Written by Liz Antaya

Many employees on corporate health plans rarely use their benefits. Other unfortunate individuals, however, suffer from chronic illnesses like diabetes, heart disease, or Lupus, and tell a different story. The health plan these employees utilize can mean the difference between living life to its fullest, just muddling along, or worse! It can also mean the difference between financial solvency and medical bankruptcy.

For employees managing a chronic illness on a traditional BUCAH (Blues, United, Cigna, Aetna, and Humana) health plan, the biggest concern likely becomes the Out-of-Pocket Maximum (OPM) exposure, because they will most likely hit it each year, up to a maximum of $8,700 in 2022. This happens because they have no one in their corner ensuring that they are getting the right quality care, at the right place, at the right time, and lastly, at the right price. And because of rising deductibles, co-pays, and co-insurance calculated off egregiously inflated bills, this adds up quickly.

An employee managing a chronic illness on a FairCo$t Health Plan that Mitigate Partners constructs and oversees, however, has a whole different experience. Some of the “bricks” in the house that we build for a high-value, actively managed, employer-built health plan are the following:

Direct Primary Care (DPC) is the foundation of the plan, where a member selects a DPC doctor and has 24/7 access to the services provided. There is a true and “direct” doctor/patient relationship that is established, which harkens back to Dr. Marcus Welby and the good old days. It is estimated that a DPC provider can handle 70-85% of the medical needs of any patient, including one struggling with an ongoing illness that needs monitoring.

Cost and Quality Guidance and Navigation is a crucial component in managing cost and improving health outcomes for patients by making sure that if care is needed outside of the DPC model, they are pointed to providers and specialists of the highest possible quality with the best possible outcomes. Consequently, the misdiagnosis, infection rates, re-admission rates, complications, and, logically, the costs, all come down when the quality of care goes up.

Pharmacy Benefit Managers (PBMs) that are transparent and pass-through will commit to “passing through” all discounts and rebates to the plan sponsor, ensuring they get the best possible price on needed medications. The DPC can also ensure, on a personal level, that the patient stays compliant with any prescribed and necessary medications.

Defined Benefit Pricing Strategies ensure that the employee and the plan are paying a fair and agreed-upon price before the service is rendered. Depending on the employer, other “bricks” or risk mitigation strategies might also be included, like Medical Bill Review, Direct Contracting, Active Data Mining, Telehealth, Second Opinions, Centers of Excellence, Onsite Clinics, or carveouts for Joint Replacements or Transplants. All these strategies can help alleviate the financial burden of managing a chronic illness while providing a higher quality of care and a more personalized care experience.