Tag Archives: dpc

Health Insurance: Near-Record Panic?

I’ve been caught a little off guard recently. I am seeing a level of panic in the industry that I don’t think I’ve seen since Parker Conrad was threatening to drink the industry’s milkshake.

Chances are, you have been reading about the exciting trend taking root in the industry. Advisers are reengineering how they build medical plans for their clients. Direct primary care (DPC), bundled services and transparent pharmacy are just a few of the ideas strategies being put into place.

The result? Advisers now have a way to improve the level of benefits their clients receive while actually, and significantly, reducing the overall cost. That’s freakin’ awesome!!

Putting on a brave face

As awesome as I think most of us can agree this trend is for the industry and employers/employees, I can’t tell you how many times I’ve had verge-of-breakdown conversations with very sophisticated advisers. Many of you are convinced you are the last in the industry to be learning these approaches.

You are reading about the success stories of other advisers online and hearing about their implementation victories from the stages of conferences. Many of you have drawn the conclusion that the rest of the industry is putting every one of these solutions in place for every client they have.

Friends, the reality could not be further from the truth!!!

First, it’s only a very small part of the industry that is even aware of these new solutions. Trust me, we talk to agencies big and small that are sometimes not even aware of these trends, let alone putting them in place.

Second, a significant percentage of the ones talking about the solutions are talking a big game but have yet to take the first step of any meaningful walk.

Third, even the most advanced advisers are only putting these strategies together for a relatively small portion of their book. (I’m sure there are exceptions. If that’s you, congratulations; you are a pink unicorn.)

Now, don’t get me wrong, I am not saying you shouldn’t make learning these strategies a priority. Maintain a sense of urgency, but take a deep breath, relax a bit and lay out an overall strategy as to how you will position yourself to use these ideas most effectively.

But make a conscious decision to move forward with a realistic sense of the effort actually required. Way too many talking a big game have yet to figure this out for themselves.

See also: How Likely Is Zenefits to Change? 

The unintended consequence?

Too many advisers see the new trend as a silver bullet that will separate them from their competitors and drive growth. Those who try to hunt with a silver bullet are destined to shoot themselves in the foot.

As much as advisers need to be arming themselves with this new strategy, there are a few things you need to remember.

  1. Not every client or market is ready for these strategies.
  2. No one solution satisfies all the HR/benefit needs of a client.
  3. You (still) have to ensure that the foundation of your agency is strong.

Are clients really ready?

Many of these new strategies are dependent on moving clients to a partially self-insured program. Of course, this idea isn’t new at all, and you likely already know it can take a long time to get a prospect/client comfortable with this idea. And, that’s okay, educating them to the point of comfort/confidence with this idea is a critical part of your job.

But, if this is a prospect you’re talking to and you are depending on this as your single strategy to earn their business, it’s going to take a while to uncheck the Prospect box and check the New Client box.

Of course, these ideas aren’t just about moving to self-insured; there is additional education to take place as to how direct primary care, bundled services and transparent pharmacy can be managed effectively and successfully. The thing is, even once they understand, some employers just don’t want to be that involved in the management of their benefits program.

Right or wrong, some will only want a plug-and-play program regardless of how tilted that game is against them. That’s just the reality, regardless of how much you may want to help them make the change. And then it’s up to you to decide if you’re going to help them in their fully insured program or walk away. But, if you choose to walk away at this point, you’re missing out on a lot of opportunities – opportunities to still help and opportunities to grow your business.

Finally, some markets just aren’t ready to allow these solutions to be implemented. If you believe, as I do, that a strong network of direct primary care (DPC) physicians is a key to this new direction, you also understand that the framework/infrastructure of those DPC practices doesn’t yet exist and will take a while to build.

Live by a single solution, die by a single solution

I have watched many times as this industry gets giddy with excitement over a solution being introduced to the market; this isn’t the first silver bullet for the industry. It’s happened with technology solutions, compliance solutions, HR resources. The list is long.

If you put all of your chips on any single solution, no matter how important it might be, you’ll eventually lose.

As an adviser, you will never be differentiated by the solutions you offer. Your greatest chance for sustainable and meaningful differentiation is in how you use those solutions. Even if you are the first to market with a solution, the advantage will be short-lived. Every viable competitor will soon be promoting the same solution.

Besides, your clients need WAY more than any single solution. It is more difficult to run a business today than ever before, and your clients need guidance in ways they never have before.

I wouldn’t criticize anyone for a moment leading with new strategies and solutions, but I strongly advise that you better be plugging any solution you offer into a value proposition that addresses the broader needs of your prospects and clients. Face the obvious: Just because you have a powerful strategy to control healthcare doesn’t diminish your clients’ needs for help with compliance, technology and HR, to name a few.

And, with more complex solutions being put in place, the need for compliance and an effective employee communication strategy has never been greater.

If you’re going to try to live on a single idea, just know it will only work until one of the following inevitably happens:

  • You run into prospects/clients/market that just aren’t ready;
  • Every competitor arms itself with the same idea;
  • Competitors show up with the same idea and have built it into a broader platform of solutions (again, compliance, technology, etc.).

See also: Zenefits’ Troubles Don’t Let Brokers Off

Are YOU really ready?

When your value proposition and solutions become more complex, it is more important than ever to ensure that the foundation of the agency is strong enough to support it. Here are a few areas you need to evaluate to determine if you can really support these new solutions/strategies:

Sales Process — One of the things that concerns me about these new solutions/strategies is that advisers will simply see them as another insurance solution and feel the right time to talk about them is at renewal. Now more than ever, it is critical to be meeting with buyers off renewal to prepare them for the ideas and strategies you can bring at renewal. And, with off-renewal conversations, having a structured sales process in place is an absolute requirement.

And, no, going out to get quotes is not an effective process. You have to have a process that allows you to help the buyer effectively evaluate the insurance and non-insurance parts of the business to determine what is working and what isn’t working and create an overall plan of improvement.

Marketing — But, for that sales process to be effective, you have to have an effective marketing strategy in place. These ideas need to be featured on your website. You need to be writing about them regularly in your blog. You need to be out on social media sharing these ideas and participating in conversations. You have to integrate these ideas into your automated marketing campaigns.

Team education/training — You must have a plan for how are you going to educate your team to sell and service these more complex solutions. You must develop more effective team structures/processes to ensure your sales and service teams work together effectively enough to sell/service these programs.

Compensation — Because these new strategies are outside the traditional insurance products with attached commissions, you have to be comfortable with charging fees, discussing how much you need to get paid and articulating what you do in return for that compensation. I know this is pretty scary for many of you.

Take a deep breath

The world of employee benefits is going through one of those transformational eras that redefines an industry.

  • Yes, it’s a bit scary
  • No, not all of the answers are clear
  • Yes, it’s a lot of freakin’ hard work
  • No, doing more of what you’ve always done isn’t the answer
  • Yes, you are going to have to reengineer your agency
  • No, not everyone is going to survive

Don’t curse these facts, celebrate them. Celebrate because very few of your competitors have the courage, curiosity, work ethic, creativity, grit or resilience it will take.

Those of you who emerge on the other side will find there has NEVER been a more exciting or rewarding time to be in this industry. The destination is exciting, but let’s not forget to enjoy the journey.

Finally, don’t make your journey any more difficult than it needs to be. There are many groups out there working together to help one another learn these ideas and put them into practice. My advice is to find a group that fits with your style and get started sooner rather than later. Your success, and that of your clients, may very well depend on it.

This article originally appeared on Q4intel.com.

Consumer-Friendly Healthcare Model

Best-selling Author Og Mandino once said:  “Always seek out the seed of triumph in every adversity.”

It appears that a small, yet growing number of America’s front line health providers are doing just that. Instead taking on increased risk, greater healthcare bureaucracy and more administration headaches, these medical mavericks have drawn a philosophical line in the sand.

I’m speaking of direct primary care (DPC). For the uninitiated, DPC is an emerging model where general practitioners elect to disassociate from, and no longer bill services to, health payers, including Medicare. DPC practices average between 600 and 800 total patients (vs. the national 2,300-patient average for traditional primary care provider (PCP) patient panels).

This return to front-line doctoring — “sans insurance” — translates into a cost-reduction of as much as 40% in staffing and reduced administrative complexity. Electronic health records (EHR) software finds itself replaced with lighter applications to track, schedule and bill patients. Practices may also choose to use mhealth/telehealth technology to monitor/connect with patients.

Patients in these practices are often those with low to middle incomes, with high-deductible health plans (HDHPs). For this reason, DPC doctors develop network relationships with other local medical specialists and services. The result is patients gaining access to discounted medications, imaging and labs, plus lower service fees from local specialists — all on a cash basis.

And presto! We have a true two-party care relationship, where doctors focus purely on patients, instead of blending in payers as their second healthcare customer.

The median monthly DPC fee for an adult is about $70; and fees for kids are priced between $10 and $20 per child. Many DPC practices also cap monthly family fees. Pricing is independent of pre-existing conditions and current health status and allows for more face-to-face time, as often as needed.

These practices report reducing urgent care and ER visits, plus hospital admits and re-admits. Quality and outcome data has apparently started reaching malpractice insurers, now quoting lower rates for direct vs. traditional primary care practices.

Here is where it gets sticky. DPC is rightly considered a “health service,” both by the Affordable Care Act (ACA) and by 16 states. However, under section 223(c) of the U.S. tax code, the I.R.S. wrongly considers DPC a “gap,” or secondary, health plan. Therefore, DPC is not a qualified medical expense — and fees paid by patients are not reimbursable by health savings accounts (HSAs).

Changes are in the works, per the introduction of Senate Bill 1989 – The Primary Care Enhancement Act of 2015, which would make DPC fees a part of HSAs. The bill, with strong support from the American Academy of Family Physicians, also seeks to require the Center for Medicare and Medicaid Innovation (CMMI) to create a new payment pathway for DPC as an alternative payment model (APM) in Medicare and with dual eligibles.

The plan is for DPC to show Medicare its mettle — and eventually receive a modest flat fee payment for primary care services offered by a DPC medical home. The legislation includes allowing qualified physicians who have opted out of Medicare to participate in the program. It also serves as a partnering catalyst with Medicare Advantage, in an affordable care organization (ACO)-like structure.

DPC is a disruptive “hot knife” model, whose entry is well-timed to cut through the cold stick of butter called high health costs.

Today, PCP co-pays have gone up to $45, and deductibles are sky high. Many consumers have no idea that at or around the same per-visit patient fee, DPC exists as an option. Employers are just beginning, on a larger scale, to integrate DPC with other options such as HDHPs and self-insured health coverage. Using this new model with self-insured companies makes sense, to hedge risk, lower health costs, improve outcomes and improve quality of care.

One county in North Carolina, which employed a DPC option, saved nearly $1.5 million on yearly medical expenses — on just 800 covered lives! It may surprise you that, apart from HSA standing, there are already early employer adopters who have chosen to pay the monthly DPC fees for employees themselves.

A British Medical Journal study showed patients of Washington state DPC provider Qliance coming in with 35% fewer hospitalizations, 65% fewer emergency department visits, 66% fewer specialist visits and 82% fewer surgeries. DPC benefits appear to not only reduce primary care costs, but lessen the healthcare costs and utilization outside of their practices.

Payer transparency is a significantly important strategy to the future growth and integration of DPC.

We talk about the importance of transparency in hospital pricing to patients, and for drug companies to reveal their true R&D costs. But have you ever stopped to consider the importance of transparency in how payers calculate and price plan premiums for each covered member? Just how much of the premium payment can be carved out as estimated primary care services to be received?

More than ever, healthcare consumer groups and fully insured employers should push health payers for transparency. Because I’ll bet what payers have estimated for per-person primary care usage and costs, adding in the associated patient responsibility portions (co-pays, and any applicable deductible or co-insurance fees) will be much more than an $840 yearly DPC payment.

But wait…there’s more. Don’t forget to have payers deduct an additional…let’s be conservative…1/3 of the Qliance savings percentages for the estimated care cost savings relating to carved-out estimated care outside of primary services.

Next, look at Medicare and do the same thing. But…instead of the wallets of health plan members, think federal budgets, taxpayers, subsidies, growing liabilities and the potential to hold off future tax increases.

Then look at Medicaid for the same reasons, remembering that DPC would certainly create a greater improvement of care quality than Medicaid care providers and facilities. Remember the “triple aim” — cost, outcomes and quality — and that doctors are happier.

DPC injects disruption and greater consumerism into healthcare.

Something interesting happened along the way to transforming our healthcare system. The ACA fell far short of its goals, and America’s care delivery and coverage became even less affordable for millions of employers and individual consumers.

We should know by now that improving quality and pricing for all will not come from laws — specifically, from those who force people into lower-quality Medicaid coverage, and insurance plan exchange options with punishing deductibles; in essence, giving people a broken Christmas toy with a pretty bow on it and pretending they will enjoy it.  

No matter how you dress it up, and much money you throw at it: Healthcare coverage is not the same as affordable healthcare.

In the heart of even the toughest situations, there are innately driven people who make bold, fresh choices and take stands — efforts that emphasize principles we know to be just and right, rather than gaining financially on the backs of others’ misery. My hope resides in what Lincoln called “the better angels of our nature.”

DPC offers a free-market “injection” into healthcare’s regulated pricing model. If Senate Bill 1989 or a similar law passes, it will provide individuals and companies a better chance to gain better quality, more affordable care. Unlike some DPC purists, I see a future inflow of Medicare dollars to non-enrolled DPC qualified providers as stimulating a transformation where coordinated care begins from outside of the umbrella of big medicine ownership.

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Like the plunging penguins who emulate the courageous actions of others, I believe many primary care physicians are looking for the right time to enter a DPC model. Whether that happens individually, through groups, or by strategic partnerships, is up to industry forces. It’s the beauty of filling consumer demand.

Making healthcare services, drugs and coverage affordable to consumers appears completely disconnected from the industry’s mission to improve care quality and outcomes, and lowering health “costs.”

Free market forces are what bring down consumer prices in most every market. Their introduction into U.S. healthcare will likely cause short-term fallout and financial pain within healthcare industries, but it would leave us, and future generations, with a more sustainable, stronger system. We’ve gotten to the point where healthcare bloat and unaffordability will require sacrifice from all involved.

By allowing consumer-friendly models like DPC to enter the regulated world of healthcare, perhaps slowly through the back door, we will see transformation come from within. History has repeatedly shown us that better models fueled by consumer desire rise to the top.

To See Healthcare’s Future, Look at Cable

The great unbundling is coming to the cable industry. For decades, the cable providers transformed the television industry, first as a substitute, and then ultimately as the disruptive force behind the demise of free television viewing. Since the 1990s, bundled packages have become the pervasive force in delivering movies, live sports and music. The cable industry, with the help of armed lobbyists, has changed the way local channels broadcast. The number of channels has skyrocketed as the way content was sold and programming was distributed resulted in vast volumes of content to sell. Bundles were created to package less popular and rarely watched content with popular programming. Size was a proxy for quality, and bigger was marketed as better. The business model has worked for decades.

Pre-Paid Bundled Pricing: a Dying Business Model

Subscribers of bundled cable receive hundreds of channels even though industry research finds that the typical viewer only watches 17 channels. Forget that they have hundreds of channels they don’t view. How many subscribers, in fact, don’t even know what they pay for in their bundle? As the internet has expanded in depth and breadth of services, wireless connectivity has become ubiquitous. Mobile smartphone technology is growing globally at exponential rates. People can watch video on their phones without a second thought.

Consequently, more people are demanding that they only pay for what they actually watch. Why pay for more than you use? And now you don’t even require a television to watch pay TV. Today, an internet connection means you can watch almost anything online. Websites like Netflix, Apple, Hulu, Amazon, YouTube and a growing list of new entrants are forcing change on the cable industry. The cable industry could see this new force and demand coming for years, but with typical stuck-in-the- past leaders, the industry has mostly chosen to lobby for anti-competitive legislation and incremental, slow change. The beginning of the end has already started for the old cable industry.

See also: To Bundle or Not to Bundle?

The writing is on the wall, and the industry players don’t like it one bit. Unbundling is here to stay. Pay-TV subscriptions are falling, and the rate of disconnect is increasing. Simultaneously, the rate of unplugged nontraditional non-subscribers is growing annually. The industry refers to the people who cancel their connections as “cord cutters”: and the people who have never subscribed as “cord-nevers’

Healthcare Is Unbundling Because Buyers Demand Change

Just as millennials, the internet and mobile devices are changing the cable TV industry, healthcare is being changed by the ACA, self-funded employers and a legislative shift to value pricing. Think about the parallels with the healthcare industry where the key players dictate terms and pricing, bundling unnecessary and ineffective care and then charging fees based on the volume of treatments with little or no transparency. Disrupting the status quo is already here; it’s just not evenly distributed – yet.

The healthcare buyers of today and tomorrow are controlling their costs and experience by flexing their demand muscles in local and regional markets around the country. Enrollment in prepaid fully insured health plans is dropping annually as employers learn about the advantages of self-funded pricing, taxes and cost of claims.

The most successful business purchasers of healthcare are predictably and measurably saving 30% to 50% off the standard provider-driven pricing. By focusing on the elimination and reduction of claims, smart health buyers are slashing hospital, surgical center, pharmacy, physician and ancillary expenses by double digits. Some of the tools have been successfully implemented for a decade and only now are gaining attention. Solutions like RBP, SIHRA, DPC, 100% audits, PBM re-contracting, fixed-fee bundled pricing, medical necessity, coordinated care, COEs and many more are saving organizations millions of dollars and changing the experience of health buyers, patients and providers.

See also: Ready for a New Consumer Channel?

Unlike the solution providers changing the cable TV industry with national virtual footprints, the healthcare industry is being disintermediated in local and regional markets. Because healthcare is 20% of the economy, reducing healthcare costs by billions barely registers on the meter, as hard as that is to believe,  but the results are enormous for employers creating EBITDA from healthcare.

Follow the smart money. Healthcare is an experience where every encounter with a patient is a market of one and the buyer is becoming aware of his power in this transaction with the healthcare supply chain. Other industries have recognized the efficiency and pricing economies that come with managing the supply chain because demand is elastic. Think how WalMart has changed inventory controls and Amazon has changed “last mile” logistics, to name a few.

Healthcare buyers can now negotiate, force transparency and control the cost of care. The cost of inaction and taking the path of least resistance will place your company in an uncompetitive position. Self-funded employers need to change because your employees’ financial well-being is ruined by the health care cost shift. The healthcare industry will never be the same.