Primary Healthcare (PHC)
PHC EFFICACY PLAN
Quarterly Report Template
INTRODUCTION
“Without monitoring, there can be no credible commitment;
without credible commitment,
there is no reason to propose new rules.”
Elinor Ostrom ( 1933 – 2012 )
The lingering “hang-over” from the HMO experience ending around 1995-2000 has left an indelible scar within the history of healthcare reform. Unfortunately, the improvement in the control of health spending was not correlated with an understanding of its benefits to the providers. Many of its onerous attributes were not balanced by a collaborative effort to mold a connection with a collective action process to engage all of the components within the healthcare process that is driven by data. Remember that the Health Maintenace Organization (HMO) concept became increasingly recognized beginning around 1975. The ability for it to produce meaningful efficacy data did not really begin until nearly 10-15 years later.
The intent of a Primary Healthcare (PHc) financial efficacy process may be its most meaningful when a community’s PHc Clinics evaluate the results by themselves. This initial process could begin with a fee-for-service model and a modest “management compensation” payment based on a fixed fee per insured person per month. Over time, the fixed fee could go up or be eliminated based on the level of confidence developed by the PHc Clinics for managing their financial efficacy. In reality, it should be considered a collective action proposition. The details form the basis for considering an evolving reporting model.
This Sub-Page uses a basic Income Statement structure for understanding the overall allocation of the premium revenue and healthcare expenses by each Payer for the healthcare of any PHc Clinic’s patients, viz their insured. It is intended to represent a 3-month rolling average that is reported within 3 months using an accrual accounting format. Assuming a calendar year for the annual totals, the first year’s initial quarterly report for January through March would be available in July. Similarly, April through June would be available in September. The first year’s annual report would not be available until March of the succeeding year.
The original ACA 2010 (“Obamacare”) required that at least 80% of the premium dollar was allocated to healthcare, aka “medical loss” for an insurance company. This feature was actually added by the efforts of Senator Ben Nelson from Nebraska. Before becoming Governor of Nebraska and thereafter a Federal Senator, he had managed the Department of Insurance within Nebraska’s State Government. A fixed designation for the “medical loss” allocation becomes somewhat clouded when considering other sources of revenue to health insurance, such as PHARMA rebates and any coordination of benefits, such as third-party liability. In addition, the insurance company may undertake non-healthcare purchases in the community such as a community worker, transportation, and case management. In sum, the details of how the premium dollar is allocated by a Payer are affected by all sorts of issues.
STOP-LOSS PROTECTION
To consider this carefully, the Quarterly reports for premium revenue by each Payer would be divided into three age groups: Pediatric (18 years of age or less), Adult (Age 19 years of age thru age 64 Years, excluding Medicare eligible persons) and Geriatric (age 65 years or more for a Medicare advantage Plan). Each of these reports might eventually represent the combined reports of multiple insurance Plans. In reality, each of these Plans could have individually different utilization issues. However, the intent of this reporting process would be to evaluate the overall financial management by a Primary Healthcare Clinic’s group of Healthcare Teams.
Presumably, the first 2-3 years would provide a means to understand the financial reports and the initial performance data. This would also be necessary to understand the stop-loss arrangements to exclude the financial impact of the high-utilization persons. Thereafter, the PHc Clinics could assume more or less risk as their individual groups achieved a perception of confidence in their skills for managing each person’s Comprehensive Healthcare Plan. The “nesting” of these PHc Clinics could also form several layers as in State, 1 or more Counties, Hospital affiliation by more than one PHc Clinic group, or multiple Primary Healthcare clinics within a single PHc Group. Regional arrangements might also apply to the financial structures for the PHc Groups and their Stop-loss Pools.
DISASTER PREPAREDNESS
It is likely that justly efficient and reliably effective healthcare will improve as the Stop-Loss Pools are optimized. Actuarial assistance may be necessary to account for the status of disaster preparedness among the communities of each State. Each State’s insurance payers should participate in this strategy. Obviously, this would also have a special priority in the absence of a regularly upgraded MASTER DISASTER PREPAREDNESS PLAN and its associated Survival Commons for each community within a State.
FREE RIDERS
Each collective action cluster will need to consider its response to a PHc Clinic that fails to participate in the collaborative function of the cluster, either as a PHc Clinic or by a physician within a PHc Clinic’s group. The design principles defined by Elinor Ostrom apply. This also applies to individual patients who are substantially non-compliant with their Comprehensive Healthcare Plan. The entire cluster of PHc Clinics will need arrangements within each plan for the responsive management of these outlier issues. A steady commitment to Trust, Cooperation, and Reciprocity as each hospital’s cluster begins its own traditions for managing its affairs regarding their performance attributes.
A key attribute of each hospital’s affiliated PHc Clinics cluster will require an initial phase of setting minimum operating standards for the PHc Group’s Clinics. This might require that each identified PHc Clinic represents 3-5 full-time physicians who share after hours, on-call responsibilities for their Clinic. There might be outlier tolerance for a maximum of 2-3 years. Eventually, there might be requirements for how the office phone number is managed during clinic hours. Finally, the PHC Group might have a requirement to offer standard immunization requirements and to have an ambulatory defibrillator. Eventually, the community level of the nested hospital affiliated PHc Clinic Groups could choose to develop a minimum operating character of their community’s PHC Group’s clinics.
HEALTH INSURANCE REPORTS: each PHC Group
[ HEADER page 1 ]
( Insurance Carrier ) ( Page __ of __ __ )
PRIMARY HEALTHCARE GROUP: EQUITY REPORT
(quarterly or annually) (month-day-year) thru (month-day-year) Annualized
(PHc Clinic: “Name” and its nesting ID)
REVENUE current year one year ago two years ago
Premium Revenue
- Pediatric — — —
- Adult — — —
- Geriatric — — —
SUB-TOTAL — — —
Adjustment for OUTPATIENT Health Care stop-loss fund contribution
- Pediatric — — —
- Adult — — —
- Geriatric — — —
SUB-TOTAL — — —
Adjustment for SPECIALTY & INPATIENT Health Care stop-loss fund contribution
- Pediatric — — —
- Adult — — —
- Geriatric — — —
SUB-TOTAL — — —
TOTAL REVENUE — — —
[ REPEAT HEADER page 2 ]
EXPENSES current year one year ago two years ago
Primary Health Care
- Pediatric — — —
- Adult — — —
- Geriatric — — —
SUB-TOTAL — — —
SPECIALTY & HOSPITAL Health Care after stop-loss adjustment
- Pediatric — — —
- Adult — — —
- Geriatric — — —
SUB-TOTAL — — —
ANCILLARY SERVICES Health Care after stop-loss adjustment
- Pediatric — — —
- Adult — — —
- Geriatric — — —
SUB-TOTAL — — —
TOTAL EXPENSES — — —
SURPLUS / (LOSS) — — —
Rank if >6,000 mm __ __ / __ __ __ __ / __ __ __ __ / __ __
[ HEADER page 3 ]
UTILIZATION current year one year ago two years ago
Hospital days per 1000 members
- Pediatric & rank __ __ /__ __ __ __ / __ __ __ __ /__ __
- Adult & rank __ __ __ / __ __ __ __ __ / __ __ __ __ __ /__ __
- Geriatric & rank __ __ __ __ / __ __ __ __ __ __ / __ __ __ __ __ __ /__ __
Ancillary Services: Medication expense pmpm – stop loss adjusted
- Pediatric & rank __ __.__ __ /__ __ __ __.__ __ /__ __ __ __.__ __ /__ __
- Adult & rank __ __ __.__ __ /__ __ __ __ __.__ __ /__ __ __ __ __.__ __ /__ __
- Geriatric & rank __ __ __.__ __ /__ __ __ __ __.__ __ /__ __ __ __ __.__ __ /____
Ancillary Services: Laboratory Expense pmpm – Stop loss adjusted
- Pediatric & Rank __ __.__ __ /__ __ __ __.__ __ /__ __ __ __.__ __ /__ __
- Adult & Rank __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __
- Geriatric & Rank __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __
Ancillary Services: Imaging Expense pmpm – Stop loss adjusted
- Pediatric & Rank __ __.__ __ /__ __ __ __.__ __ /__ __ __ __.__ __ /__ __
- Adult & Rank __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __
- Geriatric & Rank __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __
Ancillary Services: Other expenses pmpm – stop loss adjusted
- Pediatric & rank __ __ __.__ __ /__ __ __ __.__ __ /__ __ __ __.__ __ /__ __
- Adult & rank __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __
- Geriatric & rank __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __ __ __ __ __.__ __ /__ __
[ Header Page 4 ]
OTHER REPORTS
Complaints – any current year one year ago two years ago
- Pediatric & Rank __ __ /__ __ __ __ /__ __ __ __ /__ __
- Adult & Rank __ __ /__ __ __ __ /__ __ __ __ /__ __
- Geriatric & Rank __ __ /__ __ __ __ /__ __ __ __ /__ __
Complaints – Class 4 or 5 // 5
- Pediatric & Rank __ __ /__ __ __ __ /__ __ __ __ /__ __
- Adult & Rank __ __ /__ __ __ __ /__ __ __ __ /__ __
- Geriatric & Rank __ __ /__ __ __ __ /__ __ __ __ /__ __
Longevity – average length of member’s enrollment by age at enrollment & rank
- Pediatric & Rank __ __ __ /__ __ __ __ __ /__ __ __ __ __ /__ __
- Adult & Rank __ __ __ /__ __ __ __ __ /__ __ __ __ __ /__ __
- Geriatric & Rank __ __ __ /__ __ __ __ __ /__ __ __ __ __ /__ __
Churn – average ratio of members transferring to another Primary Physician by members enrolled for less than 18 months with Primary Physician
- Pediatric & Rank __ __.__ __ /__ __ __ __.__ __ /__ __ __ __.__ __ /__ __
- Adult & Rank __ __.__ __ /__ __ __ __.__ __ /__ __ __ __.__ __ /__ __
- Geriatric & Rank __ __.__ __ /__ __ __ __.__ __ /__ __ __ __.__ __ /__ __
COMMENT The mere existence of a PHc Clinic “risk-sharing” reporting scenario will require a steady process to reconcile various options or “understandings” for managing certain National and State public and private institutional rules. Some of these issues are explored as the reporting structure is preliminarily described above. Most importantly for the efficacy (efficiency versus effectiveness) issues of a national risk management, reporting system begin with a balanced consideration of baseline over-all financial risk pools. We would favor three as in Basic Healthcare Needs, Complex Healthcare Needs, and a deeply nested Stop-loss Risk management system for healthcare utilization involving 70% of annual health spending beginning with the initial payor.
Currently, 12% of our resident persons account for 88% of health spending and 88% of our resident persons use 12% of health spending. (See Figure 1 in CHAPTER 3c) The distribution of health spending among our nation’s resident persons represents a Power Law Distribution. As such, it is possible that a 70/30 distribution would be more efficacious than the current 82:18 distribution. Thus, the nested stop-loss protective measures would be different for Basic Healthcare Needs, Complex Healthcare Needs, and the national risk management relationship between resident persons, direct payors (insurance companies), state government, and Federal government.
For the purposes of the Primary Healthcare efficacy model proposed above,
- Primary Healthcare (Basic Healthcare Needs) would receive 30% of premium revenue with an annual stop-loss protection of $70,000;
- Specialists and Hospitals (Complex Healthcare Needs) would receive 55% of premium revenue with an annual stop-loss protection of $300,000; and
- Plan sponsors (Federal and State government, ERISA institutions, private insurance) 15% of premium revenue with an annual stop-loss protection of $1 million.
- NOTE: Stop-loss protection refers to a person’s health spending that becomes responsible by progressively higher levels of authority.
The ultimate re-insurance for the persons with catastrophic Complex Healthcare Needs and its health spending involving more than $1 million would be the ultimate responsibility of a Federal-State consortium that could be managed by the reinsurance carriers. The level of transparency among all the participants would by itself induce a level of trust, cooperation, and reciprocity currently undetectable.