Oscar Health: Payer Discipline in Utilization Management & Cost Control

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Out of curiosity, to the extent you know how this works across the system, with technology over time, was Oscar able to reduce the burden on medical staff? Were they able to automate decision-making more, setting aside edge cases like neonatal? Can technology be used to reduce the personnel burden?

It sounds very simple, but it means setting the rules. This was a significant project even when I was there, and I don't know if it is completed. For me, that was a big opportunity. If you can remove certain cases that clinical teams are reviewing unnecessarily, even a small increase in percentage can lead to significant cost savings. I remember benchmarking, and I might mess up the percentages, but I think we were in the low single digits for auto approvals, while industry-wide it was in the double digits, over 15%. For me, that was a big opportunity. However, it goes back to our identity. Are we a tech company or an insurance company? We wanted to build everything from scratch. The entire platform was built in-house, and part of the team that I stood up was a dedicated vertical that worked almost daily on some of the tech or product-related work. We were able to get feedback from nurses using the platform to fix bugs and make improvements. Even with auto approval, when I started, less than 1% of cases were auto-approved. I thought we should be hitting 25% by the end of the year. But because we wanted to build everything from scratch, my personal view was to bring in someone who does this well while we build internally, so we could achieve this quickly and save costs. However, because we wanted to build everything in-house, we continued to work on it. Given we are a tech company with limited resources, there were multiple projects, leading to resource constraints and delays, causing further burden. Long story short, can technology help reduce variable costs? Yes, most definitely. Is Oscar doing that well? It's a work in progress. There are many pain points that can be addressed.

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