Health Rosetta vs. the Status Quo
1. Transparent Open Networks
Wildly variant, opaque pricing for items such as scans, surgeries and other medical services. If there is any price/quality correlation, it’s inversely correlated. Sometimes “transparency” solutions are available giving the best, bad deal while still having co-pays, deductibles, the oxymoronic "Explanation of Benefits", etc. and all the other things that make for a horrible consumer experience.
The good news is there is a solution to the most vexing problem healthcare has had -- pricing failure.
- Fair, fully transparent price to employer/individual at high quality centers who readily accept quality reporting such as Leapfrog.
- Providers able to set a price that works for them while avoiding claims/collections hassles and accompanying receivables.
- No charge for individual going to these providers. No EOBs, bills, etc. -- just a thank you note.
2. Patient Stewardship
Employees left to navigate an extremely silo’ed and uncoordinated healthcare system receiving conflicting and often non-evidence based recommendations.
Having resources to help you navigate the system that can draw on expertise for quality and cost including understanding benefits plans, best provider options, etc.
3. Value-based Primary Care
- Flawed reimbursement incentives have turned primary care into “loss leaders” that are like milk in the back of the grocery store (i.e., low margin designed to get people to high margin items)
- Short appointments due to not investing properly in primary care
- Primary care shortage due to making primary care discipline unappealing
- Long wait times to get in can lead to small “fires” blowing up
- Medically unnecessary face-to-face appointments clog the waiting room and delay care for people who truly need face-to-face encounters
- Record levels of dissatisfaction & burnout amongst PCPs
- High Net Promoter Scores
- Quadruple Aim leading organizations
- Ounce of prevention is worth a pound of cure
- Same or next day appointments for issues not addressed via email/phone
- Extensivist (for the sickest patients) has smaller panel allowing proactive care management & coordination.
- Can reduce issues 40-90% and spending 20-50%
4. Active, Independent Plan Management
- Many ERISA plans have “holes” that expose employers unnecessarily
- Pay for high cost ASO networks
- Fully-compliant ERISA plans that protect companies from abuse
- ERISA fiduciary oversight and review at least as strong as 401k oversight and management
- Use TPA networks focused on high quality providers and geographic coverage
5. Transparent Pharmacy Benefits
- Limited or no transparency and control over Pharmacy Benefit Manager (PBM) services
- Actual costs often hidden or obfuscated under AWP analysis, rebates, or pseudo-transparency
- Including drugs on “preferred” tiers often based on financial, not clinical efficacy, reasons
- Provide transparency and control over Pharmacy Benefit Manager (PBM) services
- Ensure members have relevant information to make informed choices
- Ensure clinical decisions are based solely on efficacy and ACTUAL cost
- Is a process that works on behalf of the purchaser’s best interests
6. Major Specialties & Outlier Patients
- Quality and prices vary widely
- Studies find 40% of transplants are medically unnecessary
- High rates of complications at community hospitals who don’t do high volumes of complex procedures
- Little-to-no evidence-based or patient-specific care or treatment protocols
- Highly disjointed care with little communication between providers
- No defined approach to match patients to high-quality specialist providers
- No access to non-physician resources to facilitate ongoing management or support
- Second opinions at no charge for employee at world class Centers of Excellence facilities (e.g., Mayo & Cleveland clinics)
- Unit cost often higher but lower complication rates & avoidance of unnecessary procedures drives strong ROI
Due to the infrequency of these procedures (transplants, neurological procedures, cardiac, spine and other six-figure or more procedures), this pairs well with Transparent Medical Networks for more common procedures.
- Access to evidence-based and disease-specific care navigation, pathways, and treatment protocols
- Highly coordinated care with defined handoffs between care providers
- Simple access to high-quality providers with demonstrable strong outcomes
- Non-physician care team resources facilitate ongoing management and support
7. Transparent Advisor Relationships
- “Shops” the insurance every year
- Facilitates insurance 1 year at a time
- Believes costs are dependent on the best offer of the carrier
- Gives limited data on where your money is going
- Provides limited ways to control underlying costs
- Doesn't talk about their compensation or worse, is solely paid on commission, meaning more income the more rates go up
- Advocates cost shifting in the form of increased deductibles and copays to lower the employer impact of premium increases
- Blames costs exclusively on employee behavior and poor health
- Creates a 2-3 year plan
- Brings transparency to where the money is going
- Talks about their compensation and is willing to tie compensation to performance
- Provides risk management to suit the needs of the business owner(s)
- NEVER surprises with a “shock” renewal rate
- Returns control over your costs to you
- Bring the “benefit” of Benefits back to your business
- Makes this a real attraction and retention tool
- Understands improving benefits is the only way to lower costs
- Provides detailed data driven analysis and actionable insight