By Bill Rusteberg
The chart shown above illustrates the New Age of health care financing. The traditional role of the TPA is quickly becoming more of a fading memory than a value add.
The TPA is removed from the center of the plan, replaced by AI powered high tech coordination between plan members and health care providers. This strategy effectively removes the third person in the room, an unnecessary third party intermediary whose former purpose is no longer needed nor relevant.
The role of the TPA is that of a filing cabinet in the basement, manned by the Maytag Repairman. The TPA does little work other than that of record keeping. No need for customer service or account representatives.
Another important aspect is the rising role of Direct Primary Care. As the gateway to all care, coordinated upstream care brings efficiency and savings for both plan sponsors, plan members and health care providers.
Primary care doctors are taken out of the referral business. Upstream care is managed by the plan in partnership with plan members, saving primary care physicians time and administrative expenses.
Managed care networks are replaced with transparent claim repricing strategies used as a secondary wrap. These strategies include a variety of methods including Reference Based Pricing.
When something new is introduced in health care financing there will be early adopters followed by middle adopters followed by late adopters. We have seen this with the rise of Reference Based Pricing over two decades ago. Early adopters were few and far between. Middle adopters slowly joined in while late adopters never have.
This time it will be different. Lead by visionaries paving the way like Mark Cuban and others with the credibility and courage to prevail, others will follow in rapid succession. We are seeing that unfolding before our very own eyes with the rise of New Era enablers like Mishe Health and many more coming out of nowhere, a place we’ve never been before.
