The Holy Grail of DPC. Craig Scurato

Transcription

1 The Holy Grail of DPC Craig Scurato

2 Activity Disclaimer The material presented here is being made available by the DPC Summit Co-Organizers for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The DPC Summit Co-Organizers disclaim any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the DPC Summit Co-Organizers.

3 Faculty Disclosure It is the policy of the DPC Summit Co-Organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. The following faculty in a position to control content relevant to this session has disclosed the following relevant financial relationships: Craig Scurato The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

4 Learning Objectives At the end of this session, participants will be able to: Demonstrate a robust understanding of how DPC-based insurance plan products should be structured to capitalize on the Direct Primary Care Medical Home provisions contained within the ACA. Evaluate the various methods and processes that DPC practices have established to collaborate with insurance carriers and/or insurance brokers to develop DPC-based health plan products. Determine if there is an opportunity for them to begin exploring the development of a DPC-based insurance plan product in collaboration with an insurance carrier and/or insurance brokerage.

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6 Quiz Alert!

7 Since the Dawn of DPC

8 Quiz Alert!

9 DPC Rapper

10 How Do You Get a Seat at the Table? Especially for Employer Sponsored Plans

11 Successful DPC + Insurance Integration Qliance + Coordinated Care Ambetter Turntable Health + Nevada Health Co-Op Paladina + Self-Funded Clients

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13 The Good Qliance and Coordinated Care s Ambetter Plan Offers membership for individuals selecting Qliance as provider Not a wrap plan but more of an enhanced network Summary of Benefits and Coverage (SBC) the same regardless of provider selected Hard for consumers to find out the advantages of selecting Qliance requires promotion from Qliance at first visit

14 The Good II Turntable Health partnership with Nevada Health Co-Op Excellent cross promotion on both sites Establishes an enhanced network to wrap plan around the DPC membership Point of Service drives reimbursement, so underlying policy has nothing carved out

15 The Good III Paladina Onsite-Nearsite model with Self-Funded employers Embedded in the fundamentals of the program Client drives behavior by providing no cost/low cost convenient access Some plan designs use Tiered networks

16 The Bad If it sounds too good to be true

17 The UGLY Do a little research on anyone bringing you a wrap plan from an insurance company you have never hear of IRG Brokerage Beats Claims It Sold Fake Health Insurance By Kat Greene Law360, Los Angeles (July 30, 2013, 9:18 PM ET) -- A putative class that claimed it bought fake health insurance from IRG Brokerage LLC was spurned by a New York federal judge Monday when the judge tossed its racketeering class action, saying the plaintiffs didn t sufficiently allege they were lied to about health coverage. The class, led by Holly Dulsky, said would-be insurers who ran IRG sold them health insurance that didn t exist. IRG took their money and issued insurance policies that didn t provide health coverage in a conspiracy to steal from them, the class claimed in an action filed in the U.S. District Court for the Southern District of New York in BEFORE THE DEPARTMENT OF INSURANCE STATE OF NEBRASKA CEASE AND DESIST issuing, making, providing, administering, selling or offering, either directly or indirectly, insurance benefits in the State of Nebraska which are not insured by an insurer licensed to transact insurance in the state. Specifically, pursuant to NEB. Rizv. Stat , NOTICE IS HEREBY GIVEN:

18 Quiz Alert!

19 Sometimes it is Better to Just Go With What You Have

20 DIY Wrap Always use a Qualified Health Plan Individual Health Insurance On or Off Marketplace allows maximum customization Group Health Insurance multi-option plans that are fits for DPC and those not joining Self-Funded plans for groups 10+ in many states

21 Goal is to make your DPC membership Top of Wallet And right now the Insurance Card is at the top

22 DIY Wrap Individual Health Insurance PPO makes the most sense network over deductible Stay away from Gatekeeper HMO or POS Help members with Premium Tax Credits to reduce overall cost Steer clear of HSA Compatible membership precludes funding and monthly fees not eligible expenses (Check out DPC Coalition for details)

23 Employer Sponsored Plans

24 DIY Wrap Small Group Health 2-99 Employees Starting 2016 Small Group defined as under 100 FTE Same rating basis (age/location/smoker) as Individual Not as much choice as Individual but still possible to align plans to fit with DPC Delivery system is critical how are you enrolling the DPC and the Medical - Front End Decision Support tools for employees - Back End Member Management for Employer and Practice Steer clear of advising on taxability DPC not eligible for Section 125 Pre-tax. - Employer Paid should be included in Wages - Employee Paid with Post Tax dollars - FSA and HRA funds not allowed to pay membership, but can be used for incidentals

25 DIY Wrap Self-Funded 10+ employees Each State has different rules for minimum size - Just because your State allows down to 10 does not mean there is a market that writes to that size Self-Funding requires Reinsurance aka Stop Loss to work and there is underwriting. Not all companies qualify. Delivery system is critical how are you enrolling the DPC and the Medical Steer clear of advising on taxability DPC is not eligible for Section 125 Pre-tax. - Employer Paid should be included in Wages - Employee Paid with Post Tax dollars - FSA and HRA funds not allowed to pay membership

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27 Be Careful What You Ask For Working with Exchanges/Carriers and TPA s Being ON an Exchange what does that even mean? Integration with a plan brings in Section 125, ERISA and COBRA are you ready for DOL & IRS Regulators? Integration with a plan invites DOI regulators particularly in states without DPC protections Onsite clinics providing more than preventive and occupational medicine conflicts with HSA regulations Fair Market Value of Onsite clinic to be included in 40% Cadillac Tax 2018

28 Really Be Careful What You Ask For Seriously, Working with Agents and Brokers is tough. I did for 20 years! Very difficult times with reduced revenue for more work not unlike an Independent FFS Family Dr. Show them the $$$ - in terms of gaining and retaining client s with your DPC model Beware of paying someone to bring in memberships - Is this Fee Splitting or a kickback and do you start looking more like an insurance product being distributed by a broker? Have your answer ready for will you reduce your fee for my clients - At a minimum offer a volume based discount after the final enrollment

29 A Bright Future for DPC Friendly Plans MedLion ACA Approved Wrap Plans for Affiliated Practices Hint Health Liberty Direct health sharing ministry with DPC built in Physicians Direct EHOP captive based program to pool medium sized employers from volatility of self-funding OnStage Health Integrating DPC with Local Health Systems for selffunded employers in WA,ID,CO Simplifi Benefits/US Health/HMA Precis Primary Plan for small and medium employers levering DPC and Referenced Based Pricing

30 Questions? Craig Scurato Managing Member, Simplifi Benefits,