The Clover Health president links the company’s open-network model to greater equity for patients and providers.
Health equity and open-network strategy are two of Andrew Toy’s favorite subjects. The Clover Health president links the two with an attention-grabbing description of what he believes narrow networks represent: “It’s provider gerrymandering.”
Gerrymandering: the process by which incumbents draw tortured maps to cluster constituents in the most favorable way possible. Toy believes narrow network design does the same thing—jutting here, constricting there, while leaving disadvantaged patients and providers stranded within the delivery system.
The narrow-network approach runs counter to Clover’s desire to “double down on the importance of health equity.” Toy notes that the company’s open-network, PPO-first approach allows it “to work with any provider, anywhere.” This is the puck Toy believes all health plans will eventually skate toward. “If we say we want health equity, and it’s a priority, the industry will be moving toward open networks to achieve better equity, quality, and care.”
Clover’s mission is to “improve every life”—traditional Medicare beneficiaries and Medicare Advantage (MA) enrollees alike. Clover supports both populations as an MA plan and a CMS Direct Contracting Entity (DCE) supporting traditional fee-for-service (FFS) members. “We are going after the entire one trillion dollar-plus Medicare market,” notes Toy.
“Serving all people is the right thing to do morally,” he adds. Clover reports that more of its MA members identify as people of color, report multiple chronic conditions, and live in disadvantaged area compared to other plans—another advantage of an open network of physicians who look like their patients.
“People often want a physician of the same ethnicity,” says Toy, adding that anything that helps increase trust is good.
Clover Health’s current enrollment stands at 85,026 insurance members (MA) and 172,416 non-insurance members (Medicare FFS lives through DCE). Clover expects to participate in ACO REACH, CMMI’s iteration of the DCE and Global and Professional Direct Contracting (GPDC) Model, beginning January 1, 2023.
Toy says of the new model: “We applaud and welcome CMMI’s evolution of ACO REACH to focus on advancing health equity for America’s most vulnerable by making value-based care accessible to more physicians.”
In other words, providers need equity, too? “This is only the second time I’ve heard anyone talk about health equity from a provider standpoint,” answers Toy, adding: “Doctors who serve more disadvantaged patients tend to be dropped by other plans. We want to include them and help them get through their day with better tools."
One of those tools is Clover Assistant, which Toy terms a “digital on-ramp for value-based care.” As highlighted in a 2021 HealthLeaders interview with Toy, Clover Assistant gives PCPs the tools for better, more personalized, data-driven care. Clover Assistant creates actionable data aggregated from EHRs, pharmacies, and labs, as well as socioeconomic data and evidence-based protocols.
Clover 2021 data shows lower MA medical cost ratios (MCR) for returning customers whose primary care providers use the Clover Assistant. And MCRs were lower depending on when the customer’s PCP went live with the technology and how long they have been using it. For example, members with doctors who started using it in 2018 had a 4.2% lower MCR than members whose PCPs who went live on Clover Assistant in 2019. Similarly, members with PCPs who went live in 2019 had a 5.5% lower MCR than members with PCPs who started using the technology in 2020.
Toy adds that Clover Assistant’s scalability is one component of its expansion into traditional Medicare, aided by the company’s unique business model.
Clover’s new CTO, Conrad Wai, has noted that “building … [a] proprietary tech stack within an insurer allows us to prioritize developing functionality that makes the product more useful to physicians. At the end of the day, helping doctors practice more effectively and efficiently, by definition, means healthier patients."
Toy adds: “While other companies may be constrained by antiquated technologies, geographic limitations, or asset-heavy approaches, we believe our tech-centric strategy enables us to quickly and cost effectively deploy software to providers nationwide, including in historically underserved markets."
Toy believes trust must be present for any technology to do its job, and that all technologies are not created equal in this regard.
“Member portals, for example, disintermediate care,” says Toy. “The best interface for a patient is their doctor, not an app. Trust is one of the most important ways that MDs help manage care.”
That and Clover’s open-network approach.
“Since we’re not tied to specific providers or physical locations we can scale at the speed of software.” It’s an approach that pre-dates the pandemic but seems designed for it and the continued adaptation that will follow.
Toy states: “Coming out of COVID, we see the tailwind moving toward where Clover is.”
“If we say we want health equity, and it’s a priority, the industry will be moving toward open networks to achieve better equity, quality, and care.”
Andrew Toy, president, Clover Health
Laura Beerman is a contributing writer for HealthLeaders.
Clover Health has been a market disrupter since its founding in 2014.
President Andrew Toy believes health equity is the next challenge that the company is uniquely positioned to address.
Toy outlines how Clover’s proprietary tech stack and open-network model combine to support not only patients who are disadvantaged, but also providers.