Bringing luxury to healthcare without the luxury cost. That’s the stated mission of eternalHealth, a Medicare Advantage plan based in Massachusetts.
Led by 26-year-old founder Pooja Ika, the youngest person to ever start a MA prescription drug plan, and board chair John Sculley, the former CEO of Apple, the company operates on a cloud-based platform that embraces robotic process automation and machine learning.
eternalHealth was founded in 2022 and was the first MA plan to get licensed in Massachusetts since 2013. Touting low monthly premiums, primary care and specialist visits, a $4,500 dental allowance, $0 vision and hearing exams, low out-of-pocket costs and unlimited transportation to doctors and the pharmacy (as well as grocery allowances for the chronically ill for select members), the company is expanding into Maricopa County, Arizona. Both markets have a combined two million individuals eligible for Medicare.
Ika told Fierce Healthcare that she sees Arizona, or “Florida 2.0,” as a location with a lot of business potential, coinciding with many people across the country retiring to Arizona. She also said the expansion gives the company more opportunity to venture into value-based contracting, a contrast from Massachusetts’ fee-for-service landscape.
“We wanted to go to an area where there was a lot more awareness and understanding of Medicare Advantage, not just with the members and the consumers but also with the broker community,” she said. “We wanted to go into markets where we could embrace risk, capitation and different payment models.”
Through the company’s tech platform, Ika said they are able to eliminate the need for vendors because 15-20 departments normally siloed within a traditional health plan are able to be placed under one umbrella. That saves eternalHealth money and resources, since the platform can automate up to 3,000 functions within the plan. The company is seeing significantly lower administrative costs than its competitors, as well as a reduction in error.
Since the experience is fragmented on the backend for many health insurers, the customer experience feels clunky on the frontend. Ika explained that one health claim can interact with hundreds of transactions, making its way through the utilization management system and member billing system, just for the claim to be adjudicated and paid to a provider.
If an error occurs, which is not uncommon, providers and members will feel the downstream effects. eternalHealth says it can pay providers within nine business days of a claims request, quicker than other major health plans.
“As a result, we have a lot more savings we can allocate towards areas that really matter for us as a health plan,” she said. “We can make sure that our products are richer. And then we can also allocate more dollars towards the customer service approach to really ensure that we're retaining our membership.”
Those rich benefits get back at the company’s mission to provide quality care at affordable prices, made possible Ika said because the customer experience is more geared toward the individual, unlike some plans by national carriers. Her goal is for the customer service at eternalHealth to be as streamlined as the technology underpinning the company. Then, she wants the business to provide care to more than 11,000 people by 2026, at which point the business should reach breakeven profitability.
In September, eternalHealth partnered with Inovalon to leverage the company’s risk adjustment capabilities, helping to improve risk score accuracy. Through the partnership, eternalHealth can deliver actionable data in a format providers can utilize. Ika said the company will continue to look at acquisition opportunities of other health plans.
“There’s a need for disruption,” she said. “There’s a need for change.”