Congrats -- great post, new health insurance options are much needed! How did you assemble your provider network and how do major hospital options compare to other major carriers (eg. BCBS Texas PPO)? Does this EPO plan offer any out of network / outside of Dallas coverage? What is your target employee demographic? How has your experience been getting brokers to distribute this new plan?
Launch HN: Evry Health (YC W18) – Better health insurance for companies
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Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#121) Are there deductibles and co-pays for members who visit an emergency room with an out of network hospital? 2) What is your national payer id? Do you support 837s with electronic attachments, 835, 270/271, and 276/277 transactions to help providers manage claims? What about corrected claims? 3) What kind of contract would an in-network provider expect to get from you all? Some kind of capitated/case rate thing? 4)…
1. There is a $300 copay for an emergency room visit (both in-network and out-of-network). This is actually our only copay period. It is to encourage people to only use emergency rooms for emergencies. There are no deductibles for our primary plan though we do offer a HDHP as well (for employers with HSAs), so for the secondary product a deductible does apply. Emergency care is always covered as an in-network benefit and no copay would apply for inpatient care/admissions.
2. Payor ID is EH001. Yes to all except 276/277 for right now.
3. Naturally, this depends on the type of provider. We work with our providers to contract on a basis that is comfortable for them. Not all physicians are ready to accept something like capitation. We collaborate with physicians on the quality parameters to track. Some agreements are done as bundles for the entire episode of care. Some agreements are case rates or capitation payments. Some are still benchmarked off of Medicare but tied more closely to patient outcomes. For example, with primary care doctors we target avoiding poor control of diabetic A1C levels to be below 15% and to do depression or anxiety screenings for more than 80% (among other metrics).
4. Nope. We contract directly and do all the claims processing ourselves. Sometimes that means negotiations can take awhile (for large health systems) but it almost always means we reach favorable terms with a mutually beneficial structure.
Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#13> We pay most doctors and hospitals based on patient outcomes, not fee-for-service. I'm curious how you convinced providers to bill based on outcome. The metric seems very hard to quantify. How are the outcomes measured? How are chronic conditions handled (e.g. there is no clear resolution to the underlying issue)? Is it a sliding scale or a binary? What happens when a pt visit does in fact involve expensive labs and…
thallium205 does a great job of summarizing some of the common approaches insurers have used to try and get outcomes to be part of the payment of care delivery. We find that most physicians have not been asked what they consider to be critical outcomes related measurements and benchmarks. We are approaching the physicians we contract with on a basis of partnership rather than combatant, and as a result we have been able to achieve direct physician contracts with value-based metrics and payment components that they are comfortable with. We have the technology and analytics to support the timely and accurate reporting of the emerging experience to support them because quite frankly we are only successful if they are as well. To the point about chronic patients, we support the physicians with extensive care coordination capabilities and analytic support to identify gaps in care, opportunities for broadening the clinical team, and to leverage efficient solutions in telemedicine. We make sure all of the efforts are being communicated back to the primary care and/or specialists so they know what’s going on with their patient when their patient is not in their office.
There is a long way to go however because there is not a lot of trust and there are significant technology barriers. We believe our approach is a breath of fresh air.
Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#14> We pay most doctors and hospitals based on patient outcomes, not fee-for-service. I'm curious how you convinced providers to bill based on outcome. The metric seems very hard to quantify. How are the outcomes measured? How are chronic conditions handled (e.g. there is no clear resolution to the underlying issue)? Is it a sliding scale or a binary? What happens when a pt visit does in fact involve expensive labs and…
Typically what they do is pay one time for a particular "case". So if you came into the doctor's office consecutively for the same symptoms for a week straight, they'd treat that as an episode of care and pay it as if it's one visit. Another strategy is to pay a flat rate for seeing a patient. So if they come in once or come in 20 times that month, they get paid the same. For hospitals what they like to do is pay onl…
Thanks for the great summary!
Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#15> We pay most doctors and hospitals based on patient outcomes, not fee-for-service.
Wouldn't doctors be incentivized by this fee structure to walk away from difficult cases, where a treatment is risky but is the last hope for the patient, if they won't be paid for the likely bad outcome?
Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#16Congrats -- great post, new health insurance options are much needed! How did you assemble your provider network and how do major hospital options compare to other major carriers (eg. BCBS Texas PPO)? Does this EPO plan offer any out of network / outside of Dallas coverage? What is your target employee demographic? How has your experience been getting brokers to distribute this new plan?
Thanks! We’ve built our primary network ourselves. We have about half of the major regional hospital options working with us, as well many of the top specialist provider groups. It’s narrower than the network of a BCBS but growing rapidly. An EPO does not support out-of-network coverage but we do handle out-of-area through a partner, so people don’t need to worry while traveling, etc.
The target employee demographic is younger/Millennial focus but we’ll work with any employer group that has 100+ employees.
For distribution, it took time to build trust with brokers. We went through a lot of introductions and meetings to find people we trusted, and to help them also trust us. It required a lot of personal interaction. Currently, we work with two commercial brokerages, and will continue expanding and growing our broker relationships. We are "broker-friendly."
Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#17> We pay most doctors and hospitals based on patient outcomes, not fee-for-service. Wouldn't doctors be incentivized by this fee structure to walk away from difficult cases, where a treatment is risky but is the last hope for the patient, if they won't be paid for the likely bad outcome?
Good observation. This already happens within certain hospital systems, based on "protecting the numbers". So for instance a surgeon not wanting to take on a patient because it is a likely mortality on their record.
Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#18Curious on your medical and pharmacy trend combined, how does it compare to other insurance carriers like Aetna, United, Kaiser Permanente, etc.
There is only so much you could do on the administration/retention side of the cost puzzle, I believe for KP it's around 3-4% of the total PMPM, a lot of the cost savings will come from
1) not participating in the government programs (medicaid, medicare, aca), which the commercial market largely subsidizes 2) controlling the provider costs, how much control/influence do you really have with a small membership base to negotiate from?
Interesting concept, I think the legacy carriers are working to improve their tech stack and providing this on-demand type of care. I wish you a lot of luck!
Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#19> We pay most doctors and hospitals based on patient outcomes, not fee-for-service. Wouldn't doctors be incentivized by this fee structure to walk away from difficult cases, where a treatment is risky but is the last hope for the patient, if they won't be paid for the likely bad outcome?
Good question, and thank you for asking it. The short answer is No.
We have “escape” codes to make sure the doctor is not penalized. For example, if there is a risk of embolism or if there is an aneurysm complication during surgery, then the payment reverts to a fee for service. The point is to ensure patient safety and high quality of care, not penalize the doctor for events not in their control.
If the care being sought is highly experimental or risky, we work with physicians to determine if there are centers of excellence that may provide higher quality of care.
Re: Launch HN: Evry Health (YC W18) – Better health insurance for companies
#20Can you speak more to the “free mental health coverage”? I assume this includes psychotherapy.
What kinds of therapy are covered? How did you build your network of therapists?