What happens when managed care surges in IVF, reimbursements drop, and physicians are expected to do more work for less?
Dr. Ravi Gada and Manish Chhadua are back on the show, and they don’t hold back. Dr. Gada is a partner at one of the largest independently owned practices in the United States and he and Manish co-own and operate a firm called CloudRx,
In this episode, they dig into:
What 70 fertility centers are doing to slash administrative costs from prior authorization chaos
How medication side savings are shifting into the medical services side (and what that means for practices)
Changes in the payer market and insurer preferences you need to know about
Why Organon and Follistim have gained so much market share in the past 5–7 years
Why academic fertility center ratings are shockingly low (and what private practices can learn from that)
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Dr. Ravi Gada (00:03)
When insurance gets involved, it's a volume play. You've got to do more cycles for less money and try to make it up in economies of scale. And that just that sheer number of patients that need to go through and in order to keep overhead steady, you've got to figure out how to get the one thing all clinics hate doing is prior authorizations for insurance.
Griffin Jones (00:35)
Managed care is going way up in IVF, reimbursements are going down.
How do you like that? Making less money.
to do more work.
you know, didn't like it.
Ravi and Manish, they're back on the show. late night episode recording.
Yes, mean, Dr. Ravi Gada and his business partner, Manish Chhadua
Ravi's also practicing REI.
and a partner, one of the largest.
independently owned fertility practices in the country.
Manish owns and operates 249 other businesses with Ravi
Today we talk about what 70 fertility centers are doing to decrease their admin costs.
for this prior authorization hell
and how they've done that mostly on the medication side up to this point.
now being asked to help on the med services side.
They talk about changes in the payer market.
They talk about changing preferences from insurance providers.
why they think Organon and Follistim
might be gaining so much of that market share.
in the last five or seven years.
and holy smokes I had no idea that academic fertility centers ratings were so bad
I'm not trying to offend you if you work for an academic fertility center. There are probably some with really good reviews.
and I know that it doesn't speak to your clinical care.
But gosh, I am telling you what we discovered in this sample size.
of Academic Fertility Centers.
is very different from a sample of privately owned practices.
And if it makes you feel bad,
Ravi has me read.
his newest one-star review that someone left this morning. In its entirety,
to Inside Reproductive Health's audience of 300 million people.
Enjoy this conversation of me hanging out with my buddies.
Manish Chhadua (02:12)
The biggest challenge with entrances at fertility centers is it's a growing part of our clinics. There's a lot of paperwork and administrative burden that comes with that. Generally reimbursements are going in the downward direction, but overhead is going up and we're struggling to find that balance to really.
handling the overhead and the administrative burden that insurance companies and patients that have insurance coverage come with.
Griffin Jones (02:38)
Can you tell us how much overhead is going up? Like, it going up a couple percentage points? Is it going up a lot more than that? And over what period of time has this been happening?
Manish Chhadua (02:50)
Yeah, I mean, some of it's tied to insurance and the administrative burden there, right? Gosh, I graduated fellowship in 2012. And when I started down here in Texas, we were probably 30 % insurance, 70 % self-pay. Today, Texas is probably closer to a 60%, 65 % insurance state with 30%, 35 % self-pay.
a dramatic shift in a matter of 12, 13 years. But you have other headwinds as well, Salaries have gone up, inflation has gone up, cost of buying products to service IVF patients. And so in the past, historically, that was adjusted for in the self-paid patients, but increasingly that's not adjusted in the managed care market.
but they still continue to go up. In fact, the trend is probably in the downward direction in the managed care market for reimbursement.
Griffin Jones (03:44)
it's in the downward direction
Manish Chhadua (03:46)
I would say stagnant or downward, yeah. Especially if you compare it to the self-pay patients or the cash patients.
Griffin Jones (03:52)
So it makes sense that it would be less than them, but why is it, why is it, why is it projecting downward, do you think?
Manish Chhadua (03:58)
Well, I mean, and again, on the clinic side, in the IVF laboratory side, you're really down to probably five to seven big payers that really manage a majority of the insurance patients. And with their contract renewals, they come to you and say, here's our reimbursement, formulary, here's our fee schedule. And you're left with take it or leave it. You take it.
great if you don't or you try to negotiate it, the leverage is no longer in the clinic side. I mean there are certainly MSOs that are getting larger and larger but even despite that they're able to say take it or leave it and you still have 10 other clinics in town that are willing to sign it and take the volume and play the volume game.
Griffin Jones (04:39)
And so where you used to if inflation went up or if your cost of labor or supplies went up, used to be able to raise prices because of self-pay patients. And that's no longer the case because you're being reimbursed from insurance and they're reimbursing less.
Manish Chhadua (04:57)
Yeah, and listen, this isn't unique to fertility. This is across the entire medical industry at large. And I would say.
Griffin Jones (05:04)
But it's been that
way in the medical field at large for a while. It's relatively new to us.
Manish Chhadua (05:09)
And it's just new to us.
Yeah, it's new to us and we're seeing it firsthand now ⁓ more than we have historically, certainly at all time highs in terms of managed care coverage today.
Griffin Jones (05:20)
Manish, the heck are you doing about this? What are you doing to make yourself useful with all this?
Manish Chhadua (05:25)
Well, you know, I'm a technologist, right? So what we're trying to do is just create process and efficiencies out of what is basically wastage or loss in the market. you know, one of the biggest components of how insurance companies work and basically the rest of that side of the industry is a lot of labor, a lot of manual hours, basically.
putting paperwork together, creating justifications for why these more expensive treatments are required. And like he said, IVF is just kind of coming into this where it's becoming more and more of a problem. And obviously, as Ravi alluded to, labor costs are going up in the last five years pretty dramatically. And so what we do is, you know, we decided probably about five years ago, four years ago, to take that problem on head on.
And basically, as opposed to hundreds of clinics figuring out how to train individual employees to do this work, we thought, well, why don't we just become as much of the experts as efficiently as possible in tackling that, and specifically the drug side of the Preroth process.
Griffin Jones (06:32)
What was the waste? You said there was a lot of waste. What was the waste?
Manish Chhadua (06:35)
It's mainly time, sitting on the phone with PVMs, going through paperwork, digging through insurance documentation, and then pulling that information from the EMR. The other interesting thing that's kind of part of that ecosystem is that the clinics were having to do a lot of this work. The pharmacies were having to do a lot of this work.
And ultimately those prescriptions end up going to single source pharmacies. So even the pharmacies that are trying to help out in the clinics that are doing the work, it exists on the drug side and basically they're not going to be able to fill those prescriptions anyways. Well, and on the clinic side, the waste comes from who's doing the prior off at the clinic. I would bet you half of the clinics that we've onboarded at CloudRx is being done, the prior is being done by the nurse.
and half is being done by the financial team. I mean, imagine a nurse whose job is to do clinical care day to day that's now stuck on the phone or filling out paperwork a third, a quarter of her day dealing with getting a prescription through versus taking care of patients.
Griffin Jones (07:37)
So I'm not sure if I'm understanding the challenges you were just describing, Manish. Can you go over that again?
Manish Chhadua (07:44)
⁓ sure. mean, so again, labor, paperwork, know, time on the phone. Basically, there's a lot of this type of information and it follows the 80-20 rule, right? You you have 80 % of these patients that you can probably get through pretty smoothly, but 20 % of these patients basically working with their insurance, the appeals process, getting through all the minutia there really is a time waste.
at the clinic and definitely not what nurses and physicians and everybody at the clinic are trained to do.
Griffin Jones (08:17)
So you see this going on in clinics across the board. There's 500 clinics, maybe all trying to figure it out themselves or a whole lot of different people trying to figure it out themselves. How are you streamlining it?
Manish Chhadua (08:30)
Yeah, so that's another, you know, big hurdle, right, for us to tackle. you know, our approach to a lot of that is building out workflows using robotic process automation, using AI where we can, and basically taking that process and trying to dissect it down, right? One clinic operating on, you know, 30, 40 patients a month gets exposure to
maybe three of this plan, five of this plan, one of this plan. And so there's a lot of diversification, diversity in what that job entails over the course of a month. Whereas for us, now we're doing, you know, 2000 patients a week, 8,000 patients a month. We really do get fairly keenly focused in on, what particular plans need, what exactly we have to submit, how to basically do that efficiently. And for the most part, we try to do that with technology first.
as kind of the easiest way to scale that process.
Griffin Jones (09:24)
And are you doing this for prior auths for IUIs and IVFs and things that are billed on the clinical side or just the meds?
Manish Chhadua (09:34)
It's mostly on the medications, right? Long-term, we're looking at doing the medications plus the medical benefits side. But in this first part of kind of launching this company since 2020, it's mostly on the medication side. Now we have a relationship with most of the clinics that we work with and their billers. And so we work kind of hand in hand with them, but they usually get the med off in first. But that's actually something that we just are the
medical site authorization first, but we're actually just starting in the next probably year or two to start working on the actual procedural authorizations as well.
Griffin Jones (10:10)
Someone that I work closely with went through an experience with a center that I know and like a lot, but had a really hard time because she was calling the center and they were telling her to call the PBM, who was telling her to call the pharmacy, and she was just in this triangle and, you know, almost Mr. Cycle, and it was a nightmare for her. She's spending hours doing this. Is this something that would have been prevented with you all?
Manish Chhadua (10:31)
Yeah, that's
Yeah, I prevent it is a too finite word or too infinite word. I'd like to say that we could definitely help. Now, and this is the travesty of this is typically it is the patient that's basically stuck in this whirlwind of trying to get information from their clinic, trying to get the pharmacies to be able to communicate with them, to be able to get this done, as well as working through their insurance. Like I said, we spend hours
doing this all the time and we know how hard it is to do, imagining that a patient's having to do it one or two times or going through that process on their own, you know, that's just such a sad thought.
Griffin Jones (11:11)
You said that maybe you guys are up to 65 70 percent covered in in Dallas right now in Texas isn't even a mandated state so this is just by virtue of really large employers in the Dallas Fort Worth area that are offering These benefits now is it?
Is it going up as much as it was? Are we going to reach a certain plateau where maybe 20 % are never covered? Are we still seeing the same growth of the PBMs? have they reached a... And I should say the employer benefits managers, are they reaching a plateau? What kind of growth are we seeing?
Manish Chhadua (11:55)
Yeah, you know, even in the managed care states, we are seeing them peak out at like 70, 75 % managed care, 25, 30 % is still self-pay, but where we're seeing the growth is the volume, right? So the percentage might stay the same, but as you know, the number of IVF cycles being done every year is going up. Other states that are probably hovering in the 30%, 40%, 50 % ranges are going to get to 70%.
So there's still gonna be percentage growth across quite a bit states, right? Dallas is easy because it has such a high percentage. Houston also I'm sure is quite similar because we have so many large employers. But you get out into like Alabama, Mississippi, Arkansas, certain states, they're probably sub 50%, but that will grow. But the biggest growth is really just the sheer volume and number of patients. And again, this goes back to the economics.
when insurance gets involved, it's a volume play. You've got to do more cycles for less money and try to make it up in economies of scale. And that just that sheer number of patients that need to go through and in order to keep overhead steady, you've got to figure out how to get efficient. And we looked at this model five years ago, we thought, can we help clinics get efficient? And I said, the one thing all clinics hate doing is prior authorizations for insurance.
So
Why don't we do that? I mean, that's really where the genesis of CloudRx came about. And we said, hey, Manish, listen, I can assure you if we figure out how to solve this problem, we can make patients and clinics very happy. And we've had quite a bit of growth. mean, we have 70 plus clinics on board at CloudRx. Like Manish said, mean, 40,000 plus prescriptions a month are going to CloudRx. So the growth has been phenomenal. In fact, I mean, for a clinic to get...
signed on with Clouderx, there's a wait list right now because we have to scale ourselves in terms of just getting the number of employees in place. So it becomes economies of scale for us. And we think to Manisha's point, I mean, now we know these plans inside and out versus a clinic who might only see a certain plan every once a week, once every other week, and then they don't realize.
what drugs are covered, what's not, what's the formula. I mean, there's so many nuances to this process. we thought we, some, you know, someone needs to become a subject matter expert in this and deliver a service at a leaner, a leaner model so that it helps to save time and honestly overhead costs.
Griffin Jones (14:22)
employees in place. What's up with that, Manish? What's up with that, Mr. AI? You don't have a digital assistant doing all this stuff right now, scaling this to infinity?
Manish Chhadua (14:26)
Thank you.
You know,
I don't think the employees, you know, are ever something that we would go without, honestly. I mean, we have really sharp people. There are certain things that still you need to have the double check. You need to have somebody that understands what the patient's going through, understands a little bit more than where AI is today. But, you know, they're...
There'll be a point in time where most of our employees will be focused primarily on the touch aspects of it, mainly on the final approvals, and the rest of this will get fairly automated. I do believe that.
Griffin Jones (15:06)
How far are we away from that? Because I called for my HVAC annual servicing and it was about 30 seconds into it that I'm like, am I talking to a robot? And I'm thinking it would be rude to ask her if she's a robot. So I'm not quite going to ask. And then maybe like a minute in she says, I'm a smart digital assistant. And ⁓ then so that was like, all right, well now I can ask. you a robot? And she said, no, I'm not a
Manish Chhadua (15:21)
Ha
Griffin Jones (15:35)
I'm a smart digital assistant. But you're not a human. No, I'm not a human. it was like, wasn't, like, there still are some gaps and obviously in fertility you're talking about something more sensitive than HVAC, but the point is just the competence of that technology. It was not the old credit card phone tree, you know what I mean? Where it's like,
Manish Chhadua (15:37)
There you go.
Griffin Jones (15:55)
I'm sorry, I didn't quite get that. Five, four, three. It's not like that anymore. It's actually a competent system. Where it wasn't competent is integrating it with the rest of their workforce because then I got a call from a human to confirm everything and well, that totally negates the point. But I was pretty impressed. How close are we to that in the fertility space?
Manish Chhadua (16:19)
And I think we talked about this a little bit more about how fast these things are happening. What we see as consumers or as people in industry, and we see AI moving really fast even in just what we're interacting, under the cloak or under the table and basically everywhere else where we don't see what's going on, it is moving at a lightning speed pace.
I don't think people realize it. It's not quite there yet, just like you were alluding to. We can still kind of tell, but I can almost assure you we're not very far off from not being able to tell the difference. And basically getting to the point where now these bots that you're talking to are actually talking to bots that you put in play to do different things and knock out different tasks for you. So we'll have bots talking to bots.
Griffin Jones (17:07)
Yeah, the insurance bots will be talking to your bots, right?
Manish Chhadua (17:10)
Yeah. Well, and I would tell you, right, so if you dissect out
healthcare in general, investigation of benefits, looking up what someone's coverage is, looking up their deductible, almost all of that is automated in-house now, not just for us, for other hub services, other companies, but getting a prior authorization done for IVF is still a very manual process.
requires a lot of phone calls and looking into a plan. You can't just log into a portal for most insurance companies and understand it. It's on the side of the insurance company. mean, you can have certain ones like ⁓ Optum actually has a portal that is a lot easier to look up what benefit it is, but then others have no codes for ICSI, for PGT, for Cryo, for all the different.
Griffin Jones (17:38)
Why is it so manual?
Manish Chhadua (17:56)
Codes that are required for IVF that you end up having to call a plan and talk to some
Griffin Jones (18:00)
Do you think that this will help the employer benefits management companies, like the fertility benefit carve out companies, because they have codes for all that stuff, right? Like Progeny's got codes for all of those fertility specific things where some of the traditional insurance carriers might not, right?
Manish Chhadua (18:19)
Yeah, I mean, they both have the codes. do think that the fertility benefit managers, whether Maven, Progeny, Kind Body, Carrot, know, the big four probably in our space, they have figured out a way to help streamline that to a certain degree. So there is some benefit there. The question will be as they continue to grow, still the traditional PBM and insurance companies are also growing at the same pace. So I don't know that they're going to replace
all of the traditional models that going that are out there.
Griffin Jones (18:48)
Now somebody was asking me this question recently and I could only speculate.
And so I thought maybe they'll continue to grow for those reasons. But I also wonder if we actually do get a federal mandate or we do see a much, much higher volume of IVF. Will the insurance companies, the traditional people, the United, the Blue Cross, the Atenas, will they start to want to try to get some of the
market share back from those carve outs.
Manish Chhadua (19:19)
Yeah, it's entirely possible, but I think what we're seeing right now is more so that they try to partner with the carve-outs because, and I do think, you know, these carve-outs are doing a much better job than even those insurance companies feel like they can do themselves right now. And fertility is such a unique space with different needs, different demands that, you know, even then, you know, we talked about this, you know, there's plenty of other pharmacy hubs that do this kind of work in other disease states, but it's so unique that
basically it requires someone with fertility focus to really do it right. But I think actually I think it's the opposite. I think as it scales, I mean you follow the money, they're going to see what they're giving up and they're going to ask to bring it back in house. Definitely quite possible.
Griffin Jones (20:02)
We have point counterpoint with the cousins here. Where do you think, all right, Manish, let's pretend that Ravi's wrong because I like pretending that Ravi's wrong and that you're right on this and that they're gonna continue to partner with the carve-outs. Do you think that it will be like one...
Manish Chhadua (20:05)
Yeah.
Thank you.
Griffin Jones (20:21)
insurance company treated like like United goes with progeny for example and Blue Cross goes with Maven. Do you think it will like it'll be exclusive deals like that or they'll each work with each other?
Manish Chhadua (20:33)
Can I just point,
before Manish answers, can I just point in order for me to be wrong, we have to pretend. I just like that. I'm gonna record this bit. ⁓ You know, I think, you know, and again, this is not a formal opinion, but you know, at the point in time when a lot of the carve-outs were growing and this was kind of a few years back, it was like there was maybe 20 of these out there in the market.
Griffin Jones (20:40)
Ha ha ha ha
Manish Chhadua (20:59)
I remember seeing job postings for employees to apply for XYZ employer's job, and they would list the fertility benefits that they provide in the job posting. And so the reason why I think that this might persist, and again, this is not a formal opinion, is that so long as employers are trying to recruit top talent and employers have to say so,
of how exactly they market or build this product of recruiting top talent, they're gonna basically try to differentiate themselves by saying, hey, we have access to the XYZ carve out benefit as opposed to a traditional benefit. And I think that'll persist for a little bit longer. You can't argue with the money argument, I don't think, because I do think that that's a pretty big factor. So there you have it.
Griffin Jones (21:48)
You heard it here on Inside Reproductive Health, Manish's official unabashed, unapologetic, certified opinion. Do all the insurance companies cover the same drugs or do some companies cover other drugs? How does that work?
Manish Chhadua (21:50)
you
Well, most of them have a formulary. So they cover IVF drugs as an umbrella, but they have a formulary, which is essentially a preference or to a certain degree, you could even say a mandate that it needs to be one drug or another. example, Follistim is on formulary for United Healthcare or Optomrx. So if you're a patient who has United Optomrx and that's your
That's who your employer has chosen for their insurance company. It's Falisten. Aetna and CVS Caremark is also Falisten. So a lot of employees that are in that have to use Falisten. Men appear a little bit different. They're usually on most plans. Avadril HCG triggers, it depends. Interestingly, that you asked that question recently, CVS Caremark changed their formulary from
Avadril to HCG and so even your trigger shot can be determined, but it's usually a GonaLef or Falastin formulary at the top, but as you get further down into the other drugs, it just depends.
Griffin Jones (23:07)
I know that faring makes men a pure I know that the way I remember Falisdem versus gonna laugh is EMD Serrano you think of the letters gonna laugh Oregon on one brand name Falisdem one brand name. That's how I remember who makes Avidrill and ACG triggers
Manish Chhadua (23:23)
So Avadril is made at EMD and then Pregnil, which is the HCG is made at Organon. Navaril is another HCG it's made at Faring. So it's still the same three drug manufacturers for those. Then antagonist, which are like Ganarellix, Cetrotide, those are made at Organon makes Ganarellix, EMD makes Cetrotide. Some generics have come into the market. So, but mostly you're still
dealing with the three major fertility manufacturers in the United States make up 80, 90 % of the IVF drugs.
Griffin Jones (23:58)
So those insurance companies have a, what did you say? It's basically a mandate, but what do they call it? So is a formulary just a euphemism for a mandate, or is it sometimes not a mandate?
Manish Chhadua (24:04)
Formulary.
Well, it's a euphemism because when it's on formulary, something may cost $100. You can get the non formulary, but it's going to cost you $1,000. it's essentially you have options, the second option too is a magnitude higher in price.
Griffin Jones (24:28)
So some of these insurance companies have a strong preference for follow-stem. Has that always been the case?
Manish Chhadua (24:33)
Um, it, it, you know, it kind of goes up and down. It's interesting. would say if you go back eight, seven years ago, it was maybe a more of a gone a left heavy market. If you look at today, uh, I think the market has shifted and, it's probably leaning fallast in, um, they've had some big wins in the last five years with a couple of major, um,
So it's probably now leaning Organon-fallastin, but they're close.
Griffin Jones (25:02)
why do you think organ has had the i'm probably asking you speculate why you think they've had those big wins in the last five or seven years
Manish Chhadua (25:10)
You know, it's a variety of things. I mean, it's hard to really pinpoint, but I mean, they do, you know, with a lot of different things, they've been a lot more present in the market. They've been a lot more aggressive with winning plans back. think, you know, they realized that the managed care market helps out in the self-pay market as well. So just ⁓ maybe a little bit different tact, a little bit different level of aggression in trying to those plans over. You know, the other one is
it wasn't always organ on, don't know, Griff, if you remember, but probably when did that change? Three, four years ago. I think four or five maybe, but it used to be under Merck. Yeah. So it used to be under Merck, but even before that it was organ on. it went from organ on, then it went to Merck. Merck really grew with a product called Keytruda. It's an oncology drug and their oncology and vaccine divisions exploded. mean, they were so
Griffin Jones (25:40)
Six or eight years ago. No, I was longer than that
Manish Chhadua (26:01)
ultimately, let's call it in the last five years, they spun off Fertility and Women's Health to a new company. That new company, they could pick the name and choose whatever they wanted to. The nostalgia from when Organon was around, and this was probably even before my fellowship, was high on the list. So when it came back out, it came back as Organon. And it's very much a women's
it's one of the largest, if not the largest women's health pharmaceutical company globally. And so I think spinning that off, making Organon a women's health pharmaceutical company on its own standalone separate from Merck also plays some role in it, to what extent, I don't know.
Griffin Jones (26:40)
Well, is that like the rule of the rule of business of do a couple things really, really well, as opposed to trying to do everything that they're in the one space so they can focus on.
Manish Chhadua (26:51)
I think so. Yeah, I mean,
it makes sense, right? It makes sense to the three of us, at least.
Griffin Jones (26:55)
It makes sense to the three of
us. That's our story. That's it. No further explanation needed. Are all clinics struggling with the same things that you guys are seeing? Are they all having the same challenges? Or do you notice that some clinics really have this challenge and other ones really have a different one?
Manish Chhadua (26:59)
You
No, I think it's the same. know, I've gone to a handful of these advisory boards and this and that, and you get, it's fun because you get into a room with doctors and nurses and administrators from all over the country and everyone starts talking. And I think the three, four things that percolate up to the top is insurance managed care, you know, dealing with that. HR has a huge problem in clinics and maintaining staff and just
all the things that come with HR, and then cost and overhead. mean, these really are almost universal. Obviously, everybody has their own little things here and there, but if you really ask everybody sit in a room and keep talking about it, it does come down back to these handful of things.
Griffin Jones (27:56)
Some people, do some people see the urgency more than others though? Do you think everyone understands that we're moving to a much higher volume field of medicine and that managed care is going to take up a much larger piece of their business than it is now?
Manish Chhadua (28:12)
I think two, three years ago, I don't know if people really, where they stood on it, I think today. Yeah, I think it's pretty prevalent. I think efficiency is the name of the game, optimizing your workflows, basically figuring out how to train staff faster, making them more efficient. think there's a handful of clinics that are maybe in their sunset phase that are just like, I'm going to ride it out and see where it goes. But I think for the most part, all of them are.
fairly active. The NSOs especially, know, name of the game is efficiency. Yeah, the big networks definitely understand this, right? You look at Pinnacle, Prelude, First for Time, and these guys are really pushing the growth model, which is, I think, helpful to really service the number of patients that are in this space. And interestingly, those, some of those large, large networks are
some of the first people to sign up for CloudRx because they realize they've got to become more efficient. So we service a lot of MSOs.
Griffin Jones (29:10)
Yeah, for them, and I wonder if that's skewing your view a little bit, Manish. Like, what about those independent wahoos out there, like Dallas Fort Worth Fertility Associates?
Manish Chhadua (29:21)
Who are they? They're
not allowed on side RX actually. Yeah. ⁓
Griffin Jones (29:25)
Look them up on Yahoo!
But our
independent groups because I've been interviewing a couple recently and And and I do like that everyone doesn't have the same focus on efficiency But some of them I worry like you don't have it. You're not paranoid enough for me, man Like you're not you're not focused enough Quite enough on the efficiency and I like that it they're not looking at it as numbers that they have to hit or quotas but I just worry that they'll get
that steam rolled if there's a big jump in managed care in their area. what do you think? So obviously the MSOs, they're really hyper-focused on this efficiency. What about independent practices? And what about the university systems?
Manish Chhadua (30:12)
I mean, I know I'm probably closer to that, the individual clinics, like all things, I think it's a very heterogeneic population. Some clinics are still getting more more efficient scaling. Others are kind of like Manish said, might be like in a phase where they're trying to finish out their 10 year career. Academics is where it really gets interesting. And I think that the...
clinicians and ⁓ nurses and embryologists that practice in the university settings are isolated from it because they have a huge team of coders in terms of billing coders and as well as software coders running in the background. Some of them that are kind of privademic might know it, but like the ones that are purely academic, I don't know that they're doing a whole lot of these processes that are happening in the background and
those, it just kind of almost happens magically. Now they probably get stuck in the nuance of it's not approved, patient can't go forward. Okay, fine, call the billing office and then come back to us. That's probably one of the beauties of being practicing in academic medicine is maybe you don't have to deal with that as much and you've got an army of people, but certainly the finance team.
Griffin Jones (31:22)
But the patient still
does, though.
Manish Chhadua (31:24)
The patient's still 100%. The patient still does the finance. People in the background still see it. And the patient gets caught up in that. We have had a little bit of a hard time onboarding academic university centers at cloud for these services. Interestingly, I think there's a benefit for all kinds of clinics for this, but the red tape in just contracting and outsourcing certain parts of their ecosystem is very hard. So
of all the clinics that we've onboarded and the numbers that I've shared with you before, very little is actually in the academic university setting. So they're still doing a lot of this on their own. Well, and just one other thing to kind of touch on the earlier question is, we do this every day. I can't imagine a nurse or a clinical staff that would volunteer to want to do this job every day. So from that point of view,
You know, some people are just change averse possibly. But again, it's not something anybody I think is volunteering to do outside of us.
Griffin Jones (32:22)
I can't believe I've
never done a little analysis on this before, but just in the last 20 seconds, I pulled up six different academic fertility centers. I'm not sharing my screen and I'm not going to. They're horrendous. These are good programs. These are the programs that everyone would know. I'm Googling University Plus Fertility
Manish Chhadua (32:38)
Ha
Griffin Jones (32:45)
So I'm getting the fertility centers Google my business listing, not the entire system. are,
Manish Chhadua (32:53)
What's horrendous? What are you saying is horrendous?
Griffin Jones (32:55)
like
threes, 2.9, 3., yes, yeah, their overall rating. And not from small sample sizes either, but sample sizes of 50, 100, 150, that you could, that just, don't, I never see that. I shouldn't say never. I seldom see that in private practice. And if I were to click on those, I bet you, I bet you a lot of it is about billing stuff.
Manish Chhadua (32:58)
the reviews, the reviews, the reviews. I got it. Understood.
Well, it's just a-
Well, it just shows you how useless Google review ratings are because I mean, I'm sure these centers are excellent and it's just, you know, this is the problem with the Internet.
Griffin Jones (33:30)
we well
You can see how useless reviews are because you have really good ones, Ravi. So obviously something's not working out. No, they're not useless though, because people aren't reviewing clinical outcomes. Online reviews, feedback, patient experience is not SART data. It is something apart or overlapping, but it is people's overall respective of their
Manish Chhadua (33:35)
Exactly.
Griffin Jones (33:56)
perspective of their entire experience at that fertility clinic and they don't like it. the redeeming quality for them is the clinical team, right? Like when you see good things, they're talking about the nurses, they're talking about the doctors, but these things...
that people are giving them one star reviews on are like, they don't answer the phone. I got this bill, nobody explained. Yes, correct. But I...
Manish Chhadua (34:20)
It's their experience, obviously not their pregnancy rates.
This is interesting to see this
debate from this point. We're gonna get sidetracked here for a minute, but I want you to Google the South Lake location and Go and click on the newest review it came in at 330 this morning 330 a.m
Griffin Jones (34:45)
South Lake office Dallas Fort Worth fertility. Let me make sure that I get the right listing. OK. 71 Google reviews and clicking on I'm clicking on newest this clinic. This clinic is busy. But yeah, that was all right.
Manish Chhadua (34:51)
This is my problem with the internet.
newest.
You can read it out loud.
No, no, okay, go to the next one. That was a five star. Go to the next, sorry, the
one after it.
Griffin Jones (35:09)
My private medical is the one star. My private medical info is being given to a complete stranger who used my name on a different email server. I am not getting any of the emails about what I am supposed to do in preparation for egg freezing, which means an enemy of mine is potentially attempting to sabotage my opportunity.
Manish Chhadua (35:30)
An enemy is...
Griffin Jones (35:36)
Biological children of my own, that's incredibly evil, jeopardizing me potentially being the mother of my own biological child. You're a monster,
Manish Chhadua (35:44)
An enemy has stolen my email and is sabotaging it and therefore we are clinic out at one star I'm like just good you can't rate the enemy anyways
Griffin Jones (35:51)
Yes.
So if your point is that there are sometimes frivolous reviews, yes, you cannot take the credibility of any one review at face value, but you have a 4.7 rating overall. So this one star review of someone taking their cybersecurity issues out on you, which is great, is not supported by
the body of evidence of other reviews. We've already established that the fact that you have a 4.7 means that it isn't valid.
Manish Chhadua (36:32)
It's just amazing. Grip,
I hope you're impressed that Ravi knows his reviews were Yeah, look at that. knew exactly what the last two reviews came in at. That's how little value he thinks Because it pisses me off when people write these things.
Griffin Jones (36:40)
See? That's...
except for when it's amusing, right? ⁓
Manish Chhadua (36:49)
Right. But
anyways, you're so, hey, listen, that bodes well for us, right? Because we want people to get good ratings and we want good experience at the patient level and at the clinic level, which is why a system like CloudRx to help really get these patients through and an insurance and not getting your prescriptions on time is where the frustrations come in. So.
mean, it's a great segue back into this whole thing about prior authorizations. And so I think it's partly why we've had a lot of success. think it's why, honestly, the process is very onerous. We had a former nurse that is a nurse at OptumRx, and she didn't know that we were part of CloudRx. And at some point, we were talking on a weekend about CloudRx.
And she was like, that's, that's you guys. That's you in Manish. And I said, yeah, I mean, we're yes. That's a lot of that is from a company that. And, ⁓ she told me she thinks 20 % of all phone calls that the fertility division takes at OptumRx is from CloudRx calling them 20 % of all of OptumRx fertility division. She's like, they receive more calls from you than anybody else by far.
Griffin Jones (37:43)
Yes, we own 30 businesses and that's one of them.
Manish Chhadua (38:04)
And partly that's because of how arduous the process is, the phone calls, but also they know us pretty well at every single one of these insurance companies now. I mean, we can't really be ignored. And therefore, when we call, we have now account managers, we know we have relationships there. We can find out why have you not gotten this through? What do we need to send you? I mean, it's a friendly relationship, but it's also everybody on that end is trying pretty hard to get these things through to you as well. don't really.
At an individual level, they're not really trying to delay the prescription, but it is so time sensitive because you get your menstrual cycle start date and all of a a lot of things have to happen and one of those is getting your medications on time. And so, you know, that's the advantage of having a company that's niche is to try to get this through fast.
Griffin Jones (38:53)
So are you taking it? You said you got a waiting list. Can fertility centers still work with you or are you making them sweat?
Manish Chhadua (39:00)
No, no, we're signing up clinics. There's a process. I mean, it's not, you know, I wish it was just as easy to sign people up. So there's a process. There's an onboarding process. There's a lot of agreements, legal documents, because we're talking about patient information, patient files, as you know, BAA agreements, that you name it. So there's a whole process that when you decide, hey, we want to, we want to join and use CloudRx services, then we have to go through all the paperwork that needs to happen.
probably a two month onboarding process to get a clinic primed and ready. And for us, because it is not fully automated, it's not all robotics, we have to hire employees for those roles, right? We can't just bring on a clinic, especially a large volume clinic, a thousand retrievals a year type of clinic without really getting on, ⁓ helping grow on our end too to accommodate that. So.
We're certainly taking on clinics and we try to scale that and grow as fast as we can. mean, the wildest, craziest things are November, December, January, it turns into a little bit of a nightmare because December flipped to January when most plans change over for clinics, they'll all tell you, I mean, it's the highest burden month because everybody's got a new insurance plan, a new carrier, a new formulary, new design benefit.
And so at CloudRx, I mean, have a role we really won't onboard and scale in November, December, simply to brace for January, January into February. And then you're back into kind of a normal cadence again. So there's a lot of nuances for that. But no, our goal is to continue growing. I mean, you look at the growth trajectory, it's been on a rocket ship the last probably two years. And we have people calling on offices explaining what services we offer.
⁓ you know, jumping on the pod like this, making sure people know that there's a service like this that's out there. And just, you know, but if there's a clinic that you want, you have in mind, we'll let them jump to the front of the line.
Griffin Jones (40:53)
Especially if they've got a 2.9 Google rating. They get to jump to their need of help stat. Before we sign off on this, you guys are my early adopters. What's new in your tech stack, like your personal tech stack? What are you using now that you weren't three or six months ago?
Manish Chhadua (41:14)
Well, I mean, listen, it's a, for me, it's pretty much a rolling ball. mean, we're constantly adopting a lot of new tech. I could tell you that a good 80, 85 % of all the code that's being built at Rheon and CloudRx is all through AI. And, you know, we just adopted Copilot as part of that solution. And it's really is amazing how fast it can move and what all it can do.
basically how clean the code is afterwards. mean, it's geeking out a little bit, but fairly impressive. On my side, it's interesting ambient listening. I mean, we're getting better and better at having these ambient listening devices and recording meetings, minutes, but even I'm starting to try to play with this in the clinic side. so ambient listening devices are
are really, I think, also going to be quite important. And they really do help you keep track of the action items that are needed during consultation or meetings. So I think that's also something that we'll see a lot of over the next 12 months.
Griffin Jones (42:15)
For personal use, what's each of your favorite LLM right now?
Manish Chhadua (42:19)
I'm still, mean, there's a risk factor for a lot of LLMs that are out there. So we stick to mainstream right now. So, I mean, we're still on chat GBT for the most part. Chat GBT also, have you heard of notebook? What's it called? Notebook AI from Google. Notebook AI from Google. It's a podcast.
Griffin Jones (42:36)
now use is
clod no no
Manish Chhadua (42:39)
No, it's a podcast. You can upload four or five PowerPoint presentations, two, three articles, a couple of websites, and two people will come on and create a 30 minute podcast completely like voice inflections, everything. You should check it out. It's pretty cool.
Griffin Jones (42:55)
Well, there goes my career. It's down the toilet. so when it is when it when that does happen, though, then all of my episodes would just be hanging out with you guys because nobody will pay to do that. So I'm looking forward to it because it's always a blast having you guys back on. Maneesh, Ravi, thanks for coming back on the program.
Manish Chhadua (42:57)
Yeah.
Yeah.
Yeah, thanks for having us. Thanks a lot. Love listening to the show. take care, bye.
Manish Chhadua
LinkedIn
Dr. Ravi Gada
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