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Angela McCann

My idea comes at a time where health care is forced into drastic changes to accommodate life in a world with a novel coronavirus controlling almost everything we do. I have to find some silver lining in the horror that COVID-19 has wreaked on the world; and that silver lining is that we have been presented with an opportunity to prove health care in the U.S. can change quickly and dramatically-because it just did. COVID 19 is the biggest disruptor of our time. Now we must innovate! And when the COVID-19 crisis is “over”, we need those innovations to stick.

My company is a community health center with three locations serving about 17,000 patients in two counties. Geographically, one service area is predominantly rural while the other is a little more urban. Two of the health centers serve all ages while the third office is a pediatric practice. Access to health care is a challenge with a business model where patients come to our physical locations and receive services in person. Wait times for a provider visit can be long depending on the provider and the patient need. Another barrier is cost. Our health system provides care to a large volume of lower income patients, and we have resources and programs to enable patients to receive services regardless of their ability to pay. Despite those efforts, patients we serve often have a difficult time covering the cost of their health care and frequently do not seek care when needed due to costs.

Internally, we struggle with providing appropriate care to individuals in “one-size-fits-all” business model. Not every patient needs the same level of care, the same time with a provider or the same number labs, medications or visits. But that is how we get paid. We see patient, we bill patient for co-pay, we bill insurance for seeing patient, insurance company pays us (usually, and never as much as we bill for). Providers often feel they can’t devote the time needed for some patients which can lead to poor outcomes. Additionally, once the patient leaves the exam room, the provider moves on to the next patient and the patient is on their own to manage their health. If they need to see their provider again, they go through the visit process again.

The idea I have come up with is based on the model of direct primary care (DPC). I would like to offer a new access model where the patient can access their provider as often as needed and providers can provide the kind of care they feel is necessary without the influence and bureaucracy of insurance companies. Patients would pay a monthly membership to the health center for full access to their provider, labs and in-house tests. Insurance companies would not be billed for the services provided, thus reducing the administrative burden seen with third party billing. The membership fee, ranging from about $75-$125 per month would cover a pre-defined number of “visits” with their provider, any labs needed, and any other services offered in-house. Visits can be in person, via phone or virtual through the telehealth platform. A fee can be charged if the patient requires or requests visits over the pre-determined allotment per month. This will allow the patient to access their provider for quick questions as well as for acute needs. The provider also does not have to worry about exceeding insurer restrictions on the number of annual or monthly visits.

Strengths and Weaknesses of this Proposal

People

People want what they want and they want it now. Two key target groups for this proposal are based on the desires and abilities of people. One is Millennials, the other is employers. Millennials are pushing healthcare in directions its never been before. Their desire for transparency, purpose and technology are demanding that health change quickly and because they shop around for their care like no other generation has, health care providers must be competitive in securing them as consumers (Harpaz, 2019). The other target segment, employers, taps into businesses looking for ways to cut costs and improve the health of their workforce. If we can market to employers and offer this as an alternative to high cost commercial insurance plans, we could secure contracts that would give us critical mass needed for success.

Conversely, health care providers are not creatures of change. Well established procedures and processes have them stuck in their comfort zone with much reluctance to move to new things, and certainly not rapidly. Adjusting to a model where the patient can call them at the patient’s convenience is a completely foreign concept. How many times have you called your doctor’s office and spoken to them directly? They have layers of gatekeepers and actually talking to your provider can take days and usually requires that you come to see them. Provider willingness to change will be a challenge to overcome.

The biggest people strength we have is that everyone is looking for something different in health care in this country. This model will fit very well with providers that are already challenging the status quo and understand health care isn’t just a 15 minute billable conversation with a patient.

Products or Services

The strengths of this proposal are increasing the speed of delivery of services, providing a level of service that is not currently provided by any other healthcare system within the service areas,  offering a service model that addresses the growing concerns over health care cost, and a predicted improvement in health care quality outcomes due to more flexibility for the provider and patient.

A weakness I foresee is being able to acquire the number of “members” in this payment model to be able to breakeven or turn a profit. The cost structure will have to be considered very carefully to ensure the membership fees, at minimum, cover the cost of services rendered.

Technology will also be a weakness as some patients don’t have internet. Some patients have limited data use and may not have the capacity to participate in a program like this.

Company

The biggest challenge I see with this plan relates to some patients’ perceived needs and expectations. We often have patients with very disrespectful and disruptive behaviors, including excessive phone calls, unrealistic demands and threatening behaviors toward staff, especially if their needs are not met as they would like them to be. Clear boundaries would have to be established and patients enrolled in this program would have to be screened for appropriateness.

Our strength, as a company, is having leadership that likes to try new things. We strive to be a leader in care innovation, and we have a board of directors that supports efforts to differentiate ourselves in a very competitive market.

I think with all of these considerations we are poised to try this model. COVID-19 has laid the groundwork for alternative ways to deliver care, especially virtually through telehealth and insurers have had to come on board with reimbursing for it. Provider and patients are primed for change right now.

References

Harpaz, J. (2019, August 26). 6 Expectations Millennials Have For Their Healthcare. Retrieved from Forbes: https://www.forbes.com/sites/joeharpaz/2019/08/26/6-expectations-millennials-healthcare/#55e4360730ec