The Role of DPC in Next-Gen Health Plan Design

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Information about The Role of DPC in Next-Gen Health Plan Design

Published on June 12, 2019

Author: Hint-Health

Source: slideshare.net

1. Sean Schantzen Health Rosetta The Role of DPC in Next- Gen Health Plan Design

2. Health Rosetta Infrastructure for a New Health Ecosystem. Highly Confidential. Do not share without permission. 2

3. What is Health Rosetta? The Foundation for High-Performance Unbundled Health Plans Platform Open Framework & Taxonomy Ecosystem 3

4. Value-Based Primary Care Independent, Active Plan Admin. & Oversight High-Perf. Plan Design, Docs. & Risk Mgmt. Transparent Open Networks Major Specialties & Outlier Patients Transparent Pharmacy Benefits Individual Stewardship Health Rosetta Inside Platform EnablingTech Transparent,AlignedAdvisors Taxonomy Summary Framework 4

5. 20k+ in 16 months BOOKS SOLD How we source our insight Building a self-perpetuating movement & market intelligence Hundreds of contributors HEALTH ROSETTA Plan sponsors Benefits Advisors Industry Experts Clinicians Technologists 40,000+ followers TRADITIONAL & SOCIAL MEDIA REACH 65 articles in H2:18 3.7 million CERTIFICATIONS 110 advisors 37 states Largely mid-market 100’s of sources Broad goal is to drive decentralized, grassroots action 5

6. How Plans Work 6

7. Types of Plans Partially self-funded Fully-insured Level-funded Fully self-funded 7

8. Types of Self-Funded Plan Administration Independent TPA Fully-bundled Carrier Owned TPA 8

9. Main Players in Typical Self-Funded Plan Network Plan & Plan Sponsor Risk Mgmt. TPA PBM People 9

10. Value-Based Primary Care Independent, Active Plan Admin. & Oversight High-Perf. Plan Design, Docs. & Risk Mgmt. Transparent Open Networks Major Specialties & Outlier Patients Transparent Pharmacy Benefits Individual Stewardship Health Rosetta Inside Platform EnablingTech Transparent,Aligned Advisors Structure of Ideal Health Rosetta Plan 10

11. The Problem Repeatedly building successful, client-tailored unbundled plans is overwhelmingly complex for all key stakeholders. Traditional plans Unbundled plans in today’s current market Health Rosetta-based unbundled plans 11

12. Problem Manifestations 1000’s of little things add up to one enormous problem Vetting & Selection Data Integrations Contracting Cross-stakeholder Collaboration Implementation Execution Workflow & Process Management Performance Reporting Plan detail tracking Member Education & Experience 12

13. Health Rosetta Inside Lifecycle Infrastructure for Health Rosetta Plans Plan & Sponsor Data FluiditySolutions Health Rosetta Taxonomy Ever-Improving Foundation 13

14. What Health Rosetta Inside Does 14

15. Certified Advisor + Inside Platform Empowered Plans 15

16. Average Plan Lifecycle 16

17. Plan Lifecycle Summary Architect Implement Iterate Monitor Underwrite Optimize Plan Sponsor & Member Needs 17

18. VBPC-centric Plans 18

19. What Value-based Primary Care Addresses Navigating Complex Conditions & Episodes Day-to-day Acute Care Emerging & Latent Population Risk Different plan architectures impact each area differently. 19

20. How Advisors Decide To-do or Not To-do Possible in Geography? Possible for Client? Select the Right Approach Include Docs to Get Employer Onboard 20

21. Main VBPC-Centric Plan Architectures Bolt-On Bolt-In Built-Around High Deductible Plan + MERP/member paid/other. Paid by self-funded plan, w/ minimal plan changes. All care, point solutions, & incentives flow from VBPC How Members Enroll Depends, but typically optional for members Typically Optional, but can be Incentivized or Required Incentivized or Required Execution Complexity Low Moderate High Typical Group Size <50 50+ 50+ Access/Experience ↑ High High High Cost Savings Varies. May increase costs Varies greatly by utilization Greatest savings potential Key Partners Ideally level-funded or other aligned fully-insured plan SL/Captive/TPA + ideally some key point solutions. SL/CaptiveTPA + solutions in all main Health Rosetta Components + ideally a TON 21

22. How to work w/ plans 22

23. Speaking Employer What they care about Showing ROI 23

24. Remembering the Spend Distribution Primary Care typically does not directly address the largest human and financial costs in a plan. <10% of members >80% of spend 24

25. MSK General Steward Ideally Value-based Primary Care Individual Stewardship CancerComplex Care Cardiometabolic HospitalizationProceduresRare Diseases Specialty Drugs 25

26. Potential Pitfalls Broker Sophistication TPA, PBM & Med. Mgmt Swimlanes Underwriting 26

27. Questions? 27

28. Value-based Primary Care Approaches Smaller Patient Panels + Independence + Aligned Economic Incentives Nearsite ClinicsDirect Primary Care Onsite Clinics Various HybridsACO/IPA-centric Virtual DPC Emerging Trend: Combine approaches to better meet the needs of multi-location and/or decentralized populations. 28

29. Key Selection Issues Any VBPC & Single Clinics Adding a DPC Network and/or Combining multiple VBPC Types ● Scope of Services of clinics ● How integrated into the rest of the plan? ● Employer friendliness of practices ● General VBPC provider vetting ● Doctors of both Genders ● Aligned TPA and SL ● Deciding the right combination of approaches ● Normalizing scope of services & pricing across clinics ● Dealing with Varying state laws 29

30. Key Execution Issues Any VBPC & Single Clinics Adding a DPC Network and/or Combining multiple VBPC Types ● Eligibility & Enrollment ● Employer friendliness ● Coordinating w/ other stakeholders ● Integrating w/ other care interfaces ● Reporting and metrics creation ● Who holds the contracts? ● Administering Contracts & Payment ● Physician selection process for members ● Coordinating reporting and administration ● Simplifying member education 30

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