I’ll answer your questions for the benefit of all the readers but the first thing I’d say to anyone is to get the right benefits advisor (good list at www.healthrosetta.org/map). If they don’t know have experience doing the items you’ve asked about, they can tap our team who has worked directly in the trenches (with advisors) with over 400 employers doing these things. They can also draw on the Plan Grader™️ report that provides customized guidance. This link goes to the RFP for advisor services
1. Hint Health has created a network of DPC docs that covers a lot of the country. One contract should provide access to it
2. My first advice would be: Don’t fight. Starve (route around them). If you are committed to RBP, Health Rosetta Advisors have access to a bunch of RBP related resources — template letters, etc. [See also #4] This is a draft of a short story that includes how an employer in a single hospital town owned by the 900 lb gorilla in their region avoided their price gouging. Big bloated health systems have more brittle business models than many realize. Starve them and they become more reasonable people. That’s what’s happening there. Of course, every system is different. Most plan members are willing to drive an hour (or more) to the best surgeons/facilities if they’ll pay $0. Read more at https://docs.google.com/document/d/1cHmZMsH2U5BAgrsRlMicbg3XHLCgxbDv2SA-qB_qlIk/edit?usp=drivesdk
3. As you’ll read, when carriers/employers try to do the steering, it’s often not received well. However, when an unconflicted nurse who already has established a trusted relationship can help people navigate the clinical, emotional and financial complexities of our goofy system, it absolutely works. For complex scenarios, most people would rather go to Mayo Clinic than their community hospital if it’s high stakes. Hopefully, you’ve read the chapter on Centers of Excellence in my book about the high rates of misdiagnosis for cancer, MSK, cardiometabolic, etc.
4. No need for you to do the direct contracting. There are plenty of alternative networks and approaches that work.
I hope you can join us at RosettaFest. There’ll be 200+ employers there who’ve been doing these things along with the benefits advisors who’ve helped them. They all freely share their battle scars and successes.
Love this Dave and all the work you and Health Rosetta have done to empower employers to make better decisions for their health plans. For the 100-employee company where I was CFO, I’ve implemented most of these approaches for designing a better, more affordable health plan. These are the areas I still haven’t fully been able to solve: 1) Direct primary care - we have employees across the country, with a concentration in Chicago-land. Also, many of our employees and their families want to keep seeing their trusted family doctors. How do we solve for this? 2) RBP and high cost claimants - we are still running into health systems like Advocate that aggressively balance bill our employees at 350% or 500% of Medicare. How do we fight back? I’m not willing to go to a RBP vendor who charges fees for billed charges but acts as fiduciary because I think the incentives are too misaligned. 3) high cost claimants drive 95%+ spend for our plans. But I’m reluctant to steer employees away from their trusted providers. Can we accomplish the right amount of steerage through plan design? 4) Direct contracting - beyond just DPC, I would love to direct contract with physician offices and health systems. But this is just not feasible at 100 employees - it’s not with the time of the physician offices or health systems and we have very low volume spread across many sites of care.
I think it's also notable how cooperatives could be a middle ground that works far better than a completely extractive profit-driven system on one end of the spectrum and a 100% government run system that isn't nimble enough to adjust to the new generations and technologies that are radically changing the face of what healthcare needs. The current system was built for the Greatest Generation & Boomers when acute medical situations were the primary concern. Today, it's chronic disease, mental health, etc. Might the cooperative approach be an approach that would work? Read this and share what you think https://www.linkedin.com/pulse/what-rural-electric-co-ops-can-teach-us-fixing-dave-4k7bc
I find most people wouldn't argue with this. The question is how to bridge from today's reality to a future that's much brighter. Three very different communities are showing how it's done (all are very challenged communities in their unique way). I am writing short stories on these three but this keynote deck is sort of the executive summary -- https://bit.ly/FutureWeChooseDeck
The small subsection of health rosetta brokers I have worked with are good at their job. The framework health rosetta advocates is generally an improvement of our current for profit system though I expect many will read this and say energy should be focused on a move to single payer/universal healthcare rather than improving the current system.
Some of the improvements mentioned require really unpopular cost containment measures like more narrow provider networks, more prior authorization requirements and more claims denials. I agree that broad provider networks with relatively liberal claims payment policies are expensive, but good luck explaining to Joe Blow employee that the doctor they grew up seeing charges too much, provides poor care and they're going to have to change docs. Try to explain to an insured with severe lower back pain that the MRI their ortho is recommending is denied because it's unnecessary/wasteful without trying PT first. These are not always easy pills to swallow despite the significant savings for employees.
I primarily work in the individual and not the group market, so my expertise to response is more limited than an expert in the group world. I expect that, even if the blueprint provided generally would be a net positive for employers/employees, I am interested in hearing more of the downsides of the five points in the article as the article doesn't admit any of the challenges/downsides of implementing these savings measures.
It's very true that these things succeed or fail based on the experience of Johnny/Janey Lunchbucket. The folks having the greatest success nail their outreach with employees/union members. A great example of that is what we captured at one of our events where a Health Rosetta Advisor replicated the 30 minutes they get once per year with employees in a 101 (year one) and 201 (year two).
Agreed. Great communication is absolutely key. Advance primary care, in my experience, almost always ends up being loved by employees even if there may be initial resistance. Other strategies like narrowing networks, even if directing employees towards more quality care, may be harder for employees to accept. That being said, it's better than losing benefits altogether. I have worked with many an employee who made their way to me because their employer dropped their health insurance coverage altogether.
Edit: I appreciate the videos. I'm still interested in the arguments against a transition to this system. Considering size, demographics, health needs and other variables, what type of business is not best off hiring a third party administrator, direct contracting, hiring an independent PBM, using nurse navigators, etc? Are there certain regions of the country where this model doesn't work? Are there certain types of employees who might be worse off? What are the most common complaints from the employer? The employees?
Did I understand from the article that Rosetta is open source? That would be phenomenal. Physician groups have been so burned by PE we are wary of contracts that promise improved practice efficiency
Basically, yes. We are a public benefit corporation that has always had open sourcing be a central element of our long-term strategy. To that end, we catalyzed Nautilus Health Institute (a 501c3) with about $4 million of Health Rosetta intellectual property that resides in the 501c3. Thus, technically, it's Nautilus that is open source but the contributions to date have been from HR PBC. We are now getting more contributions (financially & IP) that extend beyond just Health Rosetta.
If you are talking about provider networks and ownership of medical practices, we seek to create the economic condition for independent/high value practices to thrive. In other words, we're dependent on them but we are fully independent. One of the exciting developments is OpenNetworks.org which is a provider network cooperative. Go to their site for how it is structured.
It’s broadly applicable to all include FQHCs. The biggest obstacle for FQHCs is many are stuck in the mindset of feeling stuck with fee-for-service and accepting status quo. It causes orgs to think hand to mouth and feeling impaired from thinking beyond a 12-month horizon.
The numbers on misdiagnosis and dependent eligibility waste are brutal. There's another operational layer contributing to this that didn't make it into the piece. I'll leave it at that
Indeed. A book could be written (and probably has) on the various operational layers -- many of them there for no good purpose other than profiteering.
These operational layers often seem too entrenched to challenge. I wonder if there are real-world cases where someone’s managed to roll one back- without triggering institutional pushback. That would be worth studying
Thank you. The years of tender and hard work has been accomplished.
Call your representatives and senators and tell them to cosponsor the Medicare for all acts house bill 3069 and senate bill 1506 in this 119th Congress
I’ll answer your questions for the benefit of all the readers but the first thing I’d say to anyone is to get the right benefits advisor (good list at www.healthrosetta.org/map). If they don’t know have experience doing the items you’ve asked about, they can tap our team who has worked directly in the trenches (with advisors) with over 400 employers doing these things. They can also draw on the Plan Grader™️ report that provides customized guidance. This link goes to the RFP for advisor services
https://docs.google.com/document/d/16NGaSO4KLYLkNhekuAGu6JWnjLTBjVIOTwaQrCnlPlE/edit?usp=drivesdk. Go to www.nautilushealth.org for $4 million (and growing) of open source resources freely available to anyone.
1. Hint Health has created a network of DPC docs that covers a lot of the country. One contract should provide access to it
2. My first advice would be: Don’t fight. Starve (route around them). If you are committed to RBP, Health Rosetta Advisors have access to a bunch of RBP related resources — template letters, etc. [See also #4] This is a draft of a short story that includes how an employer in a single hospital town owned by the 900 lb gorilla in their region avoided their price gouging. Big bloated health systems have more brittle business models than many realize. Starve them and they become more reasonable people. That’s what’s happening there. Of course, every system is different. Most plan members are willing to drive an hour (or more) to the best surgeons/facilities if they’ll pay $0. Read more at https://docs.google.com/document/d/1cHmZMsH2U5BAgrsRlMicbg3XHLCgxbDv2SA-qB_qlIk/edit?usp=drivesdk
3. As you’ll read, when carriers/employers try to do the steering, it’s often not received well. However, when an unconflicted nurse who already has established a trusted relationship can help people navigate the clinical, emotional and financial complexities of our goofy system, it absolutely works. For complex scenarios, most people would rather go to Mayo Clinic than their community hospital if it’s high stakes. Hopefully, you’ve read the chapter on Centers of Excellence in my book about the high rates of misdiagnosis for cancer, MSK, cardiometabolic, etc.
4. No need for you to do the direct contracting. There are plenty of alternative networks and approaches that work.
I hope you can join us at RosettaFest. There’ll be 200+ employers there who’ve been doing these things along with the benefits advisors who’ve helped them. They all freely share their battle scars and successes.
Thanks Dave. I appreciate it. Hoping to get back to RosettaFest this year. It’s an amazing event!
Love this Dave and all the work you and Health Rosetta have done to empower employers to make better decisions for their health plans. For the 100-employee company where I was CFO, I’ve implemented most of these approaches for designing a better, more affordable health plan. These are the areas I still haven’t fully been able to solve: 1) Direct primary care - we have employees across the country, with a concentration in Chicago-land. Also, many of our employees and their families want to keep seeing their trusted family doctors. How do we solve for this? 2) RBP and high cost claimants - we are still running into health systems like Advocate that aggressively balance bill our employees at 350% or 500% of Medicare. How do we fight back? I’m not willing to go to a RBP vendor who charges fees for billed charges but acts as fiduciary because I think the incentives are too misaligned. 3) high cost claimants drive 95%+ spend for our plans. But I’m reluctant to steer employees away from their trusted providers. Can we accomplish the right amount of steerage through plan design? 4) Direct contracting - beyond just DPC, I would love to direct contract with physician offices and health systems. But this is just not feasible at 100 employees - it’s not with the time of the physician offices or health systems and we have very low volume spread across many sites of care.
Part 3 is Titanic.
The employer was not interested in updating regulations regarding life boats.
I say take profit and employers out of healthcare.
Sometimes a person is not able to choose their employer, illness or degrees of pain.
I think it's also notable how cooperatives could be a middle ground that works far better than a completely extractive profit-driven system on one end of the spectrum and a 100% government run system that isn't nimble enough to adjust to the new generations and technologies that are radically changing the face of what healthcare needs. The current system was built for the Greatest Generation & Boomers when acute medical situations were the primary concern. Today, it's chronic disease, mental health, etc. Might the cooperative approach be an approach that would work? Read this and share what you think https://www.linkedin.com/pulse/what-rural-electric-co-ops-can-teach-us-fixing-dave-4k7bc
I find most people wouldn't argue with this. The question is how to bridge from today's reality to a future that's much brighter. Three very different communities are showing how it's done (all are very challenged communities in their unique way). I am writing short stories on these three but this keynote deck is sort of the executive summary -- https://bit.ly/FutureWeChooseDeck
The small subsection of health rosetta brokers I have worked with are good at their job. The framework health rosetta advocates is generally an improvement of our current for profit system though I expect many will read this and say energy should be focused on a move to single payer/universal healthcare rather than improving the current system.
Some of the improvements mentioned require really unpopular cost containment measures like more narrow provider networks, more prior authorization requirements and more claims denials. I agree that broad provider networks with relatively liberal claims payment policies are expensive, but good luck explaining to Joe Blow employee that the doctor they grew up seeing charges too much, provides poor care and they're going to have to change docs. Try to explain to an insured with severe lower back pain that the MRI their ortho is recommending is denied because it's unnecessary/wasteful without trying PT first. These are not always easy pills to swallow despite the significant savings for employees.
I primarily work in the individual and not the group market, so my expertise to response is more limited than an expert in the group world. I expect that, even if the blueprint provided generally would be a net positive for employers/employees, I am interested in hearing more of the downsides of the five points in the article as the article doesn't admit any of the challenges/downsides of implementing these savings measures.
It's very true that these things succeed or fail based on the experience of Johnny/Janey Lunchbucket. The folks having the greatest success nail their outreach with employees/union members. A great example of that is what we captured at one of our events where a Health Rosetta Advisor replicated the 30 minutes they get once per year with employees in a 101 (year one) and 201 (year two).
Member education 101 https://vimeo.com/691878334
Member education 201 https://vimeo.com/691892184
A leading patient rights group highlighted their work by talking with regular employees in this video https://vimeo.com/730444252/28655a2596
Agreed. Great communication is absolutely key. Advance primary care, in my experience, almost always ends up being loved by employees even if there may be initial resistance. Other strategies like narrowing networks, even if directing employees towards more quality care, may be harder for employees to accept. That being said, it's better than losing benefits altogether. I have worked with many an employee who made their way to me because their employer dropped their health insurance coverage altogether.
Edit: I appreciate the videos. I'm still interested in the arguments against a transition to this system. Considering size, demographics, health needs and other variables, what type of business is not best off hiring a third party administrator, direct contracting, hiring an independent PBM, using nurse navigators, etc? Are there certain regions of the country where this model doesn't work? Are there certain types of employees who might be worse off? What are the most common complaints from the employer? The employees?
Dave Chase I admire your work.
Did I understand from the article that Rosetta is open source? That would be phenomenal. Physician groups have been so burned by PE we are wary of contracts that promise improved practice efficiency
For a percentage of gross.
What is the model?
Basically, yes. We are a public benefit corporation that has always had open sourcing be a central element of our long-term strategy. To that end, we catalyzed Nautilus Health Institute (a 501c3) with about $4 million of Health Rosetta intellectual property that resides in the 501c3. Thus, technically, it's Nautilus that is open source but the contributions to date have been from HR PBC. We are now getting more contributions (financially & IP) that extend beyond just Health Rosetta.
If you are talking about provider networks and ownership of medical practices, we seek to create the economic condition for independent/high value practices to thrive. In other words, we're dependent on them but we are fully independent. One of the exciting developments is OpenNetworks.org which is a provider network cooperative. Go to their site for how it is structured.
Did that answer your question?
Yes- you answered my question very well! It’s hard to keep up with all this when you’re in practice, so thank you for the valuable information.
I am thinking even an FQHC could benefit from this approach
It’s broadly applicable to all include FQHCs. The biggest obstacle for FQHCs is many are stuck in the mindset of feeling stuck with fee-for-service and accepting status quo. It causes orgs to think hand to mouth and feeling impaired from thinking beyond a 12-month horizon.
And we’re going to have to get creative real quick when Medicaid cuts begin.
You’ve given me lots to think about- and for the first time in awhile it is positive
The numbers on misdiagnosis and dependent eligibility waste are brutal. There's another operational layer contributing to this that didn't make it into the piece. I'll leave it at that
Indeed. A book could be written (and probably has) on the various operational layers -- many of them there for no good purpose other than profiteering.
These operational layers often seem too entrenched to challenge. I wonder if there are real-world cases where someone’s managed to roll one back- without triggering institutional pushback. That would be worth studying
Thank you. The years of tender and hard work has been accomplished.
Call your representatives and senators and tell them to cosponsor the Medicare for all acts house bill 3069 and senate bill 1506 in this 119th Congress