Value Proposition for Deploying a
Direct-to-Employer Gain Sharing Plan
Diversify payer mix by disintermediation of third party payers in order to drive additional margin
No need to establish your own insurance company
National and regional PPO network wrap
Actuarial pricing of medical provider network reimbursement contracts
No insurance risk to assume
Four to six months start-up
Minimal cost requirements, e.g., Infrastructure already in place
Proven sales and marketing distribution process
Proven population management system
Optimal revenues through gain sharing, reducing outmigration, increasing top line revenues, and addition of new administrative revenues
See why medical providers are partnering with us - On Physicians News Network
Midwest Hospital System
A Midwest acute-care hospital desired to develop a local community health plan with physicians that participated in their Physician Hospital Organization (PHO). They created a community based preferred provider organization (PPO) and used the PHO as the primary narrow network. Working with ACSG/KBA, we developed a self-funded program through the PHO and arranged for a wrap PPO network along with a national wrap PPO.
As a result, the hospital, along with several large employers, came into the program representing over 10K employee lives utilizing KBA's administrative and population management infrastructure. The hospital has been able to control the client relationships through their own managed care approaches that have been augmented by KBA and AHDI's CDM programs, customized customer service, customized fulfillment systems, and detailed reporting and analytic data systems.
Midwest Multi-Specialty Physicians
A large multi-specialty physician group in a medium size Midwest City saw an opportunity to develop health care programs for employers and other public sector members in their community. Their desire was to take more control of their destiny in order to retain their independence from hospitals attempting to purchase medical practices. The physician group contracted with ACSG/KBA as their back office administrator for a proprietary self-funded plan and to manage their Health Maintenance Organization (HMO). The HMO is being licensed for commercial and Medicare Advantage beneficiaries.
The goal is to utilize our population management process in order to drive optimal gain sharing to their independent medical practices and to further diversify their payer contracts with third parties. The objective is to drive 50% of the current commercial market to their own programs within the next 5 years.
West Coast Multi-Specialty Physicians
A large multi-specialty physician group in a large California metropolitan city retained ACSG/KBA to develop a Direct-to-Employer Program for their medical delivery system. The objective is to sell their narrow network to mid and large size employers in their geographic service area from HMO insurance arrangements to a self-funded program. The program is designed to be sold in a dual-option offering, thus offering HMO-like benefits and a three-tiered network based program with strict referral management and medical authorization protocols.
By incorporating our AHDI population health management processes and data analytics, the goal is to drive employer budgets for health care costs below trend and optimize projected gain sharing opportunities. They also desire to mitigate the impact of continued medical practice consolidation and retain their practice independence.