Program Description
The MedEncentive Program is based on an innovative process called the Trilateral Health Accountability Model® (“THAM”), for which the company holds three U.S. patents and a Canadian patent. THAM combines behavioral science with human factors engineering and web-technology to create a system of monetary and nonmonetary motivators. These motivators inspire providers and patients to improve health and healthcare in a manner that lowers costs to a point that the plan sponsor (health insurer, employer, government, etc.) realizes a return on investment. This outcome of simultaneously improving health and healthcare in a manner that lowers costs is widely referred to as the “Triple Aim” (better health, better healthcare and lower cost). Population health experts added patient and provider satisfaction to form the “Quadruple Aim.” The Triple/Quadruple Aim is a goal that has been, heretofore, rarely, if ever, attained.
Plan Sponsors (Customers) - MedEncentive’s customers are health insurance plans sponsored by self-insured employers, governments, health systems, and commercial insurers. Plan sponsors enter into a service agreement with MedEncentive to underwrite the Program’s costs, with the expectation of realizing healthcare cost savings that produce a meaningful return on investment.
The MedEncentive Information Therapy Program bolts onto the sponsor’s health plan (“plan”) as an additional benefit to the plan’s members (beneficiaries). In the case of self-insured employers, the health plan’s summary plan description (SPD) is modified to recognize the Program as a benefit. As part of the service agreement, the plan sponsor directs its plan administrator (third party administrator or TPA) to electronically transmit plan member eligibility and claims files to MedEncentive, on a daily basis, and to receive and pay reward files transmitted by MedEncentive. These electronic data exchanges are designed to use industry-standard protocols and formats, so that they are automated and maintenance-free.
How the Program Operates – The following is a description of how the Program operates.
Launching the Program - In order to operationalize the Program, MedEncentive uses the eligibility data to assemble orientation letters, with personalized membership ID cards. These orientation letters are sent to all adult plan members just prior to the Program’s launch date to inform members that they are enrolled in the Program. Members are also informed, and that there is nothing they need to do until they have an office visit or rewardable event, at which time they will receive a letter or email notification from MedEncentive with simple instructions on how to take advantage of the Program. The orientation letter further informs plan members that their doctors will also have an opportunity to participate in the Program, and that participation is purely voluntary for plan members and their doctors, on a visit-to-visit basis.
Program “Opportunities” - A Program information therapy “opportunity” is initiated when a doctor accesses the MedEncentive website in conjunction with an office visit for a covered patient, or as a result of processing office visit claims transmitted by the plan administrator to the MedEncentive computer system. Both doctors and patients are given “opportunities” to participate in the Program with each office visit (or covered medical event). Participation is voluntary for both parties on a visit-by-visit basis. Non-participation by one party does not prevent the other party from participating and earning the associated financial reward. When claims are received by the MedEncentive computer system, the system checks to see if the doctor has already accessed the website and participated. Provider participation that occurs before MedEncentive receives the claim (e.g., during the office visit) is referred to as a “realtime” or “Point-of-Service” initiated “information therapy prescription.”
If the computer system determines that the doctor has not yet participated, then the system automatically sends a fax or email notification to the doctor, informing him/her of the “opportunity.” Doctors have four (4) days to respond to these notices before their opportunities expire. Patient participation “opportunities” occur after office visits. They are initiated as a result of doctor participation, or as a result of the processing of office visit claims. Again, patients are notified of their opportunities to participate by email or letter, sent to their home.
Provider Recruitment - Doctors are recruited to the Program over time by MedEncentive, in concert with the plan sponsors and their plan administrators. While physician inclusion is essential, physician participation is optional. This implies that the Program functions effectively, even in its early stages, with limited physician participation. MedEncentive employs a variety of methods to recruit physicians, to include letters, faxes, emails, and phone calls, as well as orientation meetings with physician organizations and practice administrators.
The Provider’s Experience – Any doctor (MD, DO, DPM) or physician extender (PA, NP) enrolled in the Program, who provides office visit services to covered plan members, is eligible to participate in the Program and earn additional compensation with each office visit. To participate, providers access the Program’s website to select relevant educational content as an “information therapy prescription” for their patients who are covered by the Program. As mentioned previously, providers can accomplish this in two ways:
1. Real-time, while the patient is in-office, or any time prior to the medical claim for that office visit being received by MedEncentive from the plan administrator., or...
2. After-the-fact, as a result of MedEncentive receiving a medical claim for the office visit.
In the after-the-fact method, MedEncentive sends an email and/or fax notice to providers to inform them that they have an “opportunity” pending. Again, providers have four (4) days to respond before these “opportunities” expire.
Once online, providers are asked to enter or confirm their patient’s diagnosis for an associated office visit. Based on the diagnosis, the system presents an evidence-based medicine treatment guideline, if one exists, and a list of educational articles for the patient. If a guideline is available for the diagnosis, then doctors are asked to:
review the evidence-based guideline, below, and answer the following question. Your response will be shared with your patient, so a "Yes," a "No, because..." or a "Not Sure" answer is equally acceptable and will earn you the same rate of compensation.
If a guideline is not applicable, the doctors are asked to explain to their patients by selecting a reason from a comprehensive list.
Co-morbidity
Contraindicated because:
Patient declines for other reasons:
Using an advanced treatment w/patient's consent
Guideline is in error
Pending lab or other test results
Emergent condition
Patient declines because:
Guideline is out of date
Guideline does not match diagnosis
Not Sure
This design is intended to encourage physicians to use their clinical judgement in rendering treatments, provided they agree to be accountable for informing their patients about the applicability of a guideline.
It should be noted that the Program has treatment guidelines available for about half of the office visits of a normally distributed population. When a guideline is not available, the system automatically directs physicians to the patient educational content, for which there are articles available for virtually all diagnoses.
From the list of educational articles, which are arrayed in order of relevancy to a patient’s diagnosis, physicians are asked to select an article as homework for their patient. This is referred to as an “information therapy prescription.”
Since timeliness in delivering information therapy is important, providers are paid $15 for real-time sessions and $7.50 for after-the-fact sessions. Either way, it typically takes a provider familiar with the Program, less than a minute to complete a prescription.
In terms of time and effort, participation in the Program is intended to be one of the most lucrative services a doctor can render in clinic.
The Patient’s Experience – As mentioned previously, patients are notified of their “opportunities” to participate in the Program by letters or emails sent to their home after each office visit. Through the Program, patients earn back some or all of their office visit co-payment (typically $15) by accessing the MedEncentive website to do the following:
1. Read the prescribed educational article relevant to their diagnosis;
2. Demonstrate their understanding of the article by passing an open-book test and/or declaring their comprehension;
3. Declare their adherence, or provide a reason for non-adherence, to the article’s recommendations;
4. Agree to allow their physician to review their knowledge and declaration of adherence, or reason for non-adherence;
5. Rate their physician’s performance against what they have read, and the physician’s declaration of adherence, or reason for non- adherence, to the recommended treatments.
The Program also asks a series of questions that survey the patients’ medication adherence, perception of the provider’s influence on their compliance with recommended treatments, and impression (rating) of the educational content.
Who and What is Covered? - Every office visit (or other rewardable event) rendered to a covered person (man, woman or child) by a primary care provider or specialist or licensed physician extender (physician assistants or nurse practitioner) for any type of illness, treatment or wellness exam (except optometry, dentistry, or chiropractic), is an eligible Program “opportunity.”
What Happens if the Doctor or the Patient Does Not Participate? – Participation in the Program is optional for both doctors and patients. Since tests of the Program have indicated that patient participation clearly produces the most significant results, the typical Program configuration allows both parties to earn the Program’s financial reward independent of the other party’s participation. In other words, physicians and patients may choose to voluntarily participate in any, all or none of the Program “opportunities.”
Rewarding physicians when their patients do not participate, is straightforward. A physician is compensated for his/her successful completion of an information therapy session associated with a covered office visit, whether or not his/her patient subsequently participates in the Program for the same office visit.
So how can the patient participate after an office visit if his/her doctor fails to participate?
Rewarding patients when their doctors do not participate is also straightforward. This is accomplished as a result of the claims filing process.
Since MedEncentive receives replicate electronic claims from the plan sponsor’s administrator, on a daily basis, the Program’s computer system identifies the applicable office visits. The system then matches claims to completed physician “real-time” sessions. If no real-time session is found, the system automatically sends notices (fax or email) of all non-matched claims to providers, offering them an “after-the-fact” opportunity.
Providers have four days to respond before these “after the-fact” opportunities expire, at which time the system creates a “system-generated” information therapy prescription for patients, using the diagnosis on the claim submitted by the provider.
These prescriptions function just like a provider-generated prescription, except the list of educational articles that the provider would have been offered, are instead presented to the patient. The articles are listed in order of relevance to the patient’s diagnosis. Patients simply select one of the articles from the list to complete their information therapy session.
In this way, patients are not deprived of the opportunity to participate in the Program, even if their provider fails to participate.
It should be noted that studies of the Program have determined that, while provider inclusion is essential to Program effectiveness, provider participation is not so essential. These studies indicate that the process of informing patients that their provider was given an opportunity to participate, and may participate in the future, establishes a level of patient anticipation.
In effect, even though a provider may not participate for any given office visit, patients realize that their provider can access the Program at any time in the future, and review patient participation/questionnaire responses, back to the point of patient enrollment.
Program Operations, Analysis and Reporting – The Program is designed to be highly automated, and relatively maintenance-free. The data exchanges between the plan administrator and MedEncentive are electronic and set to occur on a fixed schedule. The MedEncentive computer system is equipped with quality-assurance monitoring that reports any failures in throughput, and prevents downtime.
Eligibility and replicate claims data is transmitted from the plan administrator to MedEncentive, while reward notices are transmitted from MedEncentive to the plan administrator, for payment to providers and patients. The handling of data follows industry-standard transmission and formatting protocols, and meets strict HIPAA privacy and security standards.
While a variety of financial incentives could be employed in the Program, to include gift cards, lotteries and other forms of gamification, patients and physicians are typically compensated by check, printed by the plan administrator as part of its normal claims payment and refund processes, using designated procedure (payment) codes.
Historically speaking, the most important predictor of the desired outcomes is patient engagement. This is best accomplished with a statistic referred to as the “patient success rate,” which is simply the ratio of successful information therapy sessions completed by the covered population over a period of time, divided by the total number of session opportunities that occurred during the same period. Session opportunities are analogous to office visits. This statistic is reported to the plan sponsor on a regular basis, until it reaches a level that assures the desired result. Steps are taken to maximize patient engagement, to include a series of reminders and “second chance campaigns.”
There are a number of other reports that track provider participation, user comments, questionnaire analysis, etc. that help determine the Program’s effectiveness. These reports are used to improve the Program.
Costs and Expected Savings – The ultimate measure of success with any healthcare cost-containment solution is its ability to bring about the greatest improvement in health behaviors and associated cost savings, for the smallest investment of time and money.
To this end, the Program is relatively inexpensive when compared to the average cost of employer-sponsored health promotion incentives. At $80 to $100 per person (plan member) per year, all-in costs, to include patient rewards, provider compensation, and administration fees, the Program costs a fraction of the national-average annual incentive of $742 for employees and $694 for dependents, according to the 2017 Fidelity and National Business Group on Health Annual Employer Incentive Survey.
Based on independently validated study of previous MedEncentive installations, the plan sponsor should expect a 150% to 300% return on investment. This means the savings, net of the cost of the Program, should be between $120 to $300 per person per year.
Content taken from the 2018 MedEncentive Study: 'Analysis of the cost containment capabilities of the MedEncentive Program in normally distributed employee health plans'