When we think of insurance, it’s usually for things that are rare and expensive. You never want to use your car insurance, fire insurance, or disability insurance and you don’t use file a claim for routine things like changing the oil, buying a fire extinguisher or missing a day of work with a sore back. Insurance works best when it spreads big risks over a large pool of people.
But healthcare is different, and health insurance covers even small, routine things like primary care physician visits. Direct primary care practices change the model because they are paid directly by the patient, not the insurance company. That keeps costs down and increases the alignment between doctor and patient.
I like the idea, and in fact I interviewed an early practitioner of primary care back in 2009, before the Affordable Care Act!
Recently, I spoke with Dr. Jeffrey Gold, of Gold Direct Care in Marblehead, MA. He filled me in on how his practice works and why he’s a proponent of the direct model.
(0:10) What do you mean by “direct” primary care?
(0:47) How does that feel different from a typical primary care office? Is it the same thing as a concierge practice?
(4:58) You don’t accept insurance. Does that affect your overhead and enable you to be more cost effective?
(7:08) What happens when a patient goes out of your orbit to see a specialist or be hospitalized? Do you still have to deal with insurance companies then?
(9:38) Are there particular kinds of patients that are a really good fit for a direct care model?
(11:22) What would be the impact on the overall healthcare system if every patient were a direct care patient?
(14:10) Does the Affordable Care Act help or hinder what you are doing? What changes would you like to see in the healthcare law?
Uber and Lyft have transformed (and largely destroyed) the taxi industry. Now startup companies like Veyo are applying similar approaches to the medical transportation field. I interviewed Veyo’s CEO, Josh Komenda to get his take.
1.How is non-emergency medical transportation (NEMT) defined? What’s included? How big is it?
Non-Emergency Medical Transportation (NEMT) is a transportation benefit for Medicaid or Medicare members who need to get to and from medical services, but have no means of transportation. NEMT provides eligible patients with trips that are non-emergency in nature, meaning there is no immediate threat to the health or life of the participant, and no elements of life support are required in the vehicle during the trip. This includes transportation to medical appointments, urgent care, or the hospital. NEMT exists to ensure that participants have access to routine and preventative care, increasing overall health outcomes and avoiding costly ambulance bills or emergency room visits and it’s especially important for those with chronic conditions such as diabetes, heart disease, cancer, COPD, or asthma. As of December 2016, just under 70 million Americans were eligible for Medicaid NEMT benefits.
2.How is NEMT provided today? What’s good and bad about the traditional model?
Today, a large majority of NEMT benefits are managed under the brokerage model. State Medicaid agencies and health plans contract with an NEMT broker to manage their NEMT benefits for them. The broker is responsible for ensuring their members have access to transportation and managing the transportation providers who perform the actual services. Brokers must manage provider procurement, provider credentialing, trip scheduling, eligibility, reporting, FWA monitoring, provider payments, etc.. NEMT benefits may cover a variety of transportation modes, including sedan, wheelchair van, taxis, stretcher cars, and mileage reimbursement. It also may include reimbursement for public transportation or long-distance accommodations such as air travel if a member requires long-distance or out-of-state treatment. NEMT benefits cover all regions from urban to rural, and transportation is always the least costly and most appropriate mode, which is determined on a case-by-case basis for each member.
Quality of service in the NEMT field is plagued by inadequate technology, outdated business models, inconsistent and unprofessional medical transportation providers, and virtually non-existent transparency for the customer. The issues stem from an overly complex, fragmented, and difficult to manage process that has not changed in decades. For example, limited communication between the broker and transportation provider means little to no data is collected around the actual trips. Important metrics like on-time percentage or customer satisfaction are often self-reported by the provider. And the fixed fleet model that traditional brokers employ leaves little opportunity for flexibility – any issues stemming from scheduling, traffic, or weather can throw off the entire system. Even with current NEMT benefits, over 3.6 million Americans still miss or delay medical care due to transportation issues.
3.What are the characteristics of NEMT users?
Those receiving NEMT benefits are often frail, handicapped, disabled, in rural areas and without smartphones. Patients may require NEMT for a variety of reasons, including: lack of a valid driver’s license, lack of a working vehicle, geographic isolation, or the inability to take traditional transportation for physical, mental, or developmental reasons.
4.Who pays? What is the role of government and private insurers?
Medicaid NEMT is a $5 billion industry, funded by state and taxpayer dollars, and overseen by the Center for Medicare & Medicaid Services. Over the past several years, Medicaid spending for NEMT equates to approximately 1% of total Medicaid expenditures.
5.Have the rideshare companies like Uber and Lyft had an impact? What has limited their effect?
Some traditional NEMT brokers have begun exploring partnerships with consumer TNCs such as Uber and Lyft, although due to credentialing and training requirements set by CMS, most trips completed by those TNCs are consumer trips based in a healthcare setting (aka the member or facility is paying), instead of true NEMT trips. It’s important to note that this results in a solution that is not as efficient, coordinated, or suited to healthcare as Veyo’s. Veyo’s vertically integrated model is far superior for a number of reasons. Veyo is directly connected to its own TNC supply that it controls. When a traditional broker partners with a consumer TNC, it necessarily includes an extra administrative middleman in the value chain which is less economically efficient. What’s more, Veyo directly controls and oversees all aspects of its Independent Driver-Provider (IDP) network, meaning it can directly affect credentialing, training, background checks, messaging, etc., ensuring that its network is optimized and trained specifically for its customers. In addition, it can directly monitor, track, and manage its supply to ensure it always has the right vehicles in the right places, and it can directly control matching, routing, and scheduling tactics to make sure that it solves transportation needs for all member needs in all areas.
6.What does Veyo do? How are you different or better? What barriers do you face?
Veyo is a next-gen tech solution for patient transportation. The traditional NEMT model utilizes commercial fleets that are inflexible, expensive to maintain, and managed using traditional dispatch models. These fixed fleets have a difficult time scaling when demand is high, and leave providers with a surplus of vehicles on the road when demand is low. Unlike a fixed fleet, flexible fleet models allow capacity to be rapidly scaled up and down in minutes to meet demand changes. Our dynamic supply system constantly manages and optimizes the right supply levels for different modes across geographies (both urban and rural), ensuring that every member gets picked up on time.
The Veyo Virtual FleetTM is composed of traditional transportation providers and our flexible independent driver-providers (IDPs). Our cost-effective fleet provides the safest, most reliable, on-time service possible. Veyo’s model is a complete, end-to-end NEMT solution that matches supply with demand, making it more efficient and effective, and ensuring the right vehicles are dispatched each and every time. This provides a better participant experience and more efficient use of vehicles. Launched in November 2015, Veyo is changing the face of what it means to be a non-emergency medical transportation broker by bringing this innovative ride-sharing technology to the antiquated NEMT industry.
Here is how we are different and better:
Veyo brings innovation for the very broad needs of health plan memberships. Consumer TNCs are built to primarily serve individuals without any special needs in urban geographies. Veyo’s virtual fleet model seamlessly includes its network of IDPs (Independent Private Drivers), and traditional, specialized NEMT fleets to meet the broad array of needs from ambulatory, wheelchair, bariatric, stretcher, and other modes as required. Our IDP drivers are trained and credentialed to federal and state CMS requirements, including First Aid, CPR, HIPAA, ADA, patient sensitivity, and hand-to-hand service. We serve members in big cities, small towns, and rural areas, and use a variety of scheduling, routing, and matching techniques that are designed to get every member to their appointments on time with efficiency and high quality service no matter where they live or what their needs are.
Veyo’s platform is designed for management of a transportation benefit. Government agencies and managed care organizations spend millions of dollars on a critical benefit that ensures their memberships can get to and from their appointment reliably. Veyo’s system is designed to bring next-generation tools to manage this benefit to ensure maximum effectiveness. Veyo supports call centers, booking portals, and member apps that verify eligibility, determine the most appropriate mode of transportation, and ensure the highest-quality access, reliable on time performance, and trackability and transparency, while employing sophisticated mechanisms to detect and prevent fraud, waste, and abuse. In addition, it can support customized eligibility criteria and steer members to alternative cost-saving modes such as mileage reimbursement and public transit where appropriate.
Veyo is built from the ground up to be a healthcare ally and use data and technology to cut costs and improve outcomes. From basic requirements, like managing eligibility files, PHI, and providing encounter data, to more advanced dashboards, reports, caseworker/intervention alerts, and app campaigns, Veyo’s platform, data, and tools are at plans’ disposal to drive initiatives aimed at understanding their membership better and piloting new programs to drive better outcomes. More than just a basic transportation service, Veyo understands that it is part of the continuum of care, and uses its ability to interact with members and collect data to help plans make the most of their investment in NEMT.
Some barriers we are currently facing include hesitation in the market about such a new solution. Because Veyo was built on technology for the healthcare market, our model is drastically different than the traditional players in the market and our results can often seem too good to be true. As we continue to record data and results from our current markets, it allows us to prove that the Veyo model does work for the NEMT market and can make huge changes for health plans and state agencies alike. For example, in our current markets, after completing 3.4 million trips, we are seeing on-time performance percentages of 98% and an overall grievance rate of just 0.09%.
7.Where do you go from here?
We are continuing to expand our model into new states, with plans to double in size in 2017. We are continually adding new benefits and features to the Veyo model, including a member-facing app that will allow members to book and manage trips on their own schedule. In addition to managing their own trips, members will be able to manage their own information, ensuring that health plans always have the most up-to-date contact information for their member population. In addition to focusing on improving the trip lifecycle, we’re also looking for ways to better increase the transparency between health plans and their members. Wellness initiatives such as flu shot reminders and annual wellness exam reminders can be built into member-facing apps, giving health plans one more connection to their members. Our high-powered, data-oriented technology team and strategic focus allows us to reimagine many processes within the broker’s function, introduce new automation and efficiency, and provide new NEMT-specific tools and data insights for plans, agencies, and members.
Serious students of the US healthcare system understand that costs are high and quality is uneven. While there are some incredible components of our system, it’s clear to me that we should look elsewhere for best practices that we could apply in the US. That outlook led to my interest in “medical tourism,” which I spent some time focusing on just before the Obamacare era.
A Harvard Magazine article (Global Health at Home) starts with the same premise, and cites a statement from the World Bank president that “situations of scarcity lead to innovation.” This gets right to the heart of the matter, because in the US high and rising costs are taken for granted, and budgets are not really a constraint. As a result we are not forced to think differently and creatively.
I was a bit surprised that the authors then jump to the conclusion that the solution is global health, which is “premised on taking responsibility for all people in a given location.. and at all levels of income. Philosophically, global health is guided by the words of… Paul Farmer, co-founder of Partners in Health: ‘The idea that some lives matter less is the root of all that is wrong with the world.’ Equity is the soul of global health.”
The authors use the term “Global Health at Home,” to describe their concept of bringing this global health approach, developed for poor countries, back to the US. Their solutions are pretty sensible: a holistic approach to chronic diseases, attention to identifying and addressing the social determinants of health, deployment of community workers, and an emphasis on care at home. These are good ideas but we don’t have to go abroad to learn them and frankly I don’t see that equity is the key lever for cost containment in the US or elsewhere.
I’m thinking about how scarcity has led to innovation in other fields: like how farmers in Israel innovated in irrigation to compensate for the lack of water or how earlier computer programmers developed elegant programming approaches when memory was a scarce resource (unlike the typical bloatware we see today).
What are the equivalent opportunities in healthcare, from both a process and product standpoint? What clever and efficient approaches are being taken for diagnosis and treatment in resource constrained settings? Can we apply them to the US? If we do, are there trade-offs that we need to consider?
What barriers are in place and can or should they be lowered? These may include regulatory requirements, malpractice risks, and payment methodologies.
It’s a topic worthy of systematic inquiry. I assume people are working on it, so if you’re aware please let me know on Twitter @HealthBizBlog
As a sidenote, it’s inspiring that the lead author of the Harvard article is in his 90s and still going strong!
You’re a middle market private equity firm that’s just signed an LOI with a profitable and growing healthcare company. What started as a proprietary deal turned into a competitive process and you had to stretch toward the top end of your valuation range to win. Now you have a few weeks to complete the due diligence process and close the deal. A boutique consulting firm specializing in M&A for healthcare companies may be your best bet to assist.
What help do you need?
When middle market PE firms hire consultants for commercial due diligence of healthcare companies they usually have a few objectives:
To generate insights on topics that are critical to the investment thesis. There are often macro questions, such as the fate of healthcare reform after an election or the speed of adoption of a new technology. Then there are questions about the competitive landscape and specific competitors, and about market demand and the needs and satisfaction levels of key customers. Sometimes the potential buyer also needs an assessment of the management team and company processes. A PE firm can do some of this work itself, but often finds it useful to leverage additional resources and skill sets, such as the ability to extract valuable information from players throughout the industry on an unnamed basis.
To gain access to an objective third party that can play the role of a constructive skeptic and thought partner, making sure that investors don’t let their desire to close the deal cloud their judgment. The best consultants have the instinct, gravitas and wisdom to challenge consensus thinking and are willing to point out potential pitfalls in a deal and to counsel against proceeding when needed, even if the potential buyer doesn’t seem to appreciate it at the time.
To prepare for a fast start after closing by generating and validating compelling strategic initiatives and tactics.
To get as much high quality support as possible in a tight timeframe while staying within a reasonable budget.
What firm to hire?
Premier strategy consulting firms such as McKinsey, Boston Consulting Group, and Bain have strong due diligence practices serving PE firms. There are solid reasons for their success. These firms can:
Mobilize large teams of highly intelligent consultants around the world to gather and analyze data. They hire the best and brightest from business schools and undergraduate programs.
Leverage their knowledge base and industry networks built from hundreds or even thousands of relevant client assignments. Their proposals often reflect the perspectives and data they have assembled over the years.
Produce high-grade graphical presentations, with professional staff dedicated to consistent, visually pleasing outputs.
Offer their brand name as a seal of approval, which is reassuring to investment committees.
But boutique firms, typically consisting of 3 to 20 professionals, represent a superior due diligence option for middle market private equity firms. Why?
Consultants at boutique firms are often former senior professionals from the big, premier firms. The consultants performing the data gathering and analysis are frequently more experienced than the partners from the big firms, who are mainly selling and managing client relationships while fresh graduates staff the cases. A boutique firm’s consultants don’t need time to get up to speed, which is crucial when the project is only a few weeks long.
Boutique firm consultants are generally better than their big firm peers at thinking like investors and board members. Many gain this perspective by serving as board members of PE or VC-backed companies and as LPs in PE and VC funds. This profile makes it more likely that the consultant will approach the work with a practical, focused mindset, crisply addressing the questions that really matter. This differs from the classic strategy consulting project that employs elegant but often theoretical approaches. In select cases a consulting team member from a boutique firm is appointed to the board as an independent director post-closing, something that is generally not possible with a big firm.
Certain boutique consultants are entrepreneurial and commercially astute. When appropriate, they highlight opportunities for post-closing business development and partnering to help the new owners hit the ground running. Compared with the big firms, there are fewer constraints on introducing clients to one another and aligning with the PE firm for commercial success.
Professional fees for the engagement are usually a fraction of what the big firms charge. There are multiple reasons for this. Boutique teams are smaller and flatter because there are no trainees. Consulting veterans don’t need mid-level managers to watch over them. Everyone on the team pulls their weight; no one is there just to boost the billings. There are fewer fixed overheads like HR, administrative staff and downtown offices to cover, and boutiques are not charging a premium for their brand name. All this means that boutique firms can pay staff as well as the premier firms while still offering compelling value to clients.
I co-founded the company that became Health Business Group back in 2001. At that time most of our clients were former colleagues from my days at Boston Consulting Group who had moved into PE firms or senior management roles at companies. After being on the inside they understood our value proposition. Over the next few years we attracted new business from referrals and networking. Recently, we have been pleased to receive a number of qualified inbound inquiries from our website contact page, which represents a change in how clients find consultants. Middle market PE shops are searching the web specifically for boutique healthcare consulting firms to perform due diligence. After interviewing us and checking our references, they often bring us on board and are pleased with the working relationship and results.
Wayne Lipton runs Concierge Choice Physicians, which converts traditional physician offices to “hybrid”concierge practices that provide new options for patients and increase physician income. While we typically hear about concierge practices in primary care, the model is expanding to other specialties.
In this podcast interview, Wayne and I discuss the hybrid concierge model for cardiology:
(0:11) What is a typical cardiologist’s practice like these days and how has it changed?
(1:01) How have the practice changes worked out for physicians and patients?
(1:48) Do patients with cardiac issues use their cardiologist as primary care physicians or do they still maintain primary care relationships?
(3:06) Within primary care we’ve seen a shift toward concierge models. Why haven’t we seen that in the specialties?
(4:22) What is a hybrid model like? Does a physicians have to remember when they are acting as a concierge versus the traditional hamster wheel model?
(6:15) Are a lot of the cardiology concierge patients also concierge primary care patients?
(8:26) How does a concierge cardiology practice differ from a concierge primary care practices? How do the economics compare?
(11:08) What do health plans think of concierge medicine? What is the impact on new models of reimbursement?
(13:37) Would a practice that added on a hybrid model be more or less attractive to an ACO? Would the practices want to participate?
(15:50) How broad is the opportunity to add this model in cardiology? Are other specialties also ripe?