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PAY. FOR. BABY.
Fertility specialists sell a vital service that no one truly desires to purchase—a grueling IVF cycle—yet it's essential for achieving what patients desperately want: a baby.
Nader AlSalim introduces an innovative model where patients pay only after successfully having a child, shifting the financial risk away from them.
This episode is a must-listen for CEOs, practice owners, and revenue cycle managers looking to embrace this transformative approach.
Key Takeaways:
Understanding the true need behind fertility services: patients want a baby, not an IVF cycle.
The ethical dilemma: balancing risk between patients and providers.
Introduction to Gaia’s model, where patients pay only upon successful outcomes.
Insight into how innovation in fertility services should extend beyond the IVF lab.
Practical advice for revenue cycle managers on implementing this model efficiently...
Enjoy this insightful conversation with Nader AlSalim and explore how your practice can adopt these innovative strategies.
Griffin
P.S. My suggestion--try to meet with Gaia at ASRM. Or Email them here.
Nader AlSalim
LinkedIn
Transcript
[00:00:00] Nader AlSalim: On a simple, basic, fundamental human right, do you think it is right that the difference between me having a child or you not having one is how much money I had? And if you want to distill it to that fairness, and I personally get accused of finding that David and Goliath story all the time, but that's just deeply unfair, it's just wrong on so many levels
[00:00:18] Announcer: Today's episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free to you. Here, the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.
[00:00:36] Griffin Jones: Fertility doctors, you sell something that no one wants. You sell and perform something that people very much need, but think of it in those terms. No one wants to buy an IVF cycle. They want a baby. The risk of what you do in the case of most patients is placed on them.
Is that fair? Heck no. Is it fair for that risk to just be transferred to you? I don't think that's fair either.
Someone else needs to de risk this process for each of you. Someone with an exceptional model.
I'm going to introduce you to Nader AlSalim. He's the founder of a company called Gaia. I had dinner with him last ASRM and the whole time I was thinking, this is someone you're going to want to talk to.
CEOs and practice owners, he talks about how innovation needs to stop being isolated to the IVF lab, innovating so that after a protection fee, patients only pay for a baby.
But how do you incentivize your revenue cycle managers to implement?
What do revenue cycle managers really want? Revenue cycle managers, the latter part of this episode is for you. The fastest payer on the market, no prior auths and everything done in three clicks. Listen up.
We're putting contact links and buttons to reach out to Gaia everywhere this podcast is distributed. If you're in the car driving and you can't click on anything, Gaia is spelled G A I A. Find their contact info on their website. But if you're listening to this prior to ASRM 2024, try to get on that or schedule.
Talk to him about one of these topics. Challenge him if you want, but have these conversations now or be an instrument of an unfair past.
Enjoy this conversation with Nader AlSalim, founder and CEO of Gaia.
[00:02:07] Griffin Jones: Mr. AlSalim, AlSalim, welcome to the Inside Reproductive Health Podcast.
[00:02:11] Nader AlSalim: Thank you, Griffin. Thank you for having me. Great to be here.
[00:02:14] Griffin Jones: Be agnostic for a moment. Be a Vulcan from the Star Trek world who, this logical race that isn't from this world, that doesn't have emotion, they only think in logic. You come to the planet Earth and you see how IVF is paid for, is sold, you have to report that back to the Vulcans in a completely passionless way. Logical manner. in your report?
[00:02:43] Nader AlSalim: You wouldn't believe I came down to earth and there is this industry that have seen explosive growth by selling something that people don't want. Imagine they start selling something that people want.
[00:02:52] Griffin Jones: Tell me about that. What do you mean by that?
[00:02:55] Nader AlSalim: Let's say I went down and a bunch of excellent doctors and excellent providers That are selling people cycles of IVF. They may or may not lead the result that they want, but people want to buy babies, but people are buying cycles, and there's this crazy mismatch between what people want to buy and people, what providers are selling, and that created such a misalignment of incentives, then we structured the whole economics of that model On what I want to buy and what you want to sell, and given that it's the only time in healthcare that it's not the same commodity, and I would report that I found this exceptionally shocking.
[00:03:25] Griffin Jones: So it is exceptional in your view and with regard to the rest of healthcare.
[00:03:31] Nader AlSalim: What part of healthcare do you buy without any control or visibility on the outcome? Yet you pay for the price regardless. Because all of healthcare is a marginal improvement, and you'd argue that the component of value based when it comes to any point solution is a gradual improvement on a scale. But when it comes to fertility treatments, it's the only time you couldn't have a more binary outcome. And you can measure it, yet you're paying for the underlying unit of that treatment, not the outcome of that treatment. I
[00:03:57] Griffin Jones: It's hard to think of this passionatelessly, isn't it? Because I looked at your your company's Instagram, and a few weeks back. There was a post that says, how the F are we going to pay for this? And I looked at the comments of what people say, and some people were saying, I had to get a high interest loan.
I just didn't have , another way of being able to do that. Other people were saying it was all of our savings. Another person says side gigs, extra shifts, no vacations, savings, all of it. It's hard to. see people going through that and then just think of it in an actuarial sense, isn't it?
[00:04:41] Nader AlSalim: I couldn't agree more, and I think, like I'll add, people remortgage. If you go on, crowdfunding platforms today, you'll see pages for families that are crowdfunding for IVF journeys. People remortgage their own house. People go to friends and family. Grandparents, I think, fund about 20 percent of treatment.
I think the very ugly reason that those treatments are expensive is because they can afford to be. Because people will pay everything they have and they don't have for a baby. And you have this unique dynamic where demand is fairly inelastic because of that price of the hope that it's fairly intangible.
[00:05:13] Nader AlSalim: And usually the two forces that exist in order to put pressure down on pricing are either a public health care payer, which does not exist in the U. S., or sufficient insurance coverage to put pressure on pricing, which also does not exist. Absence of those two forces that stabilize prices, everybody reports that these things are expensive, but nobody reports why are they expensive.
And the reason is You can be as expensive as your local market dynamic allow you to be because you're pricing an inelastic demand into a commoditized product, being a cycle, not linked to the outcome. So you create exactly what you've just seen, where people will wonder how would they fund this? And they go to really bizarre means on how to fund that put them at more financial risk than they would otherwise, which adds a lot of more strain to what is emotionally and physically a very painful experience.
[00:06:00] Griffin Jones: One of the things that you said earlier, thinking of if you were reporting back to Planet Vulcan that there are people that are in pursuit of an outcome, but they're paying for a method regardless of the outcome. Is it possible now to get to this world that David Sable has been talking about of pay for baby, not for cycle? Is it possible to be there now?
[00:06:27] Nader AlSalim: I think it is possible to be there now, and I don't want to put that pressure on the providers themselves, and I think the provision of care and the payment of care is the crux of why we've created the healthcare system in the U. S. that is so fundamentally broken because of the misalignment of incentives.
Is there a possibility for you can appear to come and say, I'm going to move this market from a cycle basis to outcome basis. I think the answer is yes. And there is no breaking news in this, right? No one wants to buy an IVF cycle. And to quote our dear friend David Sable again, He'll be the first to tell you that certainly no one wants to pay for a negative cycle.
The ability to transfer the risk of a bad outcome, and bad outcome, no baby, from a patient to the provider will be an enormous competitive advantage. And what we do, which a lot of people hold as like innovation, I would call as a great form of dinosaur insurance. We apply a 19th century insurance model to a 21st century problem, and much of that innovation happened by moving the risk of a negative outcome from the provider onto the patient onto us.
For And managing that risk is the business that the patient should be in, because again, I do not want anyone to pay if they don't have the outcome they desire.
[00:07:37] Griffin Jones: But the providers can't assume the risk on their own, right? Or I think it would be extremely difficult to say that just the providers, without having additional help, would be able to say, we're just charging you if there is a successful live birth. Would that be possible. Why do they need the help of someone else?
[00:08:00] Nader AlSalim: Because I don't think the provider should be in the business of risk management. I think the provider should be in the business of care management. And the separation of the two, by having a specialized risk management on top of your care delivery, that is at arm's length, Where you're not betting against your own odds because the house will always have better information asymmetry, which is a critical problem in IVF to begin with.
You are creating a risk bearing business outside of the provider that is interacting with the patient, where the provider gets paid regardless of the outcome, and I'm managing the risk on someone else's behalf. I do think it creates a cleaner transfer of risk between all three parties in a much more transparent way.
to render the service versus a wraparound by which I provide the service and I provide the warranty.
[00:08:44] Griffin Jones: when you said a new way to pay for this, Gaia is a new way to pay for this. Your model is different though than that 19th century insurance model. What are the differences? E,
[00:08:58] Nader AlSalim: I think the fundamental difference where Gaia operates in as a business model to begin with is we said there shouldn't be a way by which you're paying this on a cycle basis because it doesn't make any sense because of what we said earlier. You shouldn't buy this in bulk because healthcare should not be bought in bulk in order to get some value out of it.
What should be is a better way to predict the risk on two levels, on an individual patient level and on a clinic level. And I want to reflect the personalized risk of that patient performing at that clinic in the form of any other insurance that you buy that would calculate your personal chances of something happening based on your own personal data.
And in this case, it could be your biomarkers, it could be your clinical data, it could be the clinic's performance, and so on and so forth. And then the way this is very different fundamentally is we shifted the market from a fee for service into an outcome based and shifting that not on a select few or on those who are eligible, shifting that on every single person that goes through the IVF so that we're pricing the risk, not rejecting the risk, and we're passing that on risk to the patient.
It's how this is highly differentiated because with Gaia,
[00:10:12] Griffin Jones: explain that to me. The difference between pricing, the risk versus rejecting the risk.
[00:10:16] Nader AlSalim: absolutely, when you put a LinkedIn post the other day and you're asking for questions, there's a gentleman who asked a very good question, like, how do I know that Gaia is not cherry picking the risk, which is a very valid question because you could design like risk shared programs and you can say 1 in 10 people will be eligible.
So that's a shared risk program where I cherry the risk for those who qualify. And Guy's approach is a little bit different. We said, our job is to understand Griffin's chances of success on an individual basis, and for me to price the risk reflecting your probability of success. My job is not to lump you with a 35 year old.
My job is not to say, this is the laws of averages. My job is not to say that people like you will have chances of X. I actually want to understand your own performance as a patient, and I want to correlate that with the patient's performance at that clinic. And together, I move very close to the unit of risk that I'm measuring, which is the predictability of IVF as an outcome.
And if I can do that, why can't I underwrite it? And what we pride ourselves here, and we try to do a lot of education, no two people at Gaia will have the same price to start IVF. Because no two people will have identical risk, not because they happen to be 35, not because they happen to have a PCOS or any other condition.
And I think that's highly differentiating because then you're moving that risk unit to the individual and then you're superimposing the clinic performance on that individual. So you really move as close to reality or to the truth as possible. And then you'd say my job is to give you a price for that risk.
Your job, if you want to accept it or not, as opposed to say you're eligible, you're not eligible. And today, Our eligibility is about 92 percent so 9 out of 10 will walk away with a prize to reflect their chances.
[00:11:49] Griffin Jones: What's insufficient about the current shared risk programs that have been introduced. What's the lacking with those types of programs?
[00:11:59] Nader AlSalim: I'm not criticizing them, I think they were great when they were introduced and Some of them are going on for 30 years and they're clearly like a bulk of innovation if you go back all the way to when they started. I think there is a bit of the one size fits all element that does not work.
I think there is a little bit of the standardization of the package is based on if Griffin needs four cycles of IVF and Nader needs two cycles of IVF, the solution is not to sell them both three.
And back in the day when we didn't have the data that will allow us to go on an actuarial level of what is the relative performance of each cycle and the enhanced probability of each cycle. That was the easy approach to create these shared risk programs based on multi cycle approach.
But today, if Griffin needs four and Adam needs two, you need four and I need two, and both of us will not use three because someone would have overpaid or underpaid by one, and we're eliminating that sort of bundling from the system. A group basis to an individual basis.
[00:12:53] Griffin Jones: How did you get into all of this, both from the actuarial background and why the fertility space?
[00:13:01] Nader AlSalim: I do ask myself that question a lot. And I think the answer is it's a complete accident. My story is very well documented and I do not want to bore yet another podcast audience with it, but it's the, reason I have a child. I had a hundred thousand dollars to spare, so I spent five.
IVF cycles in over three years in two clinics in two countries, and you wouldn't believe it, but I would go to the doctor after every failed cycle and ask a simple question, what happened and what happens next? And they go, we don't know. And I've always thought what an insane answer. And yet, I do exactly the same thing and expect a different outcome, which is the definition of being insane.
I would show up the next day and pony up 15, 000 and say I'm ready to go, let's go. And it's such a bizarre experience because that emotional lottery of going round after round expecting a different result, but you actually don't know what happened and you don't know what informed the next decision.
And that journey took a while. And then the more I started being part of that journey as a patient myself, you crystallize the problem, right? The better the treatment gets at solving the infertility, the more intolerable the lack of access or the lack of better outcome becomes. But the reality, which is What informs sort of the business model around being insurance or spending a lot of time on actuarial is Cost remains the greatest barrier to infertility anyway You cut it or slice it You've seen the stats all over the news and you've seen how many babies out of a hundred in the US are born out of IVF And how many people in other parts of the world and it's not like people from other parts of the world like IVF more than the US does it just cost an arm and a leg and it's free in many other places and What I kept thinking about is the misalignment of the unit of sale versus the unit of outcome I kept going back to the lack of someone in the middle who's de risking the probability of a negative outcome.
And I kept going back to not being able to understand the patient risk at a very small and accurate unit. And in any other forms of insurance, and I'll tell you a little bit more about my background earlier, but in any form of insurance and the way it works in multiple contexts in finance.
There is this old saying, if you can predict it, you can price it. And if I can predict it, why can't I price it? If I can predict it, why can't I underwrite the risk of it? If I can predict the probability of a hurricane in a certain state that I can design a financial instrument that protects against that hurricane, why is it different?
When it comes to a woman having a child, because so long as it's non random, and I can predict it with a degree of accuracy, certainly means I can negate that risk of a negative outcome by providing an underlying insurance against that risk not happening. And I started going down that path, and it didn't evolve much, to be honest.
It evolved in maybe in certain nuance of the product and the structure, but the premise of it on day one, After year four it's exactly the same. We want to be the first value based underwriter of fertility treatments moving that market from the unit of a retail sale of a cycle to that of an outcome.
[00:16:15] Griffin Jones: If I can predict it, why can't I price it? Why have the traditional insurance models not been sufficient in being able to achieve that?
[00:16:27] Nader AlSalim: Lack of data, lack of will, lack of innovation, all three. I think if you're an insurer of a certain scale, even when I started, people would think fertility is like this niche little problem that affects a small percentage of the population, so on their list of priority, it's probably very low. And what is the low hanging fruit if you are a large insurer with a large book that is managing billions of volumes of other forms of insurance and healthcare on its own is hard to navigate, so the point solutions even gets relegated to second order.
Two, I think, absent a mandate, there is a lack of care, meaning if you can get away without providing that cover, why would you?
And lack of innovation. And I I don't think you look at the insurance world and you think, what an innovative bunch.
[00:17:15] Griffin Jones: That's true. I don't think the model has changed much, at least not from the consumer perspective for decades as far as I can tell being a consumer. I think we need to get into the mechanics of how Gaia works a little bit, because it is radically different than these previous uninnovative models, as far as I can tell. And I don't think that. I can paint the picture for people at the level of detail that you can. Tell me about how GAIA works.
[00:17:53] Nader AlSalim: I'll give you an example on our IVF product, which is one of our products, but I'll give you an example because it's simple and it's straightforward. So you come to me and I predict the risk of your success and failure over a cumulative rounds of IVF up to six cycles. And then that risk will tell me what is the level of protection fee that you need to pay in order to start.
You tell me what is a protection fee. A protection fee is akin to a premium. You pay it at the beginning of a cycle. It is a percentage of the total cost of a cycle. It is personalized to reflect your own chances of success. You pay me that protection fee at the start. It's about 25 percent of the cost of a cycle.
I pay the clinic on your behalf. You don't have to worry about a single payment that comes your way. Every single payment, every single line item, every single treatment that the clinic will charge you, I will pay it on your behalf. All you have to part way is that 25 percent of the cost at the beginning.
Then you go do the cycles that you'd want. When you have a baby, you pay me 400 a month. If you don't have a baby, you pay me nothing.
[00:18:48] Griffin Jones: This is a mix of insurance and patient financing, isn't
[00:18:54] Nader AlSalim: Correct, and I think it's a good point that you picked on. Because what we do not do, and I think it's such a lazy way to label Gaia, we're not a financing option. We're far from a financing option. We're not in the business of financing IVF. I don't think that's remotely close to anything that we do.
Because we don't finance the process, we finance the outcome. So the example that I just spoke to, financing only kicks in to pay me back what I paid on your behalf, in case you walked away with a child. So what you're financing is the outcome. If there is no outcome, there is no financing.
Because I'm going to waive the cost of the treatment that I've paid on your behalf.
[00:19:32] Griffin Jones: And the difference between this and shared risk is that in traditional shared risk, I would pay a much higher fee. Premium, if I were not to have a baby after a certain number of cycles but this is, I pay a certain amount, I pay a percentage of the IVF cycle, that is the protection fee, and then I either have a baby, and then I pay over time, or I don't and I pay nothing.
Is that the difference between this and traditional shared risk?
[00:20:06] Nader AlSalim: correct. Amongst other nuance, but the crux of the difference is that you're not overpaying for cycles you do not use. Repaying the cycles that you use in order to get the outcome that you want, whether it's one, whether it's two, whether it's three. And I think that's fundamentally different than you committing to paying three cycles regardless of what the outcome is and whether you got pregnant out of one, two, or three, it's the same bill.
It's just a much more fairer way to estimate that risk and get to charge for that risk.
How does
[00:20:31] Griffin Jones: this work in the UK?
[00:20:33] Nader AlSalim: The national health system in the UK is such a source of pride for all of us. But I think the reality is When it comes to fertility treatments, it does fail. We build this world class healthcare system that is publicly funded, but when it comes to the elective treatment of fertility treatments, we just don't do it sufficiently.
The NHS funds about 25 percent of all treatments in the UK, and 75 percent of those treatments are privately funded. If you think about it and how it equates to the U. S., it's very similar to how the employer market plays out with a cash payer. So about 25 percent of it is covered by the employer of some sort through your house plan, and about 75 percent of it is paid out of pocket.
So similar dynamic from that. If you double click on the 75%, i. e. how do people like you and I pay for it if they're not covered by their employers, it's a very similar pattern to how the U. S. market pays for it. It's a bunch of things, right? Savings, loans, credit cards, friends and family, yadda.
From a market structure and dynamic, it's exactly the same, the little contribution that happens from the public healthcare system, it's the same that happens from the employer in the U. S., and then the combination of them opens up a big market for it comes to the cash payer. The two things that are different here is we do not have a private healthcare model in the U.
K. There isn't that model. People don't buy private healthcare the way that they do it in the U. S., especially from an insurance perspective. For And especially from a coverage perspective, they don't. It's often these elective treatments that fall outside of the public health care spending that gets paid out of cash.
So the level of awareness on how to pay for IVF and how to optimize for the outcomes, whether it's egg freezing, embryo batching, so on and so forth, is weaker as it compares. So against that backdrop, we've launched here two and a half years ago, and the success that we've had is a true reflection that there was a big need in the market because the market was not as big as it needed to be because a lot of people are priced out.
And two and a half years in, hundreds of people through the program, we've underwritten thousands of cycles now. I still think most human KPI, we're now delivering a baby every six days in the UK. With that in mind, if you look at the composition of the people that we're serving, 20 percent of the people that we're serving, for example, today are same sex couples.
Today, in the UK, they don't qualify for any form of funding. And you look at the diversity of the regions that we're covering, and you look at the difference that we're making on those people's lives, because A lot of the members, and you see it through a lot of the testimonies that come through, will tell you very openly that if it weren't for that protection, if it weren't for that early place to start, if it wasn't for that low cost to start, they just wouldn't embark on a family.
So for you to understand that the difference that you're making is you are the reason why this family exists or not, it's a very humbling metric by which we should hold ourselves accountable to how much we can expand the market. Because what annoys me a lot, especially about the U. S.
market, is we decided to fantasize about how to improve access for those who already have access.
[00:23:26] Griffin Jones: Upper class people that can afford it, for example, and then they get employer coverage because they are the people that work for the type of companies in the type of positions where employer coverage is
[00:23:39] Nader AlSalim: precisely, and we said, for those people, we're just not going to stop innovating. Because you already have access, but we're going to make our access much better. But if you're not working for Google, tough luck. If you're a public school teacher from Ohio, we don't care enough about you. And we're just not going to innovate because you don't deserve the same chance of having a family.
As someone who happened to be employed by an employer within a certain class that allowed their employees. And I think there couldn't be anything morally wrong than that. I'm not saying this is bad we should innovate across the spectrum. And those people deserve better access, and if you have them easy, deserve better access.
But we should just not leave people out. And what's happening today, Griffin, we are leaving people out. And we are sending the message that we don't care about you. On
[00:24:21] Griffin Jones: Tell me more about that because I've heard you talk about a value based mission and These types of values seem to be what you're talking about now, but how does that integrate into what you're doing?
[00:24:35] Nader AlSalim: a very lofty vision don't you want a world where anyone who wants a family can?
On a simple, basic, fundamental human right, do you think it is right that the difference between me having a child or you not having one is how much money I had? And if you want to distill it to that fairness, and I personally get accused of finding that David and Goliath story all the time, but that's just deeply unfair, it's just wrong on so many levels.
And it's not only for people who want treatment, just imagine if you're modeling what's future behavior is going to be in terms of consumption, it's becoming very apparent that it's outside of heterosexual couples that are starting treatment. It's, think about the LGBTQ families that are being formed, think about rare disease risk and people who would need to eliminate that risk of inherited disease by using IVF.
Think about oncology patients that have to freeze because. Because obviously, not by choice, think about the large and growing elective treatments such as social egg freezing. And today, we've created a world where you'd say, all of that is available if you have the means, and all of that is unavailable if you don't.
I think that's the fundamental value that, that, that grounds us here. That we need to make sure that there is equity, and we need to level, the playing field between those who don't have the means and those who do.
[00:25:55] Griffin Jones: Why now, though? Why not 5 or 10 years ago? Why not 5 or 10 years from now? What inflection points are happening in the fertility space now?
[00:26:07] Nader AlSalim:
There has been an explosive growth in the last 10 to 20 years where when you're witnessing that growth, you're usually not worried much about where the new wave of growth comes. And I think that's what pertained in the fertility space. I will quote, from Pinnacle innovation should stop being in the lab.
And I think that's the inflection point that's really happening in fertility.
[00:26:26] Griffin Jones: Innovation should stop being isolated to the
[00:26:29] Nader AlSalim: Correct innovation is not restricted to the lab. And I think that's a good point, because that is the inflection point that's happening, that is allowing people to understand that there is a bigger market.
We're far off the true potential of the market. The goal of one million baby a month may seem lofty, but it's not lofty, it's basic math. And given where we are versus where we need to be, there is a lot of innovation that needed to happen yesterday so that we can catch up on that. And innovation should not be restricted to what happens in the lab as it has been for the last 20 to 30 years.
And on that spectrum, there is a lot of things that need to happen. , there are mighty and exciting companies I love what Josh and Alan are doing at Conceivable, with the aim to reinvent, the whole hardware and software of it, but also reinvent the lab, and we need to innovate on the most basic unit of treatment.
But we also need to go further to say, yes, we're innovating on what's happening in the lab and how the lab and the services are rendered, but how about we innovate on how we sell it and how we price it and how we package it. And that end to end is now happening, because people have realized that the market has grown to a certain level, yet the market that is priced outside, that we're not serving, is far bigger than the market that we're truly serving today.
And if you want to realize the opportunity, whether you want to chase the missing babies, or you want to chase the missing dollars, whatever is your incentive, that market should be. At the crux of innovation right now, or that inflection point, as you say.
[00:27:53] Griffin Jones: Everything that you've said to me thus far makes complete sense and sounds like it could completely transform access to care in a way that we have not been able to achieve thus far because this is a meaningfully different model, Nader, but now I want to get to a sticky point, a potential bottleneck, which is clinics.
For Clinic operations. How do you work with all of them? And let me start with another one of those questions that came from one of our listeners on LinkedIn, which is what about reimbursement rates and what about undercutting clinics? And when I've heard clinics talk about The employer benefits groups or insurance coverage in the past, sometimes they like a lot of things about them, but other times they will show me what they're being reimbursed, and it's a fraction of what they're getting, and then they're effectively subsidizing the cost. So So, how what's the incentive for clinics?
[00:28:56] Nader AlSalim: It is a good sticky point, by the way, and I think if you go to clinics today versus five years and you contract how they feel about the emerging payers in the employer space, you'll have a very different response to the initial excitement of all that added volume versus the actual cents on the dollar that they collect from all that added volume.
And I think this is our opportunity, quite frankly, because there is a fatigue from payers, not only from a reimbursement rate, from how they work. From authorization, from inefficient processes, legacy systems, you name it, right? The quickest eye roll that you will get is talking to another revenue cycle management personnel and telling them, I'm a new payer.
And that doesn't stop at I'm collecting less cents on a dollar. That goes all the way to the process. I would like to really use this as an opportunity for shameless self marketing, and say there needs to be an emergent of a new payer, a fundamentally different payer, that does not stop and start at better reimbursement rate, but goes all the way to making the life of the revenue cycle management personnel at a clinic substantially better, so that you're incentivizing them to work with you, not being a payee.
Arm twisted to work with you. Number two is,
contracts that last are by definition fair to both parties and there is enough juice in them so that they sustain themselves without one being squeezed more than the other should. Clinics margins are no rocket science. Where clinics do hurt is not rocket science. We're very transparent about , what do we need in order to make the math work.
So long as we're in the money and we're passing some of that to the clinics so they continue doing the great service that they do and getting paid for it. No one wants to get the clinic out of business, and certainly I don't want to enter into a contract where I squeeze the clinic to the point by which rendering the service is no longer viable.
But I'm happy because I'm squeezing them because of the margin, because that is not equitable when it comes to creating the power relationship I want to create with a clinic. We're building a network. We're building a high performing network. It doesn't mean that we're going to work with every single clinic.
It means that we're going to work with a select few and that we're able to reward their excellence because we are outcome based as opposed to volume based. It also means it's very important to us. As a new payer, to own the end to end experience substantially better than any other clinic and reward them on a better reimbursement rate, but also make sure that we're making their life easier, because there are horror stories of how payers get paid and what's the process and what's the mechanics that we're trying to eliminate by being a technology focused company as opposed to a paper based company pushing volume.
[00:31:22] Griffin Jones: I want to pull out something that you said about incentivizing revenue cycle management and the people that are behind the implementation, because I bet all of the CEOs listening are just picking up what you're saying, and they see it, and they see the value in it. I would expect that their challenge would be, How do I implement this?
How do I incentivize my middle managers, those people that implement, to get on board?
[00:31:55] Nader AlSalim: I always say with all due respect a lot of the CEOs get super excited about Gaia and that's wonderful. The champions within any provider network is the revenue cycle management decision makers that will make this happen or not make this happen. And designing a seamless process What do they want is the question, right?
They want simplicity, they already have so many things to do and so many pairs to deal with and so many obscure and legacy systems to deal with. Reducing the friction points between clinical referral pathways, authorization, the lack of prior authorization, agreeing everything up front, transparent rate system.
No back and forth. We've eliminated all of that, so we're creating almost no friction, and we always say we'll contract on three clicks between you seeing a patient and you referring a patient and you getting paid versus filling ungodly long forms, faxing it to somewhere in the ether, waiting for a respond that may or may not come so that you can get paid 180 days before.
We're the fastest payer in the market today. We pay upon the completion of any service. On a scheduled timeline, on a pre agreed schedule, with no back and forth and no prior authorization. And that alone will improve the life of anyone substantially better than anyone that you've seen from a payer perspective.
[00:33:14] Griffin Jones: The revenue cycle manager's ears are probably perking up right now, but I am not a revenue cycle manager, so explain how this is different from the normal process. You alluded to it a bit with faxes and longer terms, but tell me about how the process often looks versus how it looks in your process.
[00:33:34] Nader AlSalim: What do they want? They want to get paid the closest number to their cash dollar in the fastest possible way by filling the least amount of forms. That's what they want, right? Forget all the fancy acronyms, forget all the, just forget it. We make sure that they get the closest cent on the dollar to their cash price, and they get paid the quickest possible, with the least amount of clicks that they need to click on in order to submit a form in order to get paid.
That's what we do. And if you compare us to a normal process, any of these metrics, we cut it by a half, if not more. An average payer takes 120 days to pay an invoice. We pay in 30.
That alone would save a ton from the revenue cycle management perspective by how much they need to chase a payment. And how much they need to wait on a payment of an opportunity cost of their dollars not being sent versus someone who will honor the payment on a schedule in a very transparent way.
[00:34:30] Griffin Jones: I know you're not in the lead gen business per se, but it also seems to me like you could help clinics with their patient pipeline because you have Patients that find you at the consumer level and get qualified, they get in your system, and a good percentage of them aren't matched a clinic. Am I inferring too much about how You would help with that, but it seems to me like you've got a lot of patients then need a clinic to go to.
[00:35:06] Nader AlSalim: I think you're right to start with it that it's a not lead gen model we say with clinics as we build the network. Two thirds of the people that come to Gaia today, top of the funnel, do not have a clinic in mind, which is telling you something very important, two thirds. It's telling you something that we both know, which is people are beginning the journey of through how do I pay for this thing versus where do I go?
And if they're coming to me to figure out how to pay, the next natural step in that process is to send them somewhere to go. And what we do, without any monetization of any effect, because that's the bi directional partnership that we would have with the clinic, and that's the point of working with a select few of networks, not too many, is in every area we start directing the people that don't have a clinic in mind to a default clinic that we work with, so that this becomes us sending them qualified leads that are interested in pursuing treatment that are very close, like we're very low in the funnel, to the clinic network that we have.
So that our providers get the first dibs at sending them that traffic before they go and they try to find somewhere else or they shop somewhere else and they go outside. And it's been a very effective, bi directional, highly appreciated flow of traffic that we gather. That is outside of the remit of the clinic.
There is also a concept of an arm's length and who do they trust more as the advisor to come and start the journey. You've seen a lot of emerging brands, whether it's on communities or support, or any of the ancillary business that people come to them in order to recommend the clinic. People struggle, like, how do I fund this treatment?
How do I pay for it? Is there any other solution other than what exists today? And people come to us and, again, if two thirds of the traffic comes directly to us before a clinic, that will tell you a lot about the direction of travel.
[00:36:51] Griffin Jones: It seems to me like that might also help with retention. Some people might say I've got a full pipeline, but then, They are losing patients in between cycles or they're losing people in between new patient consult and IVF. How does this help with conversion or patient retention?
[00:37:12] Nader AlSalim: ,
I think such a good point, and I was surprised to see that not a lot of clinics do actually measure retention. And some of them do, and some of them don't. Some of them measure the unit of the first sale or cycle that they do versus how many cycles that they sell on a journey. And with Gaia today, 80 percent or 78 percent of the people that walk through the door end up with a baby on an average of 2.
2 cycles. If you see what do they do in comparison to the national average, that's about 60 percent uplift number of cycles. Of what they would've done otherwise. So a good sticking point has always been patients with us will go further. When they go further. That means two things happen. They stick with you for longer, you increase the revenue per patient, but you also see the success outcome of that because they've stuck with you and they didn't go somewhere else and someone else picked up the benefit of that.
So you don't only see the LTV increase. You also see the outcome associated with that increased journey.
[00:38:06] Griffin Jones: And there's a patient experience component to that too, isn't there? Because probably eight years ago now, I analyzed Several hundred reviews, maybe thousands of reviews, and I categorized those reviews that were negative and those that were positive, and as you could expect, those that were negative had to do with A negative outcome that was not categorical.
Some people were happy when they didn't have success, and some people were not happy when they did, but it was the biggest predictor on if someone was going to leave a negative review or a positive review, and no small part of that is because they forked over their life savings. They gave up that vacation.
They put the second mortgage on the house. They sold the house. They didn't buy the house. they are late on their student loan payments because this is something that they had to put first. It seems to me like there's a patient experience, patient satisfaction component to this.
[00:39:10] Nader AlSalim: And it's critical, and it's critical for many reasons, and I like what you say, because this is a classic consumer experience problem, and it's something I personally quite like, for two reasons, right? First reason is, you are selling a service on top of a service, meaning not only your experience have to matter, but the place where they render the experience also have to matter because it needs to match.
This is a classic Airbnb problem, right? You might have a great booking experience on Airbnb where everything is so clear and you pay and it's great and seamless but you go to the actual unit and it's a disaster and then who do you blame, the unit or do you blame Airbnb? And it's the same experience, it's like the byproduct experiences that happens next and who gets to blame where and how.
So it's a critical one to monitor what's happening next. The second aspect of it. And I always like to remind ourselves, you are selling a service and a product that no one wants. In the ideal world, people wish I don't exist. This is not the kind of company that people say, I wish they existed. They actually rather for us not to exist because they would have not used us and they would have conceived in a much more simpler, straightforward way.
And that adds a level of complexity when you're dealing with a consumer. The third and the most important is, it's also a vulnerable consumer. You're dealing with the two of the closest things to people's heart, money and health. The combination of that can either offer you an opportunity to reimagine the consumer experience and serve it the way we do today, which generally is sometimes beyond me of how good the team is in delivering that experience.
Or you can just mess it up completely. And it's that critical if you build the company on day one to say, we don't care about the financial utility or the OR, or the function of the product. We care about the emotional benefit that we attach to the product, and we're going to craft an incredibly well designed experience that's going to pay attention to every little detail along the way.
People might not care about the outcome because they know they can't control it, but people will remember how you made them feel. Every little interaction along the way. And that matters much more than you controlling something that you can't control being the outcome of the treatment and whether they end up happy or not happy.
So the attention is really focused on what support do we give people along the way so they're handheld, they're treated with respect and dignity, and there is just built in empathy in every single word you use, adjective you use, feature you build. And if I tell you that the team's been laser focused on this, continue to be laser focused on this, And even go way above, beyond what's expected of them to deliver that experience.
You'll see it reflected in what people say about the experience, not the product. And I think the two are very separate here for a reason. And I wish that a lot of the ecosystem service provider within the fertility had paid the same amount of attention to the journey of the human being that's going through this and designed it for them because it's a classic design problem in healthcare.
Everybody designs for two people. You either design for the payer or you design for the provider. And somewhere in the middle you forget that there is a patient and you sandwich them in the middle. Because the payer is often the person who pays or the provider who renders. And then somewhere along the line people remember that there is a patient going through this and say, hold on, wait a second, how do we sandwich them in?
And it's often too late.
[00:42:21] Griffin Jones: You're selective about the clinics that you partner with. What makes a good clinic partner?
[00:42:28] Nader AlSalim: Outperform the national average when it comes to success rates. There's two things that matter. You want a clinic that quantitatively produces better results, what we call a first quartile. If you go to a new city, if you go to a new market, a new state, you chart all the performance, clinic performance is charted by quartiles, and you want to pick a first quartile because that is the clinic you'd want to work with if you want to reward the outcome, not the process, and hence you're incentivized to work with a first quartile performance.
The second thing, which is qualitative, Which is the patient experience. You also want a clinic that has a reputation for great patient experience. The REIs are very well known for delivering world class experience. And it has the brand, because of what I told you earlier, because my brand is attached to that clinic brand.
And it's often, that's where the most of the experience happens. We want to make sure that we're owning that journey or co owning that journey, we're owning it with people that share our ethos when it comes to patient experience. So I think the outcome and the patient experience are what matters the most here.
[00:43:27] Griffin Jones: You've had the success in the United Kingdom for a while, but now you're in the United States. What's that been like?
[00:43:33] Nader AlSalim: Another humbling experience. It's the world's largest IVF or fertility market. It is complicated because it's 50 states with 50 different mandates, with 50 different health plans, integrations, with a lot of bells and whistles and regulations for all these states. Yet, the fundamental need is exactly the same.
The fundamental untapped demand is exactly the same. You couldn't be more excited about a market with that size and that potential. Finding the right partners has been a critical step. In our U. S. market entry, we went live a couple of months ago in Virginia with Pinnacles Acid there, Dominion, and early signs confirm everything that we know all along.
There is a lot of work that needs to be done on how do we sequence the next states. The plan is to be in every single state with a select group of provider clinics. Allowing them to improve access in those markets and or improve conversion if that's something that those markets suffer from due to competition or due to the lack of option or due to saturation of some sort.
It's clearly a very differentiated product to add to your shelf, but more importantly, it's a different kind of payer that you need to integrate with. And the plan is whether it's an employer, whether it's a health plan, whether it's a cash payer, We do not separate on the source of the funding or the source of the channel.
We're focused across all channels to make sure that we serve the underlying patient and we want to build the network to match those patients in the states that we want to be in and we want to be in every single U. S. state. And I
[00:45:04] Griffin Jones: We've been talking about topics for the revenue cycle managers and the CEOs and maybe the more senior clinicians,
what advice do you have for the younger REIs that are going to make a career of the next 30 years of how this transforms the way they practice?
[00:45:23] Nader AlSalim: think, I think you're absolutely right. I think if you're a young REI today coming in and you want to build the next 20 to 30 years of your career, you're going to build it on a very different fundamental ways of practicing medicine that one has existed in the past. You're going to understand that technology in general will play an indispensable role in taking those treatments from an inconsistently performed labor intensive procedure to something that is optimized like in any other engineered industry.
You're going to think about innovation, to go to Beth's point, not only what happens in the lab, in, every structure along the way this, whether it's patient acquisition, whether it's patient management, whether it's protocol management, what role can you play in order to go and take care of that very large unaddressed population of the patients in need?
And last but not least, you cannot think of all these services and integration without thinking about the outcome based pricing that you need to adopt in order to align more to what the patients want to buy while you get paid for the service rendered and someone needs to come and manage that on your behalf so that you're focusing on what you do best, which is care, and then you're moving that to a third party that comes and manages all of that, maybe in a box, Maybe you walk in and what you sell is a 15, 000 baby, and if there is no baby, no fee, and you're really doing all the medical practice, and you're isolating technology, and you're improving the data, and you're improving all those protocols in order to enhance the performance and the outcome, but you make sure that you're getting paid a fee regardless, and someone else is on the hook.
Because what you're selling is not a service, it's not a unit, it's not a cycle. You're selling a child for 15, 000 and if you don't deliver that child, someone is not getting paid. And I'm happy to be that someone.
[00:47:04] Griffin Jones: We're going to put some buttons and links for people to be able to contact you, to be able to get in touch with the company. I suspect that there's other people that are going to say, I want to talk to this guy. When you and I met last year at ASRM, we sat next to each other at dinner, and I thought, this is somebody that people are going to want to talk to.
So some people are going to want to have maybe to sit down with you and I, this episode is going to come out before ASRM 2024. People are listening to it before ASRM 2024. Would you be all right with me sharing your information if they want to connect with you? that introduction so that they could meet up with you there.
[00:47:47] Nader AlSalim: Absolutely. I met you and I met a lot of people along the way, those are the most enlightening conversations that shaped a lot of my thinking but also been invaluable to like how we build Gaia. Because I don't want to build a vacuum. And we're building to an existing problem.
There is a lot of people that are far more experienced than I am and who we are. We bring a little bit of a new eye to this and a new level of innovation that has not been happened before. But we also are very aware that we don't operate in a vacuum and I would love that.
[00:48:13] Griffin Jones: The first time that I got connected with Eduardo Harriton and with David Sable, after the first conversation, I thought, man, I'm glad I met that guy. had that feeling about you, and maybe others will, too. Nader AlSalim, thank you so much for coming on the Inside Reproductive Health podcast. I hope to have you on plenty more
[00:48:35] Nader AlSalim: Thank you, Griffin. I enjoyed this.
[00:48:36] Announcer: Today's episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free to you. Here, the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.
