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Digital Health is the Gateway Drug: Part II

Written by Andrew Le, MD

UpdatedFebruary 28, 2024

Welcome to the CEO Corner, where Buoy CEO and Co-founder Andrew Le, MD sits down with industry leaders to chat about the provocative topics of healthcare today. Andrew recently spoke with Jeb Dunkelberger, the Chief Executive Officer of the Sutter Health | Aetna joint venture, which offers both self-insured and fully-insured commercial health plan products to employers in Northern California.

In Part II, Andrew and Jeb discuss Jeb's book, Rich and Dying: An Insider Calls Bullsh*t on America's Healthcare Economy, as well as their viewpoints on healthcare today and in the future.

Andrew Le: We have to be weary of digital health becoming a new channel that just replicates the old ways of doing things, versus what we should be doing: truly changing the way health care is delivered and paid for and how risk is spread and all that good stuff. This might be a great segue actually, into your new book, Jeb. Can you tell us a little bit, what motivated you to write it and what it's about?

Jeb Dunkelberger: Sure, I’d love to discuss the new book - funny enough, somebody recently messaged me saying they think it's the only healthcare insurance book that has quotations from Allen Iverson and Tupac in it. I was born in the Philly area, so I wanted to get Meek Mill in there as well, but I couldn't really figure out a way to work one of his verses in. When the pandemic hit, I found myself thinking in those first few months, that sooner or later we would flatten the curve and get back to normal. Then we were four or five months into it, and I felt like I needed to get my thoughts out on paper. I found myself wondering why things weren’t getting better, despite everyone’s great ideas and sound strategies. The pandemic was sort of the levy breaking moment for me, when I said, “wow, we spend more than $115k per second in the healthcare sector yet we don’t have a formal pandemic response strategy - we spend more money than any other country on healthcare, how can we possibly be this disorganized.” That was the moment when I decided I’m writing this book.

"Rich & Dying: An Insider Calls Bullsh*t on America's Healthcare Economy" by Jeb Dunkelberger

The book is broken down into three pieces. The first part was denouncing the traditional two poles of the spectrum, Medicare for All and the Free Market approach, and really explaining objectively why those don't work at face value and why most people tend to gravitate towards one or the other. Part two is really around insurance companies themselves and highlights some of the most recent self-reform efforts. Digging into value-based reimbursement, network design, value-based insurance design for products, the clinical services that come with insurance companies, innovation hubs within insurance companies, etcetera. All things that I do buy into because I've worked with the people in those industries and I've seen the value they create, but it still makes me question, is it enough? We see this continued pace of premiums and we all have to question, are we getting the value for that?

Part three digs into some of the things we’re going to have to just swallow and deal with, like the fact that healthcare is always going to be a high-cost element of our nation’s economy. It employs roughly one in seven people. You can't just erase that overnight and fire millions of folks just to curtail costs. It would be a classic “squeezing the balloon” analogy - air just moves before the balloon pops. 

The subtitle is, "An insider calls bullshit on America's healthcare economy," naturally that's probably going to raise some eyebrows. But what I'm trying to do is allow people to feel like they can speak freely and openly. Many people in this industry know we need to do better, and we need those folks to speak louder and feel encouraged to be authentic and genuine. It's just a matter of solving a human-made issue - rationality can solve this.

Andrew: I can't wait to read it. I am going to literally buy it right after this call. To dive into some of the things that you just described, when you think about part two of your book and the way insurance is working now, you were talking earlier about how there's this great alignment of incentives that you're seeing with a Sutter | Aetna CVS combo. And there are other care delivery organizations that have combined or vertically integrated onto the payer side. Do you see that as one of the cures to what ails healthcare and insurers today? Or maybe just give me a little sneak peek here, what about insurance do you think is intrinsically broken?

Jeb: The first part of your question, I do. This kind of emulsification of payer and provider coming together is definitely where we need to be going. Everyone that talks about value-based reimbursement talks about glide path, a progressive, step-by-step, three-to-five-year plan. And if you think about a provider and payer coming together, you're jumping to the tail end of that five-year plan, because you are now making the provider feel and see the insurance side of the equation within every transaction and every intervention that they have. To me, that's powerful - that is a fully aligned incentive between healthy people creating an equitable profit margin.

The insurance companies as a whole are at this very pivotal stage, because the amount of data they have and the amount of knowledge they have on how this machine operates makes them extremely valuable. And now it's up to them to decide which way they want to push the inertia. It’s difficult for any single insurance company to make a change within healthcare because they typically represent five, ten, or maybe 20% of a provider's patient panel. And as well, that is always churning, right? You're always losing employers, gaining employers, adding members and then losing them - outside of some of the largest in the sector, most insurance carriers don’t have the weight to change this trajectory.

The insurance industry as a whole needs to decide what role it's going to play in this new archetype of healthcare delivery. And that's where I see Aetna partnering with CVS, to see Aetna partnering with Sutter Health, and Allina, and Banner, and Innova. I'm bullish on that model. The insurance companies that are sitting back thinking everything's copacetic and they're just going to collect things off the status quo. I'm worried about those companies because it's going to be hard for them to justify their relevance in the value equation. And that's just me being blunt and honest.

The insurance industry as a whole needs to decide what role it's going to play in this new archetype of healthcare delivery.

Jeb Dunkelberger, CEO of Sutter Health | Aetna

Andrew: I love that. And also kudos to you for dropping copacetic into an interview. You can tell that you just successfully wrote a book.

I can't help but ask one last question for you, Jeb. Given everything that you know, where do you see healthcare in five to ten years, given all of the stuff that you just laid out for me? You have all these insurance companies at the crossroads. You have digital health either creating the status quo or recreating the status quo or creating something net new. You've written a book about what ails us, but what are you optimistically seeing. In one minute, where do you see healthcare in five to ten years?

Jeb: Given the growing percentage of the working economy that is millennial or younger, you're going to see a lot of expectations for change that will slowly grow into a demand for change, which is going to be incredible. It's going to be the employees who are just bound with information, and they're then able to make very educated and informed decisions, the same goes with employers that are led by these younger generations. I could see something of an individualized commercial market really taking hold. But I don't think that there's going to be a Medicare for All. At the very most I think it'd be like Medicare Advantage for all, so you still have a lot of insurance companies still playing a very important role.

The Delancey St. Foundation. Image courtesy of The Delancey St. Foundation

You’re going to see a lot of very unique value-based arrangements developing within local communities because providers will become payers, payers will continue to become providers. Look at the Delancey Street Foundation in San Francisco, or the Denver Social Impact Bond - we are going to see commercial businesses made on fixing the inequalities in our local communities. Similar to value-based reimbursement, you can reward partners that have real impacts on improving lives while decreasing cost.

But what I really want to see is for people to get loud and collaborative. What you guys are doing at Buoy is just the exact thing that the overall sector needs to be focusing on, which is just the transparency and enablement of everyone to be a consumer of the care that they're paying for. I'm really excited about what you guys are doing and seeing where you guys go. Most importantly, Andrew, I’m curious to hear what you think.

Andrew: When I think about our role in all of this, we want to create that competitive marketplace that you described by filling those information asymmetries clinically, providing the transparency, and relevance to the individual so they can better understand what kind of care to consume. We want to recreate as much of the free market as possible within healthcare, and create the competition that is healthy for society and ultimately healthy for the user or the patient at the end of the day, when it comes to outcomes and costs. To close, I’m so glad to be able to meet you and appreciate your time. This was super fun for me.

Jeb: I’ve got to tell you, I wasn't sure where this was going to go, but I cannot wait for us to work together. Because we have to. The country actually depends upon people like us collaborating and inviting others into the conversation.

About the participants:

Jeb Dunkelberger, CEO of the Sutter Health | Aetna joint venture, which offers both self-insured and fully-insured commercial health plan products to employers in Northern California.

Andrew Le, MD, is the CEO and Co-founder of Buoy Health.