Benefits for Employees and
Other Healthcare Consumers
The RE·MEDI system makes its members the smartest healthcare shoppers in the world ... and the freest: they may receive treatment from virtually any licensed doctor in the world without any loss of benefits. Because the RE·MEDI system empowers healthcare shoppers with the best available information on their treatment choices, only the providers offering them the best healthcare values are likely to receive their business. Providers will have to compete (by lowering their prices and improving their patient outcomes) to attract patients, and this will drive down healthcare costs and raise the quality of the healthcare they deliver.[If this is your first stop after visiting our home page, click here to read a synopsis of the RE·MEDI system, or for more detail read the RE·MEDI Overview
article.]Healthcare benefits for consumers fall into five major categories: cost, quality, level of risk, quality of service and variety of choices. The RE·MEDI system excels in each. Benefits to members in each of these categories are discussed briefly below. A more-detailed discussion can be found by following the links.
Cost
Lowest Medical Prices. The RE·MEDI system significantly reduces the medical costs of Diagnosticians, clinical laboratories, doctors, hospitals and pharmacies. With respect to Diagnosticians, we first determine which physicians will make the best Diagnosticians, and then we negotiate with them to get the best price. We use a method of compensation that rewards them for the work they actually perform and for how well they perform it. We subject clinical laboratories to a competitive bidding process, so we get the best prices for the diagnostic tests that Diagnosticians order. These savings are passed on to our clients (e.g., employers), who pay directly for all of the medical costs incurred by our members, and their employees.
Doctors are compelled to compete for their patients, and one way in which they compete is by offering competitive prices. This competition is driven by The Doctor Shopper and especially by its Value chart. Moreover, doctors find it in their financial interest to treat their patients at those hospitals that help them to achieve the best outcomes per dollar spent. Hospitals compete with each other by offering competitive prices and by supporting the doctors who use their facilities with the most cost-effective technology and support staff. The Doctor Shopper identifies those doctor/hospital combinations for the patient searching for the best treatment value.
The RE·MEDI system also makes pharmacies and other prescription drug vendors compete with each other. This is accomplished by publishing the prices of the specific drugs required by the patient in the Rx Shopper, which is included within The Doctor Shopper.
The competition produced by the RE·MEDI system actually causes many changes in the healthcare delivery system that are not readily visible to the healthcare consumer, but which manifest themselves in lower medical prices. For a discussion of these changes, see the Scorecard article, which demonstrates that the RE·MEDI system either eliminates or significantly reduces virtually every major healthcare cost-driver.
Cash Back for Economical Purchases. When transferring from another health plan, our members will typically receive approximately the same dollar amount of healthcare benefits. However, they will receive them via Ca$hback Coverage, which significantly increases the value of these benefits by lowering medical costs and increasing the quality of the healthcare delivered. Any time that members receive cash back, their healthcare costs are reduced.
No Cost-Shifting. Cost-shifting occurs when providers raise their costs on one health plan group to compensate for special discounts or other price breaks given to another group. Under RE·MEDI, members can be confident that doctors, hospitals and other providers will not shift costs onto them. Providers who increase their costs without producing commensurate improvements in the outcomes of our members will make themselves less competitive. They will find themselves further away from The Cutting Edge, and this will cause our members to select them less frequently or not at all.
Quality of Care per Dollar
The RE·MEDI system offers its members the highest quality of care per dollar spent on Diagnosticians and on treating doctors. This is a result of the incentives that are embedded in the RE·MEDI system.
Rating Diagnosticians. Because the RE·MEDI system has a dual structure—Diagnosticians and treating doctors—each group has its own incentives to provide the highest quality care. The primary functions of Diagnosticians are to: establish the diagnoses of their patients; administer routine care to members; determine a prognosis rating for patients requiring non-routine care; refer their patients to a well-qualified treating doctor; and oversee the patients recovery by coordinating with the treating doctor. Each of these factors is rated for each Diagnostician, and the better that Diagnosticians perform with respect to each factor, the greater will be their end-of-year bonus. Diagnosticians who fail to perform adequately one or more of these functions may lose their right to practice as a Diagnostician. Patients will be able to select a Diagnostician by comparing their performance measures at our Web site.
Competing to Excel. Treating doctors strive to perform well because of the market forces that are brought to bear by The Doctor Shopper and by its Value chart. In fact, it can be shown that it is always in the financial interest of treating doctors to produce, for a given cost, the best possible outcome value for each patient. Because the patient's selection of a treating doctor from the Value chart establishes the cost of her treatment, her treating doctor will strive to produce for her the best possible outcome at that cost.
Hospitals also are motivated to produce the best outcome values for their patients. Hospitals compete for doctors who will bring them paying patients, such as our members. Doctors will be attracted to those hospitals whose organizational efficiencies, equipment, and staff best enhance the ability of these doctors to improve the outcomes of their patients. In addition, hospitals must price their services so that their doctors are well-positioned on The Cutting Edge. The hospitals that best succeed in these twin endeavors will be the most successful.
We believe that, between the information provided at our Web site and the information contained in The Doctor Shopper, the RE·MEDI system has no parallel when it comes to guiding members toward the best performing Diagnosticians, treating doctors and hospitals.
Levels of Risk
Practice Guidelines. The RE·MEDI system has several features that reduce the medical risks that patients face when receiving tests and treatments. Because the RE·MEDI system eliminates defensive medicine, our Diagnosticians can apply practice guidelines that strictly follow evidence-based medicine. Any diagnostic tests that are found not to be cost-effective will be excluded, as will any risk associated with them.
Unnecessary Treatments. Unnecessary treatments are those that add to costs without providing commensurate benefits to a patient. To remain competitive, doctors in the RE·MEDI system will seek to avoid such treatments, including those that may also pose a medical risk to the patient.
Malpractice Risk. The Outcomes Index also reduces medical risk by driving doctors with excessive malpractice away from The Cutting Edge. Doctors with poor patient outcomes will find it difficult to attract new patients, and they either will have to change the way they practice medicine or pursue another career. Clearly, reducing the incidence of malpractice will reduce patient risk.
Automatic Second Opinion. Whenever a member requires non-routine care, both the Diagnostician and the treating doctor must agree on her diagnosis. Thus, she receives an automatic second opinion. Because it is much less likely that both the Diagnostician and the treating doctor will be wrong about the diagnosis than either alone, the likelihood of applying a wrong treatment is much reduced, as is its associated risk.
Improved Communication. Good communications between doctor and patient reduces patient risk. The RE·MEDI system strengthens communications. When a member receives a formal, written treatment plan and The Doctor Shopper from her Diagnostician, she also receives a written letter from him explaining her diagnosis, proposed treatment, and her prognosis in language that she can readily understand. Moreover, because a member who is recovering from a non-routine illness must periodically report her symptoms to her Diagnostician via a self-administered, electronic survey, he can regularly track and assess her recovery progress and reduce her risk of relapse.
Team Support. If a Diagnostician wants assistance in determining a diagnosis or wants a specialist to prepare a member's treatment plan, he will involve one or more other Diagnosticians. They will work together to determine the member's diagnosis and establish the best treatment protocol. The Diagnostician is also responsible for overseeing the patient's recovery progress and communicating recommended changes to the treating doctor when a course correction is indicated. This collaborative effort will also reduce our members' medical risk.
Individual Support. The RE·MEDI system is information-rich and can reduce a member's medical risk by guiding her toward her best treatment options. However, for the information to be useful, it must be clearly understood. Consequently, we offer several ways for members to receive assistance in using the information we provide. First, workshops are offered that explain the information in The Doctor Shopper and how to use the information most effectively. Next, whenever members receive a formal treatment plan from a Diagnostician, they can address questions to the Diagnostician's receptionist or other staff. And, finally, members can always obtain assistance from our customer service representatives.
Electronic Health Records. The RE·MEDI system features an electronic health record (EHR) system that greatly reduces the potential for human error. In addition, it makes the patient's health records readily accessible to affiliated doctors, all of whom have electronic access to our central claims processing center, where the records are maintained. This information network can significantly reduce duplicate tests and treatments, as well as the prescribing of tests, treatments and medications that may be contraindicated. The fragmented nature of our current healthcare delivery system is a significant source of unnecessary patient risk that a comprehensive (see next item) EHR system can minimize.
Member-Owned Medical Records. Upon enrolling in the RE·MEDI system, members are issued an encrypted flash drive containing their personalized medical information, which includes the member's medical history, family medical history, and a special record accessible by emergency responders in the event that a member has a medical emergency. Members are encouraged to bring their flash drives to each medical encounter so that their EHR can be updated with information relating to the current medical transaction, including tests, treatments and images.
Providers who are not affiliated with the RE·MEDI system, but who have a personal computer, can gain access to the relevant medical records on the flash drive. These member-owned flash drives make the member's records available to most providers, further reducing the medical risks associated with the current, fragmented, healthcare delivery system. (NOTE: Members select the level of privacy that they wish to retain while receiving medical care through the RE·MEDI system, including the option of interacting with the medical system with complete anonymity. They also retain the capability of releasing the information on their flash drive selectively.)
Variety of Choices
Freedom of Choice. The RE·MEDI system gives members the total freedom to choose any doctor they want for their treatment. Indeed, once they receive a treatment plan from their Diagnostician, they may go to any (other) licensed doctor in the world with no reduction in benefits.
The reason why we can offer such freedom is because the benefit amount is determined by the treatment plan and not by the cost of the treatment. (There is an exception, however, if treatment fails.) No matter what doctor a member chooses for treatment, the cost to the insurer will be the same. With their health insurance based on the principles of Ca$hback Coverage, members are never encouraged to choose the least costly care. In fact, we actively encourage members to find the very best healthcare value they can, since this is what stimulates the competition that we believe is crucial for reforming our healthcare delivery system.
We also give members the maximum freedom in selecting a Diagnostician. They may choose any available Diagnostician in the RE·MEDI system—even a specialist. If a member doesn't like the results or the manner of the first Diagnostician, they may choose a different one. In fact, they may change Diagnosticians as often as they like. However, most members are likely to settle on one Diagnostician, who will become their trusted family physician.
Separating diagnosis from treatment allows the RE·MEDI system to substantially reduce healthcare expenditures because of the competition that it creates. Therefore, if a member wishes to bypass the Diagnostician completely, or if she wishes to have the Diagnostician perform the treatments he has prescribed, she will be permitted this freedom, but her benefit amount will be reduced by the imputed savings lost to the system because the treatment provider did not have to compete.
Optional Features
Patient Advocate Program. The RE·MEDI system has an optional program called the Patient Advocate. The Patient Advocate is a healthcare professional, preferably a nurse. If a member receives a treatment plan from a Diagnostician that requires inpatient care, then the PA will make an appointment to visit the member in her home. The primary purpose of the PA is to reduce the substantial costs of inpatient care and to assist the member in choosing a hospital for her treatment.
The Diagnostician's treatment plan for a hospital stay may be a lengthy document with many medical procedures, diagnostic tests, prescriptions and other items. This complex document also contains the information required to make what is usually a major health care decision: selection of the admitting doctor and the hospital with which the doctor is affiliated. Therefore, many patients and their families might welcome an expert who can identify and explain the alternatives and inform the decision-making process.
The PA will meet with a member shortly after the formal treatment plan has been prepared, but usually before the member has chosen her physician and hospital. The PA will explain the treatment plan and answer questions that her or her family might have. She will explore with the member the physician and hospital options that are available. The Value chart in The Doctor Shopper usually will prove especially helpful in making this decision.
If a member has a low prognosis rating, i.e., her prognosis is pessimistic, the PA can explain the advantages of obtaining a more highly qualified doctor, as measured by the doctor's Outcomes Index. The PA also can explain what different values of the Outcomes Index imply with regard to the member's recovery. For example, the difference between an Outcomes Index of 4 and an Outcomes Index of 3 might mean that the member can expect to return to work two weeks sooner and suffer one less week of pain and discomfort.
Cost considerations include the charges for both the doctor(s) and hospital. The PA will have a notebook computer with a database so she can show the member how much the treatment will cost at competing hospitals. If only one or two hospitals are available locally, she can also present information about hospitals and doctors located out of town. Urban doctors and hospitals may offer improved recovery opportunities at the same or lower cost. Then again, recovery prospects might be much improved at an out-of-town hospital, even though the treatment cost could be higher. The member could then weigh the inconvenience of going out-of-town (or even out-of-country) against these performance and cost considerations. Most people will welcome these kinds of choices. Of course, under Ca$hback Coverage, all cost savings accrue to the member, which gives her a strong incentive to be price-sensitive.
Besides providing members and their families with the information and guidance they need to make well-informed decisions, the PA also stimulates competition among hospitals and the professionals that work in them. Even when the choice of hospitals within the local market is limited, a significant competitive impact often can be achieved by presenting patients with attractive options that lie outside the local market.
In summary, the Patient Advocate program is a powerful instrument for promoting price competition among providers, increasing the quality of care delivered, making patients aware of their options, assisting patients in making enlightened healthcare decisions, and promoting good will among RE·MEDI members.
Personal Healthcare Manager. An optional feature of the RE·MEDI system is the Personal Healthcare Manager (PHCM). The PHCM is a healthcare professional or company that members could engage to manage their treatment and recovery. A PHCM would have detailed knowledge of the local healthcare market, including the prices, performance, qualifications and expertise of local providers. Unlike a case manager, the PHCM is hired by the member. Hence, the PHCM is morally and legally obligated to serve only the member's interests.
PHCMs are likely to be most valuable when a member has a serious and complicated medical problem. If the member is also elderly and doesn't wish to be proactive in selecting a doctor or hospital, the PHCM can be especially helpful. The PHCM can take command of her treatment and guide her through the local healthcare system. PHCMs may offer to assume full responsibility for all of a member's treatment costs and pay all doctors, laboratories, hospitals, pharmacists, and other providers that become involved in the treatment. The PHCM would be compensated by the insurer from Ca$hback Coverage benefits, but could also contract with the member for additional payment.
Proceed to the Next Article (Employer Benefits).