Baylor Scott & White Health is revolutionizing health insurance in North Texas by offering a plan that integrates the incentives and funding structure of direct primary care into the larger network of healthcare providers. This means that primary care physicians operating in this plan will not be billing for individual services, and payers will be paying a flat rate for the person’s primary care needs no matter how many times they visit the primary care physician or what work is done while there.
BSW says it is the first of its kind in North Texas, which separates primary care from other services while still covering for hospital, specialist, and other ancillary services. Before this plan, there were providers who did some value-based and direct primary care, and other direct primary care practices that were not part of insurance networks, but employers and payers had to do a lot of work if they wanted to utilize the incentives and structure of direct primary care while still providing coverage more specialized care was needed.
At direct primary care practices, physicians are paid per patient, per month on a subscription basis, which disincentivizes unnecessary care or lab work, while fee-for-service physicians make money for every test they run or procedure they perform. During the pandemic, many have been staying away from the doctor, meaning those who are funded by each service performed were struggling to keep the lights on in many cases. A group of physicians has been lobbying the state and federal governments to move to the prospective payment model that Medicare already uses, which gives providers a certain amount per member, per month, and if that member is kept healthy with fewer dollars than was given, both sides c benefit from the savings.
The BSW plan brings all of that together in a more traditional insurance plan, unbundling the primary care physicians already in the BSW health plan’s network and combining them with the specialists and hospital services that BSW provides. Some employers who have seen the benefit of direct primary care have already started to pay for their employees to go there because of the changed incentives and better access, but it often meant they had to pay for primary care twice, as most insurance plans did not unbundle primary care from other services.
“Integrating direct primary care with an employer benefit offering aligns incentives across the spectrum to address increasing healthcare costs for both the employer and their employees,” said Trent Hadley, CPA, vice president and chief financial officer of Baylor Scott & White Quality Alliance, Baylor Scott & White Health’s accountable care organization (ACO) via release.
In the BSW iteration of direct primary care, employers contribute toward a monthly membership fee for the patient that covers office visits, lab work, immunizations, and virtual visits at a participating primary care practice. “Our direct primary care offering will help make the cost of healthcare more predictable and transparent for employers. By strengthening the link between the individual and their primary care provider and leveraging the strength of our virtual care platform, we expect to deliver better health outcomes and higher satisfaction with their care,” said Jeff Ingrum, president and CEO of Scott and White Health Plan via release.
The network was created with the help of Accressa, a local technology company that specializes in payments and administrative solutions in the primary care market. “Networks of physicians are dynamically creating and maintaining multi-location coverage maps by leveraging our patent pending technology to develop their direct care programs/plans that employers and participants are installing into their healthcare solutions,” says Accresa CEO William Short.
The direct primary model will allow for the medical team to care for patients, as they no longer have to worry about doing enough billable actions and procedures to stay in business, and can focus on the patient’s care. Care management can keep costs low and patients out of more costly hospital visits, but practices are often unable to bill for the calls and relationship building that enables them to keep their patients healthy. With a monthly fee, they can devote more time to care manage and still be paid a good rate. “There is a care team approach, and the practice can now use those resources to the full extent to manage high risk,” says Hadley. “They can stop the the rat race of fee-for-service and innovate healthcare.”