Is MedEncentive A Health Insurance
Company?
How Does MedEncentive Get Paid?
Who Pays for the Higher Physician Reimbursement Rates and Patient Rewards?
What Constitutes the MedEncentive Product?
How will the MedEncentive program work with my provider?
What studies are available that prove MedEncentive works?
What is MedEncentive?
How does MedEncentive Work?
What Makes the MedEncentive model differet than other P4P programs?
Is MedEncentive A Health Insurance
Company?
MedEncentive is not an insurer nor does it underwrite the risk
of health insurance coverage. The MedEncentive program is designed to "bolt-on"
to a health insurance product to make it better and more affordable.
How Does MedEncentive Get Paid?
The Company charges its customers a monthly fee based on the number
of health plan subscribers or members that need or want access to the MedEncentive
program. This method of charging for services based on a per-member-per-month or
PMPM is common in the industry.
Who Pays for the Higher Physician
Reimbursement Rates and Patient Rewards?
Ultimately, the health plan purchaser pays for these program costs
including MedEncentive’s fees. Purchasers are commonly health insurers, self-insured
employers and governments. These parties are interested in investing in cost containment
programs that offer an attractive return on their investment. The Company has developed
an Economic Analysis it shares with purchasers to help them understand the return
on their investment in MedEncentive’s program.
What Constitutes the MedEncentive
Product?
The Company has created a number of product components needed
to make the MedEncentive program function in a "turn-key" fashion. These components
include everything from instruction videos to user agreements to health card logos
to participating physician decals to standard electronic interfaces for automated
claims processing.
How will the MedEncentive
program work with my provider?
The MedEncentive Program is designed to "bolt-on" to existing
health plans (such as Blue Cross, Medicare, commercial insurers, self-insured employers,
health plans, etc.) to improve the standard of care and control healthcare costs.
MedEncentive accomplishes quality improvement and cost containment by effectively
and efficiently dispensing evidence-based medicine (EBM) treatment
guidelines and information therapy (I x) to physicians and their
patients through MedEncentive's proprietary Internet Website applications (Figures
1 and 2). The program achieves high physician and patient participation through
financial rewards and simple but profound checks and balances and other features.
This method of financially rewarding physicians for quality considerations falls
into a national movement referred to as pay-for-performance or
P4P. The P4P movement is in its infancy but enjoys the support
of powerful sponsors such as the Federal government (Medicare), Fortune 500 companies,
and managed care plans.
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What studies are available that prove MedEncentive works?
Studies by reputable organizations have concluded that the American health system
is broken for the following reasons:
• The healthcare in the United States is more expensive than any other developed
country on earth and yet life expectancy and infant mortality in the U.S. ranks
toward the bottom of developed countries.
• 45 million Americans are without health insurance coverage and this number
continues to grow as coverage becomes increasingly unaffordable.
• Patients receive recommended care only 55% of the time (RAND Corp).
• Doctors and patients do not communicate well (University of Toronto ).
• Patients tell their physicians all they need to only 2% of the time
• Physicians interrupt their patients in the first 23 seconds of an encounter
• Patients understand what their physicians tell them 15% of the time
• Patient follow their physicians instructions 50% of the time
• The practice of defensive medicine by providers to reduce their malpractice
risk adds 5% to 15% to the overall cost of healthcare.
• Physicians and patients control the vast majority of cost (approximately
80%) and yet physicians receive less of the premium dollar (17%) than pharmacy (22%),
administration and underwriting (25%) and hospitals (28%).
• Americans are increasingly unhealthy.
• Patients and physicians are not accountable or empowered enough to improve
health or control costs.
• Inefficiencies in the American healthcare delivery system may account for
50% of the total cost of healthcare ( Boston University )
Additional studies and the consensus of opinion have concluded the following:
• When the standard or quality of healthcare improves then clinical outcomes
improve and overall costs are reduced. Therefore, the efficacy of a healthcare quality
improvement program can be measured by cost trends.
• The consensus of the medical community is that evidence-based medicine (EBM)
treatments represent the highest standard of care.
• Americans would prefer that their healthcare providers be compensated on
the basis of value (which is referred to as pay-for-performance or P4P) as opposed
to volume (Blue Cross and Blue Shield Association of America).
• Pay-for-performance (P4P) programs have been successful in improving the
standard of care and clinical outcomes.
• P4P programs that mandate adherence to guidelines are considered by many
physicians as "cookbook medicine", counterproductive, potentially dangerous, and
will be rejected by the medical community (American Medical Association).
• According to experts, the success of P4P programs will hinge on:
• physician (and patient) participation and compliance
• the incorporation of evidence-based medicine (EBM)
• the incorporation of information therapy (Ix)
• investing first in quality improvement to achieve cost control
• the ability to effectively control fraud and abuse
• the cost of deploying and maintaining the program and the return on investment.
• Information therapy (Ix) changes patient behavior, improves clinical outcomes,
and lowers costs (Blue Cross and Blue Shield Association of America and RAND Corp).
All of these factors contribute to the quality and cost of healthcare. Each factor
must be taken into consideration to solve the problems that plague American healthcare.
The developers of the MedEncentive Program have done just that by creating a simple
yet effective system that lowers healthcare costs by improving the standard of care.
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What is MedEncentive?
The MedEncentive Program reduces healthcare costs by improving
the standard of care. MedEncentive accomplishes these objectives with proprietary
Internet Website applications that function as very efficient and effective vehicles
to dispense evidence-based medicine (EBM) and information therapy
(Ix) to physicians and their patients. However, the essence of MedEncentive's
success is not simply dispensing EBM and I x through its Websites. Instead, it is
MedEncentive's other features that are designed to achieve high levels of participation
and adherence by physicians and patients. These features include financial rewards
for participation and adherence (referred to as pay-for-performance
or P4P), plus natural built-in checks and balances that provide
important benefits. A description of how the MedEncentive Program works will explain
how all of these features come together to make MedEncentive a breakthrough in progressive
healthcare reform.
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How does MedEncentive Work?
The MedEncentive process is initiated in two fashions, 1) when a doctor accesses
MedEncentive's fast and easy to use Website (Figure 1) during a
patient encounter ("Real-time Version") or 2) by a doctor's normal
insurance claim filing process ("Claim Initiated Version"). With
the Real-time Version, the doctor enters the patient's diagnosis(es) and MedEncentive
supplies an EBM decision-tree treatment guideline (Figures 2). With the Claim Initiated
Version, MedEncentive captures affected physician services from a submitted claim
and sends an e-mail notification back to the doctor that contains the guideline.
The doctor responds by answering three simple questions: "Are you following this
guideline in the treatment of this patient?", "Do you wish to prescribe information
therapy to this patient?" and "How do rate this patient's compliance to recommended
care for this diagnosis?" The doctor's appropriate responses to these questions
affect an automatic increase in reimbursement and send an information therapy prescription
to the patient through MedEncentive (Figure 3).
The patient receives their doctor-initiated information therapy prescription by
mail (Figure 3) or e-mail from MedEncentive or from their doctor in his/her office
in the case of the Real-time Version. This letter or e-mail directs them to MedEncentive's
patient Website (Figure 4). There the patient is asked to read evidence-based medical
content (Figure 5) and answer a series of questions (Figure 6). These questions
are designed to accomplish four objectives, 1) test the patient's understanding
of their condition, 2) determine and/or have the patient declare their adherence
to recommended treatment, 3) seek their impression of their doctor's care relative
to recommended care, and 4) allow the patient to authorize the release of the physician's
rating of their compliance (which, in effect, causes the patient to contemplate
whether their physician's rating of their compliance will coincide with their own
compliance declaration). As the patient answers these questions, they score points
toward a financial reward or rebate of their out-of-pocket medical expenses (Figure
7). The patient's score is automatically forwarded to their health plan who affects
the rebate. The patient's actual responses are forwarded to their doctor to support
subsequent care and to create another check and balance.
In time, the Program will be used to enhance other quality improvement/cost containment
initiatives such as population health management, disease management, and consumer-driven
healthcare. It will also financially reward hospitals and other caregivers for efficiency
and quality.
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What Makes the MedEncentive model differet than other P4P programs?
There are a number of important characteristics that make MedEncentive
unique with significant commercial potential. These characteristics include:
• Only Pay-for-Performance (P4P) Program to Reward Physicians and Patients
- Out of nearly 100 private and governmental pay-for-performance pilot
programs being tested across the country in 2005, the MedEncentive Program is the
only one that rewards both providers and patients on a per-occurrence-of-treatment
basis in what the Wall Street Journal described as a "strategy of cooperation".
• Elegant Functional Design and Powerful Strategic Checks and Balances
- The MedEncentive Program functions as a very efficient
and effective vehicle to deliver evidence-based medicine and information therapy
using P4P. Keys to successful P4P are physician (and patient) participation and
compliance, and the prevention of fraud and abuse. MedEncentive's P4P rewards mechanisms
are designed with built-in checks and balances to achieve higher
levels of physician (and patient) participation while preventing fraud and abuse
better than any other P4P model.
• Exceeds P4P Success Criteria Which Has Produced Excellent Beta Site
Results - Based on industry experts such as the American Medical Association,
Medical Group Practice Association, and from our own experience, the five key criteria
for a successful P4P program are:
• Acceptance and participation by physicians and patients
• Achieving quality improvement that leads to cost containment
• Prevention of fraud and abuse
• Being fair and equitable (win-win)
• Being simple and inexpensive to deploy and maintain
Industry experts agree that the unique design of the MedEncentive Program meets
each of these criteria better than any other P4P model. This is being borne out
by the of our test employers who are enjoying reduced health cost.
• The "Anti-Cookbook Medicine" and "Patient Empowerment" Program -
High on the list physician turn-offs is P4P mandates to treatment guideline adherence.
Physicians describe this as "cookbook medicine" which they resist because it infringes
upon their clinical judgment and can be harmful to the patient. MedEncentive is
the "anti-cookbook medicine" solution that encourages physicians
to use their own judgment to follow an EBM guideline or deviate from a guideline
for a specific reason. Either which way, the MedEncentive model financially rewards
the physician for "considering" the EBM guideline and for prescribing information
therapy to their patient. This works because the patient gets to review and rate
their physician's performance (though MedEncentive's Internet application) according
to their own interpretation of the guideline. This simple yet powerful check and
balance is a key to higher quality, clinical judgment independence, and patient
empowerment. It is also the key to making EBM, Ix and P4P a win-win
for physicians, patients and payers.
• Only P4P Program with Pending Method Patents - The developer
of the MedEncentive program recognized its uniqueness and filed three method patent
applications on the invention. This, in and of itself, makes MedEncentive unique
among both P4P programs and other healthcare reform initiatives. And there are more
patent applications to come.
• Growing Number of MedEncentive Disciples - Recently, there
has been strong interest in MedEncentive. Dr. Mark McClellan (Administrator of the
U.S. Medicare and Medicaid Programs), the American Medical Association, General
Motors, Voluntary Hospitals of America and a host of other payer and provider organizations
have committed to proposals or have executed letters of intent. Oklahoma Senate
Bill 896, which creates a MedEncentive demonstration project with state employees
and teachers, passed the Oklahoma House 99-0 and Senate 45-1. It is currently awaiting
the governor's signature. The Bill enjoyed board, bi-partisan support and was endorsed
by the Oklahoma Public Employees Association, The Oklahoma State Chamber of Commerce,
and OU Physicians.
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