Resource Center

By Dr. Matt Resnick, Chief Medical Officer | SVP, Health Plans and Partners, Embold Health

When we talk about rising healthcare costs, we almost always zero in on one thing: price. The assumption is that lowering costs means negotiating better rates. But what if that’s only part of the story - and not even the most important part?

As a physician, I’ve spent years living inside the very system we’re all trying to fix. And now, as Chief Medical Officer at Embold Health I see it even more clearly: the greatest opportunity to reduce healthcare costs lies in improving healthcare quality.

But to get there, we have to start by redefining what we mean by both “cost” and “quality.”

Why Price ≠ Cost

When I first started working closely with health plans, I realized just how differently cost looks depending on your vantage point. As a physician, I thought about care decisions. As a health plan partner, I started thinking more about the downstream impact of those decisions - how much they cost, where they happen, and whether they needed to happen at all.

What became clear is this: cost isn’t just about price. It’s about what providers choose to do, where they do it, and how often they do it. Cost is the sum of clinical decisions and care settings, both carrying weight, and shaping a patient’s journey in different ways. At Embold Health, we break it down into three distinct, and equally important, levers:

1. Clinical Decision Making: What a provider chooses to do has massive cost implications. Take a patient with knee pain. One provider may recommend physical therapy and weight management. Another may go straight to surgery. The difference? Tens of thousands of dollars and wildly different patient journeys and risks.  

2. Site of Service: An MRI at a hospital outpatient department can cost three times as much as the same scan at a freestanding imaging center. Same test, same patient, but very different cost.

3. Price: Yes, negotiated rates still matter. But they’re just one piece of a much bigger puzzle.

Cost, in other words, isn’t a fixed number. It’s a product of clinical decisions, settings, and contracts - all of which are driven by provider behavior.

The Hidden Connection Between Cost and Quality

Cost and quality are often treated as separate metrics, managed by different teams, using different tools. That’s a mistake.

Why? Because high-quality care is cost-effective care.

I’ve experienced this first hand. I contionue to treat prostate, kidney, and bladder cancer, working tremendously gifted colleagues, among them trainees.. Despite working at a top institution, I had (and continue to have) limited visibility into how my own clinical decisions compared to my peers. That’s not unusual - it’s the norm. And without meaningful feedback, there’s no way to improve.

When we start measuring clinical appropriateness, not just whether boxes were checked, but the quality of the decisions being made, we open the door to real improvement.  

To truly improve affordability, we have to stop thinking about cost in isolation. The better question isn’t just how much something costs, it’s whether it should be done in the first place, and how well it’s done when it is. Once we optimize on whether (appropriateness) and how well (effectiveness), we can also optimize on site of service and price, as a sustainable path to delivering value to patients and to those responsible for the health plans in which patients are enrolled.  

We define quality as care that is appropriate, evidence-based, and aligned with best clinical practices, not just completed tasks or box-checking. It’s about doing the right thing, at the right time, for the right patient. And when we improve quality in this way, we reduce waste, outcomes improve, and  costs fall as a result.

The Real Untapped Value in Healthcare

^Some estimates suggest that 30% of healthcare spending in the U.S. is unnecessary. Reducing that waste - even by a few percentage points - can have a far greater impact than any marginal improvement in negotiated rates.

The key is to bring cost and quality together, anchored in provider-level appropriateness data. When you measure the right things, you unlock smarter networks, more informed members, and a system that rewards high-value care.

At Embold, this is exactly what we’re building: credible, clinically grounded analytics that shine a light on the true drivers of both cost and quality.

Because the most powerful lever in healthcare isn’t price - it’s performance.

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‍The Impact of Pediatric Care Variation

When considering the health and well-being of our children, the quality of pediatric care they receive is rightfully top of mind for most parents. Unfortunately, not all doctors are created equal and variation in pediatric care across the country means that not all children are getting the best possible treatment. Not only does this put the safety and wellbeing of our children at risk, but it also adds stress to parents and guardians of adolescents. Inefficient or low-quality care results in increased absenteeism at work for parents, more school absences for children, and unnecessary medical expenses. The discrepancies in pediatric provider quality are significant, and understanding how to find high-quality care is crucial for parents, employers, and healthcare providers alike.

Trends in Pediatric Care and Their Implications

32.6 million families (about 40% of families in the United States) have children under the age of 18. Amongst these households, two-thirds of them have both parents fully employed, which illustrates the immense need for childcare. According to a Mott Poll Report, 62% of parents with children in childcare report that their child could not attend at least once in the past year because of illness.

While it is inevitable that children will get sick, it is imperative that parents have access to the highest quality medical care, ensuring their children receive effective treatment promptly and without the burden of unnecessary tests. These types of excessive procedures not only inflate direct medical costs but also exacerbate the financial strain on families through lost wages, as parents are compelled to take paid time off to care for their children. Innovative healthcare organizations like Embold Health are equipped to mitigate these challenges, leveraging rigorous data and analytics to guide families to the most efficacious care from the outset.

The Importance of High-Quality Pediatric Care

High-quality pediatric care can prevent unnecessary medical procedures and overprescription of medications, but the quality of care varies widely, which makes it difficult to ensure children are seeing the best pediatricians. Respiratory conditions are especially prevalent, with nearly 58,000 to 80,000 children under the age of five requiring hospitalization each year. Steroids have been shown to offer minimal benefit for these conditions and pose significant risks to children's health, yet many low-performing doctors persist in overprescribing them. This not only jeopardizes the well-being of countless children but also contributes to unnecessary medical costs and strains healthcare resources. Embold Health’s data indicates that families who choose high-performing doctors are 27% less likely to have their children prescribed unnecessary steroids for common respiratory illnesses.  

Overprescribing can lead to extended and unnecessary hospital stays, unnecessary pharmaceutical costs, and longer recovery times. As a result, it’s not surprising that the per member per year (PMPY) cost for low-quality pediatricians is 66% (or $1,215) more than that for high-quality providers (illustrated below). In addition to concerns about work productivity for parents, this cost difference highlights the financial burden placed on families and the healthcare system when children are exposed to substandard care.

National and Regional Variations in Pediatric Care

Just as we see unnecessary steroid prescriptions for kids with respiratory infections, variations in pediatric care quality across the nation reveal significant differences in treatment approaches more broadly. This disparity is not limited to specific cases; children receiving care from high-quality pediatricians consistently experience substantial benefits compared to those treated by lower-quality providers as demonstrated in the chart below:

The Role of Employers in Ensuring Quality Pediatric Care

The burden of finding a solution to low-quality pediatric care should not fall entirely on working parents. It is unfair to place this responsibility on them, as they often lack access to reliable, objective information about healthcare quality. Historically, parents have had to rely on online reviews or recommendations from friends and family, which can be inadequate. Employers can play a crucial role in bridging this gap by partnering with organizations like Embold Health. Providing a comprehensive dataset and rigorous methodology to evaluate healthcare providers offers clear, actionable insights into where high-quality doctors are and how parents can benefit both medically and financially. This empowers employers to guide their employees towards making well-informed healthcare decisions for their children.

Providing access to information is just the beginning; it's also important to actively engage members with regular reminders about their benefits. Employers can enhance this effort by using interactive email campaigns, SMS messaging, and physical postcards to keep the information top-of-mind. Additionally, some employers go above and beyond by offering incentive programs that not only reward employees for choosing high-quality providers but also highlight the tools available to help them find those providers. These proactive approaches help increase utilization rates and support employees in making informed decisions about their children's care.

By playing an active role in encouraging high-quality healthcare, employers can ultimately improve their community’s healthcare ecosystem. Providing educational materials and resources on child healthcare, including preventive care guidelines, vaccination schedules, and tips for managing common childhood illnesses, will help working parents and their families. Collaborating with healthcare solutions, like Embold, to provide employees with access to advanced tools and resources will equip parents with information to eliminate the guesswork of pediatric care.

Conclusion: Take Action Today

The variation in pediatric care across the country is a critical issue that affects the well-being of our children and the productivity of parents. By understanding these variations, we make it possible to choose high-quality providers, ensuring better health outcomes and reducing unnecessary medical interventions. Embold Health empowers families to make informed healthcare decisions by providing access to top-performing doctors, thereby avoiding the pitfalls of substandard care.

Employers and healthcare providers must advocate for and implement programs that prioritize high-quality pediatric care. By doing so, we can safeguard the health of our children, support working parents, and improve the overall efficiency of our healthcare system.

“2024 was a transformative year for Embold Health. From groundbreaking partnerships to expanding the scope of our data and earning industry recognition, we’ve continued to innovate and empower better healthcare decisions for patients, providers, and employers alike." - Dr. Daniel Stein, Founder and CEO of Embold Health.

As the healthcare industry continues to prioritize quality improvement, transparency, and technology-driven innovation, 2024 has proven to be a pivotal year for driving meaningful change. Embold Health kicked off 2024 by being named among Newsweek’s top 50 best healthcare data analytics companies in the U.S. This accolade underscored our pivotal role as one of the top healthcare analytics companies, shaping the future of healthcare navigation through advanced analytics and performance-driven insights.

Fueled by this momentum, we deepened our commitment to improving healthcare quality and enabling employers and members to access high-performance networks and make smarter, data-informed decisions.

Expanding the Reach of Data and Innovation

This year, we advanced our capabilities to deliver accurate, actionable insights - critical for empowering employers, health plans, and members to make informed care decisions. By incorporating Medicare data, Embold now evaluates provider quality for over 200 million lives. Updates to our scoring methodology also added advanced practice providers, such as nurse practitioners and physician assistants, expanding the evaluated provider pool to over 528,000. These enhancements ensure our partners have access to reliable, data-driven healthcare decision-making tools that help identify high-quality providers and drive improved health outcomes.

Additionally, Embold’s innovative approach was recognized with two U.S. patents for our clinical performance measurement system and member-facing navigation tools like Provider Guide. These milestones underscore our commitment to advancing healthcare navigation and quality assessment.  

New Products Elevating Healthcare Navigation

In 2024, Embold focused on driving innovation to improve healthcare navigation, expand the reach of high-quality provider data, and foster meaningful engagement. Embold leveraged AI to streamline complex healthcare processes, making it easier for individuals to access the care they needed quickly and efficiently. Our tools connected people with top-tier providers, ensuring better healthcare outcomes.  

To further enhance member engagement, we implemented strategies such as personalized communication, digital tools, and education campaigns to encourage active participation in healthcare decisions. Additionally, we developed customizable incentive programs that rewarded employees for making informed choices, empowering them to prioritize high-quality care while supporting organizational goals for better health and cost efficiency.

Strategic Partnerships Enhancing Care

With new patents secured and further developed analytics, we turned our focus to key partnerships. In collaboration with Quantum Health, provider search and analytics capabilities were integrated into Quantum’s navigation platform. This collaboration enhances the quality and cost-effectiveness of care for members, showcasing our ability to drive impactful results through strategic alliances.

We also announced our partnership with Microsoft in 2024, developing an AI-powered Provider Selector that is integrated with Microsoft’s healthcare agent service. This conversational search engine combines provider quality insights with predictive analytics to guide users to the right doctor, the first time.

Engaging Members for Better Care Outcomes

The impact of these advancements is amplified by our focus on directly engaging members in their healthcare journeys. In 2024, Embold Health prioritized personalized strategies, from events with hands-on demonstrations to tailored email campaigns and educational videos. Thoughtfully designed resources kept healthcare navigation accessible, while close collaboration with HR teams ensured communication strategies resonated. These efforts bridged the gap between insight and action, empowering employees to confidently choose high-quality care.  As a result, we’ve seen a notable increase in member engagement, with more employees actively using tools like Provider Guide to make informed healthcare decisions.

Looking Ahead

Embold Health reflected on this pivotal year of innovation, growth, and collaboration. From expanding datasets and launching new products to earning accolades and forging impactful partnerships, we remained committed to empowering better healthcare decisions throughout 2024.

In 2025, we will continue advancing our tools with enhancements to Embold Virtual Assistant, aimed to simplify healthcare navigation, as well as Referral Guide to help coordinators and providers connect with high-quality providers. Our focus remains on creating innovative solutions and fostering member engagement to drive better health outcomes.

Together, we have the power to transform healthcare for the better. At Embold Health, our commitment to empowering individuals, employers, and providers drives us to build a future where high-quality care is the standard, not the exception. Join us as we shape a healthier tomorrow, together.

Don't forget to subscribe to our newsletter and stay up to date with the latest Embold Health news: https://emboldhealth.com/newsletter.  

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ICYMI: Leadership in Action and Industry Recognition

Interested in hearing more from the Embold Team? Our leadership made waves this year by contributing to key industry conversations and earning notable recognitions:  

• Dr. Daniel Stein (CEO, Founder at Embold Health) appeared on the NEJM Catalyst Podcast, exploring healthcare innovation. He also received the Roaring 20 Award Spotlight from ACG Tennessee, further celebrating Embold’s impact on healthcare.

• Dr. Matt Resnick (Chief Medical Officer | SVP, Health Plans and Partners) was featured on multiple platforms, including The Benefits Playbook Podcast and Catalyst for Payment Reform Podcast, to discuss the importance of quality care measurement.

• Manon Neu (Client Success Executive) shared insights on 'The Future of Personalized Benefits: Enhancing the Employee Experience through Benefits' as a panelist at the HCTN 2024 Employer Conference, exploring innovative strategies to tailor benefits to meet employee needs.

• Steve Dufour (Chief Security & Privacy Officer) and Mark Blackham (VP of Engineering) discussed AI governance and patient data security on the Deploy Securely Podcast.

• Matthew Berns (Chief Technology Officer) was honored in the Nashville Business Journal’s C-Suite Awards.

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As the new school year approaches, parents and guardians are busy preparing their children for the transition from the sunny days of summer to the structured routine of school. Amidst the excitement of new backpacks, lunchboxes, and school supplies, it is crucial not to overlook an essential aspect of back-to-school preparation: your child's health. Ensuring that your child is healthy as they return to school is key to their success and well-being throughout the year.

Finding a High-Quality Pediatrician

The foundation of your child's health starts with having a reliable and high-quality pediatrician. A pediatrician treats illnesses and provides preventive care, vaccinations, and advice on maintaining a healthy lifestyle. To make an informed choice, it's important to evaluate pediatricians based on their credentials and experience, rather than just patient reviews.  

Common Illnesses and Their Impacts

When children return to school, they are exposed to various germs and viruses, leading to common illnesses such as colds, flu, and stomach bugs. These illnesses are often spread through close contact in classrooms and playgrounds, making it essential to recognize symptoms early and take appropriate measures.

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Seeing a high-quality pediatrician is crucial for your child's health, especially when it comes to preventive measures. Statistics reveal significant differences in care quality when seeing low-quality pediatricians:

• A child under 3 is 22% more likely to undergo an unnecessary strep test.  

• Children under 6-years-old are 11% more likely to experience overuse of cough and cold medications.

• Children are 23% more likely to receive anti-anxiety prescriptions.  

These figures underscore the importance of choosing a reputable pediatrician to ensure appropriate, evidence-based care and to avoid unnecessary treatments and medications.

The impact of these illnesses extends beyond the child. Parents may need to take time off work to care for their sick children, leading to absenteeism and potential disruptions in their professional lives.

Precautions for Children's Health During the School Year

Sending your child back to school each fall involves more than just academic preparation. Here are some precautions parents can take to ensure their child stays healthy throughout the school year:

1. Immunizations: Ensure your child’s vaccinations are up to date. This is crucial for preventing the spread of contagious diseases.

2. Healthy Diet: Pack nutritious meals and snacks to support their growth and immune system.

3. Regular Physical Activity: Encourage participation in physical activities to promote physical health and reduce stress.

4. Sleep Routine: Establish a consistent sleep schedule to help your child get adequate rest.

5. Hygiene Practices: Teach your child proper handwashing techniques and the importance of maintaining personal hygiene.

6. Mental Health: Be aware of your child's mental health. Encourage open communication and seek professional help if necessary.

The Importance of Vaccines

Staying up to date with vaccinations is one of the most effective ways to protect your child from preventable diseases. Vaccines are crucial for maintaining public health and preventing outbreaks of diseases such as measles, whooping cough, and influenza. Consult with your pediatrician to ensure your child is current on all recommended vaccines.

Additional Considerations

• Mental Health: Be attentive to your child's mental health. The transition back to school can be stressful, and children may experience anxiety or other emotional challenges. Open communication and support are key to addressing these issues.

• Routine Check-Ups: Schedule regular check-ups with your pediatrician to monitor your child's growth and development and address any health concerns promptly.

Conclusion

As you prepare for the new school year, prioritize your child's health to ensure a smooth and successful transition. By finding a high-quality pediatrician, taking preventive measures, staying up to date with vaccines, and being mindful of both physical and mental health, you can help your child thrive in the school environment. A healthy start to the school year sets the stage for a year filled with learning, growth, and joy.

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Ready to learn more about how Embold Health can help your employees find the right doctor, the first time? See how we can improve health outcomes and lower healthcare costs in a free demo.

Today marks an important moment in Embold’s journey. With the closing of our merger with Quantum Health, I want to take a moment to reflect on how we got here and to thank all of you who have made it possible.

When I founded Embold, I had a clear belief: that people deserve better information when making decisions about which doctor to trust with their healthcare. That belief became a mission: to shine a light on high-quality providers and raise the bar for care across the country. And that mission became a company, one built on clinical rigor, transparency, and trust.

From the very beginning, our goal has been to make healthcare work better for the people who rely on it. It is a challenging endeavor, but we’ve had a lot of help along the way to push our efforts forward. From Lisa Woods’ whiteboard, where we first sketched out an approach to using data to objectively identify high-performing providers, to the virtual Teams whiteboard sessions with Microsoft, where many of our member product ideas took shape, our clients have helped us evolve every step of the way. We wouldn’t be here without you.  

Through the various challenges, our team has persevered: transforming my vision into products, turning our ideas into measurable results, and helping millions of people find better care.  

Now, we’re taking our next step. Joining forces with Quantum Health gives us more support to scale what we’ve built and more opportunity to do what we do best: deliver data-driven solutions that improve care quality and drive value, while staying focused on the clients and mission that got us here. We’ll continue to operate independently, with the same team and the same mission, now with more resources behind us.

To our clients, partners, and investors, thank you. Your belief in our work and your willingness to push the industry forward have made our progress possible. We’re excited to build what comes next with you.

And to the Embold team: none of this is possible without you. Your commitment to doing things the right way, your tenacity, your talent, and your care are what set Embold apart. I couldn’t be more proud of what we’ve achieved together, and I couldn’t be more energized about the work we have ahead.

We’ve reached an important milestone. But this isn’t the end of the story. It’s the start of an even bigger chapter.

I am honored and grateful for the opportunity to continue this mission together, as this next step in our journey.

Daniel Stein, MD
President and Founder of Embold Health