Employer-Directed Contracting

Report
Employer-Directed Contracting
Stanley N. Schwartz MD FACP
Healthcare Consultant, The Holmes Organisation
Tallgrass Analytics LLC
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Stan Schwartz MD:
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•
Jim Millaway (The Holmes Organisation)
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Direct Primary Care models
Models that transform specialty care
Ann Paul (St John/Oklahoma Health Initiatives &
Brice Habeck (QuikTrip Corporation):
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The Accountable Care Organization
commercial model
Warren Buffett
“a tapeworm eating, you know, at our economic
body.”
What are you buying?
•
Healthcare?
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Insurance?
Direct Primary Care
(DPC)
Insurance
Insurance is the equitable transfer of the risk of a loss,
from one entity to another in exchange for payment.
It is a form of risk management primarily used to
hedge against the risk of a contingent, uncertain
loss.
Why insure something you
are almost certain to use—
or certainly should use?
What if you bought insurance for
your gasoline?
•
Cost of gas based on risk of future use, not current use.
•
Purchases at an out-of-network station would cost way
more
•
Trips out of town would need pre-authorization
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Someone at the next pump might be paying a lot more
or a lot less for the same gas
•
No card, higher price—or no gas at all!
Insurance
or
pre-payment?
Terms
Direct Primary Care
Membership Care
Concierge Medicine
Two distinct service types (generalizations)
Direct Primary Care
Concierge
Typical Panel size
usually less than1000
usually less than 600
Retainer
$50-80 / month
$125-200 /month
Payable
monthly
quarterly or annually
24/7 cell access
usually not
almost always
Instant appointments
sometimes
usually
Insurance
not for primary care
covered services billed
to insurance
Purchased through
employer
individual and private
Location
Typically at/near
workplace
often chosen close to
home
Direct Primary Care
Traditional Primary
Care
independent group
health system
Physician
Compensation
Typically salary +
Typically volume,
usually relative value
units, (“production”) +
Non-face-to-face
services
part of work in the
salary structure
Most not compensated*
Employed by
Specialty Care
may be chosen based usually within system;
on available prices many services provided
and discounts
at hospital rates
Coordination
Often do not share
EHR
Shared EHR creates
single record
Hospital Care
single or multiple
affiliations
provided by system
* chronic care in 2015 recognized under Medicare
New Chronic Care Payment by Medicare
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to start in 2015
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monthly payment of $41.92
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“multiple, significant chronic conditions” requiring
care plans, coordination and medication
management
Other DPC services
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generic dispensing at cost or service markup
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discount arrangements with radiology and other
ancillary services
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Common laboratory tests may be covered
•
Many offer 24/7 electronic communication with
providers (patient portals)
•
Many offer same-day or next-day appointments
Potential benefits to
employers
•
early intervention
•
reduced loss of work productivity
•
“Working mother of three with diabetes”
Drawbacks?
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Lack of infrastructure and resources for high-level
clinical quality measurements and population health
activities
•
Being outside an integrated system could produce
friction at points of transitions of care
•
Exacerbate primary care shortage? Or stem primary
care attrition due to career changes and retirement?
The Equalizer
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Connected physicians and entities can share
medical information
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Referral and communication pathway
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Provider-agnostic and network-agnostic
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Data usually extremely current
“Price is what you pay.
Value is what you get.”

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