| Cutting out the managed care middleman
| |
| | developed, the advantages of "owning" a
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| and contracting directly with medical
| |
| | network quickly outweigh "leasing" one
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| providers may seem like a drastic
| |
| | from a managed care company. There are
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| solution for reducing health plan costs.
| |
| | no recurring network access fees; less
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| Yet for employers who've been whipsawed
| |
| | physician attrition; fewer employee
|
| by relentless cost increases, it may be
| |
| | complaints; simpler self-renewing
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| the only solution that actually works.
| |
| | contracts; better provider relationships;
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| The profit-bloated managed care industry,
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| | straightforward plan design features; and
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| with much to lose, has propagated many
| |
| | the ability to choose the best
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| myths about why this sensible approach
| |
| | contractors for utilization review, case
|
| won't work. But their solutions haven't
| |
| | management, claims processing, and other
|
| worked. Costs continue to surge and
| |
| | administrative tasks. Managed care
|
| employers are desperately seeking relief.
| |
| | companies have failed to contain employer
|
| A.J. Lester & Associates, Inc. has
| |
| | medical cost increases, despite all their
|
| debunked the myths about direct provider
| |
| | so-called network management efforts.
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| contracting, shedding much needed light
| |
| | Ironically, and coincidentally, managed
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| on this ingenious and innovative
| |
| | care industry profits are at an all-time
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| cost-containment strategy.
| |
| | high while employers continue to suffer.
|
| Myth 1: Employers cannot negotiate as
| |
| | Myth 5: Direct contracting exposes
|
| good a deal with medical providers as can
| |
| | employers to greater liability. The
|
| managed care companies. The truth is
| |
| | truth is direct contracting poses no
|
| employers can often negotiate just as
| |
| | greater risk of litigation than any other
|
| good a deal, or better. Providers
| |
| | benefit program component and may
|
| welcome direct agreements for the very
| |
| | actually offer greater protection against
|
| reason that they are not like
| |
| | it. Direct contracting is intended only
|
| conventional managed care contracts.
| |
| | for self-insured employers whose plans
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| Physicians have complained for years
| |
| | are governed by ERISA, which offers
|
| about adversarial agreements and poor
| |
| | built-in protection against liability.
|
| reimbursements forced upon them by HMOs
| |
| | ERISA preempts state tort laws and limits
|
| and PPOs. This negative perception has
| |
| | the employee's ability to hold an ERISA
|
| created a strong willingness among
| |
| | plan liable for malpractice under state
|
| medical providers to do business directly
| |
| | laws, which govern malpractice, not
|
| with employers. These "win-win"
| |
| | ERISA. Because direct provider
|
| agreements ultimately save employers
| |
| | agreements state the employer is not
|
| money without shortchanging the
| |
| | providing/directing medical care and has
|
| providers. Unlike managed care
| |
| | no role whatsoever in any medical
|
| companies, direct agreements disclose all
| |
| | decision, protection afforded by the
|
| contractual details so both employer and
| |
| | ERISA preemption is safely maintained.
|
| provider know the deal they're getting
| |
| | Myth 6: Managed care companies can't (or
|
| and nothing can be hidden by a
| |
| | won't) process claims for direct
|
| middleman's "cut."
| |
| | networks. The truth is that processing
|
| Myth 2: You need large numbers of
| |
| | claims and administering benefits for
|
| employees to negotiate direct provider
| |
| | employer-owned provider networks are well
|
| contracts. The truth is physicians and
| |
| | within the technical capabilities of
|
| hospitals will often contract with
| |
| | managed care companies. Their feigned
|
| employers for limited numbers of
| |
| | inability to process direct network
|
| employees. When a direct agreement is
| |
| | claims is one of many ways that managed
|
| fair and reimbursement terms are
| |
| | care companies hold their
|
| reasonable, providers quickly realize
| |
| | employer-clients hostage in networks that
|
| it's a smart business decision to work
| |
| | are owned, leased, or arranged by the
|
| with employers in their own community. A
| |
| | managed care companies themselves. If an
|
| local employer, regardless of size,
| |
| | existing managed care company cannot or
|
| represents an established group of
| |
| | will not administer direct network
|
| existing lives as prospective patients,
| |
| | claims, there are plenty of third party
|
| ready to use the direct network
| |
| | administrators (TPAs) than can handle it,
|
| providers. Direct networks have been
| |
| | usually at a lower cost per employee.
|
| successfully developed in areas where the
| |
| | For employers that want direct networks
|
| employer had as few as 30 employees.
| |
| | in select locations (but want to keep
|
| Myth 3: Direct contracting won't work in
| |
| | commercial networks elsewhere), using a
|
| areas where other PPO networks are
| |
| | TPA is a convenient and cost-effective
|
| available. The truth is doctors are sick
| |
| | way to get the job done.
|
| of disadvantageous agreements and
| |
| | Myth 7: Managed care companies do a
|
| miserable reimbursements forced upon them
| |
| | better job containing costs and saving
|
| by managed care companies. They actually
| |
| | employers money. If that was true,
|
| welcome the opportunity to contract
| |
| | employer medical plan costs would be
|
| directly with employers. For many
| |
| | falling instead of rising. The truth is
|
| doctors, the very fact it's an agreement
| |
| | employers who have implemented direct
|
| with the employer, and not a managed care
| |
| | provider contracting are experiencing
|
| company, is reason enough to participate
| |
| | lower costs and higher savings. One
|
| in a direct network. A direct agreement
| |
| | national employer with 20,000 employees
|
| establishes a true business relationship
| |
| | has used direct networks to keep their
|
| between provider and employer, one that
| |
| | health plan cost trend flat for the past
|
| promises the provider quicker
| |
| | five years. Another major employer
|
| reimbursements, better benefit payment
| |
| | reduced its health plan costs by more
|
| levels, and easier access to the ultimate
| |
| | than 20% without reducing benefits or
|
| payer (the employer). It's also a
| |
| | shifting costs to employees.
|
| gesture of good community relations for
| |
| | Bottom Line: Cutting out the managed
|
| any physician, medical group, or hospital
| |
| | care middleman and contracting directly
|
| to demonstrate.
| |
| | with medical providers can help savvy
|
| Myth 4: Direct networks create more
| |
| | employers reduce benefit costs and regain
|
| administrative burdens and higher costs.
| |
| | control over their corporate health care
|
| The truth is once direct networks are
| |
| | plans.
|
