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