Education Module: Outlier Patients
Speaker: Tom Emerick, President and Co-Founder of Edison Healthcare
- Future success in managing plan dollars will be contingent upon understanding and managing the outliers in your benefit plans, the 6% or so who spend 80% of the plan dollars every year.
- You can provide your covered members with better quality care, help protect them from medical harm, save them money out of pocket, and save money for your plan as well.
- The fee-for-service health reimbursement system needs an overhaul. Self-insured benefit managers in America have the power to create that overhaul. If we wait for the right laws to be passed, we all may die of old age first.
- While implementing wellness was a noble effort, it has met with limited success at best. A superior way to manage the health of your population is, again, to micromanage the outliers. It’s very easy for a condition that might cost a plan $50,000-$100,000 to turn into a $500,000-$1,000,000 claim due to complications from low-value centers and uncoordinated care teams.
This is very simple but true: if you want to save money in your health plan, you have to start spending less money. It is that simple.
Tom is a consultant on health care benefits administration, founder of Edison Health, and coauthor of Cracking Health Costs and An Illustrated Guide to Personal Health. He previously led benefits programs at some of the largest employers in the world such as BP and Burger King.
Emerick did direct contracting with providers around the country and was careful to include referral centers that were similar in many ways to the Mayo Clinic model. That program got excellent results, which in turn resulted in him being recruited by Walmart stores Inc. to manage their benefit programs, not just in the US but globally.
At Walmart, Emerick was in charge of design, implementation, and administration for the benefit programs for Walmart in the United States and in several other countries. In the Walmart’s US benefit plans, he did an abundance of direct contracting with excellent referral centers. Later, Emerick resigned from his position as VP of global benefit design at Walmart stores to become a consultant. His desire was to show other companies how to do direct contracting with centers of excellence so they could have the same great results for their employees as he got for the companies where he worked. Today, any self-insured organization can access Centers of Excellence programs once only available to jumbo employers.
Emerick did direct contracting with providers around the country and was careful to include referral centers that were similar in many ways to the Mayo Clinic model. That program got excellent results, which in turn resulted in him being recruited by Walmart stores Inc. to manage their benefit programs, not just in the US but globally.
At Walmart, Emerick was in charge of design, implementation, and administration for the benefit programs for Walmart in the United States and in several other countries. In the Walmart’s US benefit plans, he did an abundance of direct contracting with excellent referral centers. Later, Emerick resigned from his position as VP of global benefit design at Walmart stores to become a consultant. His desire was to show other companies how to do direct contracting with centers of excellence so they could have the same great results for their employees as he got for the companies where he worked. Today, any self-insured organization can access Centers of Excellence programs once only available to jumbo employers.
