CORE Conference Blog Series: 5 Lessons Learned Exploring New Delivery Models08/06/2019
In January of 2018, Amazon CEO Jeff Bezos, J.P. Morgan CEO Jamie Dimon and Berkshire Hathaway CEO Warren Buffett announced plans to collaborate on a new health venture, Haven, with the vision of “simplified, high-quality and transparent healthcare at a reasonable cost.”
The idea was that employers could better manage their employees’ health and the health of their families, if they had more control over how care was accessed and delivered. A piece of the new healthcare model would involve onsite or near-site work health centers.
At Prominence, we were fortunate enough to get involved early with a health system that is taking a similar path towards developing a service line that creates and manages employee health centers for large employers. To respect the health system’s request for confidentiality, we will refer to them as North East Health System (NEHS). In addition to offering these services through employers, NEHS is offering similar concierge services directly to consumers that reside in the buildings in which their clinic is located. The patients receiving care at this location are called “members” regardless if they are employer sponsored or direct consumers.
Below are 5 things we’ve learned while partnering with NEHS to establish and support their new delivery model.
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At the start of our engagement, we understood that we would be operating on unfamiliar terrain. Although the average Prominence Advisor has over 10 years of experience managing and leading healthcare IT projects, none of us had experience guiding an organization through this type of new implementation.
To combat this lack of experience, we looked to similar engagements we’ve managed in the past. By blending together our experience with capitation arrangements, Epic’s Community Connect processes, worker’s compensation billing, and new clinic roll-outs, we were able to piece together a playbook that helped guide the client throughout the implementation. When faced with a unique decision, this helped provide a framework that allowed us to move forward with confidence as we moved through system design, testing, and go-live.
One challenge we had to overcome was to determine how we should classify these members so they could be easily identified within the system. Patients receiving care at a worksite health center would have a majority of their services covered through their employer (paid directly to NEHS as a monthly fee) and have almost no out-of-pocket expenses. However, if these employees received care at NEHS facilities outside of the worksite health center, then their normal out of pocket expenses applied. Similar to correctly verifying a patient’s insurance, determining a way to classify these members was critical for driving billing logic that ensured their expenses were covered when care was received at the worksite. As you might suspect, correctly billing members is a critical component of satisfaction, for both the employers and members, in this delivery model.
Prominence helped to design a solid system for collecting patient demographic and visit information and then automate the billing logic to ensure that patients were billed correctly without the need for user intervention. This was thoroughly audited and tested prior to go-live, and managed closely during the first month of go-live to ensure all service lines were being billed accurately.
The highest levels of the organization at NEHS is pushing to innovate new delivery models, and pursing worksite health centers is part of their growth strategy. The teams involved are visionaries who are looking 10 years down the road at what this type of model could be, and want to make that vision happen now.
We enjoyed discussing the ideal future state with the client including customized patient portal applications, dashboards integrated with employers’ benefits systems, and telehealth visits. However we had to help align expectations with what is realistic to achieve in the first six to nine months for a new clinic, and roadmap how to rollout optimizations in the future.
Based on our experience, we were able to advise the client on lower effort changes we could implement now that would have disproportionate affects on perceived patient experience and efficiency of operations. For example, we recommended the client expand the use of information returned in RTE to reduce the amount of time patients spent registering. Many of our recommendations were how NEHS could configure their EHR in the short term that would satisfy their needs for Day 1 of patient care, while building a solid foundation that could be expanded upon with more sophisticated functionality in the long term.
The creation of the worksite health center introduces a new direct relationship between the employer and NEHS that has traditionally been brokered by the employer’s health plan provider. With this new model, the employer creates a supplemental set of covered services for their employees directly with NEHS as long as they are seen at the health center. This means that the payor does not have knowledge, or incentive, to appropriately adjudicate claims for services at these health centers.
Despite assurances from the payor that they could appropriately adjudicate the claims and ensure patients would not be billed for the supplemental services offered at the health center, the payor eventually declined to make the necessary changes on their end. This caused last minute changes to our billing workflows, requiring build audits and validation of new testing scenarios. Controlling the contractual write-offs in-house is an easy enough task. We recommend that any organization preparing to start a similar endeavor maintain control of this aspect of the billing process.
NEHS understood that one benefit to providing primary care at worksite health centers is the opportunity to funnel more patients into the rest of the health system. What NEHS also quickly realized is the need to manage expectations and clearly communicate the differences between the patient experience at the worksite health center and other facilities in the organization. At the health center, members expect to wait less than 5 minutes to enter an exam room, can get an appointment in less than 3 days, and have onsite staff dedicated to answering their billing questions. The organization is taking every opportunity to emphasize how exceptional the experience is for their members, with communications going through employer communications to their employees on benefits, messages through the patient portal, and reminders on any patient statements.
The documented benefits of worksite health centers indicates more employers will look for organizations to partner with to offer these services to their employees. By partnering with NEHS, Prominence is proud to be at the forefront of helping organizations deliver this new way of caring for patients and managing health.
