Primary care is a hot topic today in employee benefits and the broader healthcare space. Let’s start by defining Primary Care as when an employee has a relationship with a team of medical providers to access urgent care, chronic care, preventative care, and more.
The reason primary care is in the news today is that studies have found that health systems with strong primary care practices improve population health at lower overall costs and with greater equity ie health outcomes are improved for a broader population. Another notable study looked at Intermountain Health and found that members who received primary care from team-based care groups had better health outcomes, lower costs, and improved rates of acute care utilization.
In a broader sense, the lack of quality primary care in the United States is often cited as a contributing factor to our health system’s poor performance when compared to other international health systems. So primary care is a key component in our work to help employers offer more affordable and accessible healthcare to their employees. It’s then very important for us to implement strategies to increase primary care access and utilization for our clients.
From our experience, employers can give their employees greater access to affordable primary care in three distinct ways: HMO or Health Maintenance Organizations, Direct Contracting, and Direct Primary Care.
HMO or Health Maintenance Organizations
Offering an HMO is the simplest and most common way that an organization can push employees into relationships with primary care physicians. This is mostly due to the design of an HMO, which funnels care through a PCP and requires PCP referrals to any specialists.
PPO plans include primary care physicians in their network but do not incentivize primary care utilization. So we don’t think of them as a way to increase PCP utilization beyond the nature of having insurance vs being uninsured.
HMO can result in lower spending, as the perenially low-cost Kaiser HMO plans demonstrate. Other carriers offer HMOs with various network designs, sometimes narrow networks, which enable businesses to offer lower-cost plans in exchange for narrower access to providers and health systems in their local area. However, with more employees moving out of state, HMOs do struggle to adapt as well as a PPO plan.
However, an HMO has limited quality control and measures in place for the PCPs in the network. Further, these PCPs are not always practicing in integrated clinical models with behavioral health and specialties and where one EHR is utilized for the care team. And the employee is forced to use the PCP via the HMO design, a moderate incentive but not the strongest possible.
Direct Primary Care or Virtual Primary Care
An employer can enhance their primary care accessibility and affordability with a Direct Primary Care and/or Virtual Primary Care program.
In these approaches, the employer contracts with a vendor in DPC or VPC (sometimes both) who can work with all the employees or a subset of employees, perhaps those enrolled in certain medical plans. Employees can use these services for heavily discounted care and often benefit from a clinically integrated care team and a good user program such as an app.
These practices again should emphasize a clinically integrated care team, with primary care physicians, nurses, nurse practitioners, behavioral therapists and specialists, physical therapists, specialists, and more.
Examples of Direct Primary Group vendors include One Medical, Carbon Health, Forward Health, and more. Note that these are technology-scaled primary care practices so they are broadly known; your local market may have local integrated primary care groups that could be great resources for the needs of your employees.
Examples of Virtual Primary Care vendors include Galileo, First Stop Health, Teladoc, CVS Health, and many, many more. Your health insurance carrier also likely offers virtual primary care, such as Oscar, UHC, Cigna, Blue Shield (Teladoc), Anthem, Kaiser and others do.
But maybe your group is self-funded and you’re looking to take a bigger step in the direction of affordable and accessible primary care, and healthcare in general. That brings us to…
An employer entering a Direct Contract with a health system is a much bigger move than contracting with a VPC. But direct contracting has been limited to the jumbo employer market due to the contracts, complexities, and scale this strategy entails. A list of companies with direct contracts starts with Walmart, Boeing and Disney, so this doesn’t really translate to most small to mid-sized employers.
In response, some TPAs are entering the space with limited networks with just one contracted health system in local markets. The design of the health plan is to push employees to start care with either a virtual or in-person primary care physician or team, who then manages care. It’s similar to an HMO but only within that one large health system.
This tends to work best for a group in an urban environment with employees close to the contracted health system, but it can work for companies with teams in different cities if those cities have a contracted health system.
One example of this program is Centivo and what they’re doing to bring back direct relationships between employers and health systems. For example, we can direct employees to UCLA in Los Angeles and reward them with a plan design featuring no PCP copay and no annual deductible. This is accomplished because these free upfront care episodes can more than offset future large claims for the population as a whole. The integrated care model and EHR of these systems make an impact on the plan finances and the member’s health.
An example of a company using this model is Activision Blizzard which offers one of the highest AV (Actuarial Value) plans I’ve ever seen in the form of a plan with basically no copays or cost-sharing outside of the ER or urgent care. That’s free health care for your employees.
And they can accomplish all that because they recenter the relationship between an employee and their primary care team.
Click here for a complimentary discussion about how to increase primary care options and affordability for your team.
Posted by John Hansbrough in Behavioral Health, Business Strategies, Digital Health, Direct Contracting, Employee Benefits, Health Insurance, Healthcare Innovation, Healthcare Spending, Human Resources, News, Primary Care, Research, Self-Funding