Charlotte, NC, June 18, 2024 — Contigo Health, a distinguished provider of health plan benefits solutions, proudly announces its achievement of a three-year accreditation from the National Committee for Quality Assurance (NCQA) for its Case Management program, which is a fundamental part of Contigo Health® Sync Health Plan TPA (Third-Party Administration). This notable accreditation underscores Contigo Health’s commitment to excellence, innovation, and superior care coordination in the healthcare industry.

NCQA Accreditation standards are developed with input from researchers in the field, the Case Management Expert Panel and standing committees, employers, both purchasers and operators of Case Management Programs, state and federal regulators and other experts.

“Case Management Accreditation moves us closer to measuring quality across population health management initiatives,” said Margaret E. O’Kane, President, NCQA. “Not only does it add value to existing quality improvement efforts; it also demonstrates an organization’s commitment to the highest degree of improving the quality of their patients’ care.”

NCQA Accreditation standards are intended to help organizations achieve the highest level of performance possible and create an environment of continuous improvement.

“This important recognition reflects the unwavering commitment to quality and meticulous attention to detail of Contigo Health’s talented teams. It’s a testament to the clinical expertise and compassion that our 50+ nurses and dedicated staff bring to work each day as they serve our members with skill and heart. Contigo Health’s nurses have always been its superpower,” said Jonathan Slotkin, MD, Contigo Health chief medical officer. “The accreditation process further elevated the care experience we provide. Our team is energized to build upon this achievement as we continue striving to simplify healthcare, improve outcomes, and create value for those we serve.”

“We are immensely proud of our team’s dedication and expertise in achieving this significant milestone,” added John Strickland, Contigo Health CEO. “NCQA Accreditation reaffirms our commitment to upholding the highest standards of quality, efficiency, and accountability in all aspects of our case management.”

For more information about Contigo Health and its NCQA-accredited Case Management TPA services, please visit contigohealth.com, or contact Britt Hayes at britt.hayes@contigohealth.com.
 
About Contigo Health, LLC
Contigo Health, LLC, a consolidated subsidiary of Premier, Inc., is leading the way to financially sustainable healthcare. Contigo Health is a health benefits platform that leads direct-to-employer and direct-to-provider relationships. It is relentlessly focused on revolutionizing healthcare through appropriate, cost-effective, transparent, and thoughtful benefits design. Contigo Health® products include Sync Health Plan Administration, Centers of Excellence 360, Payvider Activation, and ConfigureNet™ Price Advantage, an out-of-network claims cost-containment solution. To learn more, please visit www.contigohealth.com and follow us on LinkedIn, YouTube and X.

About NCQA
NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care. NCQA’s website (ncqa.org) contains information to help consumers, employers and others make more-informed health care choices. NCQA can be found online at ncqa.org, on Twitter @ncqa, on Facebook at facebook.com/NCQA.org/ and on LinkedIn at linkedin.com/company/ncqa.

Publication: The Healthcare Innovation Company (thINc)

March 29, 2021

Amidst the many challenges faced by health systems today, the cost of health care for their own employees continues to loom large. Many health system employers are seeking greater flexibility, transparency, increased domestic utilization, and better clinical and financial outcomes when it comes to caring for their own workforce. If you’ve ever wondered how third-party administration (TPA) could support your employee health benefits objectives, or simply want to know how to make the transition, join the conversation. In this panel discussion, hear how HR and benefits teams can make the leap and develop a mutually beneficial relationship with a TPA. Gain insight into benefit designs tailored to maximize value and align with specific employee needs, all without compromising the quality of care and find answers to the following questions and more.

• How do you as a health system know if your organization is ready to transition to a TPA plan?
• What’s involved with a transition to a TPA?
• How can you operationalize employer-TPA relationships?
• How can direct contracting arrangements reduce unnecessary spend, maximize savings, and improve outcomes?
• How can you adopt a data-centric strategy to make informed decisions about your workforce and deliver quality care?
• How can you increase engagement with the ancillary benefits you already offer your workforce?
• What kind of customization is available to effectively work within your own clinically integrated network, ACOs, and PBMs?
• What conversations should you be having with your leadership?

*Courtesy of The Healthcare Innovation Company (thINc)

How health systems’ employee benefits plans can win the battle to secure greater use of their own healthcare services

The domestic struggle

Not all employee benefit plans are the same. While all benefits leaders want to contain costs by having their plan members access high-value care, the benefit managers at health systems have even more at stake: ensuring their health plan members are turning to the domestic network as much as possible. Certainly, domestic utilization is good for the health system’s bottom line. After all, that means the health plan is accessing the best rates available to them and therefore fulfilling their fiduciary responsibility. But domestic utilization is also an opportunity for health plans to motivate members toward high-quality coordinated care from a trusted team of colleagues. According to a benefits survey of hospitals, 82% of respondents indicated that retaining services within their domestic network is a top concern.¹ Adequacy and access to those domestic services was also found to be a rising priority.²

Despite its clear importance, driving domestic utilization can remain a significant challenge for health systems. For instance, their plan members may have existing relationships with nondomestic physicians they trust. In turn, those physicians can be inclined to steer patients toward the specialists the physician knows and trusts (and who may not be within the domestic network). In the end, plan members, including health system employees, may simply choose nondomestic providers based on physician relationships and referrals, even if that care comes at an increased cost. In the evolving healthcare environment, the domestic utilization challenge may be further compounded as health systems attempt to manage the trend toward an increasingly remote workforce spread across a broader geographic footprint—especially when those employees need access to specialty care.³

To get referring physicians to be open to referring to the health system’s own physicians, there is much that can be done to help domestic—and nondomestic— PCPs get to know more about the health system’s docs and be more inclined to refer to them. Here are a few ideas for health systems and health plans:

• Leverage physician profiles to familiarize referring physicians and their patients.
• Provide referring physicians with physician directories (organized by specialty area) so they can more easily help patients identify the right Tier One specialist for them.
• Consider hosting meet-and-greet events that introduce referring physicians to the team of Tier One physicians.
• Educate PCPs about the integrated and coordinated care advantages the health plan is uniquely able to provide to members when they choose treatment within the health system.
• Remind the referring PCPs that out-of-network care can cost their patients significantly more money out of their own pocket.
• Consider ways to recognize PCPs within the system that are doing a great job of supporting domestic utilization and contributing to giving health plan members the best possible care, experience, and value.

If the network of domestic PCPs is limited, so too are the opportunities to drive domestic referrals. A health system can benefit by having a broad network of referring physicians who are tied to the health system, and by making it more attractive for health plan members to engage those physicians. Consider these approaches:

• Build a robust presence of domestic PCP practices within the domestic network. These can include employed or independent practices that are part of a clinically integrated network or even virtual primary care.
• Establish employee on-site/near-site clinics that utilize an advanced primary care approach that can help attract members.
• Consider offering incentives to encourage members to establish a longitudinal PCP relationship, including annual checkups.

If health systems have not established a pricing distinction between their own domestic care and that of nondomestic providers, they may be missing out on a powerful opportunity to positively influence their health plan members. How so? If a provider-sponsored health plan has not established a tiered pricing approach to benefits, there is little keeping the health plan’s members from routinely seeking care elsewhere. With a tiered pricing approach, the health plan creates a cost differential that makes use of its own domestic providers more affordable than use of nondomestic options. This simple pricing factor helps to make domestic utilization more attractive while creating some level of disincentive around nondomestic providers in the interest of prompting plan members to rethink going elsewhere for care.

It is important to note that while tiered pricing can be effective in identifying an important contrast between domestic and nondomestic care, the cost differential alone is not likely enough to solve the domestic utilization challenge.

• Create physician bios and promote them.
• Produce simple videos that feature the clinician talking about their specialty, their background and qualifications, their passion for helping people, and even their personal interests. Such videos can make an unfamiliar physician more approachable, credible, likable, and easier for members to choose.
• Showcase the health system’s physicians through stories in employee- and plan-member-facing communications (e.g., newsletters).
• Consider establishing objective quality score information to provider directories and search tools.
• Post clinician and/or clinical team bios in the physical spaces where employees will see them regularly.
• Leverage plan member testimonials.
• Explore ways to engage health plan members to solidify their appreciation of the quality of care that is available within the boundaries of their own health system.

The path to selection of Tier One clinicians should be a simple and straightforward one. Health systems can make it easier for prospective patients—including their health plan members—to find a physician and make an appointment by establishing a patient-friendly find-a-physician function on their website that includes a simple “schedule now” function. Combined with the physician bios, videos, and other elements designed to build patient knowledge, confidence, and comfort levels, health plan members can find it much easier to find the right physician for them and make an appointment for consultation.

Perhaps one of the most effective ways to create demand for domestic care is to demonstrate ways in which the patient experience is unsurpassed. Every investment into the member experience contributes to the likelihood that plan members will not only appreciate the care and support but may also share how special the experience was. The member experience can be one of the most powerful ways of establishing advocates for domestic utilization (and, when done poorly, can also be a significant deterrent to domestic utilization). By engaging a specialty third-party administrator such as Contigo Health, a health plan can seamlessly integrate proven member engagement and support components that can quickly enhance the member experience. Working as a “connector,” Contigo Health enables integration between payor and provider. Contigo Health® Sync Health Plan TPA services integrate clinical data into care management programs, such as integration of patient tools like patient portals that include convenient health plan member tools for a one-stop “digital front door.” When possible, there is also integration of third-party data back into the clinical setting, including data from pharmacy, wellness, and disease management programs.

There are certainly benefits to employees and their dependents in simply being part of a health system. The health system may want to package those advantages as a domestic center of excellence that delivers exclusive benefits to its own health plan members. By adopting this “Tier Zero” approach, the health plan can position its own health system as a center of excellence (COE) dedicated exclusively to the core needs of its health plan members, giving the health plan an opportunity to promote select care and support services and added-value components that are only available to the health system’s employee benefits when members choose to see a domestic care provider.

The health plan can also use virtual care to provide its employees and dependents with confidential access to behavioral health services. Telehealth can be a valuable and convenient way to engage plan members for primary care and urgent care, which can then refer any follow-up care back to the Tier One domestic network.

Recognizing that 100% domestic utilization is not a practical objective (and even if it were, it would likely trigger member pushback), the health plan should anticipate at least some level of nondomestic care and do all it can to make that care as cost effective as possible. Of course, not all health systems are alike and network and provider contracting needs can vary from case to case, but a viable solution can include a mix of national primary networks, negotiated contracts, and primary supplemental offerings. Through such relationships, a health plan can go far to ensure that when members can’t use the domestic network, they are still able to access high-value care.

A good option for out-of-network care when plan members go beyond the domestic footprint is a national wrap network solution such as the ConfigureNet™ provider network from Contigo Health, with its expanding roster of specialists across the U.S. from coast to coast, all of whom have agreed to pre-negotiated rates. That’s also a good time to consider adding specialty travel centers of excellence to the network mix as well, such as those offered through the Contigo Health® Centers of Excellence 360 solution.

With an established network strategy in place, plan members will have access to the high-value care they need, whatever that is and wherever they are. Through negotiated pricing and by strategically setting pricing across the tiers, health plans can motivate their members to pursue appropriate care, with domestic resources being the most attractive when possible.

A health-system-sponsored employee health benefits plan is a unique entity. That alone may be all the argument needed to support the decision to engage a third-party administrator that intimately understands health systems and knows the ins and outs of driving domestic utilization.

Contigo Health, for instance, is a health plan benefits solution company that was born out of the healthcare industry. (Contigo Health is a consolidated subsidiary of Premier, Inc.) The organization’s Sync Health Plan TPA product was developed specifically to help health systems optimize their health plan benefits, grow domestic utilization, and manage escalating cost trends. Contigo Health has more than 25 years of experience working directly with top health systems across the U.S. In fact, 70 percent of its TPA clients are health systems.

Through the Sync Health Plan TPA solution, Contigo Health is making strides to uncomplicate the complicated for many provider-sponsored health plans by offering:

• Plan management for a complex and rapidly evolving healthcare environment.
• A tailored approach through a specialty TPA designed for health systems that has solutions to meet their unique priorities.
• A heightened emphasis on domestic utilization and cost management for employer- and provider-sponsored health plans.
• Exceptional data and analytics through Sync Health Plan Intelligence powered by Cedar Gate Technologies, Inc.
  • High data integrity
  • Powerful quarterly and annual reporting
  • Intuitive dashboards
  • Meaningful benchmarks to help set goals and gauge plan performance
  • Identification of improvement areas and addressable plan performance issues
• Support in overcoming barriers health plans often face within their organizations, including limited internal benefits administration expertise, organizational concerns regarding disruption of relationships, and more.
• Access to a nationwide provider wrap network across the U.S. at pre-negotiated rates to fill any gaps in domestic care services.
• Cost containment for inevitable out-of-network care via ConfigureNet™ Price Advantage.

The domestic victory.

In addition to claims cost containment, domestic utilization adds another layer of priority and complexity for health systems that have their employee benefits plans. Fortunately, those health plans have options that can help them grow domestic utilization and cut costs when out-of-network care is required. By placing greater emphasis on tracking domestic and nondomestic utilization metrics, instituting strong incentives that encourage domestic-first thinking among plan members and referring physicians, and establishing direct contracts and configurable Tier Two network relationships, the health system’s employee benefits plan can go far to achieve its objectives. Integrating a TPA that is designed around health systems by an organization born out of the healthcare industry can help ensure that the unique needs of the health system and its employee benefits plan are met most directly and efficiently.

1. Aon. Aon 2022 Benefits Survey of Hospitals. October 30, 2023. https://insights-north-america.aon.com/healthcare/aon-2022-benefits-survey-of-hospitals-report
2. Ibid.
3. Ibid.

Part 3 of 3: How to make your payvider solution a reality

Read Part 1: What Is a Payvider, and Why Should Health Systems Make Their Strategic Move Now?

Read Part 2: What is the Business Impetus to Become a Payvider?

If you are a health system leader, you may be convinced that the payvider model is a good idea whose time has come for your system. But now what? You want it to work, but how can you get it started, and what all is it going to take to make it a reality, especially on top of your day job? In this final installment of our payvider series, we will look at the practical aspects of establishing a payvider solution, including how to leverage assets that may already be in place, determining what additional components will need to be created, and tapping into the expertise of resources that can be invaluable in helping to get the job done and done right.

The place to start when launching a new health plan offering is to leverage current strengths to the health system’s advantage and to ensure that the right expertise and partners are engaged to help avoid common pitfalls. Fortunately, most health systems already have a substantial number of elements already working for them. Virtually all health systems have existing strengths that make them well positioned to give employers and their health plan members the “Triple Aim” of cost, quality, and experience. In thinking about their own organization, they should consider the value of the trust and goodwill that have been established by the health system over the course of years within their local community. Chances are they have earned strong market recognition and brand loyalty that can be leveraged in a payvider solution. Additionally, every health system has clinical areas where it excels and where it can truly be said to offer the highest-quality care in the region. Whether it’s a robust and successful primary care model, cutting-edge clinical trials, or world-renowned surgeons, knowing your strengths is a key component to success. Leaders are encouraged to take a fresh look at their organizations and consider the value that they may currently take for granted.

In order for a health system to create the essential high-functioning integrated delivery and finance systems it will need as a successful payvider, the following five functional actions are essential:

Health systems embarking on the payvider journey will find it beneficial to go all in on “systemness”—in other words, committing to integration. An example of systemness is the sharing of data and patient information; shared best practices and clinical pathways; team-based care, including both primary care physicians and supporting providers such as nurse practitioners; integration of behavioral health and medical care; and better assimilation of primary care and specialty care.

As Robert Pearl wrote in reference to the recent Kaiser acquisition of Geisinger and the formation of Risant Health, Geisinger will need to incorporate the fee-for-service community providers that it relies upon today more formally into the delivery system if it is to be successful.¹  In his words, “To meet the healthcare needs of most its patients, Geisinger relies on community doctors who are paid on a fee-for-service basis. Generally, the fee-for-service model is predicated on the assumption that higher quality and greater convenience require higher prices and increased costs. With Geisinger’s distributed model, it’ll be very difficult to deliver consistent, value-based care.”

The 2021 HFMA Health Risk-Based Healthcare Market Trend report identified “data integrity, reporting, and the cost of technology” as the leading internal challenges for health systems pursuing increased levels of risk.² In fact, data was named more often than collaboration, scale, and difficulty achieving quality/cost outcomes. That HFMA survey also highlights several specific mission-critical roles data plays for the health system as payvider. For instance, bringing together clinical and claims data sources effectively delivers the highest value for both sides of cost and care. That stated, it also requires significant investment in both sophisticated technology and expertise. From the perspectives of clinical care, cost efficiency, and consumer experience, establishing the appropriate types and combination of benchmarking, analytics, reporting, and clinical technologies is vital to making smart, collaborative payor-provider decisions. Additionally, having quantifiable intelligence that reaches beyond your health system and health plan members provides rigor when establishing strategies that bridge cost, quality, and operational areas of the provider-sponsored health plan. Only at this level of data analysis are leaders able to align provider incentives that facilitate further investment in preventive care and quality management. Securing actionable intelligence that can improve outcomes, support enhanced financial performance, and enable success in new, alternative payment models is what will make managing an integrated risk-based approach possible.

The payvider will also need to decide if they want to recreate some of the traditional care management functions common to payors, such as case management, disease management, and utilization management. Depending on the plan design, payment method, and “systemness,” health systems functioning as payviders may be able to eliminate most or all these oversight functions by incorporating tools such as clinical decision support, clinical pathways, and risk transfer to ensure the care being delivered meets the goal of the Triple Aim (cost, quality, and experience). Health systems would also be well served to take a good, hard look at their cost structures and determine what shifts may be necessary. For instance, health system payviders may want to offer a combination of fee-for-service and value-based care, especially in early years. The health system as payvider can be the powerful and much-needed catalyst for payment reform. Capitation is an excellent way for health system payviders to capture the value they create in “value-based care.” Capitation allows health systems to evolve their facilities and staffing models beyond a focus on the services delivering the highest reimbursement and on to those services that best meet the needs of their community.

Regardless of the preferred payment methodology, to be a successful payvider, health systems must be able to manage the cost trend. Effective ways to accomplish this include eliminating low-quality and inappropriate care, using digital enablement and team-based approaches to make care delivery more efficient, promoting early intervention with health plan members to improve outcomes, and establishing a true cost-based accounting system to understand more accurately what the “cost of goods sold” is and, from there, know how to set fair and transparent prices for each. Even with the aid of these tools, payviders will still need to have effective ways to communicate and connect with members. Such communication can be enabled by digital support systems that are designed to help providers give health plan members the little nudges they need to adopt healthy behavior—whether that be medication compliance, lifestyle choices, or helping them determine whether to pursue conservative treatment versus surgery.

Understanding how employer health plans work and what employers want most is the leaping-off point. To meaningfully approach and engage prospective employers, one must know what pains they are experiencing and what is needed most from their health plan for both members and their business. Such understanding can begin with introspection into your own health system’s experience as a sizable employer in the community that operates its own self-funded health plan for employees. Beyond tapping into that firsthand knowledge, below are a few other things to consider.

Along with their concerns about rising costs of care, employers are also highly aware—and reasonably anxious—that their employees do not enjoy optimal health. Factors such as medical history, environmental factors, social determinants, lifestyle, and more are at play and are largely out of the employer’s control.
Unfortunately, the programs and benefits that employers invest in and put in place to mitigate these factors are commonly underutilized.⁶ With less-than-optimal employee health compounded by high costs of care, it is no wonder employers are placing stronger focus on employee well-being and benefits engagement. A 2023 Forrester Consulting study indicates that 80 percent of HR and EX professionals surveyed place increased emphasis on improving health benefits offerings, growing awareness of benefits, and making access easier.⁷ Even so, utilization remains low.⁸

Beyond the employers themselves, it is essential to understand the brokers and consultants who work closely with employers as trusted advisors. It will be critical to know how to win their respect and trust so they won’t become a barrier between the health system and targeted local employers (and they can be a barrier if they are not engaged in the process early on). Instead of viewing the broker as an obstacle, health system leaders should consider the value brokers can bring as a source of precious insight into the targeted employer. If trust is established between the health system and broker—and the broker can see the value in what is being offered to their employer client—they can be an ally to the payvider. In fact, when approached properly, brokers and consultants can become the health system’s gateway to the employer and may even serve as an advocate and/or point person.

Once employer relationships are secured, it will be tremendously valuable to provide meaningful, timely reporting to all employer groups. One of the best ways to differentiate the health system payvider from traditional payors is to consistently and proactively deliver extensive, transparent reporting as well as access to data for those employers who prefer to do their own analytics. Remember that employer sales cycles are annual, but employers often begin their search for the next health plan carrier a full 18 to 24 months in advance of that plan going live. To put that in perspective for the health system just embarking on its payvider solution, it can take several years to form a health plan, have a pilot client (such as the health system’s own employee health plan), show the results, and develop a pipeline of prospects. Having a defined and disciplined approach to payvider development is crucial since slow decision-making, missed deadlines, or unclear objectives can result in lengthy delays and, most important, missing these long-term sales cycles and the opportunities they represent.

You, the health plan leadership, need an experienced health plan/payvider leader to work with you, along with a dedicated team of specialists that includes:

• Health plan executive (leader)

• Legal, compliance, regulatory, and privacy

• Analytics

• Population health

• Business development

• Network/provider

Each of those areas needs to have at least one person on the health plan side dedicated to managing and overseeing vendors. This should not be someone from the health system attempting to do the job in addition to their regular job responsibilities; it is a full-time commitment and must be a dedicated resource without other obligations. While the requirements to establish the payvider model may feel overwhelming and the mountain of details may seem insurmountable, health system leaders need not go it alone. They can find it tremendously valuable to align with a knowledgeable strategic partner who is equally committed to realizing the health system’s payvider vision, to creating a sustainable healthcare ecosystem, and to putting providers back in the driver’s seat of care.

Having a knowledgeable partner and a solution that is designed to provide a comprehensive approach and all the components needed certainly makes establishing a payvider solution more attractive and achievable. And knowing that the healthcare ecosystem status quo will not be a sustainable long-term solution for health systems wanting to be both viable and vibrant in the years to come is the impetus to make the move now while the market is favorable. Becoming a payvider is not a journey to be taken lightly, but it can be a tremendously rewarding one, especially when the effort is supported by knowledgeable payvider specialists who can help ensure everything is done properly.

Sources:

1. Forbes. 2023. “Value-Based Healthcare Battle: Kaiser-Geisinger Vs. Amazon, CVS, Walmart.” July 2023. https://www.forbes.com/sites/robertpearl/2023/07/17/value-based-healthcare-battle-kaiser-geisinger-vs-amazon-cvs-walmart/?sh=38cabad16417. Accessed 11/03/2023.

2. Guidehouse. 2021. “2021-22 Risk-Based Healthcare Market Trends.” November 2021. https://guidehouse.com/-/media/www/site/insights/healthcare/2021/gated/2021-risk-based-healthcare-market-trends.ashx. Accessed 11/03/2023.

3. Health Care Cost Institute. 2023. “Healthy Marketplace Index.” June 2023. https://healthcostinstitute.org/hcci-originals/healthy-marketplace-index/hmi. Accessed 11/03/2023.

4. TechTarget/RevCycle Intelligence. 2023. “Median Per-Person Healthcare Spending Exceeds $6K.” July 2023. https://revcycleintelligence.com/news/median-per-person-healthcare-spending-exceeds-6k. Accessed 11/03/2023.

5. Health Affairs. 2008. “The Triple Aim: Care, Health, and Cost.” June 2008. https://www.healthaffairs.org/doi/10.1377/hlthaff.27.3.759

6. HLTH. 2023. “The Business Case for Boosting Benefits Engagement: Improving Employee Wellness, Retention, and the Bottom Line.” June 2023. https://www.hlth.com/digital-content/hlth-matters/blog/the-business-case-for-boosting-benefits-engagement-improving-employee-wellness-retention-and-the-bottom-line. Accessed 11/03/2023.

7. Ibid.

8. Ibid.

9. Kyruus Health. 2022. “Becker’s Payer Roundtable Recap: Are Payviders Supervillains or Superheroes?” November 2022. https://kyruushealth.com/beckers-payer-roundtable-recap/. Accessed 11/03/2023.

10. Ibid.

© 2024. Contigo Health, LLC. All rights reserved.

Part 2 of 3: What is the business impetus to become a payvider?

Read Part 1: What Is a Payvider, and Why Should Health Systems Make Their Strategic Move Now?

Read Part 3: How to Make Your Payvider Solution a Reality

Becoming a payvider offers financial value, such as driving additional revenue for the health system, as well as strategic value. That can include building the health system’s brand and position, developing relationships with regional employers and individuals, and providing greater control in negotiations with other payors. Perhaps most important, it can give health systems the opportunity to lead in healthcare reform by providing them with a mechanism to align incentives and deliver high-quality care at a fair price.

Be a catalyst for change

While medicine continues to make great advancements in the twenty-first century, healthcare providers largely remain stuck in an outdated twentieth-century health system construct. Most health systems continue to carry the burden of enormous overhead and human resource fixed costs. Meanwhile, population health needs are becoming increasingly less episodic and more longitudinal, setting the stage for long-term management of chronic conditions (e.g., metabolic disease, behavioral health, and subacute conditions such as autoimmune diseases and some cancers). However, the archaic health system construct is simply not set up to deliver the care needed in today’s rapidly evolving landscape. Here are just three examples of how the construct is mismatched to today’s needs, capabilities, and market demands:

1. Health systems are heavy on facilities, but a significant portion of care can now be delivered effectively as outpatient or in-home.
2. Care delivery models are overly physician-centric and would benefit by evolving to leverage other qualified providers, including nurse practitioners and pharmacists, to deliver care where appropriate.
3. Current practices do not take advantage of available technology and remain too focused on the in-person visit rather than taking advantage of asynchronous communication and automation of repetitive tasks.

For a payvider, the incentives are all aligned for health system leaders to drive real change—not just payment reform, but also care transformation. By consolidating both delivery and finance under one strategic leadership team, payviders create opportunities to reconstruct the system and make progress toward the Quadruple Aim.

Build the brand and defend the strategic position

Becoming a payvider can enable a health system to regain control and create a strategic moat around themselves that can help prevent other payors or disrupters, such as independent direct primary care or virtual care companies, from significantly impacting their markets. The payvider model can also create a desirable “sticky” ecosystem that encourages high loyalty from both patients and referring physicians, leading to sustained revenue streams and growth. Because the payvider model puts the provider in the driver’s seat, health systems are better able to drive care transformation, enabling them to do the right thing for the patient while simultaneously contributing to much-needed payment reform. It’s what some might call a win-win scenario.

Establishing a baseline

What might the numbers look like for an average health system? Let us begin by establishing a workable baseline. Considering national averages,¹ we can approximate the numbers for health plan membership in the United States:

• Administrative and network access costs are approximately $40 per member per month (PMPM)
• Wellness and disease management programs beyond core health plan fees (a.k.a. buy-ups) are about $4 PMPM
• Care-delivery fees average about $5,904 per member per year (PMPY)*

*The above is based on a report from the Kaiser Family Foundation indicating that the average employee total annual premium for health insurance in the U.S. is $7,380.² Since administrative costs and profits account for about 20 percent of that premium, the amortized care costs per health plan member per year would be $5,904.

For our hypothetical example, we will apply those figures to a midsized health system in a top-25 midwestern city having 2,000 beds and 18,000 employees.

In Year One, by applying its payvider solution only to its own employees, the average midsized health system could expect to see a combination of savings and cost avoidance totaling close to $65 million.

In this reasonable Year Two expansion scenario, the health system adds 20,340 lives beyond those already within its own employee plan. Those additional nonemployee lives generate $9,763,200 in core health plan administration fees, delivering a 5 percent margin of $488,160. They also generate $976,320 in disease management program fees, producing a 10 percent profit of $97,632. The prepaid primary care, billed at $400 per member per year, generates $8,136,000 in care delivery. All care that falls outside of the scope of primary care is estimated at $4,500 per life annually, adding up to $91,530,000. Assuming that 80 percent of that care is to be delivered domestically (after all, the payvider influences domestic utilization), that equates to $73,224,000. If the health system historically claimed 50 percent of the market, it can be assumed that 50 percent of that care, or $36,612,000, is net new revenue for the health system.

Building on the success and momentum of Years One and Two, the health system can realistically continue to expand the growth of its payvider program’s nonemployee lives by 20 percent, reaching 24,408. Applying the same revenue line items presented in the Year Two example, the revenue opportunities become increasingly attractive in Year Three.

With continued focus on growth, building on three years of successes, the payvider continues to establish 20 percent growth each year, resulting in new care revenue streams reaching $63,265,536.

Additional Growth via a National Narrow Network

In addition to the care revenue generated by the growing volume of lives covered by the health system’s payvider health plan, the payvider may want to consider participating in a national network composed of other payviders and health systems. As a member, the payvider can work together with others to win national account business, accelerate growth, and generate fees for members who live outside the current reach of the health plan’s service area. Conversely, the payvider can also generate additional care revenue at fair rates for those lives covered by other payviders within that narrow national network.

Contigo Health is a consolidated subsidiary of Premier, Inc. and is committed to leading the way to financially sustainable healthcare. As a health benefits platform that leads direct-to-employer and direct-to-provider relationships, Contigo Health is relentlessly focused on revolutionizing healthcare through appropriate, cost-effective, transparent, and thoughtful benefits design. One of those solutions is the Contigo Health® Payvider Activation program, which was developed to give health systems a comprehensive, turnkey payvider activation solution that presents everything needed to build and grow their own payvider program with confidence while minimizing risk.

Part Three of this three-part series will explore how health systems can operationalize a payvider solution and make it work while still managing their full-time responsibilities.

Sources:

© 2024. Contigo Health, LLC. All rights reserved.

The partnership provides a seamless experience for patients every step of the orthopedic care journey while bundling costs for medical claims savings for employers and their health plan members.

NEW YORK, December 7, 2023 /PRNewswire/ — Vori Health, a nationwide virtual-first specialty medical practice and industry leader in the treatment of muscle and joint pain today announced a partnership with Contigo Health, a health benefits platform that leads direct-to-employer and direct-to-provider relationships, to create a comprehensive musculoskeletal (MSK) benefit solution. The highly-integrated program designed for self-funded employers combines Contigo Health’s orthopedic surgical Centers of Excellence (COE) program with Vori’s award-winning virtual non-operative MSK care model—creating a single, evidence-based benefit solution that aims to improve outcomes and lower costs for millions of employees struggling with back and joint pain nationwide.

“Giving patients access to the right care at the right time is what this program is all about,” said Vori Health co-founder and CEO Ryan Grant, MD. “It’s the key to driving value in this space. Nothing of this level of comprehensive support exists in this industry. We are excited to partner with forward-thinking companies like Contigo Health to bring this program’s unparalleled access to appropriate care to companies nationwide.”

Known as the Contigo Health Centers of Excellence 360 Orthopedics Program, the new offering provides members of self-funded employee health plans with a seamless experience for every step of the orthopedic care journey. Enrolled members experiencing issues like back, hip or knee pain gain access to convenient telehealth treatment including physician-directed screening for surgical readiness, adequate non-operative care such as virtual physical therapy and nutrition counseling, medical optimization to prepare appropriate candidates for surgery, and post-operative programs to get members back to work and life as quickly and safely as possible. Members who could benefit from surgery have access to Contigo Health’s Centers of Excellence network of high-quality, highly vetted surgical partners. All of these services are offered to employers as bundles for ease of administration, accountable utilization and more predictable healthcare costs.

“Pain is a massive issue for U.S. employers, and inadequate access to appropriate, non-operative care is fueling the problem,” added Contigo Health President and CEO, John Strickland. “We are thrilled to partner with Vori Health and address this underlying issue head on. By integrating our solutions, we’re able to give our clients and their health plan members the comprehensive care and convenient access they need to contain costs and improve outcomes for every step of the care journey.”

This partnership comes at a critical time for employers. One out of every two adults in the U.S. suffers from back and joint pain, making MSK issues the top cause of global disability and rising healthcare costs. While surgical COEs have ameliorated some of these pain points for employers in recent years, adequate access to evidence-based non-operative care remains a core problem. Studies show that 50 percent of lumbar spine surgeries are still deemed unnecessary, and as many as four in ten patients who undergo surgery did not receive first-line physical therapy.

“Orthopedic care is often a siloed, confusing and frustrating system for patients to navigate,” added Vori Health co-founder and Chief Medical Officer Mary O’Connor, MD. “Even in our most elite hospitals, too many individuals go to the operating room unnecessarily or without the proper preparation. Those are risk factors we can and should change. We’re thrilled to partner with Contigo Health to change this standard and make orthopedic care the way it should be—patient-centered, evidence-based and accessible.”

“Contigo Health has been a forerunner in the Centers of Excellence category,” concluded Contigo Health Vice President, Centers of Excellence, Heather Ridenoure. “We are proud of our programs’ outcomes and commitment to appropriate care. But we also know that surgery isn’t for everyone. And non-surgical candidates aren’t getting the support they need from the healthcare ecosystem. Our next generation Orthopedics program joins our line of other hybrid programs, including those designed to address Cancer and Substance Use Disorders, to help participants increase their speed to comfort and access high quality care that’s tailored to their needs. Vori Health is an important partner in this work.”

About Vori Health‍

Vori Health is a specialty medical practice delivering a virtual-first musculoskeletal (MSK) solution to help members get back to their lives faster. As the only nationwide MSK practice with doctor-led care teams, Vori Health is the most convenient way to access appropriate care for back, neck and joint pain without bouncing around the healthcare system. Whether members need a diagnosis, non-opioid prescription, personalized physical therapy or health coaching, they can turn to Vori Health for evidence-based care and effective end-to-end support. This holistic model reduces unnecessary surgeries, enables faster recoveries and lowers MSK spend with up to a 4:1 ROI. For more information visit www.vorihealth.com.

About Contigo Health, LLC

Contigo Health, LLC, a consolidated subsidiary of Premier, Inc., is leading the way to financially sustainable healthcare. Contigo Health is a health benefits platform that leads direct-to-employer and direct-to-provider relationships. It is relentlessly focused on revolutionizing healthcare through appropriate, cost-effective, transparent, and thoughtful benefits design. Contigo Health® products include ConfigureNet™, a network with over 900,000 providers across 4.1 million U.S. locations, Sync Health Plan TPA, Payvider Activation, and Centers of Excellence 360. To learn more, please visit www.contigohealth.com and follow us on LinkedIn, YouTube and Twitter.
 
Media Contacts
Vori Health
Carrie McCulloch, MD
pr@vorihealth.com

© 2024. Contigo Health, LLC. All rights reserved.

Part 1 of 3: What is a payvider, and why should health systems make their strategic move now?

Read Part 2: What is the Business Impetus to Become a Payvider?

Read Part 3: How to Make Your Payvider Solution a Reality

A payvider is perhaps best described as an integrated delivery and finance system. In other words, it is an entity that sells and administers a health plan product and then delivers the associated care. It is both payor and provider (thus “payvider”).

The payvider solution works with a wide range of health plan structures, including self-insured groups, fully insured groups, individual and small groups, Medicare Fee-for-Service, Medicare Advantage, Medicaid, and more.

There are three payvider models:

Model #3, the provider plan, puts the health system squarely in the driver’s seat, while models #1 and #2 take the provider out of that position of control. The joint venture and insurance company as provider models have rarely resulted in either financial stability for the health system or true care transformation.¹ Instead, they now represent the “corporatization of American healthcare,” a scenario in which providers are increasingly managed (versus managing) throughout the process and much of the value created is absorbed by the intermediaries versus being shared among providers, employers, and health plan members. The provider plan model is designed to mitigate those issues.

There are many reasons for a health system to become a payvider. First and foremost on many health systems’ minds are financial viability and stability. A payvider strategy can help health systems achieve that. Health systems that become payviders have the opportunity to build strong bonds with self-funded employer groups, thereby capturing market share and improving their payor mix. They can also add diversified revenue through administrative and program fees, as well as drive a significant cost savings on one of their organization’s largest expenses: their own employee health plan.

But the real motivation for becoming a payvider is the opportunity to drive care transformation through payment reforms and eliminating misaligned incentives and structural barriers, such as compensation design, that prevent many providers from delivering the best care in the most efficient manner.

Economics and healthcare market forces stimulated the need for innovations such as payvider solutions, but it is advanced data and analytics that have made them viable. Bringing clinical and claims data together can:

• Deliver high value for both cost and care
• Help enhance financial performance while also improving outcomes
• Empower collaborative decisions around clinical care, cost efficiency,
  and the consumer experience
• Support new, alternative payment models
• Guide and motivate investment in preventive care and quality management²

Such data can aid the primary care physician and full care team in guiding patients throughout their care journey. Further, benefit design and a network tiering structure can be optimized by data, helping to drive domestic utilization and promote use of in-network providers.

Additional advantages can include:

• Benefit and reimbursement strategy focused on advanced primary care, patient-centered medical home care, and preventive care
• High-value prior-authorization strategy, integrated communications, and situational rules, such as “gold carding”
• Integration of ancillary benefits, including pharmacy, dental, and vision, to support whole-person care

Health systems are feeling the need for change

Labor expense and shortages are now everyday trials. Capital markets are changing as bonds are downgraded. Traditional contracting is no longer working as payors increasingly squeeze providers. More than ever, health systems must make a positive impact, both financially and strategically. Unfortunately, many simply continue to rely on traditional approaches in this nontraditional environment, somehow expecting different results.

Cutting operating costs while discreetly raising prices, for instance, or adding ancillary services are merely short-term fixes. Instead, health systems needing healthy change must embrace a different strategy.

According to The Keckley Report,⁴ there are three distinct changes that providers must make now to find success in the future state of healthcare:

1. Creating regional systems of health via cooperation among public health and health-delivery entities in the interest of sharing data and resources across multiple organizations
2. Increasing competitive strength in price and value, made possible through the integration of financials and care delivery
3. Emphasizing greater accountability by health plan members, fueled by infusing self-care in care management

While health systems might have found it challenging to initiate their own payvider solution in the past, technology, regulation, and market dynamics have now shifted to health systems’ favor.

Today data integration is much improved thanks to more health information exchanges and fast healthcare interoperability resources data standards. There is greater information integration into electronic medical records, meaning that benefit design information, prior authorization, and preferred providers can now be integrated into clinical decision support systems. Meanwhile, the maturation of artificial intelligence and machine learning are accelerating next-best-actions tools, improving diagnostics, and enhancing population health trends.

On the regulation front, lawmakers are paying closer attention to healthcare affordability, access, and equity. New pricing-transparency requirements call attention to disparate rates between hospitals and payors and are driving normalization of market rates (all of which are addressed by the payvider solution).

At the same time, employers are growing increasingly frustrated as conventional approaches are no longer effective. Employers are now confronted with an aging employee population⁵ stricken with metabolic disease and chronic conditions including obesity, diabetes, and musculoskeletal issues.⁶ Younger employees are facing a higher incidence of cancer.⁷ Behavioral health and substance use disorder issues have exploded since the pandemic.⁸

Employers are ready for a better solution. Beyond the factors making it practical to initiate a payvider solution, there are also emerging opportunities for health systems who do so. With more providers entering the value-based care space come new occasions to create mutually beneficial arrangements. For instance, syndicate networks bring regional health systems together to enable access to high-quality, high-value care outside of a single hospital service area. Health systems also have the opportunity to create a payvider network, with each participating health system offering reciprocal care and rates in the interest of serving employer groups having multiple locations, remote workers, or travelers that extend the call for care beyond the local service area.

By creating a national primary network, payviders can eliminate dependence on specialty wrap networks.

Kaiser Permanente, as of June 30, 2023, has a health plan with 12.7 million members (up 81,000 members since December 31, 2022),¹⁰ an annual operating revenue of $95.4 billion in 2022,¹¹ and a high market share, including the highest rankings in six key regions.¹² According to Forbes, in 2023 the plan earned an average grade of 4.3 out of 5 from the National Committee for Quality Assurance.¹³ Kaiser Permanente continues to earn a strong reputation for its blend of low cost and high quality,¹⁴ thanks to the integration of health plan and care systems and its focus on prepaid (capitated) products, including HMOs and EPOs.

While many health systems view the payvider solution as a daring new model, the reality is that this concept has been around in the healthcare environment for nearly a century. Although the term “payvider” was still decades away, the model was introduced in the 1920s.¹⁸ With the onset of the Great Depression, providers initiated the original form of health insurance, offering care services to individuals on a prepaid basis.¹⁹ It was the first employer-sponsored hospitalization plan and the forerunner of the modern HMO, a strong idea that led to the creation of Blue Cross organizations.²⁰

© 2023. CONTIGO HEALTH, LLC. ALL RIGHTS RESERVED.

Sources

1. Fierce Healthcare. 2018. “More providers enter joint ventures with insurers to create health plans.” February 2018. Link. Accessed August 31, 2023.

2. West Monroe. 2022. “2023 Outlook: The Future of the Healthcare Industry.” December 2022. Link. Accessed August 30, 2023.

3. Change Healthcare. 2018. Report: “Finding the Value: The State of Value-Based-Care in 2018.” June 2018. Link. Accessed August 30, 2023.

4. Paul Keckley. The Keckley Report. July 11, 2022. Link. Accessed August 30, 2023.

5. U.S. Bureau of Labor Statistics. 2022. “Employment Projections: Median Age of the Labor Force, by Sex, Race, and Ethnicity.” September 2022. Link. Accessed August 31, 2023.

6. National Library of Medicine. 2021. “Metabolic Syndrome Incidence in an Aging Workforce: Occupational Differences and the Role of Health Behaviors.” July 28, 2021. Link. Accessed August 31, 2023.

7. City of Hope. 2023. “Why Are Cancer Rates Rising in Adults Under 50?” January 2023. Link. Accessed August 31, 2023.

8. EBRI. 2022. “Use of Health Care Services for Mental Health Disorders and Spending Trends.” September 2022. Link. Accessed August 31, 2023.

9. Healthcare Finance. 2016. “25 Biggest Provider-Sponsored Health Plans Include Some of the Nation’s Biggest Health Systems.” September 2016. Link. Accessed August 31, 2023.

10. Kaiser Permanente. 2023. Kaiser Foundation Health Plan and Hospitals Q2 2023 Financials. August 4, 2023. Link. Accessed August 30, 2023.

11. Cision PR Newswire. 2023. Kaiser Foundation Health Plan and Hospitals Report 2022 Financial Results. February 10, 2023. Link. Accessed August 30, 2023.

12. eHealth. 2022. Best Health Insurance Companies Compared. October 28, 2022. Link. Accessed August 30, 2023.

13. Forbes. 2023. Kaiser Permanente Health Insurance Review 2023. January 3, 2023. Link. Accessed August 30, 2023.

14. Value Penguin/Lending Tree. 2023. Kaiser Permanente Insurance Review: Why Is It Top-Rated? July 25, 2023. Link. Accessed August 30, 2023.

15. Frontiers of Health Services Management. For UW Health, Health Plan Ownership Provides Financial Stability. Kaplan, Alan S. FACHE. Summer 2023. Link. Accessed August 30, 2023.

16. Beckers Hospital Review. 2021. It’s Time for Payvider Adoption and Growth. June 16, 2021. Link. Accessed August 30, 2023.

17. Ibid.

18. Wikipedia. Health Insurance in the United States, History. Link. Accessed August 30, 2023.

19. Ibid.

20. Ibid.

© 2024. Contigo Health, LLC. All rights reserved.

Publication: Employee Benefit News

September 28, 2023

Whenever your employees need out-of-network care, they may be faced with unanticipated costs that can be eased with the right network solutions. By reconsidering various offerings and making the right choices, your organization can save money — while making their healthcare costs more predictable.

Gain complimentary insights into:

• The evolving landscape of out-of-network care
• How to maximize savings by understanding the lifecycle of a claim
• How employers can access multiple cost containment solutions without obligation

Source URL: https://www.benefitnews.com/web-seminars/the-murky-waters-of-out-of-network-claims

*Courtesy of Employee Benefit News

© 2024. Contigo Health, LLC. All rights reserved.

Premier, Inc.
June 21, 2023

Source: https://premierinc.com/newsroom/blog/celebrating-two-of-the-biggest-trailblazers-in-healthcare-at-breakthroughs-23

© 2024. Contigo Health, LLC. All rights reserved.

The healthcare industry itself is not immune to the challenges of managing health benefits costs for its own workers. Benefit administrators for health systems are faced with the same challenge that all employers are addressing in 2023 and beyond: how to provide employees with the highest-quality care while optimizing costs and maximizing plan flexibility for both their healthcare employees and the organization. For U.S. companies, the cost of caring for more than one in two Americans receiving insurance through employer-sponsored plans continues to increase.¹

For larger employers, the total cost of health benefits further rose by 5.3% in 2021.² Even as they provide care to others, many health systems’ associates are seeing increases in their insurance premiums that are outpacing inflation and wage growth. In fact, the average annual health insurance premiums for family coverage for employer-sponsored health plans have topped $20,000 for the first time, according to KFF 2018. On average, covered workers contribute 18% of the premium for single coverage and 30% of the premium for family coverage. Total costs for these premiums increased by 22% from 2014 to 2019, and worker contributions increased by 25% during that time.³ To better manage the cost of care, employers across all sectors have transitioned to self-funding options. Today more than 61% of some 150 million people receiving employer-sponsored insurance (ESI) are covered by self-funded or partially self-funded healthcare plans.

In very large companies with 5,000 or more employees, 91% of workers are in self-funded plans, and the rate of adoption among smaller organizations continues to accelerate.⁴ Just like any other self-funded employer, health systems generally require some type of third-party administration (TPA) solution to administer their health plans. Some use carriers or health insurance companies that market “administrative services only” (ASO) options for their TPA functions. Others use traditional TPAs. A partnership with a specialty TPA that offers deep expertise in the intricacies of managing health benefits for healthcare workers, however, has the potential to be transformative across a health system’s entire organization.

Plan Management In a Complex Environment

Health systems must consider a myriad of business factors when evaluating a TPA relationship. In addition to the increasing costs of employee care, they are immersed in a volatile industry environment of skyrocketing patient care costs, tight operating margins, reimbursement pressures, complex partner relationships, and moves to new care-delivery models that require greater transparency. At the same time, they are also struggling to balance the benefits of new technologies with EMR and data management complexities, ever-changing regulatory issues, aging patient populations with more complex medical issues, and highly competitive workforce challenges. Adding to the current landscape is the impact of COVID-19.

Coupled with so many other issues, the pandemic has put even greater stress and uncertainty on the country’s healthcare system. These complications can make the prospect of transitioning to a TPA plan or a new TPA partner seem overwhelming for a health system. Yet the urgency to deliver quality care at lower costs, without compromising service and positive member experiences, is greater than ever before. Forging a relationship with the right TPA that has extensive expertise and flexibility can be an ideal solution for many health systems, despite the perceived complexities of making such a move. This is particularly true for larger health systems that have already invested heavily in quality health solutions for their employee population. They require a highly flexible plan that optimizes these investments, with options that fit specific needs of employees.

Specialty TPA Advantages for Differing Priorities

Simply put, self-funded organizations may choose a specialty TPA with deep health systems expertise to gain more control over their destiny than they could achieve in a traditional carrier relationship. That greater control can translate into flexible options in benefit design, data integration, population health tools (leveraging CINs and ACOs), and nondomestic network coverage, as well as substantial business reimbursement for patient care. It can also mean more significant opportunities to utilize their clinical strengths in caring for the organization’s employees. A specialized TPA relationship can address this need for control and customization, and it can respond to differing priorities across the system. From HR to finance to clinicians and business development, each function can realize positive impacts from an effective TPA partnership. Working with a TPA that is attuned to a health system’s entire ecosystem helps to create a personalized approach that empowers unprecedented collaboration.

A Tailored Approach

For the HR team at a health system, the TPA partner must be an expert in designing flexible plans targeted to the current and changing needs of the system’s workforce. It should have the capabilities to introduce new and innovative options for the health system’s most discerning population: its associates. The plan design must also integrate seamlessly with existing health management programs, such as PBMs, ACOs, and clinically integrated networks (CINs). The working relationship with the TPA partner is also a significant factor in helping to ensure the success of the plan. HR benefits administrators should expect high levels of service, responsiveness, objectivity, and useful reporting tools from the TPA.

Domestic Utilization and Cost Management

For CFOs charged with cost and risk management across all aspects of the organization, a strong TPA relationship will help facilitate cost-containment opportunities. By focusing on actual costs rather than carrier rates, a well-designed plan can provide direct savings that remain within the health system. A TPA that possesses health system insights and expertise can identify opportunities for maximizing domestic utilization rates, which can contribute significantly to overall system revenue generation and employee benefits cost control. An experienced, employee-focused TPA will be able to lead a thorough analysis to assess gaps in quality of care and provider networks to strengthen domestic utilization. When health systems employees and their health plan dependents use the actual services they provide, they help contribute to building a stronger community and stronger brand while taking advantage of the quality of care provided by the health system.

Network providers can realize more financial benefits, and systems can play an active role in improving their staff’s health outcomes. By directly assessing and managing claims data while maintaining patient confidentiality or PHI integrity, health systems can find ways to mitigate rate increases over time. Utilization is vitally important in today’s healthcare environment. Increases in domestic utilization can make a difference when it comes to containing spiraling costs. From 2016 to 2017, spending rose 4.2%, while prices jumped 3.6%, but healthcare utilization only grew by 0.5% during that time, illustrating dramatic opportunities for improvement.⁵

Data-Driven, Patient-Centered Care

As CMOs, CQOs, and CIOs work with their systems to focus on strategies that deliver quality, data-driven, patient-centered care more effectively, a customized plan can make meaningful contributions toward these efforts. In an ideal scenario, health systems want to further improve their population health through a TPA relationship that can include tools to help tap real-time clinical information, enabling them to achieve optimal levels of appropriate care. Virtually every health system has invested heavily in data, technology, and EMR as mission-critical assets. U.S. health IT spending topped $7.1 billion in 2017 and continues to increase annually.⁶ Partnering with a TPA that has access to clinical data decision-support tools can help providers deliver a tailored plan to allow providers to offer the right care, at the right time, in the right setting, at the right costs. Leveraging these tools can help address targeted variations, thus enabling flatter overall medical trends.

Recruitment

A personalized plan can also serve as a powerful recruitment tool. HR teams must attract talent with a robust, affordable, and flexible health benefits package that enhances members’ experiences. Many employers are recognizing this need. The number of those who view their healthcare offerings as an integral part of their workforce strategy increased from 36% in 2019 to 45% in 2020.⁷ The right plan that includes work-life balance/flexibility programs, support for innovation, and mentoring opportunities can also be an essential retention tool for health systems employers in a highly competitive job market.⁸ According to a recent survey, more employees in the healthcare sector report they have been actively looking for a job during the past year than in other sectors.⁹

Business Development

Business development teams are seeking new revenue-generation opportunities. For some health systems, an optimized self-funded plan can help create direct relationships with non–health system employers looking for a better way to achieve their health benefit goals. The plan can serve as a model and a facilitator for initiating new relationships with employers in order to pursue broader strategic aims and increase market share.

Overcoming Barriers

A self-funded plan with a specialty TPA relationship can be a tremendous advantage for the right health system. But it is not always a solution for every organization. All potential barriers and objections should be assessed, along with timing, before considering a shift. For instance, the arrangement requires knowledgeable benefit administration skill sets to make the most of the TPA relationship. If the level of internal expertise is not currently present, the organization may need to invest in staffing to build or train the right teams. The same is valid for health systems that may be considering self-funding their health benefits plan as a precursor to delivering direct-to-employer offerings. Other barriers may include organizational concerns about disrupting long-standing relationships with current payors or moving from a large partner with a known brand to a nimble and specialized but lesser-known entity. In addition, an organization’s leadership may not recognize the potential value of a specialized TPA relationship without a thorough analysis of the positive impact it can have on the entire organization. HR teams should align with finance teams and be prepared to make the case. Changing the status quo in any organization is an educational process, and the transition to a new or different TPA relationship will require a thoughtful strategy. The goal should be to engage all stakeholders and address possible concerns while conveying the cost and operational benefits that can be realized. A specialty TPA partner with the requisite depth and breadth of health system experience can assist in helping to remove these barriers.

For some health systems, an optimized self-funded plan can help create direct relationships with non-health system employers looking for a better way to achieve their health benefit goals.

Contigo Health: Uncomplicating the Complicated

Today’s healthcare world is more complex than ever before. Building a self-funded plan requires a TPA partner that will help “uncomplicate the complicated” while facilitating quality care, cost savings, and innovation. An experienced TPA partner understands the unique complexities of health systems and can effectively navigate self-funding design and implementation to realize the plan’s full potential across the entire organization. While numerous TPAs exist, health system decision-makers must closely examine the additional value a specialty TPA can offer. Contigo Health® Sync Health Plan TPA is redefining health systems’ expectations for TPA services with an exciting combination of offerings and continuous innovation. In addition to its legacy of TPA leadership, Contigo Health, formerly Health Design Plus (HDP), is backed by the strength and resources of its affiliation with Premier, Inc, a leader in data, analytics, consulting, and group purchasing for health systems.

Partnership Benefits

• Contigo Health offers leading-edge, TPA custom solutions designed expressly for health systems
• A client roster featuring leading employers known for quality and innovation in health benefits delivery
• Strategic analysis, design, and integration with existing health management programs
• Flexible, objective benefit design for greater control in payment models, data integration, and network coverage
• Comprehensive reporting tools and protection of confidential information
• Exceptional client relationships, with a proven track record reflected by exceptional client retention and consistently high Net Promoter scores
• Experienced, responsive, and friendly service from a professional, caring, and hardworking team that delivers unparalleled support

Ready to learn more? Speak with a Contigo Health Representative today at 330-656-1072 or visit contigohealth.com.

1. Berchick, Edward R., Hood, Emily, and Barnett, Jessica. 2018. “Health Insurance Coverage in the United States: 2017.” United States Census Bureau. September 12, 2018. https://www.census.gov/library/publications/2018/demo/p60-264.html