"If you knew everything we knew about health care and had all the relationships with the best companies in the business, you'd build a health plan exactly like this"
Justin M, Founder of Direct Health Alliance, on the summary of what we're doing in the employer health plan space
Consider This Question
"Does your health plan provide guidance on price, quality, or patient experience so members are finding the best value in health care?"
The big 6 carriers (Bluecross, United, Cigna, Aetna, Humana, and Kaiser) would erode their entire business model if they provided information to members on best prices, high/low quality providers & facilities, or patient experience. While quality in health care is a very difficult metric to quantify, the big 6 carriers absolutely have the data on re-admissions, infections, over-use, upcoding, and waste/fraud/abuse. Interestingly, the reason they don't show the patient the information is because their actual customer is the health systems themselves, not the patient. The patient's business is earned through employer health plans and employer's are generally wanting a "big, broad network with lots of choices", which plays perfectly into the hand's of the carriers who provide exactly that.
If carriers began guiding members to best value health systems & providers, their network would shrink and employers wouldn't buy it any longer. Ironically, our desire for a large network guarantees less quality and more expensive health care.
Consider This Conflict
"What is the conflict with United, Cigna, Aetna, Bluecross, Humana, and Kaiser providing insurance while also owning health care providers & facilities, pharmacies, formularies, and more"
To simplify the conflict, imagine if your auto insurance company owned your mechanic shop, is there not an inherent conflict when insurance can make rules around what is covered, what is not covered, and how much can be done? What if the insurance company also acted as a Third Party Administrator of your funds, so not only did they write the insurance document/coverages, provided the actual care, but they also controlled the money and dispersed payments. Now, imagine if most of these vertically and horizontally integrated entities were publicly-traded and had a fiduciary responsibility to deliver profits and revenue growth to shareholders.
Independence in health care should be mandated, but the health care industrial complex has the most powerful lobby group on earth. That said, employers can choose independence in their health plan by separating the Third Party Administrator, stop/loss reinsurance, and the actual health care being provided. This is not only healthy, it's an opportunity for incredible savings as each entity must compete for your business by providing high quality service with competitive pricing.
Consider This Reality
"Why do health plans address sickness & disease, but fail to promote health and wellness through preventive and proactive measures?"
The simple answer is there's no money in prevention. None. Healthy people add $0 in revenue to a health system designed to care for the sick. Keeping people healthy is not a small task, as it's mostly a matter of changing human behavior after a basic level of education is established. So how do we effectively change human behavior to lower the cost of health care? Education, coaching, relationships, and driving accountability are the basics to change behavior and create healthy habits that prevent disease. Interestingly, the return on that spend for an employer is not immediately recognized, and most employers don't see employees as a long-term investment, so you've got a bit of a catch-22 around how to fund the preventative and proactive care.
We address this within the health plan by pairing members with a medically licensed nurse who has access to resources, programs, and methods to improve human behavior and develop healthy habits.
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