybe even an hour, with yourdoctor.
You've gotten real, genuinecare and, by the way, you've
paid no copay, no deductible,nothing out of your pocket.
Speaker 1 (05:00):
It's the real, genuine care piece that I think
really matters.
Not too many years ago I was upin New England and I had a
direct primary care doc in York,maine of all places who was
fantastic and who kept me fromhaving a huge medical procedure
called a Whipple procedurebecause the geniuses at MassGen,
even though there were nocancer cells, thought that I had
(05:22):
pancreatic cancer and Petersaid I don't know what you've
got, but I know your history.
I know it's not pancreaticcancer and it took him four
months to figure out what I hadand it was easily treated with
some long-term steroids.
If I had been in a regularphysician's or what we consider
a regular physician's office, Iwould have been on the operating
table at Mass General.
Speaker 3 (05:42):
Yep, well, and I want to say, none of what I just
said is either recent, new orgame-changing.
But when the doctor isdirecting the care from the
(06:04):
beginning and, more importantly,it's a provider that has more
time than traditionalfee-for-service providers and
more of an awareness of the paththey're sending the patient on
from a clinical and a financialperspective, that brings you an
opportunity to bring educationto that provider, to help direct
that patient down a path wherenot only are the clinical
outcomes better, but that cashpay environment exists.
(06:25):
And so we work with vendors,with partners within our plan
that are able to pay providerssame day, help us negotiate
bundled procedures in the eventthat we don't already have one.
So in the path of thismethodology and we can use it in
the traditional RBP environmenttoo.
(06:45):
It's just a little bit moreresistant and you don't get the
same uptick.
But imagine for a minute myback is hurting.
I go to my primary carephysician.
First thing is we try a coupleof things non-surgical.
But as soon as they determinethat, hey, it looks like surgery
is necessary and I'm not asurgeon, they're able to refer
me to a surgeon that we havegiven them, armed them with
(07:08):
technology in their hands.
That allows them to perhapsfind someone they're already
familiar with.
But if not, they can actuallylook up providers that are
operating in a high qualityenvironment where we can show
them what their outcomes arecompared to their peers in terms
of mortality, morbidity,readmission, reinfection rates
(07:30):
and, at the same time, havealready agreed to accept a cash
pay price bundle.
And then you pay them quickly.
You have to have a mechanism.
One of the mechanisms we use iswhere the member can actually
walk in with what appears to bea debit or credit card on their
phone and actually pay for theservice the same day.
(07:50):
From a reference-based pricingperspective, we have had
employees who are turned away atpoint of service.
I'm sure that every singleadvisor, if they're using
reference-based pricing, has hada provider where the patient
shows up and the billing officesays you're at a network with us
, we don't take plans that wedon't participate with.
So please go and have anothergood day.
(08:11):
But imagine for a minute ifthere was a way, even in the
reference-based pricing planwithout DPC because again some
employers are hesitant to forceemployees to change their
primary care physician If youwere able to go and say I need
to see an orthopedic surgeon.
Even I want to see thisspecific orthopedic surgeon.
(08:32):
And then you had a team ofpeople that immediately reach
out and say, hey, what's thebest cash pay price you can do
and can we schedule anappointment for this patient?
And what comes back, usuallywithin a day, to that patient is
hey, your appointment isscheduled with this provider
that you requested on the dateand time that you said you were
available.
When you go, please go showthis debit card.
And we're now paying on averagefor an office visit consult, a
(08:54):
hundred bucks total and the planpays a hundred percent.
The member pays nothing, butfrom the provider perspective,
they're getting paid cash sameday point of service, even at
the office visit level, whereasso much of my quote disruptive
time.
I was waiting to capture that atthe time of pre-cert of some
sort of significant procedure orimaging.
(09:15):
It's so much harder to changethe flow at that point.
And so my experience with mysurgery said hey, if you start
with cash pay from the beginning, if there's a way to do that,
but still embed it intoemployer's plan, you're going to
get people who get betteraccess to better care quicker,
for nothing out of their pocketand for less money, oftentimes
(09:36):
even than reference-basedpricing out of the plan's pocket
.
It's one of several things thatis rapidly evolving.
Cash pay has been there for awhile.
That's not what is differenthere.
It's one of several things thatis rapidly evolving.
Cash pay has been there for awhile.
That's not what is differenthere.
It's capturing that pathwayfrom the very beginning from the
office visit, consult or beforewhen it's being scheduled.
(09:56):
That's really what's startingto change this and still
allowing employees to havechoice.
Speaker 1 (10:02):
Well, and you raised an issue tangentially a little
while ago, and that is employersor plans, fiduciary duty.
One might argue that to not dosomething like this when
presented is a pretty you know,it's a pretty bad thing to do
straightforward breach of theirduty to the plan.
Speaker 3 (10:21):
It's much like the 401k.
I mean, imagine for a minute ifsome employer took a specific
Vanguard fund and agreed thattheir employees would pay a 5%
management fee when some otheremployer was using the same
exact Vanguard funds and payinga 1% management fee for their
employees.
There would be a breach offiduciary responsibility.
There they're getting the samething, but one employer's
(10:43):
employees are paying a lot morefor it than the other.
That's a breach of fiduciaryresponsibility.
But that happens in healthcareall the time, and let's not
forget the law that doesn'tallow that.
On the 401k side it's notsimilar to the law on the
healthcare side.
It is the exact identical lawand it's not being enforced.
That's the problem.
(11:04):
And so one of the things that Ihope and actually, interestingly
enough, just last night I wasat a small function with the
governor of North Carolina.
I'm pretty close with ourattorney general as well, and
we're looking to makeenforcement of this, or
revocation of nonprofit statusfor hospitals that aren't
embracing this, as well asenforcement at the employer
level, a much more real reality.
(11:27):
And that happened on the 401kside.
What was it now?
10, maybe 12 years ago?
And it radically changed boththe transparency and the fees
that employees are paying intheir 401ks.
It needs to just be enforced.
Nothing needs to change, itjust needs to be enforced and I
think it would bring that levelof responsibility and awareness
to employers.
How important it is.
Speaker 1 (11:45):
The thing that needs to change is perhaps more
difficult to change, which isgetting both advisors and I know
you work with a ton of advisorsgetting advisors to understand
this and understand themechanics of implementing it,
and then getting an employer whothinks, okay, anything new is
weird and this is like reallyweird because they already have
(12:06):
insurance.
Why would we get insurance?
Getting them able to explainthis so that mere mortals can
understand how do you do that?
Speaker 3 (12:17):
You know, I consider myself to be a pretty strong
communicator and orator, and yetI still struggle to condense
this down.
It has been, I think,intentionally made to seem
complex.
But if you really boil it downto what it is that we do in
almost every solution we bring,is we're really just changing
(12:41):
who's cutting the check and howthe amount of the check is
determined and who it'sdetermined to go to.
I mean, it's really that simple.
But getting employers tounderstand and, I think at the
HR level, getting them to helpemployees understand this even
more so this isn't being done tothem, this is being done for
them.
(13:01):
I think what's harder for me toovercome than the education that
needs to go around this is thislegacy of false promises that
both brokers like myself andcarriers have made over the
years that have not resulted inthe impact that they said it
would result in, whether it'swellness programs, hras, hsas,
consumer-driven health plans.
I mean programs, hras, hsas,consumer-driven health plans.
I mean the list goes on and onand on.
(13:23):
Icras now boggles my mindbecause, again, an ICRA is not
addressing the money coming outof the plan.
And even with the governor lastnight in North Carolina I said
and he's a Democrat.
So I used how Biden lowered thecost of insulin for seniors,
right, and I said let me tellyou Josh Stein is his name Biden
(13:43):
did not lower the cost ofinsulin.
What he did was he lowered theout-of-pocket that Medicare
beneficiaries pay.
But who picks up the rest ofthat?
Well, medicare, whichultimately is the taxpayers,
which ultimately is the verysame people that they're trying
to lower the out-of-pocket.
It's not about who's footingthe bill.
It's about why is the bill somuch?
(14:04):
And these politicians don't getthat, or at least they don't
think that's what's going tospeak to their constituency.
Speaker 1 (14:14):
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And now back to our conversation.
Uwe Reinhart talked about thisall the time when he was at
Princeton.
He called it hydraulic medicaleconomics and he said look, if
you've got a U-shaped tube andit's got water in it, it and you
put pressure on one side of thetube, the water is going to go
up the other side of the tube,but the amount of water in the
(16:08):
tube hasn't changed, it's justbeen redistributed.
And I think that that seems tome to be the hurdle that we've
got as an industry to get folksto understand.
Where you rightly came into thestory some time ago was what
should be insured.
That is to say, you know, I'man old TPA, so if I've said this
(16:28):
once, I've said it a zilliontimes there's only three things
you can do with risk you cantake it, you can share it or you
can give it away.
If you start with what riskshould be given away and what
risk should not, because each ofthose risks has a different
cost and different outcomes, youstand a chance.
I mean, is that the approachthat you guys take when you try
(16:49):
to educate folks?
Speaker 3 (16:50):
It has to be.
And then you also need toeducate them that paying less
for health care doesn't reducethe quality of care.
As a matter of fact, in manycases higher quality care costs
less money.
There's an inverse relationship, and that does require
education because it doesn'tapply in most other things.
You pay more for a car, youbetter get a better car.
You pay more for a house youget a better house.
But in healthcare we find themetric that drives both cost and
(17:13):
outcomes is frequency the morefrequently that they do a
particular procedure, the betterthey do it, the more
efficiently they do it.
And even within the specialties, we find subspecialties.
I mean I don't want to get handsurgery from an orthopedic
surgeon who mostly does feet andankles, and so there's a lot of
education that goes into it.
But helping employersunderstand not that they need to
(17:34):
personally be responsible forputting at least benefit design
that incentivizes those outcomes, but putting the right
resources in place and or rulesand regulations is a
responsibility and anopportunity that they have Now.
Having said all that and I knowwe're over time on your typical
podcast length there wasanother side effect of this that
(17:55):
really does not get addressed,and that was the mental health
side of things.
A lot of people struggle withmental health in general, but I
can tell you personally, whenyou're dealing with chronic pain
and major medical issues thatare either a direct or an
indirect result of that chronicpain, not only does that have
(18:17):
massive mental health effects,but every time I tried something
to solve that sciatic leg pain,I think, naturally I became
hopeful that it was going towork, and every time it didn't
work, there was thisdisappointment that I didn't
even understand was causing adegradation of my mental health.
(18:37):
It was impacting bothphysically and mentally, my
ability to run a business, to bea resource to my clients, to be
a husband to my wife, to be aparent to my children and even
under the best of circumstances,even with a plan that tries to
cover as much mental health aspossible….
Admitting, you need mentalhealth.
There's a stigma.
(18:59):
Accessing mental health issometimes even more difficult
than getting access totraditional medical
professionals and then gettingthe right level and the right
type of care and so anotherthing and when you implement
plans that fundamentally lowercosts for employers, it frees up
a lot of resources to put intoother things.
(19:20):
One of the things that I say toemployers they often ask me
about wellness programs becauseLord knows it's been spoken
about for so long, and I say tothem wellness program is not
going to save you money.
Just ask Al Lewis.
He's offered millions ofdollars to companies that can
prove it.
Not one has.
But if we can save you money,then you can use some of that
money to invest in the wellnessof your employees and I think
(19:44):
that's the way it should belooked at.
And when it comes to mentalhealth, most people think
there's two options there'sgoing to see a psychiatrist or
psychologist once a week orthere's going inpatient.
And those are the two options.
And getting to that outpatientmental health provider
especially if you have atraditional health plan and have
the thinking that the only wayI can get healthcare is by going
(20:04):
through the health plan, you'regoing to struggle to find a
provider that accepts it, isaccepting new patients and can
see you in any reasonable amountof time and, more importantly,
is well-educated andwell-trained.
No question reached out to alot of traditional types of care
(20:39):
and I don't want to speak tothose traditional types of care.
I want to speak to twonon-traditional types of care
for a minute.
The first and I'm going tomention this company by name
because I don't know of anyoneelse that does it, but I believe
there's a level of carenecessary that is somewhere
between doing nothing and seeinga psychiatrist or a
(21:02):
psychologist.
And there's a company out thereand I will disclose that I'm on
the advisory board because Ibelieve in it called Shoulder,
and it's spelt like a shoulderbut without the U, and they're
trained.
They're not psychiatrists orpsychologists trained, but they
are trained, not psychiatristsor psychologists trained, but
they are trained.
And it's that level of carewhich, believe it or not, is the
(21:24):
majority of care.
That is, sub-psychiatry, butabove, speaking to your friend
and you develop a relationshipwith this person, you speak with
them regularly.
It's virtual, no-transcriptHealth Parity Act, so they're
(22:12):
covering mental health now, butthis is a way that's more
accessible, more applicable tomore people and less expensive,
and so I would recommend maybeother solutions will develop,
but Shoulder out there, is agreat resource and I know they'd
be willing to speak to anyemployer or advisor who's
interested in finding out moreabout that.
Speaker 1 (22:31):
Well, I mean they have to cover it, but when you
start doing mental health parityreports, one of the things that
is the most predominant pointof failure is access to
providers.
Speaker 3 (22:41):
Yeah, and they may have a network which meets
network adequacy and they maycover it the same as they cover
a primary care physician'soffice.
It may meet all the rules ofmental health parity.
But if you can't get in to seethat provider, it's much like
when I say to oncologists whosay I shouldn't have to worry
about the cost of care, and Isay I completely disagree,
because if you prescribe atreatment to save someone's life
(23:03):
from cancer and they can'tafford it, why did you prescribe
it anyway?
There's no point.
And so, yeah, there's a lot ofreasons to do that.
Again, sharing a personal story,I try to access and I have
resources more more than many toaccess some of these more
traditional mental healthsolutions and while they
(23:24):
definitely had some benefit,there is a solution that is
being talked about but doesn'twork for everybody, more and
more.
But what I was surprised as Idid research, was the clinical
research that's already beendone behind this, including by
our own government, and that ispsychedelic therapy.
I am not a holistic frou-frouhippie, you know, make my own
(23:50):
dream catcher and have my ownwind chime guy.
That's not the type of personthat I am Watch it.
Speaker 1 (23:55):
Watch it junior.
That was my generation.
Speaker 3 (23:59):
But anyone listening to this.
I have undergone psychedelictreatment and it has changed my
life.
It has been a reset to a timeof brain processing that was
certainly pre the 18 months ofthis chronic pain and other
(24:21):
things that I went through, buteven addressed things that
existed earlier on that I didn'tknow about.
And there's a woman out there.
Her name is Sherry Race.
She owns a company calledEnthea that has programs to
bring this type of treatmentinto employer plans.
From a personal perspective, Iwas really struggling with
(24:43):
mental health issues over thelast year and a half and again I
did all the traditional stuffand it had some level of help.
I don't want to claim it didnothing, but for anyone, and I
think in particular anxiety,depression, substance abuse,
ptsd and even now Parkinson'sand dementia, there are
therapies out there that somepeople might consider fringe or
(25:04):
untested or unproven, some ofwhich are legal here in the US,
some of which are not quite yetapproved, and I just want to
make people more aware or atleast more willing to do some
research into some of thesepsychedelics, and there are ones
.
Just to name a few, there'spsilocybin, there's MDMA,
there's ketamine Ketamine is themost commonly used in the
(25:26):
United States, but there areother ones out there too that
aren't legal here in the US.
But it's something that I wantto be a part of making more
available to more people,especially through the employer
sponsored plan, putting theright people in place, making it
sure done in the right way, inan appropriate way, in a
clinical way, for the rightperson at the right time.
(25:47):
But it's something that wedon't.
We barely talk about mentalhealth, let alone some of these
other things, and I think wehave a mental health crisis.
It's not just in the US.
I think it's around the world.
I think it's particularly badin the US, but imagine for a
minute if you're able to createa health plan that is doctor-led
not carrier-led or TPA-led, butdoctor-led.
(26:08):
That incorporates better accessto a better variety of mental
health from an employerperspective.
(26:29):
So, from an employer perspective, think about what that does for
your employee, and it's easy tomeasure claims dollars spent on
an employee prescription,dollars spent on an employee,
days they've taken time off,that their finances are a mess.
They can't lose their job,right if they're under financial
pressure, which so manyAmericans are, so they're
desperate to show up every dayand be at that job, but how good
of an employee are they being?
And then, when they get home,how good of a parent or a spouse
(26:52):
are they being?
And this is something we justdon't talk.
We know it's the undercurrentthere, but we're so busy
addressing the most expensivedrugs on the drug list or the
most expensive procedures or themost expensive chronic
conditions we forget about notonly these other things that can
dramatically improve thequality of life but in many
(27:13):
cases can prevent the need forthose large things, and so I
encourage anyone listening tothis to, even if it's on their
own, explore their own mentalhealth options, recognize and
not be embarrassed.
I have struggled with mentalhealth.
Let me say that again.
I have really struggled withmental health and there is help
out there, and if we can bringthis into employer plans, that
(27:37):
might be the most game-changinglegacy I could possibly leave on
this industry, which is what Iwant to do.
Speaker 1 (27:43):
And that is an awesome place to leave our
conversation for today.
David Conterno, old friend,president and founder of ePower
Benefits.
David, thank you for yourinsight and for sharing your
personal stories with us.
Speaker 3 (27:54):
It was my pleasure.
And anyone that wants to reachout, even on a personal level,
it's easy to find me that wantsto reach out, even on a personal
level, it's easy to find me.
Speaker 1 (28:05):
I want to give a quick shout out to our sponsor
and our producer, hatcher Media.
Hey, if you need podcastproduction or professional
graphic design, josh Hatcher isthe expert to contact For more
information.
Visit him at hatchermedianet.
That's H-A-T-C-H-E-R Media dotnet.
Speaker 2 (28:23):
This Shift Shapers podcast is copyrighted content
and may not be reproduced inwhole or in part without the
express written permission ofShift Shapers Solutions LLC.
Copyright 2024.
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