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.

Publication: iMedPub Journals

Research Article
Journal of Preventive Medicine
ISSN 2572-5483
2023 Vol.8 No. 5:215

Introduction

Ensuring access to mental and behavioral health services to all who are in crisis or at-risk is one of the most challenging priorities in healthcare today. In fact, providing for the estimated 43.8 million Americans [1] who experience mental illness is so critical that President Biden declared it a national mental health crisis during his 2022 State of the Union address [2]. Just as important to the clinical response of mental and behavioral health emergencies is the prevention of avoidable conditions rooted in non-clinical factors and that diminish behavioral health equity, defined as the right of all individuals, regardless of race, age, ethnicity, gender, disability, socioeconomic status, sexual orientation, or geographical location, to access high-quality and affordable healthcare services and support [3]. Successful prevention involves employing dedicated and focused resources and applying strategic interventions that work to recognize and resolve at-risk patient issues along the continuum of care to prevent mental, behavioral and physical health deteriorations that would require costly utilization of clinical services. A surge in demand for clinical psychiatric care to treat acute mental and behavioral health conditions severely strains hospital resources and provider staff and reveals the vulnerabilities of the healthcare system. Due to the fragmented nature of the healthcare infrastructure, persistent lack of sufficient resources and longstanding shortages of mental and behavioral health professionals, far too many Americans have limited access to the professional, personalized and preventive care they need and deserve.

*Courtesy of iMedPub

Source: https://preventive-medicine.imedpub.com/care-guidance-supports-health-systems-and-mental-health-providers-with-advancing-behavioral-health-equity-avoiding-relapses-and-r.pdf

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

Publication: Validation Institute

October 19, 2023

Many individuals who develop substance use disorders (SUD) are also diagnosed with a behavioral health disorder.¹ In fact, more than one in four adults living with behavioral health problems also has a substance use problem.¹

The two are so closely related, yet often treated separately with many employer benefits plans. In this webinar, learn from industry experts about the importance of a comprehensive, equitable, and quality-driven behavioral health benefits offering designed around a growing hybrid workforce – both deskless (37%)² and remote/hybrid employees, which as of 2023 now make up 40.9% of the full-time workforce.³

In addition, this panel of industry leaders will cover:

• How health plans and clinical service providers can better support these growing populations
• How to address the stigma associated with behavioral health and SUD for non-office-based workers
• Strategies to ensure prevention and early screening of behavioral health conditions
• How offering dually licensed providers who specialize in both SUD issues and other behavioral health conditions can lead to more successful treatment solutions and outcomes
• How to create a behavioral health benefits strategy that can support members’ individual needs and preferences, including in-person and virtual treatment
• The importance of immediate and ongoing support that is discreet, inclusive, and affordable
• How bundled rates can help with the affordability and predictability of behavioral healthcare
• Bright spots in this space that our experts are seeing offering hope for those with substance use disorders

Sources:

1. https://www.samhsa.gov/mental-health/mental-health-substance-use-co-occurring-disorders
2. https://mslgroup.com/whats-new-at-msl/one-third-us-workforce-missed-traditional-company-communications#:~:text=Deskless%20workers%20comprise%2037%25%20of,factory%20workers%20and%20retail%20salespeople.
3. https://www.forbes.com/advisor/business/remote-work-statistics/#:~:text=As%20of%202023%2C%2012.7%25%20of,normalization%20of%20remote%20work%20environments.