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Uncle Sam pays Clover a monthly fee for each Medicare Advantage customer the startup enrolls. The amount varies depending on where the person lives, but it aver

Uncle Sam pays Clover a monthly fee for each Medicare Advantage customer the startup enrolls. The amount varies depending on where the person lives, but it averages $850 before adjusting for chronic conditions or healthy habits, the Medicare Rights Center says. Clover uses the money to pay members’ bills and generates almost all its revenue from whatever is left over after reimbursing doctors, hospitals, labs, pharmacies and other points of care. The company offers plans with no monthly premiums or ones that go as high as $225. Clover says the amount it gets from those payments and copays isn’t significant. So it sounds like the company's biz model is to send nurses out in the field to get senior citizens to enroll in Medicare, check up on them and collect data, and sell them healthy lifestyle products (gym memberships, cooking classes, etc.). As a 23 year old I'm not sure if this is any different than what big insurance co's do for their Medicare enrollees. The actual tech part seems to be the web portal/CMS (Django) and the storage and management of this tangential customer data that is generated with each visit: Clover uses Python for all of our backend coding so using a pipeline orchestration tool that is itself written in Python is valuable for us. Airflow meets that requirement and it’s the tool we’ve chosen to manage all of our pipelines. Here's the actual coverage sheet if you want to compare with your/your parent's plans: https://cdn.cloverhealth.com/filer_public/c4/a8/c4a894d0-000e-47b8-873e-92bd323db9bb/benefitssummary_carepointplan_2017.pdf https://cdn.cloverhealth.com/filer_public/c4/a8/c4a894d0-000... Deductibles (excluding prescription drugs) are $6,700 annually. Someone maxing out prescription charges would spend an additional $5,000 per year. I'm not sure how that compares to a traditional provider. Tangentially: I think we've almost stretched the definition of the word "startup" into oblivion at this point. It doesn't mean anything to me anymore.

ubernostrum 10y ago
(I work at Clover) As a 23 year old I'm not sure if this is any different than what big insurance co's do for their Medicare enrollees. The difference is most insurers would say something like "OK, out of X thousand Medicare-age people, Y of them will have this expensive health problem over the next year, are we profitable when that happens?". We say "OK, how can we identify the people most at risk of that and use preventive care to head it off?" So while most insurers just take the statistics as a given and budget for it, we're trying to change the statistics. storage and management of this tangential customer data I think you vastly underestimate how much low-hanging fruit there is in this field, and how difficult getting and maintaining good data (so you can find the things you can do) really is :)
- Justin_K 10y ago
  Every health plan has been doing this for years. They too have treasure troves of data... they have care coordinators, patient centered medical homes, etc. So, how are you actually trying to change the statistics?
  - Mz 10y ago
    Every health plan has been doing this for years. I processed insurance claims for over five years and that was not my observation. Granted, it was one company, I processed accident claims and it was supplemental coverage. But when I was there, I was initially encouraged by the trend towards adding "wellness benefits" because I had naïve fantasies this meant they were working towards getting people healthier. Nope. It was entirely about "If we offer specific tests and call them wellness benefits, we have higher retention." That was it. There was zero interest in actually making customers healthier. And I was horrified and I am pretty cynical these days. So, I guess, I am wondering if you have supporting evidence? (Links to articles, stats, etc?)
  - ubernostrum 10y ago
    This isn't my first insurance company. The typical experience in insurance is that those tools mostly only come out once someone already has the expensive problem, and are used to manage the cost of it after the fact, rather than prevent it from happening in the first place. Also most insurance companies aren't really set up to do preventive work to the extent we do (which involves home visits from nurses and other clinical staff, staying in touch and proactively reaching out when there seem to be problems, etc. etc.), largely because they consist of essentially competing divisions which each own a subset of the data and responsibilities and jealously guard against every other division. I worked in a company like that, once upon a time -- everyone had very clearly-defined limits to their responsibilities (well beyond what privacy rules required) and even just contacting someone in a different department to make them aware of a problem or pass along a suggestion would trigger turf-war consequences. I'm very happy to now be working with the opposite of that. Finally, it's worth noting that although there are a lot of dismissive comments about tech in this thread (and some of it I can understand -- most of what we do is internal-facing and harder to promote as a result), the perspective inside is pretty different. It's true there's not a ton we're doing that's cutting edge and "sexy" tech (though we have open-sourced some neat tools for temporalizing SQLAlchemy's ORM), but that's because health care hasn't yet caught up to just the boring everyday things we take for granted. There's an example that really drove it home for me, from about six months ago. Claims are obviously a big part of what we're about, and so we have an internal team that reviews processed claims for accuracy. They have to check against a pretty complex set of Medicare claim-processing rules, part of which involves rules about combinations of medical procedures (i.e., Procedure A might be allowed but only if alongside Procedure B, or A might only be allowed without B, or A and B might just be independent and can both appear or not appear). The canonical source for that data is... gigantic Excel spreadsheets of all the procedure codes and rules. And so the claims-review team would open up Excel, type in a code, wait five minutes while it churned to find the code, then repeat for the next code, etc. An engineer saw this and spun up a two-day project to ingest those spreadsheets (on an ongoing basis, since they change over time) into a database and wrap a search interface around them which allowed punching in all the codes and getting back a list of rules and an indicator of whether they'd been violated. To tech people that's so mundane it almost puts you to sleep, and makes you say "wait, that's it?". But to healthcare people, it was a gigantic step forward. So many people from health backgrounds came from places that never let them work side-by-side with tech staff and figure out what was possible (or where all tech was outsourced to vendors with opaque planning and feature-request processes), which is why so much of healthcare tech feels decades out of date. So just having tech and medical/insurance people in the same room, working and talking together every day, acts as a pretty impressive multiplier compared to traditional insurance companies.
maxerickson 10y ago
You shouldn't conflate deductibles and co-pays. For example, if the deductible was $6700, a 6 day hospital stay would cost $6700 out of pocket. Because it is a $290 per day co-pay, it will cost $1740 out of pocket. There is a tidy difference there.

ubernostrum 10y ago

(I work at Clover) As a 23 year old I'm not sure if this is any different than what big insurance co's do for their Medicare enrollees. The difference is most insurers would say something like "OK, out of X thousand Medicare-age people, Y of them will have this expensive health problem over the next year, are we profitable when that happens?". We say "OK, how can we identify the people most at risk of that and use preventive care to head it off?" So while most insurers just take the statistics as a given and budget for it, we're trying to change the statistics. storage and management of this tangential customer data I think you vastly underestimate how much low-hanging fruit there is in this field, and how difficult getting and maintaining good data (so you can find the things you can do) really is :)

Justin_K 10y ago
Every health plan has been doing this for years. They too have treasure troves of data... they have care coordinators, patient centered medical homes, etc. So, how are you actually trying to change the statistics?
- Mz 10y ago
  Every health plan has been doing this for years. I processed insurance claims for over five years and that was not my observation. Granted, it was one company, I processed accident claims and it was supplemental coverage. But when I was there, I was initially encouraged by the trend towards adding "wellness benefits" because I had naïve fantasies this meant they were working towards getting people healthier. Nope. It was entirely about "If we offer specific tests and call them wellness benefits, we have higher retention." That was it. There was zero interest in actually making customers healthier. And I was horrified and I am pretty cynical these days. So, I guess, I am wondering if you have supporting evidence? (Links to articles, stats, etc?)
- ubernostrum 10y ago
  This isn't my first insurance company. The typical experience in insurance is that those tools mostly only come out once someone already has the expensive problem, and are used to manage the cost of it after the fact, rather than prevent it from happening in the first place. Also most insurance companies aren't really set up to do preventive work to the extent we do (which involves home visits from nurses and other clinical staff, staying in touch and proactively reaching out when there seem to be problems, etc. etc.), largely because they consist of essentially competing divisions which each own a subset of the data and responsibilities and jealously guard against every other division. I worked in a company like that, once upon a time -- everyone had very clearly-defined limits to their responsibilities (well beyond what privacy rules required) and even just contacting someone in a different department to make them aware of a problem or pass along a suggestion would trigger turf-war consequences. I'm very happy to now be working with the opposite of that. Finally, it's worth noting that although there are a lot of dismissive comments about tech in this thread (and some of it I can understand -- most of what we do is internal-facing and harder to promote as a result), the perspective inside is pretty different. It's true there's not a ton we're doing that's cutting edge and "sexy" tech (though we have open-sourced some neat tools for temporalizing SQLAlchemy's ORM), but that's because health care hasn't yet caught up to just the boring everyday things we take for granted. There's an example that really drove it home for me, from about six months ago. Claims are obviously a big part of what we're about, and so we have an internal team that reviews processed claims for accuracy. They have to check against a pretty complex set of Medicare claim-processing rules, part of which involves rules about combinations of medical procedures (i.e., Procedure A might be allowed but only if alongside Procedure B, or A might only be allowed without B, or A and B might just be independent and can both appear or not appear). The canonical source for that data is... gigantic Excel spreadsheets of all the procedure codes and rules. And so the claims-review team would open up Excel, type in a code, wait five minutes while it churned to find the code, then repeat for the next code, etc. An engineer saw this and spun up a two-day project to ingest those spreadsheets (on an ongoing basis, since they change over time) into a database and wrap a search interface around them which allowed punching in all the codes and getting back a list of rules and an indicator of whether they'd been violated. To tech people that's so mundane it almost puts you to sleep, and makes you say "wait, that's it?". But to healthcare people, it was a gigantic step forward. So many people from health backgrounds came from places that never let them work side-by-side with tech staff and figure out what was possible (or where all tech was outsourced to vendors with opaque planning and feature-request processes), which is why so much of healthcare tech feels decades out of date. So just having tech and medical/insurance people in the same room, working and talking together every day, acts as a pretty impressive multiplier compared to traditional insurance companies.

maxerickson 10y ago

You shouldn't conflate deductibles and co-pays. For example, if the deductible was $6700, a 6 day hospital stay would cost $6700 out of pocket. Because it is a $290 per day co-pay, it will cost $1740 out of pocket. There is a tidy difference there.