New Direct-to-Employer Contracting Solution for Self-Funded Health Insurance

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Direct-to-Employer (DTE) offers a delivery program for self-funded health insurance enabling health systems, providers, employers and the insured to all share the benefits and savings. Through reinsurance for losses and employer funding, risk management is optimized to mitigate typical risks found in traditional self-funded plans.

Health Systems and Healthcare Providers are searching for solutions to achieving preferential market share in their community and this is certainly a key to a comprehensive growth plan. This new private-labeled Direct-to-Employer Program links healthcare providers with community employers.

Direct-to-Employer, or DTE, offers a delivery program for self-funded health insurance which enables health systems, providers, employers and the insured to all share the benefits and savings. Through direct reinsurance for catastrophic losses and employer funding, costs can be reduced versus traditional insurance company self-funded plans. The plan looks just like a national insurance carrier health plan with mobile apps, integrated wellness programs, specialized programs for diabetes care, and more.

A large majority of employers fall within the 20-99 size segment and would be ideal candidates for a partially self-funded or a level-funded direct to employer solution. The larger community employers would be presented the opportunity to purchase a self-funded program with specific and aggregate coverage through the DTE program.

This new direct-to-employer solution is a “turn-key” ERISA self-funded health plan with appropriate levels of stop loss insurance, outsourced administration of claims and administrative services, and a data warehouse with appropriate analytics for population health management and deploying successful population health optimization strategies.

There are 4 main reasons why the Direct-to-Employer program is a strategically important addition to any healthcare provider and the larger community it serves:

#1- It levels the playing field with the large payors and allows the development and control over your own network

#2- It provides local employers with a solution they have been asking for – the opportunity to break from the insurers

#3- It provides the Healthcare System and its providers with a robust source of new fees and revenues which includes a large share of the savings

#4- It increases the Provider’s ability to achieve the Triple Aim – improve the patient experience, improve the health of the population and reduce the per capita cost of healthcare.

With the Direct-to-Employer (DTE) program, Providers can create a direct contracting solution that allows employers with as few as 10 employee lives to buy major medical insurance and other ancillary services directly from the Healthcare Provider on a partially or fully self-funded platform. In Pennsylvania for example, 63.7% (Source: EBRI 2016) of all employers are partially or fully self-funded and the trend is moving upward due to negative impacts of community rating and secular trend with fully-insured products being sold. The direct-to-employer platform is created in partnership with Key Benefit Administrators (KBA), Accountable Care Solutions Group, LLC (ACSG), and CSuite Solutions LLC (CSUITE).

The dynamic value the Direct-to-Employer Solution delivers to Healthcare Systems/Providers:

CONTROL – the Provider will have control of plan brand (private label), design, steerage factors, referral protocols, authorizations, and direct input on complex case management, and complete access to all medical service data by every member in the plan.

SPEED TO MARKET & LOW COST OF ENTRY – If a Provider were to capitalize the necessary infrastructure to support a direct-to-employer program and DTE contracting solution on its own, it would cost more than $2 million and take up to 1½ years to deploy. By working through the partnership of ACSG/KBA/CSUITE, a fully deployed and ready-to-market DTE program can take 6 months or less to implement and cost less than $400K.

PROPRIETARY – Because the product is unique to each Provider, a competitive system cannot participate without the Provider’s permission.

FAVORABLE FINANCIALS – Increase in top-line and incremental revenues versus a passive PPO arrangement. Additional revenues under gain-sharing alone can contribute 10% to 12% to top line over any other plan with self-funded employers.

STEERAGE – The plan design incentivizes the member to access the Provider’s network for the least out-of-pocket (OOP) costs.

ATTRIBUTION AND REFERRAL MANAGEMENT – Program requires assignment of a Provider-based PCP at enrollment and requires referrals be authorized for other providers not in the primary network – allowing for control of utilization and attribution of patients.

GAIN SHARING – The Provider can share in 50% savings of an employer plan. A great means of engaging, recruiting, and retaining physicians and nursing resources.

AT THE TABLE – Ability to sit at the table with employers, employer coalitions, and chambers who are paying the bills. Establish the Provider’s brand and control the messaging without interference from payers and vendors.

COMPETITION – Competing effectively with other medical providers.

ACCESS – Complete access to all employer claims, biometric, HRA, RX, and encounters from other providers, etc., via EZView data reporting access – 24/7.

The dynamic value the Direct-to-Employer Solution delivers to Employers:

REDUCED MEDICAL SPEND – In-network Physicians are incentivized through participating in Gain Share savings to reduce the employer’s medical spend

INCREASED FLEXIBILITY – Employer(s) and the Provider control the plan, not the insurer

PLAN DESIGN OPTIONS – Elimination of state mandated benefits

DECREASED TAX LIABILITY – Elimination of most premium tax

A LA CARTE ADMINISTRATION – Administration tailored to the employer’s needs including core competency in complex healthcare administration – 40+ years of self-funded medical experience as well as on staff legal counsel specializing in ERISA law, employer law, and healthcare reform law

INCENTIVIZED CARE RESULTS – Potential Gain Sharing formula with Provider Physicians by way of focus on Evidenced-Based medicine

IMPROVED AND “SUPERIOR” ANALYTICS – Access to detailed claims reporting and analytics including healthcare risk management reports and EZ View technology

AMERICAN HEALTH DATA INSTITUTE – Risk Management through patented Chronic Disease Management (27 conditions and comorbidities)

CARE CONTROL – Active Referral Management

BUNDLED PURCHASING – Ability to select from additional ancillary services offered by the Provider as part of direct to employer bundle

IMPROVED CARE – Better care, quality, and outcomes for employees and dependents

Jointly operated by Key Benefit Administrators (KBA) and CSuite Solutions, DTE is managed and administered by some of the top leadership in healthcare systems and third-party administrators (TPAs) in the world.

For information on how to bring the DTE solution to your health system, contact Stewart Schaffer, Managing Partner, CSuite Solutions at (813) 540-7750.

Contact Info:
Name: Stewart Schaffer
Email: Send Email
Organization: CSuite Solutions
Address: 4830 W Kennedy Blvd STE 600, Tampa, Florida 33609, United States
Phone: +1-813-866-5100

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Source: PressCable

Release ID: 337494