Communities: Health Access Alternatives
By Michael Tetreault, Editor-in-Chief, and Catherine Sykes, Managing Editor, The Direct Primary Care Journal
The way companies and their employees get access to and pay for health care is evolving quickly. Surveys show that many of the estimated 30 million people who gained insurance coverage last year under health care reform do not have a primary health care physician or do not use one. According to The New York Times, many opted for high-deductible health plans. This group is expected to become picky with the dollars they spend and to be less tolerant of the opaque pricing that is still the industry’s norm.
Employers, employees and their families are starting to demand more convenient, on-demand access to health care. It is clear that this trend will continue, especially as today’s higher deductibles are causing increased consumer sensitivity to health care costs.
Wise employers and benefit managers will take heed. With rising consumerism and transparency in health care, innovative solutions are rising to the surface.
“I heard an interesting story from a colleague recently that some patients in a hospital telemedicine program rated videoconferencing more personal than an actual bedside visit by a physician,” said Terry Bauer of Stroudwater in Atlanta. “Why? Because the physicians being beamed into the room were focused, undistracted by phone calls or pagers and not in a hurry to complete their rounds.”
In this fast-changing world, retail health care is a one-stop shop for health care. For employers and insurers, retail health care clinics offer a way to reduce costs for noncritical conditions. A study by researchers at the RAND Corporation estimated that more than a quarter of emergency room visits could be handled at retail clinics and urgent care centers, creating savings of $4.4 billion a year.
Concierge Medicine Today, the trade publication for the membership medicine industry said to CNNMoney.com that there are a number of physicians around the country who have set up membership-based programs that offer employees primary care health care anywhere from $1,200 a year to $2,500 annually – depending on patient load and the level of personal attention desired. It’s a trend also known as concierge medicine, membership medicine and direct primary care. The strength of membership medicine lies in its focus on the doctor-patient relationship.
In an effort to circumvent health insurance headaches, some employers like Expedia, Comcast and others companies in small beta-site pockets around the country are looking to membership medicine and cash-only primary care physicians (typically with more than one office location) as an innovative, cost-saving solution. Just last year, an article in Forbes noted that WeCare Clinics, Iora Health, Qliance Medical Management, MDVIP and OneMedical have all reported reductions in total health care costs for their patients of 15 percent or more versus population norms.
There are third-party administrators that are beginning to see the benefits of a corporate physician working alongside self-funded employers.
“We have a third party administrator who immediately saw the benefits a corporate physician can bring to a self-funded employer,” said Bill Cossart, CEO and founder of MedFirst Partners, a consulting firm that assists direct primary care physicians with their entry into DPC. “Even smaller companies can easily adopt DPC. The employer sees the rebates. The employees love the level of service with a 24/7 DPC physician and the doctor gets to practice medicine the way they always have wanted. Everyone wins. There are no losers in this arrangement.”
We are beginning to see three tiers of fees emerging.
For a couple of thousand dollars each year, an employee can receive same-day appointments, office and home visits from their doctor, the physician’s cell phone number and the contractual promise that a physician may spend an hour with them instead of four minutes. There is also a technology component to this tier that enables the employer to work with the physician to assess the health care needs of his workers and adjust accordingly.
“Employers, both large and small, are struggling with the staggering costs of health care in this country,” said Mason Reiner, CEO at R-Health, in an interview with The Direct Primary Care Journal last year. “They are desperately seeking innovative solutions that involve something other than shifting ever more costs to employees and their families. Independent primary care physicians can be an employer’s most valuable ally as they seek ways to improve the care their plan members receive while controlling costs. When given the rare opportunity to sit in the same room with independent primary care physicians to discuss health care, employers find the DPC physician perspective both eye-opening and refreshing.”
For $1,200 to $1,700, you may get same-day service, phone consults with an annual physical included. The lowest tier is priced between $250 to $500 per-person and gives you a less exclusive package of services.
“We can help small and mid-sized businesses become self-insured despite not having large reserves, cut health care expenses and circumvent many of the stringent requirements of the Affordable Care Act,” says Dr. Samir Qamar of MedLion.
“MedLion can include workman comp injuries within its direct primary care plans, drastically reducing costs to the employer, as well as the insurance carrier, and we are able to structure agreements with employers in such a way that monthly MedLion fees can become tax deductible. We can also offer a minimum of affordable primary care benefits to part-time employees, dependents, opted-out full-time employees, early retirees and independent contractors, all of which keep the entire workforce healthy.
“Because MedLion practices have protocols for safe and effective telemedicine, in many cases employees can be treated without them having to visit the doctor’s office – increasing productivity for the host company. We also offer wellness programs, occupational health programs and screenings to employers of all sizes.”
Interestingly, this is all happening at a time when health care costs for employers is rising and becoming more complex each quarter. And, here is another benefit. By charging a flat, per-member, per-month membership fee, the doctors can then sell their various services to each employee at a deep discount.
By cutting out the middleman, [one doctor] said he can get a cholesterol test done for $3, versus the $90 the lab company he works with once billed to insurance carriers, Concierge Medicine Today reported to CNNMoney. An MRI can be had for $400, compared to a typical billed rate of $2,000 or more.
Employers are switching to high-deductible health plans where individuals are now responsible for so many thousands of dollars upfront before the company picks up the tab. When that happens, individuals and families start to treat health care spending like it is their own money and become more cost conscious.
“When you look at the numbers, if a membership medicine contract can save an employer 20 to 30 percent in a year, that could equal a few hundred thousand dollars per year for a mid-sized employer,” ” said Blaine Lindsey, JD, MPH, executive director, Aledade in Louisiana. “This leaves a lot of room for aggressive pricing because self-insured employers are often desperate just to bend the cost curve. When a practice such as that delivers the kind of savings that they are capable of, there will be champagne and crying and hugs in the company HR department.”
Seattle-based health clinic chain Qliance is feeling the impact of the Affordable Care Act, and tweaking its business model in response and pivoting from individual and families to employers. Qliance has long been a provider of primary care to employers, unions, Medicaid and uninsured individuals. CEO Erika Bliss noted that since the 2010 passage of the ACA, more employers have been coming to Qliance with questions about how to tie together new health care innovations that are cropping up in hospitals and primary care settings. Services include telemedicine, employee wellness programs, patient engagement strategies and more.
As a result, Qliance is now pivoting its business model toward employers and planning to make all of those services available in one place. The company just raised about $2.7 million from existing investors, partly to upgrade its software systems to provide these types of services.
What kind of employer groups are a good fit for membership medicine?
Small local employers <50 employees
Professional firms (CPA, attorneys, engineering, architectural, technology, etc.)
Assisted living communities
“Retailers have left it alone for decades, but now they see opportunity because traditional providers have not always been responsive to the changing needs of consumers, which creates opportunities for others to step in,” said Mark Grube, managing director of Kaufman Hall, an Illinois consulting firm to the Boston Globe (August 9, 2015).
Bottom-line selling points for direct primary care:
Enhanced and increased access to primary care services
Generally 80 percent of needs can be covered by a primary care doctor
Emphasis on wellness and keeping employees healthy
Cap on primary care costs
Decrease number of hospitalizations
Decrease total number of sick days
Decrease number of ER visits
Reduce number of hospital days
Decrease specialty visits
Reduce absenteeism and presenteeism
If offered, reduced costs on tests and screenings
What employees need and want
Accessibility – Having health care without access is tantamount to rationing. There is already a shortage of primary care physicians and practitioners especially in particular rural areas.
- Having to travel long ways to get care robs the employer of productivity and the employee of wages.
- The average employer population has 40 percent to 50 percent of employees who have no primary care provider.
Affordability – Traditional health plans continue to do the same thing over and over again. There is no cost management – only cost shifting to those least able to pay the tab.
Deductibles – We have all seen the results of the ACA where individual deductibles have been raised to an astronomical level with individuals. $6,000 is no longer uncommon. Employers are going more and more to the high deductible plans causing providers to have larger ARs than in the past.
- Out-of-pocket limits have also escalated as a result of poor plan design – medical plans have not addressed the actual expense of health care – only who pays the ticket.
- Copays have escalated like all other aspects of the plan. PBMs keep moving the formularies around while the prices for generics are growing at about 10 percent per year.
Accountability – Physicians are so busy now trying to increase appointments to stay even with the cuts in payments and paper requirements they find themselves limited in the time spent with individual patients. This is an irritant to both the provider and the patient.
- Patients want a “medical home” where the patient is cared about and they are encouraged to adhere to treatment regimens that will assure them of a longer life with better quality.
- When it comes to population health management, time and staff is limited and the patient is the ultimate victim.
The Puget Sound Business Journal in August of 2015 noted that the bigger change is coming from big employers with the muscle to design custom plans: anywhere from 500 to several hundred thousand employees.
“Those employers tend to be what’s called self-insured,” Bliss explained, which means they pay the claims themselves. “So whatever savings accrue to the plan, that’s theirs, that’s money that goes to their bottom line.” For Qliance’s institutional customers, Bliss said the savings have been in the neighborhood of 20 percent. Expedia uses Qliance for the 2,500 employees at its Seattle headquarters.
“You really do have a say in the future of primary care in this country,” Bliss said. “We believe that some of the models that continue to evolve, continue to change, will make an impact that’s going to pave the way for the next generation of doctors and all of the patients that are to come.”