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Streamlining Medicare Advantage Plan Operations
Episode 645

Tom Pelegrin, Senior Vice President and Chief Revenue Officer at Convey Health Solutions

Streamlining Medicare Advantage Plan Operations

In this episode, we are privileged to host the outstanding Tom Pelegrin, Senior Vice President and Chief Revenue Officer at Convey Health Solutions. Tom discusses how his company provides purpose-built solutions in the Medicare markets and how they work with important stakeholders to bring a level of expertise and capability. Convey leverages technology to drive outcomes and improve the patient experience. 

Tom covers the different segments of Convey, collaborations with other companies like BPO, and data analytics for improved customer experience. He shares his thoughts on setbacks, flexibility, making smart decisions, and more! Tom has a wealth of knowledge and you’re sure to learn something so please tune in!

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Streamlining Medicare Advantage Plan Operations

Episode 645

About Tom Pelegrin

As SVP and Chief Revenue Officer, Tom is responsible for Convey’s market growth, brand, and marketing. Tom has over 25 years of business development experience in the healthcare markets related to payer technology and operations. Prior to Convey, Tom was the Founder and CEO of MDInnovate, an organization focused on providing primary care services and improved patient care coordination through innovative delivery models. As an Optimity Advisors Partner, Tom provided expertise related to State and Federal Health Exchanges and payer enrollment and billing technology and operations. Before Optimity Advisors, Tom was VP of Enterprise Sales for Benefitfocus. Tom was instrumental in expanding their payer markets footprint and founding the government programs group, one of the earliest providers to serve State and Federal Health Exchange marketplaces. He’s a wealth of knowledge and the work that they’re doing in health care is extraordinary, specifically in the Medicare space.

Streamlining Medicare Advantage Plan Operations with Tom Pelegrin, Senior Vice President and Chief Revenue Officer at Convey Health Solutions transcript powered by Sonix—easily convert your audio to text with Sonix.

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Saul Marquez:
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Saul Marquez:
Welcome back to the Outcomes Rocket, Saul Marquez here. Today, I have the privilege of hosting the outstanding Tom Pelegrin. He’s the Senior Vice President and Chief Revenue Officer at Convey Health Solutions. He’s responsible for Convey’s market growth, brand, and marketing. Tom has over 25 years of business development experience in the health care markets related to payer technology and operations. Prior to Convey, Tom was the founder and CEO of M.D. Innovate, an organization focused on providing primary care services and improve patient care coordination through innovative delivery models. As an optimity advisor partner, Tom provided expertise related to state and federal health exchanges and payer enrollment and billing technology and operations. Before Optimity Advisers, Tom was VP of Enterprise Sales for Benefit Focus. Tom was instrumental in expanding their payor markets footprint and founding the Government Programs Group and one of the earliest providers to serve the state and federal health exchange marketplaces. He’s a wealth of knowledge and the work that they’re doing in health care is extraordinary, specifically in the and the Medicare space. And I’m excited to have him here today. So so, Tom, thank you so much for joining us today.

Tom Pelegrin:
Thanks, Saul. Appreciate it. Look forward to it.

Saul Marquez:
Absolutely. And so, Tom, before we dive into the work that you guys do at Convey Health Solutions, tell us a little bit about you. What inspires your work in health care? What keeps your fire going?

Tom Pelegrin:
Yeah, the industry itself is something that I’ve always been passionate about. So I view myself, Saul, as a student of the industry. I’ve been in it for, as you mentioned, twenty-five years, but it’s actually a little north of that now. So it’s been a while. And what’s interesting about. Yeah, what’s interesting about the industry is that it has so many different facets. It’s so complicated and there are so many different stakeholders involved. And for me, it’s been something that I really enjoyed to be a part of just in the different aspects of different facets of the market, the different facets of how it serves the consumer. And as I said before, I developed a passion. I’ve become and I continue to be a student of the industry. And it’s something that when you compare what we do in the United States to some other countries, which I know has been a something that’s been in the news quite recently, it’s also very fascinating. And I’ve had the luxury of looking at some of those other countries and how health care works for them and compare that to what we do. And it’s just a very fascinating industry. Obviously, it’s the biggest industry in the world. And so there’s plenty of room for anyone who’s got that kind of passion to spend a considerable amount of time. And so that’s what inspires me. I think I’m I just really think that for the consumer themselves, it’s complicated. And part of what I have always tried to do is to try to help sort of bridge that gap and complexity to the average individual who is consuming health care.

Saul Marquez:
I love that, Tom. And it’s critical. And as we start to focus more around the consumer experience and how we access health care as individuals, it’s supercritical right. and it’s those with the depth of expertise like yourself that are paving the way for a new future and how we access health care. So, you know, on that note, talk to us a little bit about how your company is offering value to the health care ecosystem.

Tom Pelegrin:
Yes, as you mentioned at the beginning, Convey was founded in serving the Medicare markets. And so we began our operations in two thousand one. And at the time we were focused on certain chronic conditions, the diabetes population. And through the years, the Medicare markets have progressively evolved. They have introduced obviously intense regulations and it’s increasingly become more and more complicated. So the fundamentals of Convey is that we built for we provide purpose-built solutions into the Medicare markets, and that’s unique. So I think one of the things that we try and do when working with our clients and their beneficiaries, members, consumers, whichever phrase you’d like to use, we bring a level of expertise and a level of capability that is specific to those Medicare, to the Medicare markets.

Tom Pelegrin:
And it’s hard because of those complicated regulations, because of the variety of ways in which those consumers are looking at their insurance and their coverage. And this is a senior population. So we’re dealing with seniors. They struggle as anyone to understand. And what benefits they have and so we have had through the years, successfully built methodology and approach to bridging that difficulty, of that challenge to those consumers and those seniors and helping them navigate their coverage in their insurance through Medicare. So for value for the market is specific to the Medicare market that we bring to the table and of course, Convey itself. We’ve progressively grown right. So we continue to be successful. We’ve looked for and been lucky enough to find organizations that we’ve been able to acquire that have contributed to sort of this mission that we’re on and serving Medicare markets. And I think one of the things that we, again, bring to the table for those clients is health plans and those consumers is that specific expertise that’s unique. And that’s what that’s what clients look for when they’re looking for growing their business and Medicare. They look for those experts and ways in which we can help them navigate the markets.

Saul Marquez:
Yeah, you know, it’s critical expertise. And, you know, there are so many things that come up with this segment. You know, it’s you mentioned that just staying on plan with those key requirements, CMS audits. And there’s a lot of things that come into play, social determinants of health. How do you guys position yourselves and what would you say you guys do better or different than what’s out there?

Tom Pelegrin:
Yeah, so talking about it specifically, we’ve got four different business units inside of the organization today. So when you break these down a little bit, we’ve got what we call advanced plan administration that provides administrative services and technology for a Medicare Advantage prescription drug employer group waiver, which is a hugely complicated component to Medicare. And so we provide both the technology and what we call BPO business process outsourcing services there for health plans. There’s a differentiator there. So the differentiator being that, again, we’ve built technology designed specifically to manage those regulations. And if you look at it from the build perspective, so what we have done in the very beginnings of the organization is that we built this technology for our own internal use. So we never intended to have this technology sort of sold independently to health insurance companies. We really built it for ourselves in becoming an outsourced organization to serve those health plans.

Tom Pelegrin:
Well, inherently, the stringent requirements of both the health plans and the Centers for Medicare Medicaid Services CMS, which governs the Medicare market, have enabled us to continue to fine-tune our technology and our services to become unique in what we do. So we’ve got high levels of automation, high levels of efficiency within the technology that drives improved outcomes for those consumers that we’re supporting that provides a better remember experience. And so that’s critical, right? So those are that’s the differentiator there. And another segment of our business is our Supplemental Benefits Administration business. And this is something that’s very exciting. This is a part of the Medicare market that’s growing rapidly. And what’s happening is health plans are seeking to add supplemental benefits into their Medicare Advantage plans, which is something that Samms has promoted and allowed for years now. And this part of the business has grown dramatically because of the competitiveness of the Medicare Advantage markets and with Medicare Advantage and with the growth of Medicare Advantage has inherently created. The growth and supplemental benefits we convey are one of the few organizations that provide an end to end administration capability of one of the more popular supplemental benefits, which is over the Counter Benefits Administration or over the counter products. And that’s significant. And so how do we do that when we do it differently?

Tom Pelegrin:
So again, we’ve got Purpose-built technology. We’ve got an advocate call center that supports those members, that helps them navigate the hundreds of products that we offer to them. And the plan, I should say, offers to them. And it does everything in a seamless fashion with the member improving the member experience and of course, reporting on it to both CMS and to the health plan. So that’s number two. And then we’ve got two other areas. We’ve got our value-based and payment accuracy part of the business, which provides, I would say, a unique solution around analytics.

Tom Pelegrin:
And so we’ve used this now across our business to be able to surface really critical data about the behaviors of the members. You mentioned SDH Social determinants of health. Those are things that now are becoming much more apparent. Plans are beginning to invest in looking at these social determinants and understanding the behaviors of them and the conditions that they have and the costs of care and how to improve those experiences. So we’ve built, not built, we’ve acquired an organization that we feel is a complete differentiator and what they provide. They have an ability to ingest data more rapidly and from a variety of sources that are more broad than most organizations. And then they have been able to action that data, which is a struggle with analytics Right. you can expose some really cool data to a health plan or two to a potential client. But having it actionable is the struggle. What do you do with the data and how do you action it? And so they’re very effective at that. And then the fourth component of our business units is our advisory group, and this is where the expertise comes in. And so we’ve acquired two organizations, the Gorman Health Group and the Health Scape Advisors. Both are leading organizations respectively, both from compliance, from operations, and strategic standpoint in serving health care organizations. So we’re extremely fortunate to have them. Those are I guess those are a long explanation to some of those differentiators.

Saul Marquez:
But you explained it so well, Tom, and you guys are a Medicare Advantage powerhouse. I mean, it’s just awesome what you guys are doing and what it takes to run a successful Medicare Advantage plan is really I mean, it requires that data. It requires coordination. How do you keep track of it? How do you keep track of these data that come from everywhere to get those insights that you need to take the action to actually make it work? And then ultimately it’s, you know, quality of care, you know? So you guys seem to be very focused on all of the right things. How has what you guys do improved outcomes or made business better?

Tom Pelegrin:
And that’s an important part of what we’ve been doing over the past couple of years within specific segments. So going into going back to supplemental benefits specifically, again, think about it from the standpoint of members today will receive a catalog of products over counter products that are available to them. And there’s just there are hundreds and hundreds of these products. Some of these products, if they’re used, can help those members in a variety of ways. And so we’ve been able to look at clinically with certain conditions, with certain chronic conditions, how some of these products, if they’re here to use and utilize more, may prevent considerable outliers of care that would occur for some of these particular members. We focused in on the diabetes population with a variety of products, and we’ve promoted those to those populations and tried to emphasize and educate those members about using these over the counter products. And then we’ve got other conditions like COPD and individuals who have cardiac or heart-based ailments to promote products to them as well.

Tom Pelegrin:
Now, what’s really important about all of this is that we’ve looked at data, so we’ve been able to spend several years and analyzing data, not just our own data, but we’ve looked at organizations like the Consumer Products Health Group, which is a sort of a think tank in Washington, D.C., who who’ve made statements to the effect more broadly, of course, not in the Medicare population, but across all populations. And they said, you know, for every dollar of O.S.S. that’s being spent, it’s saved upwards of seven dollars in health care costs. And so we’ve taken that and we’ve kind of used that as a stick and a guide to help us begin to prove that out in the Medicare markets. And so the first step of that, of course, you know, it’s very hard, obviously, to measure it. But the first step of that is to begin to educate these members about the over-the-counter products that are available to them, tailoring that education to their conditions and then talking about or talking with them about how they were used, frequency of use, those kinds of things. And ultimately, we’re beginning to look at ways to measure that. So how can we prevent E.R. visits if we can promote certain products to certain populations, et cetera, et cetera? So those are things that we’re studying very carefully with within the business. And we up to the plans, you know, that time.

Saul Marquez:
That’s so interesting. And I don’t know. But I’m starting to see this shift right. In your organizations is a prime example of this, where the consumer focus is the key and consumer engagement. Finding those insights. When Amazon tells me that I could use this desktop monitor, how do they know that I just bought it? And it’s like, you know, it’s these tweaks and these insights and ultimately these feed into what matters, I think a lot to these plans is is these Medicare Advantage star ratings, right, so it makes a big difference right, four versus five, you know, talk to us about that and what you guys are doing to help in that department.

Tom Pelegrin:
Yeah, that’s obviously critical to the health plans. Is there performance and star ratings? And, you know, within our businesses, we touch certain very certain elements of the star ratings. They call them cut points, but certain cut points in the star ratings we touch. And there’s a variety of others that we don’t touch, we don’t impact. And so the plan is, of course, responsible for that complete universe of those members. But one of the things that we touch, of course, is no experience. And so saw one of the things that we do and we really focus considerable energy around is our net promoter scores. And so a lot of the health plans today, the national health plans, they, of course, are getting themselves, their customer service centers and others. They’re getting scored and they have net promoter scores on their performance. But they also turn the focus to someone like the vendors like us, and they give us net promoter scores and they look at a variety of components. And of course, no experience is a big part of that. And so we’ve been very fortunate and having very, very high net promoter scores in comparison to our competition. And so we know that doesn’t happen without the commitment of not just customer service areas that we serve, but also the entire organization as a whole and supporting the experience of the members. And that starts with things like we’ll go out and as we build out these call centers and hire these advocates, we have very regimented training programs that we have both standardized training programs and we customize these training programs on behalf of the health plan to understand the health plans culture and their approach and their messaging and their scripts. And the detail of it is incredible. But the results are they speak for themselves and we’re extremely proud of that. So that’s one of the things that I think sets us a little bit, makes us different, and also provides that benefit of gaining that just that incremental value to those star ratings that are so important to the health plan.

Saul Marquez:
Yeah, you know, that’s great, Tommy. You know, it’s hard enough to run a business and then when you get into a niche like Medicare Advantage, it just that much more difficult. So why not just lean on an organization like Tom’s to help you do the work that you do so well, but in a niche that you might not be as good at and so convey health solutions is truly I mean, impressive work with that you guys are up to. What would you say is one of the biggest setbacks you’ve experienced? I mean, you’ve been in this game a long time. What was the key learning of that big setback?

Tom Pelegrin:
Yeah. So you know, what’s interesting about it just broadly in terms of a setback, what you want to think about is the industry today, this health plan organizations, they are having the burden of it, especially the Medicare Advantage plans. Of course, they have the burden of managing costs and rates and fees that they’re getting paid on behalf of CMS and they have the costs and so on that that we have and supporting them. The difficulty is that they have tried to sort of in the past, they’ve tried to Band-Aid things in order to cut costs. And so we’ve learned over the years. And so I’m not giving one specific setback. I’m just saying broadly, the setback that I think is experienced is that when these organizations attempt to try to patch work, certain solutions, they end up struggling dramatically. And then they’ll hire someone like us to come in and try to pick up the pieces. And a lot of times when we do that, it’s not something that happens overnight. It takes years in some cases to overcome the behaviors of that health plan, to overcome the industry’s perception of that client of ours, et cetera. And so the setback just to talk about that, I mean, we’ve done that repeatedly and it’s been a challenge, to say the least.

Tom Pelegrin:
And we do have one client. I can’t name the clients. It’s a national health plan that experienced a significant setback from CMS and they were sanctioned by CMS. And we were one of their main vendors that supported a portion of their business. And we were able they kept us on board. It was the setback wasn’t caused by us, but it impacted us dramatically and impacted us from a standpoint of supporting the volume of numbers that we originally had. But we maintain that relationship and we committed ourselves to that client. We suffered like they did through that relationship. And then on the back end, they have become a better organization. They’ve become far more successful and they’ve been willing to share in that success with us. And so, you know, that’s something that we are sensitive to. We realize that a lot of these organizations haven’t yet experienced what this organization has experienced, but we see what’s happening and how it’s occurring and you try and get them to trust you. But it’s a challenge. It’s difficult for them to see that the potential risks are greater than they could imagine.

Saul Marquez:
Now, that’s a good call out and it’s tough. I mean, when you’re already in a tough sort of low margin crunch to make that investment. But ultimately, it’s the right thing. I mean, you know, and I found myself in those situations and I have opted for both sides and it just slaps you in the face when you make the wrong choice. And so these are the types of things that that to your point, we got out, we got to be smart. And investment now is going to pay off later. Right. So you’ve mentioned a lot of really neat things today, Tom. We’ve talked about Ötzi. We’ve talked about data analytics, the advisory vote. But what are you most excited about?

Tom Pelegrin:
Well, I’m really excited about some of the innovations that we’re embarking on today. I mean, we’re looking at the behaviors of the member and how we can improve that experience as we go into some of the more advanced technologies. And so we talk about machine learning and artificial intelligence. I mean, those are very big words and they do a lot of things. But how do you really put something like that into play? And so we’re investigating that. We’re looking at personal assistance. So you have these things like Google Home and Aleksa and others. You know, wouldn’t it be nice for a member to be at home? And of course, seniors are some kind sometimes of challenge. They’re not mobile. And so if they’re in their house, they could quickly use something like Aleksa to request a product to request assistance. If there is one of the supplemental benefits that could be provided as transportation or food benefits, they could use some of these devices to request that. And of course, it has to be secure. There’s PHI involved in those kinds of things. So we’re looking at those things and how to make the members’ experience simpler, easier and ultimately accomplish the same thing that we’re accomplishing today through and through our call centers, our advocates, and those kinds of things. So the innovations, the technology is certainly there. The innovations are fun and exciting. And I think that they’re really going to make an impact, you know, over probably the next within the next five years.

Saul Marquez:
That’s interesting. And even, Mike, I mean, I just had this picture of like if one of the members falls Right., I mean, can they trigger. Exactly. Call for a response, correct?

Tom Pelegrin:
Right. Yeah, we’re looking at you know, we’ve got of course, there are all kinds of things related to our studies on fall prevention. And just like that, I mean, to your point, there’s I think there are devices today, you know, Fitbit and probably I think the Apple Watch that has the ability to detect a fall. And so wouldn’t it be nice for that to detect a fall and alert us so that we could contact, help and get help to that member? And so those are things that as a service we’re looking to provide.

Saul Marquez:
Well, you guys aren’t only just doing the blocking and tackling. Well, you’re thinking ahead. And as we well know, you know, if you don’t innovate yourself out of your old business model, then somebody will probably come and do it to you. So kudos to you, Tom. This has been awesome. I’ve enjoyed our discussion today. If you had to leave us with the closing thought, what would that thought be? And then the second one here would be, where do we get in touch with you and your team if we want to learn more or get involved?

Tom Pelegrin:
And I appreciate it. I think the closing thought would be that if there’s anyone that’s exploring or involved with the Medicare Advantage markets or health, the health care markets in general, I think that they certainly would want someone to, like, convey as their partner to assist and provide the expertise, as I mentioned in today’s call, contact us. Yeah. So again, on our website, we convey health solutions dot com. Obviously, there’s a ton of information there. There’s an insights page there that has a lot of information and details there that I think you’d find valuable. And there’s certainly an email that you could contact us that you’re happy to contact my email or you could contact our marketing department. And that’s marketing@conveyhs.com. And my email. I can provide that to you, which is TPelegrin@ConveyHS.com. So thanks again. So I appreciate it. It’s been a great holiday.

Saul Marquez:
Yeah, no I’ve enjoyed it too Tom. And I just want to give you and your team major kudos for the work that you’re doing to really improve the consumer experience, but also help the plants that are providing that experience to do a better job. And so appreciate the work you guys are up to. And we really thank you for sharing your insights today.

Tom Pelegrin:
Thanks again. So I appreciate it.

Saul Marquez:
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Things You’ll Learn

  • Always be looking for opportunities and services you can provide to your patients. 
  • Leverage technology to make member’s experience simpler and easier. 
  • Commit yourselves to your client. 
  • When these organizations attempt to try to patchwork certain solutions, they end up struggling dramatically.

 

Resources

https://www.conveyhealthsolutions.com/

businesssolutions@conveyhs.com

tpelegrin@conveyhs.com