A New Efficient and Cost-Effective "Gatekeeper" Model For Containing Health Insurance and Care Costs

With Health Insurance and Healthcare costs continuing to skyrocket and access to trained Doctors decreasing, something needs to change. The current system is expensive, wasteful, and inefficient. We are proposing a new Gatekeeper Model that will provide Employees greater access to Doctors at a fraction of the cost with far better outcomes.

The Traditional Gatekeeper Model for Healthcare?

What was the traditional Healthcare Gatekeeper Model? The Alliance for Health Reform guidebook defines the gatekeeper/care manager as a “Health Care professional, usually a primary care physician, who coordinates, manages, and authorizes all health services provided to a person covered by certain types of health plans. Unless an emergency exists, the gatekeeper generally must pre-authorize referrals to specialists, hospitalizations and lab and radiology tests.”

Unfortunately this system was often plagued by redundancies inefficiencies, and added – not reduced – costs. It has become more and more difficult to gain a Doctor appointment and the emergency rooms are overrun. Under this system – and the other traditional norms for bringing those in actual need of care together with physicians – there is a tremendous waste of time and money!

A few vital statistics!

70% of Doctor’s Office Visits are Unnecessary

55% of ER Visits are Unnecessary

41% of ER visits are unnecessary because the Patient could not Get a Doctor’s Appointment

51% of Ambulance utilizations are unnecessary

The existing norms obviously have problems. The difficulties in gaining an appointment with a Doctor are growing. PPACA/Obamacare will make this a bigger problem. Millions of people will have new found access to health insurance and will expect access to Doctors. The old system was already dysfunctional and now will be more stained.

The new Gatekeeper Model!

Utilizing Telemedicine as the Gatekeeper to bring people quickly and efficiently together with Doctors. This will remove the Barriers between Employees and Doctors for determining the best course of medical action. Telemedicine is not new! There are a number of Vendor/Providers. Each provides a different level of service and different cost structure. Most would not qualify as a Gatekeeper! I’ll qualify the requirements below.

The Telemedicine/Gatekeeper Model is new! When the Employee or Family Member Calls the Doctor First – utilizing the Telemedicine Plan – they immediately access an emergency trained doctor who assists them with their medical need, coordinates, manages, and authorizes all health services required as part of their Employer’s Health Plan. The Gatekeeper Doctor authorizes the referral to a specialist, hospital, urgent care facility or lab for tests if needed.

Let’s look at how Telemedicine could be utilized as the Gatekeeper.

What must the Telemedicine Plan Provider/Gatekeeper be capable of providing based on the Plan Providers history and their Telemedicine Plan Design?

  • A case specific ROI Calculator to show the Employer, CFO, TPA, etc. the value of implementing and supporting the model.
  • Immediate access to emergency room trained US doctors – no messaging or call backs.
  • Accepts emergency and non-emergency calls.
  • The ability to direct the caller to Emergency Rooms or Specialists care if medically required.
  • The ability to prescribe needed pharmaceuticals as required based on a health history when the person joined the plan.
  • A doctor’s prescription medical kit – in the possession of the member – providing the proper tools to administer what the doctor directs over the phone while the member is heading to their doctor’s office, urgent care center, or resting where they are.
  • Follow-up with the member after diagnosis and treatment to ascertain if there are additional needs.
  • A focus on lowering health Plan utilization costs while encouraging the use of the Telemedicine System and their trained Doctors.
  • A flat, affordable monthly fee for the Telemedicine Plan that includes the cost of the doctor’s medical kit.
  • The Telemedicine Plan must be affordable and yet have a depth of services required to encourage Employees to Call the Gatekeeper Doctor First reducing unnecessary utilization of the core healthcare plan.
  • No extra fees or charges for usage by the participants or their family members.
  • The Telemedicine Plan must be: (1) a qualified health deduction for the Employer, (2) qualified under Section 125 for the Employees to pre-tax a contribution to the Plan, and (3) HRA/HSA qualified.
  • The Telemedicine Plan must provide assistance to the Broker and Employer for implementing the Plan and Educating the Employees about Calling the Doctor First and utilizing the Plan as the Gatekeeper.

The above merely describes what features the Telemedicine Gatekeeper must provide the Employer and Employees to reduce costs while increasing Doctor access.

Now let’s look at what the Employer, Broker, and Telemedicine Provider (and possibly the TPA) need to accomplish when establishing the Telemedicine Plan as a Gatekeeper:

  1. Determine the Employer’s specific ROI for implementing the Telemedicine/Gatekeeper Plan.
  2. Determine who will pay for the cost for the Telemedicine Plan – optimal ROI will be achieved if the Employer pays for the plan and all Employees and their Families are on the Plan.
  3. Create an Employee Benefit Plan Design that requires the Employees and their Family Members to Call the Doctor First (unless there is an absolute emergency) to begin the process of diagnosis and how to proceed with medical care.
  4. Include in the Employee Benefit Plan Design an added cost for Doctor visits if the Employee or Family Member does not Call the Doctor First – much like going out-of-network charges. This will help Encourage Plan and Gatekeeper Utilization, Provide Better Employee Care, and Increase ROI.
  5. Create a systematic program – including Owners, Executives, the CFO, etc. – for Educating Managers and Employees about the Plan, Timelines for Implementation, Effective Dates for Coverage, and Proper Utilization of the Telemedicine/Gatekeeper Plan.
  6. The Owners, Managers, and CFO must be involved in monitoring the Gatekeeper Plan to encourage Plan Utilization by Employees and in reducing unnecessary Core Benefit Plan Utilization.

Five steps to implementing a Telemedicine/Gatekeeper Plan!

  • Work through an ROI Calculator to establish the Potential Savings
  • Carefully Select a Qualified Telemedicine/Gatekeeper Provider
  • Make Simple Changes to the Employee Benefit Plan Design
  • Put the Plan in place now for the Fall Enrollment and the 2014 Effective Date
  • Educate the Employees and their Families about the Value of the Plan; and explain the “Gatekeeper” function
  • As an Employer or Broker/Trusted Advisor, the Employer, and the Employees/Families will experience an enhanced, cost-saving, Plan with Greater access to trained physicians

What’s Next – (1) As an Employer (2) as a Broker

1) Employers– Use the ROI Calculator! Whether you are Self-Funded or Fully Insured, contact us to utilize the ROI Calculator – there’s No Cost. You can see the value of moving forward with a Telemedicine Plan and even better – utilizing the Plan as a Gatekeeper. You can: (a) Substantially Reduce Health Plan Costs, (b) Reduce Unnecessary Doctor and Emergency Room Visits, (c) Dramatically Improve Employee Access to Healthcare Professionals, (d) Reduce Lost Employee Work Time and Absenteeism. Employers have realized triple digit returns on their investment during the first 12 months.

2) Brokers – Use the ROI Calculator and see what it would do for your Clients. (a) You can save your Current and Potential Clients substantial Dollars (b) Improve the Employees and their Families Health Care, (c) Gain Employees and their Families immediate access to Emergency Trained Professionals, (d) Retain and Attract Employer and Individual Clients. Employers have realized triple digit returns on their investment during the first 12 months.