Mavericks of health care #3: Craig Clemente

 I have talked with many mavericks over the last few months.  In a series of four vignettes, I am happy to share some key insights and a look into the philosophies and paradigms that make someone a maverick of health care.

Common values exemplified by health care mavericks

• Caring and competence
• Innovation partnership
• Appropriateness and stewardship
• Trust and advocacy

Be sure to read the part one, featuring Nancy Giacolone, president and owner of Olympic Crest Insurance and part two, featuring Doug Hetherington, CEO & Program Architect at HealtH2Business.

Vignette #3 in a four-part series: Craig Clemente:   President & COO, Specialty Care Management Maverick Value:  Appropriateness & Stewardship “Always be ahead of the curve instead of reactive” 

Craig has a unique approach to mitigating the risks associated with high-cost claims. He discusses how the overall pain point contributing to misaligned incentives is largely responsible for crippling charges for catastrophic claims, and how the realization of this was the springboard in developing his dialysis product.

Q:  Can you share how you and your company, Specialty Care Management, employ the values of appropriateness and stewardship in developing your unique approach to mitigating high-cost claims? And how do these two values play a role in our industry today?

Craig shares how the concept of stewardship is something he considers to be a personal charge as well as a core competency and value for his company.  Particularly, he talks about the gravity of being a good steward of an employer’s funds – and that this is a role shared by the broker/consultant.  This responsibility to safeguard a group’s fund is a key component of how a good steward works to align incentives.  Interestingly, this drive to align incentives is a concept and value held by all the Mavericks I have talked with.

Safeguarding the joint interests of the employer and the broker/consultant is a key strategy to aligning incentives that ultimately protect and provide for the care of the member who is truly in the center of it all.  Nurturing the core value of stewardship is a powerful approach that ensures that the patient/member remains in the center and so that appropriate profits can be achieved – within bounds that are sustainable for our industry.

Craig says that when incentives become misaligned, then the water gets “murky” pertaining to fees, and oftentimes value is lost.  With the dynamic of exponential trends – particularly for catastrophic claims like cancer or dialysis – it can be fuzzy as to how we define reimbursement structures.

Craig maintains that a key to his company’s ability to maintain appropriateness in terms of pricing has been to untie pricing from billed charges, which he sees as the root of the problem.  Looking at how to drive incentives to avoid subsequent and ever-increasing billed charges, they found that developing an underwritten case rate that was not tied to an arbitrary billed charge was the key:  “I always want to be ahead of the curve instead of reactionary.”

He sees himself as a pioneer of elevating the attention on what a plan is paying versus just focusing on transparency.  He explains how this strategy highlights the fact that “you can be completely transparent but still be inappropriate in terms of pricing structures.”  He also shares how all players have a role in stewardship, with an example where vendors can actually drive up the costs that a provider will bill – all while looking like they are watching out for the client with arbitrary caps that sounds good, but end up being negative drivers for our system.   Motive and an eye on the end game is an important element of what we are all looking for in terms of a level of integrity and accountability that drives the demand for appropriateness/transparency in pricing.

He considers his job to maximize results and minimize risk  and he shares a passion with other mavericks who are working hard to redefine how we do just that.    When he and his team saw that the trend in his industry was that high-cost claims like dialysis were being commoditized, he knew he had to find a way to be ahead of the curve if he was to grow and maintain a value proposition.  So he started with a “Why” which turned into brainstorming on “What” he wanted to do, and then came down to putting the pieces in place to accomplish what he considers the secret to creating sustainability for his company and the industry.

Kimberlee Langford, BSN, RN, CCM, CRMT, CPC,  is director of business development at Specialty Care Management.