Amanda Eisel of Zelis: 5 Things We Must Do To Improve the US Healthcare System

An Interview With Luke Kervin

Convert paper-based payments to more efficient, effective electronic payments. To cut avoidable spending, we must accurately assess and pay claims and convert paper-based payments to more efficient, effective electronic payments. There is $500 billion of paper-based provider payments that can and should be converted to electronic payments. Notably, the cost of processing a paper check is $6 and can be as much as $20; this cost weighs on the system with billions of healthcare claims being handled annually. In addition to reducing these processing costs, e-payments result in faster payments to providers and streamline lengthy claims processes so teams can focus on other priority areas.

As a part of our interview series called “5 Things We Must Do To Improve the US Healthcare System”, I had the pleasure to interview Amanda Eisel, CEO of Zelis.

Amanda Eisel has focused the last 20 years of her career at the intersection of healthcare and technology. She has been deeply involved in creating and scaling multiple growth technology companies including Waystar, Applied Systems and Viewpoint. Amanda is a member of the Board of Directors for two non-profit organizations, Youth Villages of Massachusetts and New Hampshire and Make-A-Wish Foundation of Massachusetts and Rhode Island. She is also on the Board of Directors of Rocket Software.

Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a story about what brought you to this specific career path?

There are two key factors that brought me to where I am today. First, I spent the past 10 years at Bain Capital advising various high-growth technology businesses, and I learned that when you invest deeply and strategically in disruptive technology across any given industry, you can positively transform the way work is done. This is a fascinating era in history, particularly in vertical markets where stakeholders are rooting out inefficiencies and pain points by introducing smart technology. When you optimize the way people work, this creates a positive feedback loop that leads to higher efficiency, innovation, collaboration, and ultimately benefits the consumers served by these businesses.

The second factor that influenced my path is my affinity for purpose-driven work. Early in my career, I spent time working with non-profits as a consultant at McKinsey, which presented an opportunity to leverage my skills and capabilities to contribute to a greater good. This was an ‘aha’ moment for me, and since then I’ve been driven by the notion of creating positive societal outcomes. Like the non-profit space, healthcare presents ample opportunity to contribute to a common cause that ultimately benefits society at large. I first became involved in healthcare IT about five years ago while at Bain, and quickly realized it scratched the itch of purpose-driven work while merging my interest and experience in the technology space.

I’m excited to be CEO of Zelis because we are at the intersection of serving payers, providers, and consumers. There’s great opportunity to improve our industry and harmonize the complete payment process. Our team is focused on this mission and supporting our payer and provider clients to deliver more affordable and transparent healthcare for all.

Can you share the most interesting story that happened to you since you began your career?

One of my most memorable and transformative career experiences occurred while I was working with the United Way of Chicago, and eventually United Way USA, as a McKinsey consultant. I learned how to leverage core business disciplines that I was familiar with in the for-profit space, such as breaking down large complex issues, using data and facts to determine a best path forward and aligning stakeholders to reach an optimal outcome. Before this experience, I had assumed for-profit organizations and best practices were dramatically different from those in the non-profit world. There are more similarities than differences and as you go through life, you are able to better identify these patterns and commonalities and draw from the same core skillsets to be effective and drive meaningful change in one area and apply it to others.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

During the early days of my career, I had an overwhelming need to try to control everything and was very uncomfortable with ambiguity. These tendencies can be natural and relatively harmless in the early career phase since you only have a small range of control and influence. But as you move up in your career, this type of mindset can be damaging and limit the potential and growth at the team and organizational level.

Eventually, I learned it’s better to cede control since most of what we encounter throughout our careers, and life in general, is ultimately out of our control. What you can control is how you respond to various situations and challenges, and inspire others to do the same. I also learned the value of surrounding yourself with people from a variety of backgrounds and empowering them to leverage their unique perspectives.

In terms of ambiguity, the more experience I gained throughout my career, the more I realized that I could either view the unknown as scary, or shift my mindset to view it as an exciting opportunity. I came to accept that we inherently live in an ambiguous world, and it’s better to adopt and embrace ambiguity rather than force clarity.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

I have many, but one of my favorites comes from something my mom used to say to me, which is, “As long as no one’s dead, we just have little problems to solve.” I used to think this was rather harsh and quite a low bar to set. As I’ve advanced through my career and have children of my own now, I’ve realized a deeper meaning — there are only a very small handful of things that can be considered life or death and unchangeable, but most things in life aren’t as dire even though it may seem otherwise. If you approach things with this mindset, it frees you to look at the world as something you can positively impact in your own unique way.

How would you define an “excellent healthcare provider”?

An excellent healthcare provider is someone who exhibits empathy and listens and treats patients as individual human beings rather than another appointment in their schedule, or another member for whom their team will have to work with insurers to collect payment. They care for the immediate and long-term health of each patient. These healthcare providers have proven clinical training, skills, and expertise and integrate their capabilities and knowledge into their patient’s needs with a holistic view. They make healthcare accessible and provide equitable, quality care to every patient who walks through their door. They provide cost transparency and have the utmost integrity in billing claims and payments.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

Most of the resources I draw inspiration from are the leadership books written by Patrick Lencioni, who’s best known for authoring The Five Dysfunctions of a Team. Lencioni’s books are mostly short stories on team management for CEOs and other leaders. I find them helpful in bringing my focus back to the core principles of leadership and recognizing what really matters, which is bringing a team together by inspiring and empowering individuals under your leadership. I’ve used the lessons from these books to help guide me as a leader and reorient my mindset during moments of challenge or doubt.

Are you working on any exciting new projects now? How do you think that will help people?

I’m particularly excited by our recent acquisition of Sapphire Digital, a healthcare consumer-centered pricing and navigation software company. While our core focus at Zelis has been to transform healthcare payments into a more seamless financial experience for payers and providers, Sapphire offers technology solutions to support members as they begin to navigate their healthcare experience, from finding the right provider to understanding estimates prior to care. Ultimately, the acquisition creates synergy to accelerate development of consumer-facing tools and further transform the healthcare payments process into a more seamless experience for payers, providers, and members alike.

It is no secret that the healthcare system is incredibly complex, often leaving patients at a disadvantage when it comes to access and cost. By creating a more transparent, efficient, and simple process with smart technology, our team at Zelis is taking an important step towards establishing a more affordable, accessible and transparent healthcare system for everyone.

Ok, thank you for that. Let’s now jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?

I have been fortunate to advise and lead several technology and health IT companies, which has given me a view of the industry’s strengths and, perhaps more importantly, its challenges. In fact, these challenges sparked my initial motivation to enter the field, and the urgency to solve them is what continues to drive me to this day.

At a macro-level, the challenges the U.S. healthcare system faces tend to stem from two primary themes — complexity and affordability. The U.S. healthcare system is notoriously — and some might say, unnecessarily — complicated. The sheer number of stakeholders involved outweighs those of any other country by far. While the key stakeholders can be boiled down to patients, providers, and payers, the U.S. system offers dozens of other stakeholders a seat at the table and they all drive up costs — from pharmacy benefit managers and lobbyists to technology vendors and policymakers, and more. And the more seats there are at the table, the more this confuses patients moving through the system. When it comes time for a patient to pay for a healthcare service they received, they face a daunting task of sorting through piles of mailed documents and deciphering complicated medical jargon.

From an affordability standpoint, each of the multiple stakeholders get a piece of the pie, creating multiple touchpoints for costs that get passed to the patient and drive up the overall cost of care. Yet, despite spending more on healthcare than any other OECD country, according to the Commonwealth Fund analysis cited by Newsweek, health outcomes in the U.S. aren’t any better than those in other developed countries. In fact, Americans have the lowest life expectancy among OECD countries.

Another factor that drives up costs is the startling number of inefficiencies inherent in our healthcare system. The healthcare industry is infamous for being slow to adapt, from both a regulatory and an innovation standpoint. As a result, seemingly simple tasks, such as sending a patient information about an upcoming appointment, are unnecessarily complicated due to antiquated technology, processes and ways of thinking. This wastes precious time and costs the system more. From a patient perspective, the system is confusing to understand, frustrating to navigate, and expensive.

As a “healthcare insider,” if you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

As someone who has experienced the depth and complexity of the healthcare industry throughout my career, when I read this question, my mind races with thoughts and ideas. That said, there are a handful of changes that, if accepted and adopted by the continuum, can move us toward a high-quality, more cost-effective, equitable, and transparent healthcare system.

1. Reduce the rising cost of healthcare by driving down errors, waste, fraud, abuse, and improving payment integrity. The United States spends more than $3 trillion on healthcare each year, drastically outspending every other country. Roughly $1 trillion of that is spent on errors, waste, and abuse. Paying accurately shouldn’t be hard, nor should inaccuracies occur as frequently as they still do today. Payment integrity is of the utmost importance in achieving a less wasteful, more efficient healthcare system.
   By combining smart technology, such as machine learning-enabled technology, along with integrated network, claims, and payments data, payers are easily able to generate actionable insights that maximize claims cost savings. The benefits of prioritizing payment integrity are vast — ensuring consistent cost-containment for payers on expensive claims, driving continuous improvements in care quality, and helping members avoid costly balance-billing — all of which reduce spending and improve experience.
   To date, Zelis has helped more than 700 payers save more than $27 billion in network and claims costs by providing clinical expertise and our leading payments optimization platform with adaptive technologies and solutions to price, pay, and explain healthcare claims. Preserving payment integrity is vital for the sustainability of our healthcare system, and it requires widespread adoption of data-driven, accurate payment processes.
2. Convert paper-based payments to more efficient, effective electronic payments. To cut avoidable spending, we must accurately assess and pay claims and convert paper-based payments to more efficient, effective electronic payments. There is $500 billion of paper-based provider payments that can and should be converted to electronic payments. Notably, the cost of processing a paper check is $6 and can be as much as $20; this cost weighs on the system with billions of healthcare claims being handled annually. In addition to reducing these processing costs, e-payments result in faster payments to providers and streamline lengthy claims processes so teams can focus on other priority areas.
3. Harmonize the complete payment ecosystem. There is a massive opportunity to create alignment and transparency throughout the full payment ecosystem — from the providers and payers, to the members or consumers. Industry adoption of, and investment in, intuitive claims technology has historically lagged, leading to today’s fragmented claims ecosystem with numerous disparate claims systems and a reliance on passive networks, paper statements, and checks.
   Payers and providers are increasingly adopting digital payment technology solutions to streamline the process from start to finish, including proactively identifying pre-payment discrepancies, more quickly disbursing payment funds and data electronically from payer to provider, and retrospective identification of errors and recovery of funds minus the administrative burden and months of back-and-forth that is usually required.
   At Zelis, we are passionate about and focused on harmonizing the complete payment process in healthcare, because we believe that more affordable and transparent care is better for all of us.
4. Improve access to care. One of many common threads among all of us is our need for healthcare, from birth through our twilight years. We need the right care at the right time regardless of our socioeconomic status. Unfortunately, 15% of U.S. adults (aged 18–64) are uninsured, which can greatly impact these individuals’ access to quality and timely care. Notably, this doesn’t account for those who can’t easily access healthcare because they’re in rural areas. According to the National Rural Health Association, the patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people compared to 53.3 physicians per 100,000 in urban areas. By missing out on preventive or primary care, minor health issues that are left untreated can increase the morbidity and mortality associated with chronic and acute conditions, which ultimately increases costs and strains resources across the healthcare system. The impact of deferred care among patients who lost access to routine treatment amid the pandemic is starting to take shape. As a result of patients missing out on routine care, annual healthcare costs in the United States may increase by up to $65 billion, according to an estimate by McKinsey. As an industry, we need to collaborate to change this and improve access for all. The silver lining to the pandemic, if there is one, is the rise of telehealth. Primary care providers pivoted to make care accessible and convenient. We need to continue to innovate and look at the things we’ve been doing differently; by doing this, we can all move the healthcare system forward.
5. Do better on behalf of consumers. At the end of the day, we are all consumers of healthcare, and consumers have been underserved for far too long. This is true across the board, but specifically, when it comes to the financial experience in healthcare. Consumers deserve, and desire, more transparency, accuracy, education, and guidance on healthcare billing and payments. Great strides have been made in this effort as of late, such as the No Surprises Act, which was signed into law on December 27, 2020, and protects members from excessive out-of-pocket costs and financial hardship stemming from surprise medical bills. However, it is up to the entire continuum of care — payers, providers, and vendors — to give consumers what they need to make more informed decisions and have a seamless experience. One way to create a more frictionless, transparent financial experience for consumers is by streamlining payment processes and communication. Providing pre-service price transparency, advanced explanation of benefits, and flexible payment options help ensure that both consumers and providers have clear choices and insight into what payers will reimburse. Joining Sapphire Digital with Zelis accelerates our efforts to streamline the member experience, offering a more shoppable healthcare experience like the travel and banking industries. Additionally, providing billing access through mobile applications, like other industries, enables members to easily confirm the accuracy of bills, conveniently make payments, and access their information all from one place.

What concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

Reducing the rising costs of healthcare is no small feat, and no one person or organization can do it alone. It requires a more streamlined, efficient payments ecosystem with alignment and collaboration across the entire continuum.

Technology vendors in the payments space must innovate the solutions that drive these improvements. At Zelis, we listen closely to what payers and providers want, and deliver the technology, expertise, and improvements needed to create smarter solutions and a better way forward for the healthcare industry.

For payers, there’s opportunity not only to change the way we think about the claims cost management process, but also to change the way we facilitate it. In healthcare, cost management processes have traditionally been deployed after a claim is paid, which has proven to be error-prone and often causes avoidable delays in verifying the appropriateness of a claim’s cost. This reactive process should be replaced with proactive processes. Payers will benefit from adopting technologies to speed up and streamline the cost management process and allow them to determine claim cost appropriateness before claims are paid. Proactive, data-informed payment processes reduce costs associated with errors and manual inefficiencies. Integrating new solutions and expertise into these processes leads to the efficiency, effectiveness, and accuracy required to curb the rising cost of healthcare while helping to maintain payment integrity.

Similarly, when it comes to providers, it is important that they take strategic steps to improve billing accuracy. Implementing technology that leverages reliable, error-free data to audit claims costs removes the likelihood of inefficiencies in the payment process and helps ensure consumers are being charged for the correct amount that is owed. Additionally, providers can optimize payments and claims by transitioning from paper-based processes to electronic payments. Digitizing everyday operations will reduce costs, increase efficiencies, enable providers to be paid faster, and free up staff to focus on other priority areas.

The COVID-19 pandemic has put intense pressure on the American healthcare system, leaving some hospital systems at a complete loss as to how to handle this crisis. Can you share with us examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these issues moving forward?

The COVID-19 pandemic exacerbated many of the existing challenges that I highlighted earlier. In general, hospitals — from small community facilities to large health systems — as well as their staff, bore the brunt of the pandemic pressure. For context, outside of the pandemic, most hospitals run their daily operations with dated processes, which means administrative and staffing leaders are forced to operate in their silos making decisions from disparate, fragmented data. This lack of visibility creates sub-optimal decision-making that hinders the organization’s ability to care for patients. When the pandemic hit, health systems were forced to reckon with the painful reality that their existing capacity and resource management tools weren’t sufficient. From ventilator shortages and ICU capacity constraints, to staff burnout and financial uncertainty, the pandemic has created a sense of urgency for hospitals to modernize their approach. Beyond the pandemic’s impact on hospitals, the public health system encountered — and continues to grapple with — numerous challenges including socioeconomic disparities, unprecedented mental health concerns, misinformation, vaccine hesitancy, and an uptick in fraud, waste, and abuse.

On a more positive note, the pandemic also sparked an unprecedented amount of innovation that likely would have taken years to materialize if it weren’t for the urgency created by the public health emergency. In turn, stakeholders across the industry mobilized to adapt and discover new solutions to defeat a common enemy. The result has been an explosion in technological advancements that aim to improve upon deep-rooted challenges.

Simplifying the payments process has been another key area of improvement thanks to the technological revolution. As patients continue to look to minimize in-person visits, electronic payment systems can limit the risk of exposure for patients and providers by minimizing contact with paper bills and checks, while also simplifying the overall billing process for all stakeholders.

If there’s only one lesson we come away with from the pandemic, it’s that the biggest risk to our healthcare system is maintaining the status quo. We must sustain the current pace of innovation that was accelerated during the public health emergency to overcome the challenges inherent to our health system. By simplifying, economizing, and modernizing outdated and laborious processes through smart technology and strategic foresight, we have an opportunity to strengthen our healthcare system and mitigate its current and future challenges.

I’m interested in the interplay between the general healthcare system and the mental health system. Right now, we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?

One of the few positive outcomes from the pandemic is the de-stigmatization of mental health. This has led to a broader cultural awakening that recognizes mental and physical health are inextricably linked, and we can’t maintain one if we don’t devote the same amount of care to the other. The key to maintaining this cultural acceptance will be institutional buy-in, particularly among employers.

At Zelis, for example, we offer several programs to support our associates and their families’ mental and physical health, including WorkLifeMatters, an employee assistance program (EAP) that provides 24/7 confidential, personal, and web-based support for stress management, dependent/elder care, nutrition, fitness, and legal and financial issues. Our team also has access to GoPivot, a wellness program that supports and rewards our associates’ well-being journey, and Teladoc, convenient access to licensed therapists 24/7/365 through video or telephone sessions.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

Healthcare is universal, and it impacts every single person in one way or another. If I could inspire a movement, it would reflect Zelis’ founding belief that there is a better way to price, pay, and explain healthcare for payers, providers, and consumers. Collectively, we could create a healthcare system that better serves us all by paying for care, with care.

How can our readers further follow your work online?

Feel free to follow me on LinkedIn and learn more about Zelis on our website.

Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.