Allen Okie MDAllen Okie MDPerspectivesPerspectives

ProviderProvider – Private Practice-Board – Private Practice-Board Certified-Allergy/Immunology;PediatricCertified-Allergy/Immunology;Pediatricss

Medical AdministratorMedical Administrator – – CEO/Medical Director Vantage Health CEO/Medical Director Vantage Health Plan; Medical Director Peoples Health Plan; Medical Director Peoples Health Choice –Medicare HMO;Choice –Medicare HMO;

Consumer AdvocateConsumer Advocate

ProviderProvider – Private Practice-Board – Private Practice-Board Certified-Allergy/Immunology;PediatricCertified-Allergy/Immunology;Pediatricss

Medical AdministratorMedical Administrator – – CEO/Medical Director Vantage Health CEO/Medical Director Vantage Health Plan; Medical Director Peoples Health Plan; Medical Director Peoples Health Choice –Medicare HMO;Choice –Medicare HMO;

Consumer AdvocateConsumer Advocate

Dr. Paul Ellwood who coined the term “HMO” has acknowledged that “Managed Care as we know it is dead.”Double digit premium inflation5 Million people without health care insurance in the last two yearsDissatisfaction by patients, employers, Drs.HMO Enrollment is falling

Dr. Paul Ellwood who coined the term “HMO” has acknowledged that “Managed Care as we know it is dead.”Double digit premium inflation5 Million people without health care insurance in the last two yearsDissatisfaction by patients, employers, Drs.HMO Enrollment is falling

What do we need?What do we need?

Consumer Driven (Centric)Consumer Driven (Centric)Open AccessOpen AccessMarket DrivenMarket DrivenQuality DriversQuality DriversFinancial Viability for all partiesFinancial Viability for all partiesMedical Management – Rational Medical Management – Rational Rationing – Educate ConsumerRationing – Educate ConsumerState of the Art Information State of the Art Information TechnologyTechnology

Consumer Driven (Centric)Consumer Driven (Centric)Open AccessOpen AccessMarket DrivenMarket DrivenQuality DriversQuality DriversFinancial Viability for all partiesFinancial Viability for all partiesMedical Management – Rational Medical Management – Rational Rationing – Educate ConsumerRationing – Educate ConsumerState of the Art Information State of the Art Information TechnologyTechnology

SIMPLIFYSIMPLIFY

Simple solutions Simple solutions Captain Captain Underpants and the Perilous Plot of Underpants and the Perilous Plot of Professor Poopy-pantsProfessor Poopy-pants

Separate Insurance From FinanceSeparate Insurance From Finance Managed Care has merged and blurred Managed Care has merged and blurred

the differences between Insurance and the differences between Insurance and FinanceFinance

We (providers and insurors) have made We (providers and insurors) have made the system too complex the system too complex

Simple solutions Simple solutions Captain Captain Underpants and the Perilous Plot of Underpants and the Perilous Plot of Professor Poopy-pantsProfessor Poopy-pants

Separate Insurance From FinanceSeparate Insurance From Finance Managed Care has merged and blurred Managed Care has merged and blurred

the differences between Insurance and the differences between Insurance and FinanceFinance

We (providers and insurors) have made We (providers and insurors) have made the system too complex the system too complex

Eliminate Intermediation that Eliminate Intermediation that does not provide value to the does not provide value to the systemsystem

Develop a Value-Based health Develop a Value-Based health care delivery system through care delivery system through Providers and PatientsProviders and Patients

Focus on the Patient-Physician Focus on the Patient-Physician relationship relationship

Reward quality and valueReward quality and value

Eliminate Intermediation that Eliminate Intermediation that does not provide value to the does not provide value to the systemsystem

Develop a Value-Based health Develop a Value-Based health care delivery system through care delivery system through Providers and PatientsProviders and Patients

Focus on the Patient-Physician Focus on the Patient-Physician relationship relationship

Reward quality and valueReward quality and value

Give power back to the patientGive power back to the patient

Change the patient status Change the patient status from user to consumer – from user to consumer – Purchase PowerPurchase Power

Educate and inform the Educate and inform the patientpatient

Universal participation – Universal participation – Product Offering – “Adverse Product Offering – “Adverse Selection”Selection”

What Will Achieve These Goals?What Will Achieve These Goals?

CONSUMER CONSUMER DRIVEN HEALTH DRIVEN HEALTH

CARECARE

CONSUMER CONSUMER DRIVEN HEALTH DRIVEN HEALTH

CARECARE

Discount Fee For Service PlansDiscount Fee For Service Plans

More Patients – More Revenue – Less Overhead

NO HASSLE FACTOR NO CLAIMS (or Adjustors)NO CLAIMS (or Adjustors) NO MEDICAL INTERFERENCENO MEDICAL INTERFERENCE NO ACCOUNTS RECEIVABLENO ACCOUNTS RECEIVABLE PAYMENT AT THE TIME OF CARE –PAYMENT AT THE TIME OF CARE –

ELECTRONIC TRANSFER OF ELECTRONIC TRANSFER OF PAYMENTsPAYMENTs

More Patients – More Revenue – Less Overhead

NO HASSLE FACTOR NO CLAIMS (or Adjustors)NO CLAIMS (or Adjustors) NO MEDICAL INTERFERENCENO MEDICAL INTERFERENCE NO ACCOUNTS RECEIVABLENO ACCOUNTS RECEIVABLE PAYMENT AT THE TIME OF CARE –PAYMENT AT THE TIME OF CARE –

ELECTRONIC TRANSFER OF ELECTRONIC TRANSFER OF PAYMENTsPAYMENTs

Provider Perspectives

The New Medicine

No More “Mommy May I”No More “Mommy May I”

No More Pended ClaimsNo More Pended Claims

No More Costly Billing No More Costly Billing and Claims Submissionand Claims Submission

No More Accounts No More Accounts ReceivableReceivable

The New Medicine

Reduce Overhead

Increase Revenues from

More Patients and More Patients and efficient operationsefficient operations

The New Medicine

This system will allow the This system will allow the physician to pass savings physician to pass savings directly to the Patient directly to the Patient instead of to the instead of to the IntermediaryIntermediary

Can We Get There From Here?Can We Get There From Here?

Yes!Yes!

HOW?HOW?Discount Fee For Discount Fee For Service PlansService Plans - - clearly clearly separate Finance from Insuranceseparate Finance from Insurance

Can We Get There From Here?Can We Get There From Here?

Yes!Yes!

HOW?HOW?Discount Fee For Discount Fee For Service PlansService Plans - - clearly clearly separate Finance from Insuranceseparate Finance from Insurance

Discount Fee For Service Discount Fee For Service Plans aligned withPlans aligned with Low cost limited benefit Low cost limited benefit

insurance products insurance products Financial institution to Financial institution to

provide finance options to provide finance options to allow access to careallow access to care

Higher deductible HSA Higher deductible HSA Product (Serves as the front Product (Serves as the front end to assure cost end to assure cost effectiveness)effectiveness)

Discount Fee For Service Discount Fee For Service Plans aligned withPlans aligned with Low cost limited benefit Low cost limited benefit

insurance products insurance products Financial institution to Financial institution to

provide finance options to provide finance options to allow access to careallow access to care

Higher deductible HSA Higher deductible HSA Product (Serves as the front Product (Serves as the front end to assure cost end to assure cost effectiveness)effectiveness)

Shift to Consumer Driven ModelShift to Consumer Driven ModelShift to Consumer Driven ModelShift to Consumer Driven Model

Shift from medical management to Shift from medical management to health care educationhealth care education

Develop Value and Quality Patterns Develop Value and Quality Patterns for Provider Servicesfor Provider Services

Provide Financial Services for Provide Financial Services for Health Care AccessHealth Care Access

Sales and Marketing of Provider Sales and Marketing of Provider Networks – “Carve Outs” Medical Networks – “Carve Outs” Medical E-BayE-Bay

Shift from medical management to Shift from medical management to health care educationhealth care education

Develop Value and Quality Patterns Develop Value and Quality Patterns for Provider Servicesfor Provider Services

Provide Financial Services for Provide Financial Services for Health Care AccessHealth Care Access

Sales and Marketing of Provider Sales and Marketing of Provider Networks – “Carve Outs” Medical Networks – “Carve Outs” Medical E-BayE-Bay

Discount Fee For Service PlanDiscount Fee For Service PlanDiscount Fee For Service PlanDiscount Fee For Service PlanProvider Network – Proprietary ContractedProvider Network – Proprietary Contracted

Vehicle for Service Selection Vehicle for Service Selection

Providers are rated based on satisfaction Providers are rated based on satisfaction results and Professional Certification and results and Professional Certification and trainingtraining

Swift Payment with out HassleSwift Payment with out Hassle

Payment Authorized by PatientPayment Authorized by Patient

Market the Professional services of network Market the Professional services of network to patients and employersto patients and employers

Financial Resources for the patient to Financial Resources for the patient to access services of the networkaccess services of the network

Provider Network – Proprietary ContractedProvider Network – Proprietary Contracted

Vehicle for Service Selection Vehicle for Service Selection

Providers are rated based on satisfaction Providers are rated based on satisfaction results and Professional Certification and results and Professional Certification and trainingtraining

Swift Payment with out HassleSwift Payment with out Hassle

Payment Authorized by PatientPayment Authorized by Patient

Market the Professional services of network Market the Professional services of network to patients and employersto patients and employers

Financial Resources for the patient to Financial Resources for the patient to access services of the networkaccess services of the network

IDEALIDEALIDEALIDEALExplanation of Payment goes to PatientExplanation of Payment goes to Patient

Diagnosis and procedures are pricedDiagnosis and procedures are priced

Diagnosis is matched to evidence Diagnosis is matched to evidence based practice notices which the based practice notices which the patient checks if they were offered by patient checks if they were offered by the Provider – the Provider –

Based on the score the physician would Based on the score the physician would be paid or not paid or reducedbe paid or not paid or reduced

This is the quality criteria attached to This is the quality criteria attached to Discount Fee for Service PlansDiscount Fee for Service Plans

Explanation of Payment goes to PatientExplanation of Payment goes to Patient

Diagnosis and procedures are pricedDiagnosis and procedures are priced

Diagnosis is matched to evidence Diagnosis is matched to evidence based practice notices which the based practice notices which the patient checks if they were offered by patient checks if they were offered by the Provider – the Provider –

Based on the score the physician would Based on the score the physician would be paid or not paid or reducedbe paid or not paid or reduced

This is the quality criteria attached to This is the quality criteria attached to Discount Fee for Service PlansDiscount Fee for Service Plans

Statutory OversiteStatutory OversiteStatutory OversiteStatutory OversiteDiscount Fee for Service is NOT Discount Fee for Service is NOT INSURANCE – Keep it SimpleINSURANCE – Keep it Simple

Minimal Credentialing – no need for Minimal Credentialing – no need for primary source verificationprimary source verification

Marketing and sales over-siteMarketing and sales over-site

Patient Education over-sitePatient Education over-site

Audits of performance and satisfactionAudits of performance and satisfaction

Monitor complaintsMonitor complaints

Economic CredentialingEconomic Credentialing

Discount Fee for Service is NOT Discount Fee for Service is NOT INSURANCE – Keep it SimpleINSURANCE – Keep it Simple

Minimal Credentialing – no need for Minimal Credentialing – no need for primary source verificationprimary source verification

Marketing and sales over-siteMarketing and sales over-site

Patient Education over-sitePatient Education over-site

Audits of performance and satisfactionAudits of performance and satisfaction

Monitor complaintsMonitor complaints

Economic CredentialingEconomic Credentialing

POTENTIALPOTENTIALPOTENTIALPOTENTIAL

Discount Fee for Service Plans can Discount Fee for Service Plans can provide reductions in operational costs provide reductions in operational costs which can be passed off to the patients which can be passed off to the patients and not absorbed by intermediariesand not absorbed by intermediaries

Can be attached to an indemnity Can be attached to an indemnity insurance product insurance product

Can be the front end of a Health Savings Can be the front end of a Health Savings AccountAccount

Provides the economies of group Provides the economies of group contractingcontracting

Discount Fee for Service Plans can Discount Fee for Service Plans can provide reductions in operational costs provide reductions in operational costs which can be passed off to the patients which can be passed off to the patients and not absorbed by intermediariesand not absorbed by intermediaries

Can be attached to an indemnity Can be attached to an indemnity insurance product insurance product

Can be the front end of a Health Savings Can be the front end of a Health Savings AccountAccount

Provides the economies of group Provides the economies of group contractingcontracting

Allen Okie MDAllen Okie MD

Thank you for listeningThank you for listening