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Insurance – As Simple as a Credit Card Swipe | SamaCare Co-Founder Syam Palakurthy
22 Plays1 month ago
Syam Palakurthy is the CEO of SamaCare, a platform simplifying the prior authorization process for healthcare providers, payers, and patients. Last year, his team raised a $17M Series B with the goal of making paying for healthcare as simple as a credit card swipe.
In this episode, we explore how Syam went from Bain & Company and ClearCost Health to tackling one of healthcare’s most hated administrative burdens. He breaks down why prior authorization exists, why it’s so entrenched in our system, and what it would take to increase transparency. We talk about the coordination failures across insurers, providers, and pharma companies - and how AI and automation are finally closing those gaps. Syam also shares how scaling a solution in such a fragmented ecosystem requires both deep empathy for providers and a systems-level understanding of healthcare economics.
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Transcript
Introduction to Healthcare Theory Podcast
00:00:00
Speaker
Welcome to the Healthcare Theory Podcast. I'm your host, Nikhil Reddy, and every week we interview the entrepreneurs and thought leaders behind the future of healthcare care to see what's gone wrong with our system and how we can fix it.
Meet Shalm Palakurthy, CEO of SamaCare
00:00:14
Speaker
Today, I'm joined by Shalm Palakurthy, founder and CEO of Samacare, a company transforming one of health insurance's most painful bottlenecks, prior authorization.
00:00:25
Speaker
Before starting Samacare, Shalm worked at Bain & Company and later held senior management roles at ClearCost Health, a healthcare transparency startup that was recently acquired.
SamaCare's Mission and Funding
00:00:34
Speaker
And today he leads a team of 70 people at SambaCare, which recently raised around $17 million in Series B funding to be the one-stop patient access platform that makes getting healthcare care as simple as a credit card swipe.
Challenges and Solutions in Prior Authorization
00:00:47
Speaker
In today's episode, we dive into why prior authorization and healthcare infrastructure is so difficult and how companies like SambaCare are using AI and data infrastructure to fix that.
Shalm's Journey to Healthcare
00:01:00
Speaker
And Sham, you've been at this intersection of healthcare and tech for over a decade. In fact, you were at product ClearCost Health for back in 2011. And a few years later, you started SamaCare.
00:01:12
Speaker
And I would just love to hear what got you into healthcare. What some of the things that you learned early in your experiences that surprised you and that it still sticks with you today? Yeah, absolutely. So so when i started my career, um i started consulting and I remember that first conversation with the, yeah the staffing manager at the consulting firm I was at, she asked if I, if there's, if there's anything I did not want to work on.
00:01:38
Speaker
And i said, healthcare, care I want to be as far away from healthcare care as possible. So both my parents are physicians. Um, my brother is a physician, aunts, uncles, cousins, so many people in the medical world.
00:01:50
Speaker
And I kind of wanted to get away from that. um so So no interest in healthcare care to start off. That wasn't intentional. But when I left consulting, I really, really wanted to work in something um that I cared about. like Fundamentally, I cared whether or not it existed or not.
The Impact and Challenges of Healthcare Work
00:02:06
Speaker
It wasn't just a a paycheck or a job, but like something where I could get really excited. And I had all these conversations with these interesting startups, but I just found i I didn't care at some deeper level whether or not they existed. They were all cool. They're all interesting people doing doing interesting and intellectually like fascinating things.
00:02:25
Speaker
um I got connected to a friend's dad who was starting a company. It was pre-product, pre-revenue. um And, i you know, i took the conversation because I respected him.
00:02:39
Speaker
um but, it but was gonna just politely tell him I didn't want to be in healthcare, care but I found it actually just really was very fascinated by what they were doing is price transparency. There was kind of this immediate and obvious need that they were working on. It's just so, ah so difficult to find what the cost of services was.
00:03:01
Speaker
Um, And so I ended up taking that job and i I just have found I love being in healthcare and really it comes down to two things. One is, you know, at the end of the day, if you are doing something that is making kind of the system writ large better, then it almost certainly is flowing down to an individual
Understanding Prior Authorization in Healthcare
00:03:20
Speaker
patient's life. And, and so that was really, that was still is very compelling for me is, you know, doing anything in healthcare, doing, doing anything in industry, whatever is hard.
00:03:31
Speaker
um But if you know at the end of the day that someone's life is made better because of it, it just makes it a lot a lot more easy to kind of carry on through those hard moments. And the second thing i think um that was really motivating about and that has been motivating me about being in healthcare is you know, there's this, there's this way in which it's like an intellectual puzzle because the, the incentives like any industry exists, but they're much more complicated. They're more embedded. They're sometimes more esoteric and you need to kind of scratch a few layers deeper before you understand like how different actors are incentivized in different ways.
00:04:06
Speaker
um And I just think it's so cool when you can kind of, ah figure out how to align those incentives in a way that that makes magic happen, which is kind of what what's kept me in healthcare and why I'm so excited about being in the industries now.
00:04:22
Speaker
Yeah, i really love that you brought up those two points. There's this human impact card of healthcare, care which is important, and the intellectual challenge, which I am really gravitated towards. But of course, as you mentioned, healthcare care is extremely difficult. So I can imagine why you wanted nothing to do with it. And one of the examples why it's difficult is, of course, prior authorization And I'd love if you could dive into that a little bit. I think a lot of people here at Prior Roth, they think it's an inherently a bad thing, used to just save costs by insurers. But originally, it was designed to help navigate and make sure that patients were getting the right type of care that was meant for them.
00:04:57
Speaker
And now it's a little bit murky. So I'd love to hear, I mean, why does Prior Roth exist? And can you explain what it actually means in like day-to-day terms? Yeah, um even even answering the purposes,
00:05:10
Speaker
Depends on who you ask, you'll get very different answers. but So prior authorization is the documentation process that insurance companies require medical providers and patients to go through in order to approve the use of a certain treatment or a certain certain drug or procedure or any kind of medical treatment.
00:05:33
Speaker
um And it's the the process they use before you go and get those treatments ah to say like, okay, we are going to cover this in your insurance plan. We're going to pay the doctor. We're going to pay the pharmacy, whoever we're going to pay them.
00:05:45
Speaker
We're going to not make this be an out-of-pocket cost entirely up to the patient. um I mean, the the purpose, you know, it's funny, Nikhil. So my, like i said, my parents are both providers and my dad is so mild mannered in every facet of his life, except for really, really two things, insurance company administrators and prior authorization where he will get worked up so quickly.
00:06:17
Speaker
Um, and when we started this business, his take is, and and this is a common perception about why prior authorization exists. His, his belief, and I will never be able to shake him from it is it's fundamentally the insurance companies are trying to screw the doctors and the patients to avoid paying.
00:06:34
Speaker
um and they make their lives. Yeah. And, and it's like, let's, let's create barriers that, that make it harder. So we save a little bit more on our, you know, our overall medical spend.
00:06:45
Speaker
Um, I think there are elements of that. i think insurance companies are complex organizations, like most big organizations in healthcare with a lot of complex and sometimes conflicting incentives. Sometimes that's the case.
00:06:58
Speaker
think there are some some parties where within an insurance company where that is real. um i think a lot of times it's a documentation thing. Like sometimes it's it's a thing that is like a data transfer thing. It's a way of an insurance company understanding, okay, we're about to um we're about to potentially pay all this money before the service happened and the money is due in some form or fashion.
00:07:21
Speaker
We want to get that data in advance. So it's like a way of understanding what's about to come. um So that's, that's one other function that prior authorization serves.
Ideas for Streamlining Prior Authorization
00:07:30
Speaker
If you talk to an insurance company, fundamentally, it's like, how do you prevent, uh, fraud, waste and abuse?
00:07:36
Speaker
So how do you make sure the, uh, the ah Treatment that's about to be initiated is something that actually is medically necessary, that actually is is called for given that patient's particular conditions and needs.
00:07:53
Speaker
um But yeah, I'd say those are kind of the three the three things ah that that describe why prior authorization exists. It's pure cost containment, pure data, pure fraud, waste, and abuse. And like most things in healthcare,
00:08:10
Speaker
None of those is the absolute reason. It's some combination of the three.
00:08:15
Speaker
Yeah. and And it's interesting because we like to place the blame on certain actors, whether it's providers or patients or insurers, but it's much more nuanced than that.
00:08:27
Speaker
And ah hum was thinking, well, something Somicare focuses on is making healthcare as easy as a credit card swipe. And would love if you could elaborate on that, what would prior authorization or more so world without a burdensome prior authorization solution look like?
00:08:43
Speaker
And how would that change how people receive care? Yeah, absolutely. So i have a friend who describes um this example of when you go to a hotel, the hotel doesn't know you, you don't know the hotel, but the way the hotel manages the risk of you getting a hotel room and in paying when you're done with it, but not not like, you know,
00:09:06
Speaker
not making it so there's this complex process to like you know certify that you are who you are and that you're not going to like destroy the the hotel room, is you give them a credit card when you you check in and they run that. Maybe there's a deposit.
00:09:18
Speaker
But like it's fundamentally a credit card swipe. It's a very simple transaction for me and for the the hotel to do. and And in its idealized state, that's what you want to get prior authorization to.
00:09:31
Speaker
a credit card, like the as simple as a credit card transaction, something that gives the insurance company and the provider and the patient all confidence that it's it's a service that is going to get paid for and that they can actually go forward with it. That's the goal of prior authorization. And if that's the goal prior authorization, like that end state, I think is a world where everyone can live with it and be happy with it and and feel okay with it.
00:09:59
Speaker
The problem is, is that is not at all the world that we live in. We live in a world where, you know, to take the the credit card example, it's like, oh, I go to a credit card and the credit card says, well, here's 40 pieces of paper.
00:10:11
Speaker
ah want you to fill out like your background. I want you to like, you know, call previous health previous hotels that you've stayed at and like get them to fax information over and incorporate that. So it's a super painful process.
00:10:23
Speaker
and And that's, I think, why prior authorization is a you is it a good or a bad thing? like my My dad will never in any universe, and in a lot of doctors, and I get this, will never say this is a good thing.
00:10:34
Speaker
But it is unquestionably better if it's simple, worse if it's not. Right now, we are nowhere near kind of the, I give my credit card, the hotel swipes it, I can stay there, the hotel feels like comfortable enough that I'm not going to destroy it and and that I'm going to pay at some point.
00:10:55
Speaker
So that's really the challenge is like the way that it's been set up is so cumbersome for the provider and the patient. There's so much overhead required for them. and You know, I sometimes find myself inadvertently defending the insurance companies when I'm talking to my my dad about this.
00:11:12
Speaker
This is an area where the insurance companies could solve this problem. It does not need to be. Like with a requisite level of investment, this could be an easy, simple process, ah much simpler than it is.
00:11:26
Speaker
And so, you know, I do think it's worth noting that the insurance companies could invest in this to make it better. I think it's also hard in in the part that's not on them or that that's not entirely on them um for why it's so hard is, you healthcare interoperability, like communicating information in healthcare care just really hard.
Why Insurers Hesitate on Prior Authorization Improvements
00:11:46
Speaker
It's not just a prior authorization thing. It's like, you know, Getting my past records from one hospital to the next is sometimes so painful. And like you know I've seen providers that will literally charge the patient to be able to send that information because it's like this really onerous process for them.
00:12:06
Speaker
So so there's the the problem with just like transmitting information from one provider, from one entity in the healthcare system to another, that sometimes makes this hard. Because for the insurance company to make a decision, like they actually have to feel really confident about.
00:12:21
Speaker
look we work with very expensive, high cost drugs sometimes. And admittedly, like, understandably, the insurance company wants to feel really comfortable before they approve, you know, $300,000 a year drug, because it's $300,000 a year, it's very consequential.
00:12:37
Speaker
um And sometimes getting the information from like the disparate sources can be a challenge. Yeah, and I've seen this kind of recurring theme of data orchestration or data interoperability that's so difficult in health insurance, which makes sense. There's so many different stakeholders.
00:12:53
Speaker
But, mean, one thing that think a lot of people are curious about is that these insurers aren't small companies. They have billions in companies. in cash really to, I mean, ideally make these solutions work.
00:13:06
Speaker
But I mean, from what I know, it's not as simple as that. These problems aren't things that could be solved that easily. There's so many different stakeholders. But then again, these insurers have basically a lot of influence in the system. They touch all the stakeholders, have a lot of money and the incentive, or at least we think they'd have an incentive to fix this. So we'd love you can touch into the nuances there. Why you think this hasn't been fixed yet?
00:13:30
Speaker
I know some of the bigger insurers earlier this year have announced that they would, but what do you think is actually happening behind the scenes? Yeah. So on the insurance side I think insurance companies could, if they were sufficiently motivated, fix this overnight. But you know sufficiently motivated is a hard thing. There are some some people in the insurance companies who are strongly motivated to make this better.
00:13:53
Speaker
because they they work with providers day in, day out. And there are other there are other parties within the insurance companies that are not strongly motivated. I think what ends up happening is there isn't a sufficient level of investment um to actually make this better. You think about any organization, they have they they do this cost-benefit analysis before making an investment. Do I want to invest in X or y And for the insurance company, you know you could invest in making your operations run more efficiently and and maybe like that increases your ability to to be more profitable or you could invest in making prior authorization run more easily. It's not clear that actually makes your profits go up.
00:14:34
Speaker
It does make your physicians happier, like, you know, there's, there's a cost benefit analysis and actually believe that this gets short shrift a lot of the time. um So that I think is part of it.
00:14:45
Speaker
i do think, um,
00:14:49
Speaker
the The other thing is it's ah it's kind of a hard coordination challenge. So an insurance company, and there are insurance companies that have invested quite a bit of money in this. um but But one problem is if a single insurance company invests a lot of money, they make an awesome prior authorization experience.
00:15:06
Speaker
A problem is is it's still fundamentally at odds with the fact that like as a provider, as a say a doctor, I might have 4,000 in my panel. and the 4,000 patients are represented by 250 different insurance companies, it's like, fine, maybe one of my insurance companies has made this seamless, but it's still a different process.
00:15:26
Speaker
Like for me to submit to that like great insurance company, i got to go through their portal, which is maybe it's spanking new and it's beautiful and it's great UX, et cetera, but it's still unique to them.
00:15:37
Speaker
So I, as a provider and my staff need to understand how to submit to that insurance company, Whereas my other 249 other payers that my patients are part of have a completely different process.
00:15:49
Speaker
And so there's a coordination issue where insurance companies on their own, it's hard for them to like, they they can make it better than it is. I don't want to, and don't want to let them off the hook, but they can't solve the problem independently because it requires a high level of coordination.
00:16:05
Speaker
um So, so, That's kind of a limitation on the insurance company side. Look, I'll be honest, like we think third parties can actually help. And and i'm I'm saying this, i I understand that it sounds self-serving because we are a third party, but we believe third parties can help create coordination layer, like a coordination layer that makes it actually easier to manage it across all of our providers, payers, as opposed to just one, or as opposed to just like for one payer, for one category of healthcare services or category of drugs, et cetera.
00:16:37
Speaker
um On the legislation side, you know, I've gone back and forth about this um a lot. I think a mandate, like some sort of legislative mandate that standardize everything sounds really nice in theory unbathomable.
SamaCare's Innovative Solutions for Healthcare Challenges
00:16:57
Speaker
You know, it it sounds like it'd be great, but it creates all sorts of problems downstream. So I think you can take meaningful use for EMRs. Like basically you had an entire generation of EMRs that stopped building software because like they stopped building software around what makes the most sense from the user's perspective, the user who's actually buying this software.
00:17:22
Speaker
And they started making EMRs that were like, It was all about how do I continue to meet the meaningful use requirements? And so all of a sudden, like you you take it out of the market and and you have legislative um decision making and bureaucratic decision making saying like, what should an EMR be?
00:17:43
Speaker
at some level, like this is, you know, I'm, I'm conflicted about meaningful use in the same way I'm conflicted about the idea of like some sort of legislative standard. Like it's, it's great in theory to actually create this single top-down mandate for what this should look like.
00:17:57
Speaker
But in practice, I mean, you look at like yeah EMRs is in that, that industry, it's like on the one hand, meaningful use accelerated EMR adoption so much faster than it would have been.
00:18:09
Speaker
But on the other hand, like, I don't care if you talk to a provider or you talk to an EMR vendor, I think very few of them will say like the software as it exists today is what we would do if we were just thinking about what made the most sense for our users.
00:18:23
Speaker
um And so I think you get into this this issue of like, if there were a legislative mandate How do they make something that actually works for the various stakeholders?
00:18:36
Speaker
I don't think that we have like a strong track record as a country of like mandating these kinds of standards and having it work really well in healthcare. care um And so just be hard, like who makes that decision? Who's like influencing what what goes into the prior authorization?
00:18:53
Speaker
But on the other hand, I'm like, you know, the situation we have now is pretty terrible. So maybe it would be better. I don't know. And we have a we've established how massive this prior authorization problem is. And of course, you're tackling head on at Somacare.
00:19:08
Speaker
And in a nutshell, how does Somacare work? And what conversations did you have beforehand? What the first principles you used to build a solution that worked for providers and patients? How did you know you were kind of on the right path there?
00:19:22
Speaker
Yeah, absolutely. So, um Like I said, I had grown up in this very medically oriented family. ah parents used to complain about things like prior authorization, you know, at the dinner table.
00:19:34
Speaker
And I remember at the time, you know, being a kind of, ah being kind of annoying teenager, I'd be like, oh, my parents just need something to complain about. it can't be that bad. And so go kind of in one year and like pieces of it would filter out and some of it would stick. But mostly I was like, ah, it's not that big of a deal.
00:19:51
Speaker
um After leaving ClearCost Health, I started a company in the chronic care management space. was the first time that, you know, I'd been in healthcare care at that point for a while, but it was the first time that I was sitting in the office and actually seeing what was going on.
00:20:05
Speaker
And I was just... flabbergasted at how terrible the process of prior authorization was. It was like, you know, the providers, like the doctors hated it. They felt insulted that it existed and they felt annoyed that they they were getting their time taken to provide this documentation, which was basically like, you know, just asking for permission to do what they felt like they were qualified to do.
00:20:30
Speaker
The provider staff hated it. They spent all this time. No one wants to be a professional data mover. And that's essentially what it was turning them into. The patients hated it They would come in and they would complain about it. And they'd you know they just want to they they just want to get their their treatment and get on with their life.
00:20:47
Speaker
When we started this company, we did a bunch of interviews. We did over 400 interviews across different folks in the healthcare care ecosystem. And what was really intriguing to me is like the insurance companies also hated it too.
00:20:59
Speaker
and And when we talked to pharmas, it was a big issue for them. It was a major source of you know revenue leakage in a sense and patient leakage and patients not getting put on treatment or non-adherence as you described earlier. So everyone kind of hated this problem.
00:21:13
Speaker
And I remember we, but my co-founder and I had this conversation with a nurse and And we were kind of brainstorming how we could work on this. And she she said something that really stuck with us. She said, you know, I don't know if there's a business here. There may or may not be But if you can solve prior authorizations, every single nurse in the country will love you for it.
00:21:37
Speaker
And I remember thinking, like my my co-founder and I looked at each other we're you know what? that That seems like ah evidence of real need and a real problem. um let's Let's actually go ahead and focus there.
00:21:49
Speaker
and And I think what's what's also, um and and so basically what we do is we build software to streamline prior authorizations. um It's something that the provider can use across all of the different payers.
00:22:01
Speaker
ah we we have We initially focused on um specialty medications. and And the reason we focus there is like when someone gets diagnosed with a so-called specialty medication, so an expensive or complex medication, think like,
00:22:14
Speaker
chemotherapeutic drugs for cancer patients or certain kinds of like retina drugs for patients who are at risk of going blind or like immunological drugs for like rheumatoid arthritis patients.
00:22:27
Speaker
And when ah when a patient gets diagnosed with that, that diagnosis is one of the worst moments of their life for these drugs. Like they're only getting these drugs for really debilitating or potentially debilitating or deadly conditions.
00:22:42
Speaker
And the prior authorization is this insult to literally one of the worst episodes, if not the worst episode in their life, that they have to go through this, that it has to delay their care.
00:22:54
Speaker
um And so that's really where we focus. So we build that software. We use technology to abstract out as much of the complexity of, you know, if I'm a doctor and I'm submitting to 250 different insurance companies or 500 insurance companies,
00:23:07
Speaker
We use technology to abstract out the complex complexity to be able to get the information to the insurance company in the format that they're expecting, and then to be able to get the information back from the insurance company.
00:23:17
Speaker
And then we also work with pharmaceutical manufacturers who have a really strong interest in making sure that every patient who's been prescribed their treatment actually is able to get onto their treatment.
00:23:28
Speaker
And what we do is, in ah in a way, we're working with those manufacturers to help not knock out the obstacles that are getting in the way of an appropriately diagnosed and prescribed patient from getting onto that treatment.
00:23:43
Speaker
um So that's kind of how we work as a business. And what kind of results are you seeing? I know your platform serves many different stakeholders, and I've heard that your platform can cut the time to submit an authorization roughly in half and we reduce the overall time to get a patient on therapy about around 70%. I mean, that's huge.
00:24:01
Speaker
So how does this translate to real-world outcomes, and what are some stories that might illustrate how this might ah directly affect people's life? Yeah, so it's been a huge difference for our provider customers and for our pharmaceutical customers.
00:24:18
Speaker
So on the provider side, you know we've we've been able to show sometimes a halving of the amount of time it takes for them to actually get through the prior authorization process. Just the process of structuring the PAs and making it so it's easier to understand like what's in flight, what needs to come next, that kind of thing has also reduced the likelihood of denials.
00:24:36
Speaker
um For the pharmaceutical customers that we work with, we've been able to show anywhere from like a 30 to 80% reduction in the likelihood of a patient getting inappropriately denied.
00:24:49
Speaker
We've been able to reduce the time to treatment. So we we showed um with some of our customers that for their drug, we were able to go from about 20 days between the diagnosis to the patient actually getting scheduled to just about five days.
00:25:05
Speaker
so So major, major reduction in time to treatment, which again, like, you know, 15 days, a lot of us, like, who cares? But if you're someone who's been diagnosed with like a critical condition, and you just want to get treatment, you want to start to feel better.
Scaling Solutions for Diverse Healthcare Needs
00:25:20
Speaker
That's a huge deal. um but So like, we've been really excited by the impact that we've been able to have. And, you know, i I tell my team, like, i know, and and i'm I'm really proud of this. And I'm proud of our team.
00:25:34
Speaker
And I'm, I'm frankly proud of like the providers who are doing this. um i i can say with confidence that there are patients that are alive today that wouldn't have been alive otherwise, or that, you know, they they're able to see, but they wouldn't have been able to see it. They would have they would have had more debilitating conditions, immunological conditions, neurological conditions.
00:25:56
Speaker
if it weren't for and this software actually you know stepping in and making things much easier. And that's pretty powerful to be honest. And I think we're we are thankful to be able to see those kinds of results.
00:26:08
Speaker
I think that's really exciting. and And one thing I've also noticed is that solving Plyderroth isn't just that type challenge. It's also a bit about aligning incentives. And how do you figure out like a viable business model for somicare?
00:26:22
Speaker
Because, of course, the solution benefits many parties. It helps clinics. It helps patients, pharmaceutical companies, insurers. it's It's great because it helps so many people. It seems like a perfect product, but also raises the question about,
00:26:36
Speaker
aligning incentives and making something, making a solution that works for everybody, not just technically works, but works and solves their core pain points. So when you're thinking about that, what was the architecture used to design Somicare and build something that could layer on for everybody? Yeah, look, so so one of the things that's, it's funny, i was just talking to someone about this this morning, um who's also in healthcare care is It's pretty easy to build for a very singular use case in healthcare.
00:27:08
Speaker
Like I can go to, you know, but my my dad is is practicing one day a week. I i go to the clinic that he's working at. And he said, we're going to build this, like whatever it is, we're going to build this customized interface that makes your life a little bit better.
00:27:23
Speaker
That's not that hard. um What's really, really hard in healthcare, harder than I think almost any industry, is to be able to build at scale. So to be able to solve that problem for lots of different kinds of providers and to do it at ah at a high volume where it doesn't collapse.
00:27:42
Speaker
Because I think what's really hard about healthcare care is like, There's so much heterogeneity in the workflows of all the individual providers and all the individual insurance companies and pharmaceutical companies. Everyone operates a little bit different. And I think that is unique.
00:27:58
Speaker
It's uniquely challenging in healthcare care because there's more fragmentation in how workflows exist. um And so like at the end of the day, the honestly, the biggest differentiation is like we have a track record of doing this at scale and showing that we can actually do this across a wide variety of different use cases.
00:28:15
Speaker
um We have technology and engineers and product folks that I'm super proud of um that that have just built incredible things. And so I think that's a huge thing.
00:28:26
Speaker
think the other thing, honestly, is like we have a very, very large network of providers. And because we have this large network of providers, we're able to offer more value when we work with pharmaceutical manufacturers.
00:28:39
Speaker
like it that That network is actually really valuable in a long different way. So it means we're like we're getting all of this data on a daily basis that helps us get better at doing prior authorizations faster than somebody's doing it for one or two or three practices.
00:28:52
Speaker
So we can make a better product for providers. It means that we have a stronger network to go to the man the the pharmaceutical manufacturers with. And it means that we have a more interesting proposition to go to insurance companies with as well.
00:29:05
Speaker
So I think that's also quite powerful. and the The last thing I'll say, and this is probably less of a differentiator, everyone's kind of going down the AI track, but I'm so excited about where AI is and like what our team has built on the AI side is it's It's just downright magical is what I'll say. like Automation that was not possible a year ago, maybe not even six months ago, is now possible in such a meaningful way.
00:29:30
Speaker
And it's it's just been incredible to watch how that can actually streamline the experience of, you know, we're We're getting so much closer to that experience I was describing earlier of like, how do you make prior authorization as simple as a credit card swipe?
00:29:45
Speaker
I think AI is actually helping to solve some of like the intense fragmentation that we see among the different providers and the different payers and, you know, the um the different drugs that we work with.
00:29:57
Speaker
I think that's really awesome. mean, it's a really creative solution to what's a very difficult problem. And we'd love to hear. I mean, really appreciated you coming on today so far. I'd love to hear what are the next steps for Samacare? What are you excited about the next one, three or five years?
00:30:12
Speaker
And what do you think the future of prior authorization and your platform as a whole might look like? Yeah, absolutely. So we have this belief that the larger the network of providers that are using our software, the more valuable it is to the ecosystem.
00:30:29
Speaker
but So, you know, just talking about this, if if we have more providers, more data flowing through our system, we can offer a better, more automated offering for providers. So in the form of like, oh, you know, we see...
00:30:41
Speaker
this has a 95% likelihood of getting approved based on the the characteristics that are described, or this has 82% likelihood of getting approved within the next three days based on what we see with our data.
00:30:53
Speaker
So it it makes it more valuable for the providers themselves. basic more value so So we want to keep expanding the network. um really to be able to offer more and more pieces of the equation.
00:31:05
Speaker
like if we think about that script to therapy journey, how do we use prior authorization as a way in the door say, hey, we're solving prior authorization, but let's let's work when we can partner with other companies, we can build things ourselves that allow us to expand the ways that we get into that script to journey actually create an operating system that helps the provider, the pharmaceutical company, even the insurance company, and ensure that every patient that gets prescribed treatment is able to as appropriate, get across the finish line and get onto treatment.
00:31:36
Speaker
um And so that's kind of where we see ourselves growing.
Future of SamaCare and Conclusion
00:31:39
Speaker
I think the other thing that's interesting is like as we've grown and as we've developed a ah much stronger track record and a muscle around the prior authorization, we' we're looking around and we're we're having these conversations with partners, which is like, how do we use kind of our expertise in the prior authorization side and partner with other companies that are doing other things in that, you know, what I what i think of as the script to therapy journey that can actually knock out some of the obstacles that prevent patients from getting onto treatment as quickly as possible.
00:32:10
Speaker
And that create a lot of administrative burden. um and And so like, you know, we'd like for other companies to be building on top of our technology as well. We think that's actually where this can be super powerful.
00:32:22
Speaker
And by virtue of having a very large network that, that certainly gives us the, um, gives us the capacity to be able to to make it worthwhile for other companies. And then the last thing is like, we think we can actually help the payer side of the equation. So going back to what I was describing at the beginning,
00:32:39
Speaker
um The payers, the payers are, they certainly have some conflicted incentives, but you know, one of the things that prevents payers from being able to solve this problem is a coordination problem. They all are trying to coordinate independently. And we think by creating a coordination layer, we might be able to actually move the the system towards that prior authorization as simple as a credit card transaction.
00:33:03
Speaker
that's the goal. And, and, and that's actually where, um, where AI factors in is because there's not any, like the payers don't have APIs for transmitting prior authorizations or least not in a way that's meaningful in our world.
00:33:22
Speaker
Um, we use AI as a way to be able to build around that. So to be able to automate work that like ideally you'd automate with an API, but like the API is not coming anytime soon.
00:33:37
Speaker
So how do we build using artificial intelligence to, for example, to understand how a payer is looking for a prior authorization in their particular portal or their are particular fax form, and to be able to turn that understanding of an insurance company website portal or an insurance company prior authorization form into bits.
00:34:01
Speaker
p Artificial intelligence can help turn that unstructured data into structured information to make it more API-able. And then that that also is the case with the other side of the equation. not just what is the insurance company looking for, but like what is the the provider trying to send one of the things that we've been super excited is the ability to layer on artificial intelligence to understand the clinical history of a given patient, to be able to take that. And that's largely an unstructured information. Like most of healthcare data, like is it's it's like, I think of that as the classic ice iceberg. It's like the stuff above the surface, like the prior auth form has some structured fields, but most of the value in determining is this patient appropriate or not is below the surface.
00:34:44
Speaker
It's unstructured notes, unstructured documentation. Can we use artificial intelligence? And where our team is already doing this in really exciting ways to be able to understand that clinical history and to be able to then translate that into um what the payer is looking for. So it's like structuring the information on the provider side, structuring the request on the and insurance side.
00:35:06
Speaker
And then what you can get is truly an API that allows coordination between the two. Like that's the goal in a sense. So thank you again so much, Shama. I really appreciate that answer. I'm really excited to see where things go in the future for SamaCare. But i just want to say thank you so much for coming on the podcast. If anyone wants to learn more about SamaCare, any details will be found in the description. So we're looking forward to seeing where everything goes with your company, Shama. And I'm super excited to see how prior authorization might change in the future.
00:35:38
Speaker
Thank you so much for coming on. Yeah, thank you again. And i love that you're doing this podcast. i think it's awesome and that you're kind of filling this need in the market, so to speak. so that's really cool.
00:35:51
Speaker
Thanks for listening to The Healthcare Theory. Every Tuesday, expect a new episode on the platform of your choice. You can find us on Spotify, Apple Music, YouTube, any streaming platform you can imagine.
00:36:03
Speaker
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