The Case for Direct-to-Employer Healthcare Solutions

Troy W. Williams, First Choice Health

If you are an employer, the healthcare landscape in the United States appears dysfunctional, dire and oftentimes disappointing.

The landscape for employee benefits also remains bleak. Employers have been forced to push benefit solutions to their limit due to rising annual costs—all while facing a pandemic, transitions to remote workspaces, furloughs, layoffs and the possible loss of critical staff who are disenfranchised by their work. The conventional workplace is no longer the destination workspace, and employees are questioning their loyalty to their employer. Still, premiums are rising 4% annually, which outstrips both inflation and wage increases.

The numbers are not sustainable, and the economic reality of the public’s healthcare needs, combined with the traditional, often outdated options left in the toolbox is Exhibit A for the mass frustration with our healthcare landscape right now.

Instead of continuing down the path of this fragmented, insurance-centric approach, why not opt for provider-led direct-to-employer, or “D-2-E” health benefit solutions, which can deliver sustainable value and improved health outcomes for employed populations?

Direct contract arrangements between a provider system and an employer can produce administrative cost savings. Additionally, it is possible to remove complexity due to multiple handoffs. Providers can also find greater flexibility to workflow, autonomy to decision making and adapted creativity through D-2-E relationships. D-2-E solutions remove significant barriers, delays and potential costs which can lead to better-managed, lower total cost of care.

For Providers: Understand and Assess What You Can Offer

When developing a direct-to-employer product, make sure you fully understand the market and what’s currently being offered. What gaps in care or access can be filled? What are the biggest complaints from employers and members currently enrolled in traditional health plans? What does the landscape tell us regarding matters of trust and relationships between employers and provider systems? Is the health system brand and reputation recognized in the employer community? Has the landscape been dominated by large national carriers and has clinical care been controlled or dictated by those same entities?

Build an Employer-Centric Value Proposition

The majority of employers tend to purchase either restricted, narrow network products or broad bundles of health and wellness services. Both are expected to lead to a positive experience, but these two extremes rarely end up benefiting employees, or their employer in the long term.

In reality, the narrow network doesn’t always create enough access options and the broad ones seemingly don’t pay much attention to integration and accountability. Also, simplicity of navigation may neglect aligned quality and performance metrics. It’s an illusion of choice, and we need to be more intelligent and strategic in the types of packages being offered.

One particular issue has only fully entered the public consciousness in recent years after decades of being stigmatized. The need and demand for behavioral health services has become all too apparent in the COVID-19 era. There is an ominous mix of anxiety, depression, stress, health issues, PTSD and blurred social norms floating through our homes and workplace. Despite a recent shift towards addressing this, there remain many unmet needs.

Providing employers with dedicated behavioral health care services and putting them at the forefront of your offerings—will increase trust and perceived value for members. Even an introduction of Employee Assistance Program (EAP) services can help to fill gaps. A mindful and healthy workplace has an outlet for challenging issues and can provide assistance when pressures of home life and work balance must coexist.

Don’t Try to Own it All

What we know is that along with convenience and value, member experience is also aligned with improved outcomes. If you’re serious about developing a strong direct-to-employer product, partner with flexible and creative entities to fill infrastructure needs such as claims processing, reinsurance, disease, case and medical management. Also seek to close market gaps to ensure immediate capacity needs can be met, aligning a high performing network of providers. Identify the appropriate data along with the employer to measure improvements that are aligned with stakeholders.

Some of the analytic and clinical infrastructure can be purchased or built depending on time frame, budget and objectives. Still, it’s usually best to find a trusted partner who can align these resources and place the provider system in a position to practice at their top of license and not get distracted with back office and plan performance or network customization.

Engagement from clinical staff should feel natural and your partnerships and resources should not overburden traditional workflow or staff. Much of this performance integration can be best handled by white label independent entities. The best will allow for the customization, and can act in a collaborative fashion for items like authorization review, utilization management and network design to be patient and provider centric.

Build Relationships

Successful direct-to-employer products should be built with trust, transparency and realistic goals in mind. The broker/producer and consultant community is incredibly important in maintaining the best interest of the commercial market health plans. That relationship and accountability should also be the responsibility of the provider systems and in close coordination with the commercial health plan sponsors.

If this relationship doesn’t provide a seat at the table to represent the clinicians and the D-2-E provider systems involved in the market effort, the accountability to improvement and any healthcare transformation is incomplete. Providers and their infrastructure partners must hear first hand from plan sponsors and take these ideas and process improvement concepts back to clinical coordination committees for appropriate action.

Focus on Patient Value and Outcomes

With so many different decisions and competing factors volleying for healthcare providers’ attention, it’s easy to lose sight of what’s arguably most important for all parties: patient value and desired outcomes.

When designing plans for employer partners, stay simple and apply basic logic.

A “proprietary network” means taking a smart and well-planned approach to network design based on access and quality, as opposed to just taking a thin slice of the provider quality curve or an extremely wide slice. If a network is designed intelligently with intuitive navigation and tailored to an employer’s population, the shift in thinking can have a profoundly different impact on outcomes as opposed to the most narrow or broad networks.

Additionally, cost and outcomes shouldn’t be measured by just focusing on unit costs as part of a larger picture, but rather across a continuum of care. Members being led through the system with a laser-like focus on navigation and a positive member experience—rather than on rate negotiation and unit cost alone—can experience a differentiation in a well aligned D-2-E product.

Creating Trust and Stickiness With Constituents

Launching impactful and successful D-2-E partnerships is not like flipping a switch. It will require laying the appropriate groundwork followed by making the right investments and vetting appropriate partners. Healthcare providers who do it the right way will reap the benefits and have greater autonomy, while serving as a sentinel in an industry that is in dire need of a new direction with impactful solutions.

About the Author

Troy W. Williams serves as vice president of Health System Partnerships for First Choice Health (FCH), a forward-thinking alternative to traditional health insurance. Williams previously served as the vice president of Employer Solutions for Vanderbilt University, which is regarded as a national leader in innovative health services. At Vanderbilt, Williams was responsible for the school's statewide clinically integrated network (CIN) product as well as partnerships with Aetna, UnitedHealthcare and Cigna.