"Healthcare affordability can be improved by removing financial barriers to care for patients"

Q: Tell us a bit about TailorMed — how did you start the company? What’s the market need you’re trying to address? 

Srulik: TailorMed’s been around for the last four and a half years. I co-founded it with Adam Siton, our CTO, with a mission that intensified over the last few years – that of removing financial barriers to care. Across the United States, it’s clear that over the last few years the cost-sharing dynamics between patients and their payers have been leaning more towards patients, than in the past. There’s a noticeable, dramatic increase in out-of-pocket expenses and premium expenses, basically meaning that a lot of patients requiring either chronic or critical illness treatments are unable to afford it. This is why we started the company. 

We’re working with healthcare organizations – providers, pharmacies, and other strategic partners within that ecosystem — to find those patients as early as possible in their medical journeys and locate opportunities to offset those out-of-pocket expenses by having other financial resources to cover that, whether it’s through different financial assistance programs, governmental subsidies, optimization of their insurance etc. 

That’s happening with very consistent value creation to both patients and our partners who’re large health systems, small clinics and large pharmacy chains so, they just continue to expand with the growing needs in the healthcare industry. 

Q: One-in-five Americans today, has a problem affording health care. How does your company address that? Are you focusing more on improving health equity or helping patients and consumers get more out of what they already have? 

Srulik: From my perspective, one-in-five Americans are facing the issue of affordability. There is also the fact of the dynamics of cost-sharing between patients and their providers. Another area of our focus when it comes to treatment and medication is on the amazing investments in clinical solutions and treatments that provide better clinical outcomes. But those innovative treatments are usually coming to market at steep prices and that’s creating an even bigger gap in access to care. 

Obviously, COVID exacerbated that problem when people lost their jobs and unemployment increased. A lot of people who were maybe under-insured before became uninsured and healthcare costs on the rise for years just continued. The way we are addressing that is first, looking at what patients are covered for and trying to make sure they are maximizing their benefits. Our core focus is on the abundance of different resources out there that can serve different patients depending on where they live, what treatment they are on, what type of insurance coverage they have, and then, offsetting some of that financial burden and having another entity cover that. 

So, for example, there are patients with diabetes who need to have their insulin medication on or may be on a monthly refill cadence, something that isn’t very affordable. They need to leverage opportunities out there ranging from a governmental subsidy if they are low-income earners to a co-pay assistance by the drug manufacturer to a diabetes foundation that can support patients with either direct medical expenses or their living expenses, if they are burdened by that, as well. 

What we are doing is leveraging data from our partners that can beat the diabetes clinic or the IDM that we are serving or a Walgreens Pharmacy that we contract with. We project it as out-of-pocket expenses for that patient throughout the year, while staying proactive about approaching those patients and connecting them with those cost-reducing opportunities, facilitating enrollment and ensuring that they are able to stay on. They require treatment without going bankrupt or seeing substantial financial distress. 

Q: Are you focusing on any one particular medical condition or do you cover a broad range of medical areas? 

Srulik: We do cover a very broad range and till two years ago, focused around specialty areas — Multiple Sclerosis, Oncology and Rheumatoid Arthritis. Unfortunately, the financial barrier to care is not only focused on specific areas, so our solution is completely is disease-state agnostic. When you think about where high prevalence, high-cost conditions lie, I think that Oncology is definitely one, but we are seeing the need and the ability to support across a variety of other conditions. COPD, heart failure is another kind of chronic condition example and others that I mentioned on the specialty care areas. 

Q: So, how many consumers really know about all the options available to make care affordable? This is huge information gap in the market, and you could translate that into literacy along multiple dimensions. What does your company do to bring this information to consumers? 

Srulik: Patients are indeed completely lost in many cases about not only what the treatment will inflict on their lives, but also why they should understand what we have in terms of the insurance benefits. They might have one plan or three, but what is the meaning of a deductible and a co-insurance? 

When we see patients and interact with our partners, first, we find that patients don’t have the ability to forecast or foresee what’s coming up next, whether it’s their next encounter, not to mention a complex drug regimen that can extend through a few months, or sometimes even a few years. 

That’s why, in many cases they abandon, refuse or forgo treatment or if they do get that treatment, a lot of them face a surprise bill at the end of that encounter. So, patients are not aware of the opportunities that are available for them out there, and a lot of times their providers are not aware as well. 

We look at two ways to stop that — One is providing transparency and not only to a specific encounter of what will be their next imaging scan cost, but also, what the next six months will be like. So, it’s like saying they are about to face a high financial event. But there is an out-of-pocket limit to their plan, and three months from now, they’ll probably hear that. So, let’s speak about what happens in these three months. 

If they’re fully covered for that, they can alleviate that by providing clarity to their out-of-pocket state, that’s on the transparency side. But to tell a patient, they’ve just been diagnosed and there is a very substantial out-of-pocket responsibility coming ahead without giving an actionable opportunity to alleviate that, this is where a lot of other solutions fall short. 

For us, it’s always about bringing this as what it is — their expected responsibility — but it’s with what we have found can alleviate that through either supporting their direct medical needs with pharmaceutical company co-pay assistance programs or with a foundation that can also help them alleviate some of the living expenses they have or support their transportation to that facility. It’s making sure that they see the financial impact holistically with what comes up next, but also what can be done. 

Q: Can you give us an example of how your company is actually making this work and talk about some real numbers? 

Srulik: We are working with the very different organizations and organization types. There are >100 facilities — hospitals, 350 pharmacies and 200 clinics working with our system, both on the provider side, which can be a specialty practice or a large health system in multiple regions. We also have independent specialty pharmacies like Alliance, Walgreens that we work with. For example, we are working with Providence in Oregon where they have put together an amazing team of medication assistants that basically get referrals (from across Oregon) from Providence providers — either hospitals or clinics. And their team finds financial resources or leverages replacement drug programs or feedback programs, as they call it, for their patients. 

And since we started there, we were able to increase the level of discovery of patients who may not necessarily be aware of their imminent financial distress, and introduce to them financial opportunities to bridge that gap and then, use substantial automation and predictive analytics to increase the throughput of programs that patients got enrolled into. 

As a result of that there’s a substantial win-win for patients — It removes their financial barriers to care or financial toxicity, enables their organization to collect revenues without relying on patients and decreases the cost of drug spends when it comes to replacement drug programs and leveraging data. 

On average, we see $1500-2500 in increased revenue for patients across our customer base and about $13000 of free drug programs being leveraged. These are big numbers for this system that are seeing such financial returns from our solution while serving their patients in a better way. 

Q: Is there a specific demographic that is your target audience that that can benefit the most from your services? 

Srulik: It’s a great question and one I’m asked frequently. My answer won’t be as intuitive as you think, though. When patients are indigent and might be on Medicaid, for the most part, they would be fully covered unless it’s maybe a carve-out drug. 

Obviously patients that have a very high income might be able to afford whatever is coming their way, although that’s not necessarily the case with the high cost medication, but the vast majority of the population, whether they are middle income families or individuals on Medicare, either on high deductible plans on the marketplace or by their employers or on Medicare, with high out-of-pocket limit or even without a prescription benefit plan — when most of them are required to pay more than 5-10% of their annual income, the families are not able to find those resources. 

From the patient’s perspective, this is our main audience, but this is where most of the healthcare providers in pharmacy will see the biggest financial concern from providing care and being able to fully be reimbursed from those patients. 

Q: Now we’re in open enrollment season. Is this the time of the year when your services become more relevant? How do you approach the market now? 

Srulik: Open enrollment is a unique once -in-a-year opportunity for patients to have the ability to either keep their plan or adjust, because this is where pre-existing conditions would not be an issue for them to enroll on a new plan. 

What we do there is actually take the opportunity to adjust our health plan coverage as kind of addressing the core cause of underinsurance and definitely, people who are uninsured. So, if during the year one has to keep one’s plan and there is a financial obligation that might be mitigated by a co-pay assistance program, which is a great patch, one can do that cost benefit analysis and add a supplemental plan or Part D plan or Medicare, or pay a slightly higher premium and have a higher or a lower deductible plan. This will ensure one’s better covered. End of day, the costs out-of-pocket would be lower. 

What we’re doing is, in addition to just finding financial resources for patients, we’re detecting those within the patient population that either would be considered uninsured or underinsured. And then seeing if there is an opportunity within one of the marketplaces to optimize for that patient. For example, if a patient has a cancer diagnosis, and next year, they’re supposed to have a few chemotherapy cycles and obviously visits and imaging, and they have Medicare. But Medicare A and B only without any supplemental or Medicare Advantage plan. During open enrollment, they can elect to enroll in the Medicare Advantage. That would put a cap on their out-of-pocket limit or if they have a prescription medication that is not covered by Part B, they can include Part D (as in David). This is where it gets complicated. Fortunately, this is what we do for them within the system. We offer an educational tool for their financial counselors to be able to say “this is what you are supposed to pay with your care plan. This is what you can save if you add or switch to another plan,” even without mentioning a specific point. This tells them that it’s a time of year that they can optimize for, like the next insurance period. 

Q: Do you have these educational coaches/counselors on your staff? Or do you provide this information and educate staff in your client organization — How does this work? How does your target audience get to take advantage of your services? 

Srulik: It’s a hybrid model. We see providers and pharmacies that have their own staff but where they leverage our software solution to discover patients in financial need, those with an opportunity for insurance optimization, and then, the staff educates and exposes those patients. 

Where organizations have no staff or insufficient staff, TailorMed’s complete team comes into play. We have some of the experts in financial litigation working with us and training our team to be able to support patients or the financial counselor on the provider side. That can be seen as kind of telehealth to insurance optimization. It’s possible to go on a Zoom call and educate a patient that this is an opportunity to optimize or add an insurance plan or simply give that as a printout through their provider if they are coming into a visit. There’s a little bit of both, and each organization has their own priorities on how they want to engage and accommodate whatever is required. 

Q: I think the name of your company is very clever, TailorMed. In a space with so many startups, how do you stand out? How does a healthcare organization cut through all the noise in the marketplace to understand where the value is? 

Srulik: There are two things that help us stand out. One, the abundance of solutions within revenue cycle that are coming to optimize for either a better collection experience or a more streamlined payment plan solution. These are solutions that come downstream when a patient is faced with a bill that needs to be collected. We are going upstream. We’re trying to avoid the collection attempt by leveraging other financial resources and other pockets of revenues that can help an organization be “patient first” in their mindset and try to remove that financial barrier and increase access plus have robust financial resources to avoid going after patient collections. I think that’s unique. If you think about the holistic patient financial journey, we’re starting at the very beginning, either at the point of care or after the patient gets the cure and is trying to exhaust any other financial resource. Whatever we can find in the residual out-of-pocket, it goes downstream to the very many vendors that are trying to address that. 

Second, in general, there’s an amazing pool of companies, solutions and vendors that are providing digital health solutions. It’s very hard for providers to adopt everything, even if they wanted to. What we are very focused on is how to attribute our intervention to direct financial savings of the healthcare provider or the pharmacy and then make sure that the beneficiary is, always the patient? 

There’s a very clear business case and a very substantial ROI. As one of our latest case studies showed, they are paying for their solution within the first month or two of adopting it. So, the ROI is there and then, they are managing workflows, automatic productivity tools. But there is a very substantial attribution to financial statements. 

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity