DPC & RBP- Because it works
For those in the benefits world, you know the acronyms. DPC – direct primary care and RBP – reference based pricing. The former is a method to pay for your doctor the same way you pay for a gym membership. It’s a subscription-based program not tethered to an insurance program since the individual or the employer is buying a membership to get physician access rather than using a traditional insurance network. This model has been marketed as a concierge physician service for the upper class in the past, but is quickly gaining traction with employer-sponsored health plans. RBP is a pricing tool and a method self-funded employers use to help control claims cost and ultimately create a more sustainable health plan long term. Both services are highly innovative on their own, so what happens when you put the two together? We’ll explore.
Benefits consultants know member steerage, when done effectively, can create tremendous value for clinical and financial outcomes. That’s why there’s been a massive influx in health care consumer tools to measure provider quality and cost. The utilization of those tools varies drastically from group to group depending on factors such as communication strategy, employer support, group demographics, provider landscape in a given geography, user experience of the tool, etc.
The one thing that doesn’t vary when it comes to healthcare is that people listen to their doctor, and they go where their doctor tells them to go. So, what happens when an innovative physician group truly understands the local health care ecosystem in which they operate? When the doctor knows exactly what their patient’s health insurance benefits look like, referral patterns change. Care coordination happens with the doctor instead of a third party. Physicians know their patient’s insurance coverage and direct them to places that produce solid clinical outcomes at a fair price. It’s a great model for every stakeholder.
Any CFO, benefits manager, human resources person, business owner, or broker/consultant that has implemented an RBP program knows how hard it is to move a population from the comforts of a traditional PPO/HMO to the unknown world of an open-access plan. If done right, it’s well worth the work. If done wrong, it can lead to more problems.
Fear of the unknown and horror stories from poor experiences with discount vendors has kept many groups away from RBP. A knowledgeable DPC partner can help make the transition much smoother. It’s comforting for leadership teams to know there is a physician practice who will care for their people and help get them to the right provider when a higher acuity of care is needed.
DPC also attracts members because it’s usually free, with zero co-pays or any other out-of-pocket expenses for the member. Doctors’ office visits and prescription drugs typically account for 90% of all claims. If we have a physician group not only contracted for care but also helping direct patients to friendly specialty providers, then why does anyone need a traditional network? The argument is you do not.
It’s widely known that RBP can conservatively save a group 25% compared to traditional markets, and it’s much more in certain parts of the country. DPC subscriptions range from $40-$125 PEPM, which sounds like a lot but keep in mind, all those office visits are now covered at no cost to the member and don’t hit the employer claims fund.
Many DPC groups also offer urgent care, lab work, basic imaging, chronic care management, etc. A simple analysis can determine if the fixed cost is worth paying. We believe it is, even if it looks like it will add to the spend. Often, the value is understated because the real magic happens when the physician directs a patient to an ambulatory surgical center instead of a hospital setting for outpatient surgery. Those claims average thirty-eight cents to every dollar spent in the hospital. Other examples:
- MRI referred to a free-standing imaging center that costs $350 instead of $3,500 in the hospital.
- Blood work is done as part of your DPC program versus $400 for a basic blood test.
- A doctor sends you to a back specialist who prefers to try therapy before surgery, avoiding a large claim altogether.
It can be somewhat of a leap of faith in year one, but there’s no going back once you see it work.
The fundamental issue we solve is the traditional network system allowing plans to be overcharged on their medical claim spend. This significantly damages the bank accounts of workers and employers, while shareholders of those carriers get rich. The underlying issue is employers and consultants are talking about the problem yet failing to change the decisions they control, and vendor selections are constantly dictated by self-serving arrangements.
We are doing business with several direct primary care organizations around the country with tremendous success. We promote it because non-traditional solutions with real value need to rise to the top. We believe the traditional ways of purchasing healthcare for an organization are dated and in desperate need of a major overhaul. Please connect with us to learn more.