Value-based health benefits are a strong addition or alternative to status quo insurance carrier plans and networks. Our model delivers these in a comprehensive solution structured to provide top quality care and service at 20-40% less cost.
We accomplish this by centering care on advanced primary care and complementing it with a high performance specialty care network. Our goal is to direct contract with all significant health providers, maintain provider choice and fairly price out-of-network providers. Employers can maintain their existing networks and overlay our high performance network and services. Navigating members to top quality providers results in the best care and often the most savings. Population health management facilitates the efficient allocation of resources to achieve most favorable health results for overall plan membership.
Below are the key components of our benefit model.
Advanced Primary Care (APC)
Employers with self or fully funded plans can overlay APC on their current benefit plan anytime on or off cycle. It is a subscription-based program with a monthly fixed fee paid by employer that can be cost shared with the employee. APC targets improving member health and reducing expensive, unnecessary downstream treatment.
APC differs from traditional primary care in that the primary care providers (PCP) spends significantly more time delivering care and coaching patients with the intent of preventing serious health issues. The member has unlimited access to and care from the same PCP with no co-pays or deductibles to encourage their use of APC.
The APC practice is motivated to keep every member healthy since it assumes the financial responsibility for delivering all primary care. Limiting care such as HMO’s are reputed to do to save money does not work in APC as ultimately the practice will bear more cost if it allows patient health to deteriorate.
Members value APC for delivering care normally associated with executive health programs. This encompasses highly attentive VIP service, unlimited care with longer visits and no wait, 24/7 access to their PCP, health coaching and navigation. They welcome being able to select their own local APC from a national network of practices directly contracted with Enable Health.
If they choose not to use APC, members can instead use their employer’s existing network or our physician PPO network to receive standard fee-for-service primary care. Since this does not provide unlimited care, it will not generate health outcomes as robust as APC. For this reason, employer plans are encouraged to incentivize members to join APC.
High Value Provider Network
We seek to partner with the best clinicians in each market to achieve optimal clinical outcomes and spend efficiency. Since members often don’t have the time, patience and knowledge to identify these providers, Enable Health curates and secures these relationships to customize a high performance care network for each market.
Members are incentivized and guided by our concierge navigator to the best providers for their care needs and coached to make smart decisions that benefit both members and the plan.
Direct Contract, Group Buy, TOS Cash Pay Discount
We directly contract with select providers to best serve the unique needs of each member population. We utilize innovative pricing and quality programs to achieve value targets such as paying cash at time of service for discounts.
Employer plans within the same local market can band together to collectively direct contract with providers. This can be more attractive to large providers and can enable transition of medical risk from employer plans to health providers to benefit both parties.
Optional PPO Network
A national PPO network of primary and specialty physicians gives members the choice to select their preferred care providers. Our concierge service helps navigate members to high quality specialist providers in the network.
While we firmly believe APC provides more value than standard primary care, members can be offered the option to select the latter if an employer wants to give this alternative.
Out-of-Network (OON) Providers
Navigation and Coaching
Population Heath
A number of proven cost containment practices are utilized to preserve both plan resources and provider relationships. While members are encouraged and incentivized to use directly contracted and in-network providers, they can use OON providers and assume additional financial responsibility.
The plan determines fair prices based on estimated cost plus a reasonable profit. The member is responsible for the amount exceeding this fair price. Pre-negotiated cash discounts paid at point of service for some high cost services offer providers a simplified, expedited payment process. Services can also be repriced post service with our member services resolving remaining balances with the provider.
These services enable members to be wise health service shoppers and navigate the complex health system. Empowering members to manage their own health and care significantly impacts their wellbeing and plan spend. Yet, most traditional plans provide minimal or no useful navigation and coaching services to members. Enable Health holds these to be essential services and provides them to members through our APC and concierge member navigation service team.
Plans can employ population health strategies and initiatives to more precisely manage the collective health of their members. Programs are customized to most benefit their unique population. Data driven analytics help identify high risk groups needing additional care and guidance so our outreach team can offer these members assistance.
Self-Funded Plan
Most employer plans with over 100 employees should consider being self insured if they have the capital to manage fluctuations in claims. It’s most prudent to self fund predictable claims and stop loss the risk of unexpected loss with insurance coverage.
Insurance is intended for unexpected or excessive loss. Insuring expected costs such as primary care and a normal level of historical health care spending have little purpose as there is minimal risk to insure. The carrier is essentially being paid for financing these claims and then extracting the claim amount plus administrative cost and a profit margin for the effort.
Employers don’t diminish their financial risk by being “fully insured” with insurance carriers because carriers pass through all claim cost increases with higher premiums. So why pay carriers a margin to manage risk they aren’t incurring?
A self funded plan saves the cost of carrier administration, margin and premium tax. A third party administrator (TPA) manages a plan at less cost than the carrier. Costs are also reduced by self-funded plans being governed by federal ERISA law rather than having to comply with variable state laws like fully-funded plans.
In addition to these savings, the benefits of self funding are the employer gaining control to innovate and customize the plan as well as having full access to detailed claims data for use in analyzing and better utilizing health spend. There are other risk, fiduciary and compliance considerations to evaluate before moving to self funding. An employer does need to be more involved in managing the plan when self funded.
Enable Health can help evaluate and transition your plan to self funding. Our solutions are primarily designed for self-funded employer plans.