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Revive can play an important role in a Direct Primary Care hybrid model integrating fee-for-service primary centric health care with a virtual care partner sharing real time data. The following is part of a proposal RiskManagers recently presented to an association of primary care physicians interested in expanding their business while helping their community at the same time. This hybrid model provides primary care physicians a path to eventually move into a DPC capitated model as their hybrid model grows in acceptance within their service area.
THE SOLUTION
An Enhanced Primary Care Centric Health Plan solves the high cost of health care by doing two things simultaneously 1) controlling utilization and 2) paying appropriate prices.
Enhanced Primary Care is positioned at the center as the gateway to all health care. A properly constructed primary care centric health plan goes beyond convenient access to comprehensive, coordinated primary care and includes a medical health plan interface that uses cash as the primary benefit tier managed through an effective triage, care navigation and specialty care coordination strategy.
Virtual primary care is a vital part of the strategy. Industry statistics show that approximately 80% of primary care can be performed virtually, combining enhanced access with enhanced convenience. Virtual care is cost effective. Enhanced Primary Care operations push as much care as possible to virtual to achieve obvious cost savings and efficiency in health care delivery. Targeting 80% or more for virtual care visits, leaves more time and space for the remaining 20% in face-to-face brick & mortar visits when needed.
The combination of virtual/brick & mortar primary care and concierge guided cash payment services allows the plan to provide the same level of service to plan members who reside outside the service area.
However, neither virtual or in-person visits can achieve the levels of effectiveness or efficiency on a stand-alone basis. Both must be able share data and backup from a central source for maximum coordination and efficiency, so that care can flow seamlessly between settings.
When a virtual primary care provider partners with brick & mortar primary care providers, sharing resources, data, EMR access, and cooperating with each other to deliver superior primary care, greater efficiencies can be achieved for both patients and providers.
An Enhanced Primary Care Centric Health Plan controls utilization by offering convenient, accessible care for the majority of health care needs though an efficient blend of virtual/bricks & mortar primary care, and also controls the cost of downstream care by partnering with a plan manager that uses direct cash payment to ensure that the plan pays appropriate prices. The plan manager serves as a single point of contact for plan members and providers to manage all referrals for specialty care and other health care services that must happen outside the four “walls” of virtual/brick & mortar primary care in addition to health plan customer service and streamlined medical management.
All secondary care outside the walls of virtual/brick & mortar primary care is coordinated through the plan manager’s concierge guidance and cash payment negotiation services. The plan manager identifies secondary providers based on quality metrics and pricing, guiding the plan member step by step through the process. The plan manager uses plan assets to pay downstream providers no later than the date of service. Downstream providers are paid based on negotiated cash pricing with no claims, no billing and no collection costs. The plan member is free of all financial barriers to care, receiving high quality, coordinated health care at no out of pocket cost whenever the cash payment benefit tier is used.
Unplanned medical encounters can also be managed with cash payment whenever possible. Medical encounters that are not managed by the plan manager are paid based on a multiple of Medicare allowed amounts. In those instances, plan members may be subject to out-of-pocket expenses such as deductibles, co-insurance, co-pays and possible balance billing by providers unwilling to accept the plan’s payment as payment in full.
RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.
