Tech Series Part II

The Core Technologies Required to Support Direct Care

To see our first post in this series, click here.

Electronic Medical Records

Documenting patient visits in a sharable electronic format is as important for Direct Care providers as it is for fee-for-service providers. The fundamental difference lies in what does and does not need to be documented. In the fee-for-service model, there are numerous, strict documentation guidelines that tie directly to whether and how much a provider can bill. Direct Care has none of these requirements. Because the vast majority of EHR systems are designed to support the fee-for-service model, they include numerous features, functions and structures that are irrelevant under the Direct Care model.

Direct Care providers’ EHR needs are very unique. They need simple, intuitive, efficient patient visit documenting tools. They also require tools to record patient interactions across text, social media, mobile and virtual visits, as well clinical, cost and care experience measurement tools to help drive continuous improvements in quadruple aim goals.

Membership Billing - Consumers

The Direct Care model approaches insurance billing in a fundamentally different way than the fee-for-services model. Fee-for-service providers bill insurance companies directly and have to work through a high degree of complexity to secure appropriate payment in a timely manner. In contrast, Direct Care providers bill patients directly and typically have relatively intricate pricing structures that include age tier-based pricing, family pricing, group pricing, different pay cycle options (monthly, quarterly, semi-annually, annually), an array of discounting options, as well as different charge date options required to satisfy different state regulations and patient needs.

In addition to figuring out who and how much to bill, Direct Care providers are not immune to accounts receivable (A/R) challenges. Although fee-for-service insurance A/R carries with it material time and cost consuming challenges, patient A/R challenges in the Direct Care model can be equally challenging, largely driven by a rising rate of credit card charge failures. Since Direct Care is a relatively new practice model, many Direct Care providers don’t anticipate the full extent to which billing and A/R administration can burden a practice as it scales. Hint Health data indicates that over 7% of membership charges fail on a monthly basis and require patient follow-up as result. For a mature Direct Care practice, that can equate to approximately 35+ patient follow-up instances per month.

Membership Billing - Employers

Direct Care providers are increasingly contracting directly with employers to provide a membership-based primary care offering that can help employers achieve Triple Aim goals. In contrast to patient membership billing, employer arrangements often have a very different set of administrative challenges. Employer contracts often have pricing structures that are different and more complex. Direct Care providers also need to embrace and manage an expansive set of administrative variables including ever-changing employee eligibility, incentive driven eligibility rules, employee versus dependent rules, and opt-in versus opt-out contracting structures, to name a few.

Membership Loyalty Management

Direct Care practices must also be competent in membership loyalty management. To be successful, Direct Care practices must cultivate both affinity and long-term commitment among their members to extend their Lifetime Customer Value (LCV). There are myriad ways this can be achieved, but some foundational competencies include regular targeted communication with patients on topics including health and wellness education, clinical reminders, new treatment opportunities, and personal communication. There are two well developed solution categories that exist to support this member loyalty need: (1) CRM (customer relationship management systems), which are tools that help automate customer communication management, allow for the recording and tracking of key data points, and automatically trigger certain reminders or communication events, and (2) Marketing Automation tools that automate outbound online and offline communication to recipients based on a predefined set of rules.

For many providers, these tools and platforms are not well known because they were never required in the fee-for-service environment. Although there are numerous solutions that support this need, there are very few that are HIPAA compliant. As such, providers need to be careful to select the right solution to ensure it can be properly used in the healthcare setting.

Patient Access

The keystone of the Direct Care Model is providing patients with improved access to their care provider. Unlike in the fee-for-service model, where, according a recent Merritt Hawkins survey, average wait times to schedule a primary care appointment can be upwards of 19 days, Direct Care usually offers same or next day appointments— with many Direct Care providers offering home visits as well. In addition, Direct Care providers usually offer multiple other methods of communication and access including telemedicine, email, text and cell phone access. Ubiquitous access via multiple electronic communication channels is a very new concept in healthcare. Because the fee-for-service model has not historically paid providers for these patient “service moments,” we’re just beginning to see tools to support these needs emerge.

Patient Engagement

A growing body of evidence demonstrates that patients who are more actively involved in their healthcare experience have better health outcomes and incur lower costs. As a result, many healthcare organizations are employing strategies to improve patient engagement. These include condition specific health care education, involving patients and caregivers in care decision-making, and incentive-based programs that offer rewards for healthy behaviors. Patient engagement requires two-way communication efforts by providers and patients to help patients improve health literacy, care plan compliance, patient self-knowledge, and access to patient health information. Below is a summary of the HIT competencies required to support a robust patient engagement program in Direct Care.

* Communicate securely with provider or care team
* Complete virtual visit (telehealth)
* Receive and schedule alerts and reminders electronically
Convenient self-service
* Find physician or facility
* Make/change/cancel appointment
* Check-in and register for a visit
* Manage Rx refills
Personal health information
* Review outpatient and inpatient clinical data
* Download or transmit health data
* Enter or track personal data
* Upload data from devices
* Review medication information
* Estimate cost of services
* Manage health financial accounts
Education and support
* Educate oneself on health issues to make decisions about care and treatment
* Manage chronic condition(s)
* Receive peer and community support

In-House Pharmacy & Labs

Access to affordable care is another pillar of the Direct Care model. Many Direct Care providers help keep costs low for patients by offering prescriptions and labs at cost. Administering these services requires specialized HIT systems that support in-house lab and pharmacy management operations, which can oftentimes be extensions of exisiting EHR systems.

Population Health Management

Population health management (PHM) competencies are increasingly important in order to ensure long-term success with employer relationships. Although Direct Care is inherently designed to make improvements in cost, quality, outcomes and patient satisfaction, to stay competitive, having the ability to measure, manage and improve cost and quality performance will likely be increasingly important. PHM solutions have exploded on the scene in the last 5 years driven by the shift from volume to value-based healthcare purchasing with reimbursement increasingly moving to providers who can demonstrate with data that they are driving value-based improvements in population health.

Although the Direct Care model is still in the early stages of development, the HIT requirements to support its success are starting to become clear. Because the Direct Care model is part of the broader value-based care delivery movement, we should expect to see rapid growth in the number of HIT solutions that support its success.

In part three of our series, we’ll examine some of the leading solutions that support Direct Care requirements noted above.