CEO's Guide to Restoring the American Dream

by Dave Chase

  3. Shared Risk

  Medicare has long required providers to share risk under three different “global” periods (zero-day postoperative, 10-day postoperative, and 90-day postoperative) by refusing to pay for mistakes, complications, and re-admissions. A TMM brings that practice to private health plans.

  4. Efficient Administration

  Typical claims administration is filled with inefficiencies: slow payment cycles, prior authorization, network requirements, complicated payment models, employee cost sharing, etc. For a TMM to work, employers must make it easy for employees to access care, offer quick pay to providers (typically five days or less), eliminate barriers like copays and deductibles, and often remove oversight requirements like prior authorization. It’s important to remember that the goal of this model is to simultaneously lower employer costs, reduce costs and eliminate hassles for providers, and provide a true benefit to employees and members.

  5. Employee Education

  Models that encourage the use of specific providers for specific treatments are often a new idea for employees and their families. They need to understand that TMM is not like HMO models, which were often associated with denied care, long wait times, and poor customer service. The message needs to be simple, clear, intriguing, and just one sentence like this: Don’t forget, if you need medical care, we have a group of the highest-quality providers you can see, and choosing this won’t cost you anything out of pocket.

  6. Ease of Use

  Health care has always been confusing, frustrating, and very often scary. A TMM should be effortless. Consider offering concierge-style customer service, which gives your employees easy access to the humans and resources they need, including hassle-free appointment scheduling, medical records transfer, and both web and mobile access. These services can also create comfort for your employees around sensitive health issues they don’t want to discuss with you or your internal benefits manager.

  How Can You Ensure Quality?

  An effective TMM functions best in tandem with a value-based primary care model and use of shared decision-making tools to avoid overtreatment and radiation exposure from unnecessary scans. Any high-quality provider should be participating in all applicable quality reporting whether they are a health system, ambulatory surgery center, imaging center, or independent physician practice. Here are some resources that can help ensure that the providers you use are, in fact, of the highest quality.

  •HealthInsight is a private, nonprofit, community-based organization dedicated to improving health and health care. They offer a free ranking tool for hospitals nationwide.

  •The National Quality Forum (NQF) is a nonprofit, nonpartisan, membership-based organization that works to catalyze improvements in health care. They offer access to a huge library of evidence-based quality measures.

  •Hospital Compare is a government website that allows you to find and compare quality information for more than 4,000 Medicare-certified hospitals across the country.

  •The Leapfrog Hospital Survey is the gold standard for comparing hospitals’ performance on national, professionally endorsed standards of safety, quality, and efficiency that are most relevant to consumers and purchasers of care.

  What Challenges Can You Expect?

  1. Administrative Challenges

  Your broker, consultant, carrier, or TPA may be unable or unwilling to provide transparent specialty care and the administration to execute a TMM.

  2. Provider Reluctance

  It is common for the large health systems you currently use to push back on requests for price and quality transparency.

  3. Complex Implementation

  The process can be quite cumbersome and drawn out should you decide to go it alone. You might consider using a third party to help streamline the process.

  4. Employee Education

  TMM models require continued messaging and clear, easy-to-understand action steps.

  5. Data Sharing

  It could be difficult to obtain pricing and quality information from your current broker, consultant, carrier, or TPA. Since it is your spend, you have a right to this information.

  6. Data Analytics

  Traditional claims analysis software programs and services are often limited in scope and not designed to provide clarity or actionable insight.

  7. Confusion about Price Transparency Tools

  Many price transparency tools (e.g., Castlight) provide information on insurance PPO network pricing, but they don’t remove the hassles and costs for either providers or individuals related to claims, copays, etc.

  8. Obfuscation to Preserve Status Quo

  Your current providers who aren’t forward-looking are likely to use common “fear, uncertainty, and doubt” tactics meant to freeze progress.

  As stewards of your organizations’ and employees’ hard-earned money, you must choose whether to protect yours our your vendor’s bottom line.

  What Action Steps Can You Take?

  Ask your broker, consultant, carrier or TPA if they participate in any transparency initiatives.

  Encourage your broker, consultant, carrier, or TPA to make cost and quality data available to both you and your employees.

  Consider modifying your benefits plan to provide incentives for employees and their families to access care from transparent providers.

  Visit a local hospital or surgery center to discuss or consider tapping a third-party TMM vendor in your region or may expand to serve your employees.

  Additional Resources

  Please go to healthrosetta.org/health-rosetta for ongoing updates, including lists of TMM organizations, case studies, best practices, toolkits, and more.

  Case Study

  Enovation Controls

  When you think of innovative organizations that provide a best-of-breed health benefits package and spend far less than peer organizations, you wouldn’t necessarily think of small manufacturers in Oklahoma, where as much as 75 percent of the population doesn’t have an established primary care relationship. Yet Enovation Controls, a provider of products and services for engine-driven equipment management and control solutions with about 600 employees, has managed to save approximately $4,000 per covered life each year by working with a transparent medical market (TMM).

  A TMM puts together a network of the highest-value providers for different kinds of care and gives self-insured employers a set of fair and fully transparent pricing—typically a bundled price—for medical services/procedures ranging from a specific treatment (e.g., knee replacement or coronary stent) to a specific condition (e.g., diabetes or kidney disease) across multiple providers, and sometimes, multiple settings.

  Enovation Controls chose The Zero Card to manage their TMM. They achieved a 70 percent participation rate among eligible plan members, focusing on high-cost services like surgeries and imaging. Justin Bray, Enovation’s vice president for organizational effectiveness and human resources, attributes the high rate to two primary factors.

  1. Communications – During the rollout of the TMM, Enovation shared their current health care costs with employees, along with the consequences for the company and each individual. They then compared those costs with the costs of care under specific scenarios with TMM. The message: We’ve found a better way. Most people were shocked by the vast price disparity and that lower-priced providers often delivered the highest quality, in part because these doctors perform a given procedure more frequentlly, improving with repetition and letting them operate efficiently with fewer errors and expensive complications.

  2. Ease of Use – Employees have access to a single app or phone number that directs them to network providers where they can get care with zero out-of-pocket costs. Instead of dealing with a mountain of bills and paperwork following the procedure, they receive a thank you survey to ensure the experience went well. As Bray explained, this is particularly critical as surgeries and imaging are some of the highest-cost items they have to cover.

  Because of the f
ocus on higher-cost items, Enovation has achieved well over 90 percent of projected savings, even with less than 100 percent participation. The calculation of those potential savings compared the historic “allowable” amount from the company’s claims history with a true market amount through the TMM network, that is, what a provider would accept if you showed up with a bag of cash for a bundled procedure such as a total knee replacement.

  The savings over historical allowable amounts from their traditional PPO network ranged from 21.92 percent to 81.28 percent, with an average of 59.23 percent.

  Here’s an example of a line item for one procedure for one employee.

  Bray shared what this meant to one employee who came up to him at a high school football game to say thank you. This person had recently had expensive surgery and didn’t have to pay a dime out of pocket—no bills, no explanations of benefits, no anything. On a $30,000 salary, the maximum allowable out-of-pocket cost of $2,500 under the previous health plan would have been a financial disaster, the employee said.

  Enovation Controls Employee Monthly Premium Costs

  Like every other health care purchaser, Enovation Controls knows that tackling high-cost procedures is central to slaying the health care cost beast. Its TMM program even extends to items like complex cardiac and neurosurgical procedures, for which employees have access to the same centers of excellence facilities as large employers, such as Cleveland Clinic. Whether the Cleveland Clinic or a local surgery center, high-quality providers are happy to provide a deep discount in return for more business, less hassle, and avoiding claims processing and collections processes. Once the procedure is complete, the provider gets paid within five days for the full bundled price.

  Plus, the bundled prices frequently carry warranties, meaning post-surgical complications within 60 to 90 days are addressed at no charge—another bonus for employers.

  Using data from Mercer, Enovation Controls estimates that they save $2 million on health care every year, compared with peer manufacturing organizations. For a relatively small company, this is a highly meaningful amount of money, which it has been able to reallocate to increased R&D. While companies in their sector typically spend 4 percent of annual revenues on R&D, Enovation spends 9 percent, helping it stay ahead of the competition and attract and retain the best engineers.

  Enovation Controls per capita spending

  When a small manufacturer with few dedicated resources can pull this off, it begs the question why every employer or union isn’t doing the same. Smart employers like Enovation Controls demonstrate that it’s possible even in a state with some of the highest obesity rates and overall health care costs. Since a new primary care model or TMM can be implemented at any point in a benefits cycle, there’s no need to wait until renewal.

  Chapter 16

  Concierge-Style Employee Customer Service

  What Is Concierge-Style Employee Customer Service?

  Concierge customer service addresses a substantial challenge that exists for health consumers today—namely that the benefit and health care ecosystems are enormously complex and costly to understand and navigate. Current trends toward high deductible plan design only amplify the time and money required by you and your employees to make more intelligent decisions. Proliferation of solutions that address one or two discrete consumer needs, such as scheduling, price transparency, or finding a provider, still leave the individual to synthesize information across disparate sources, often during a serious health crisis.

  Concierge service is the conductor that harmonizes much of this discord and fragmentation, providing one point of interaction and distilling complex information down to actionable guidance.

  How Does It Work?

  Concierge services are available as a subscription benefit for employees in value-based reimbursement contexts. They come in different forms. At one extreme, there are progressive concierge services driven entirely by algorithms that offer guidance based on machine learning. At the other extreme, there are more traditional, high-touch one-on-one concierge services. In the middle, there are hybrid models built on “human-driven” technology, offering a balance between live support and technology-driven solutions. Members can speak with live support or, if they prefer, navigate through an intuitive mobile or web interface.

  Members can access a broad spectrum of support services in a single interaction or series of interactions. Specifically, the concierge can provide:

  •Triage

  •Explanations of appropriate and available care

  •Selection of plan-approved locations

  •Help scheduling care

  •Cost estimates

  •Advocacy for claims and billing questions

  The key to an effective concierge experience is integration of information so employees have hassle-free access to simple and actionable guidance on any issue when they need it. To make this work, concierge services are ingesting more and more data to improve the value of their support, tapping into information about plan design, provider networks, real-time benefit consumption (e.g., deductible and out-of-pocket status), individual preferences, and care costs and quality data.

  Why Should You Support It?

  Concierge services integrate and coordinate a vast array of fragmented solutions into one location, enhancing engagement and optimizing benefit use to lower costs.

  Employees who understand the implications of their consumption decisions are empowered to more intelligently navigate the care system. This means they can avoid unnecessary expense. As consumers use concierge services frequently and stretch their health care dollars further, risk bearing employers, insurers, and providers can accrue savings as well.

  Many programs that employers have invested significant dollars in, like value-based primary care or the small number of proper workplace wellness programs, require years to deliver return on investment. Concierge services can deliver savings in year one by guiding your employees away from unnecessary, high-cost care.

  Concierge support at “critical moments” builds lasting affinity among employees. Helping individuals understand their benefits and access the optimal care in a time of need capitalizes on powerful teachable moments to build awareness of how individuals can be smarter health care consumers on an everyday basis.

  Finally, concierge services can be implemented off cycle and introduced successfully in advance of open enrollment as a benefit that can help employees select the best plan for their circumstance. Many times, employees are more comfortable selecting higher deductible plans when they know they will have concierge support as they navigate the care system.

  What are The Key Elements to Look for?

  1. Network Directories

  Robust concierge offerings integrate the appropriate provider directories to accommodate complex network designs, including centers of excellence, onsite care clinics, or narrow networks. The concierge directs members to the highest tier in-network providers for the highest-level of care at the lowest cost, avoiding network leakage and the costs incurred as a result.

  2. Price Transparency

  Concierge services should help employees prepare both clinically and financially for appointments by explaining the cost of an encounter upfront.

  3. Scheduling Capability

  Exceptional concierge services go a step beyond and schedule care on the employee’s behalf.

  4. Understanding of the Individual Consumer

  A hallmark of true concierge care is a deep understanding of the individual consumer—including preferences and health profiles—so that care itineraries are personalized and thus more likely to be followed.

  How Can You Ensure Quality?

  Before contracting with a concierge service—and when considering renewal—ask to see documentation of the following.

  •Engagement – What portion of a concierge service’s addressable population is using the service and how frequently?

  •User satisfaction – What is the Net Promoter Score associated w
ith the concierge service? Would members recommend it to a friend or loved one?

  •Savings – What savings has the concierge service delivered for members to date?

  •Marketing support – What steps does the service take to reinforce member awareness on a regular basis through marketing campaigns, webinars, incentives, etc.?

  What Challenges Can You Expect?

  1. Employee Education

  Such models will require continuing messaging and clear, easy to understand action steps so that concierge services remain top-of-mind for employees when the need arises.

  2. Data Sharing

  It could be difficult for your concierge service to obtain pricing and quality information from local providers. Since it is your spend, you have a right to this information and experienced concierges can overcome this barrier.

  What Action Steps Can You Take?

  Ask your broker, consultant, insurer, or TPA if they are familiar with concierge offerings and how they may benefit your health plan.

  Evaluate the return on investment from your current benefits toolbox by assessing member utilization rates and savings. If employees aren’t using the tools, they may be overly complex, incomplete, or fragmented.

  Survey your employees’ aptitude for understanding and efficiently navigating the benefits landscape. Do they have an easily accessible resource to guide them through the lifecycle of a health care episode? Are they able to use the appropriate resources at the appropriate time to make educated decisions at the point of service?

  Additional Resources

  Please go to healthrosetta.org/health-rosetta for ongoing updates, including lists of concierge customer service organizations, case studies, best practices, toolkits, and more.

  Chapter 17

  High-Value, Transparent TPA