High-Value Health Care: The Intersection of Quality, Affordability and Outcomes for Employers

Employers are uniquely positioned to positively influence the quality and cost of health care through direct-with-employer contracting. But they aren't sure whom to call and how to proceed. Neither are the providers...

Maria Todd offers both sides the roadmap to cost containment and targeted business growth for providers in a win-win approach for equitable, high-quality health services starting with surgery costs. She teaches employers and providers ways to work together to meet goals and objectives that are mutually beneficial and innovative, including:

  1. What employer leverage exists to obtain high-value health care without paying networks, brokers and agencies monthly fees and commissions to get what they can on their own with just a few phone calls and a vetting checklist.
  2. What to ask for from providers in terms of quality and cost data to aid in making better health care choices for plan participants.
  3. What to share with providers about the company, its plan participants, and its healthcare pain points that need to improve. What providers need to offer to create financial incentives to attract new employer-direct business.
  4. Proprietary Provider Network™ (PPN) design and how you can use it to obtain high quality health services at a fair cost.
  5. How simple little tweaks to provider payment can boost eligibility for the best and deepest discounts coupled with better health outcomes.

The health care marketplace is broken.

Maria continually helps clients (providers and employers) collectively push for improvements in the quality, affordability, and transparency of health care. In addition to her business development duties at St George Surgical Center in St George, Utah, Maria serves on several international healthcare advisory boards and councils. She is frequently hired to help city council members and government purchasing task forces for municipalities, county, state and national government task forces to help them understand and evaluate broker proposals as an unbiased outside authority on direct-with-provider contracting. Maria helps them develop the requests for proposals and expressions of interest, and sometimes, they simply ask her to name a short list of providers she knows can help to shorten the cycle.

Maria explains how cost containment can be achieved for employers while maintaining or improving quality and engaging individuals in their health. She explains what providers must do to be ready to meet their new prospective customers.  It isn’t rocket science, but so few have done it successfully that there’s lots of opportunity to help both sides enter the new and improved marketplace. Maria’s been assisting employers and providers with great success stories to share and examples of what to do, how to do it, and what can be achieved for more than 27 years.

In her consulting roles she has tackled projects to procure health services for employers in 18 states. She’s successfully transformed hospitals ASCs and individual surgical practices to negotiate mutually rewarding, renewing contracts where both parties look back and say “Why didn’t we do this sooner?” The numbers and hard dollars saved speak for themselves. With providers, she is hired to lead and support strategic planning, product and program development and risk-based contract offers. She also helps design decision support and analytics matrices so that providers can prove their value and claim their rewards. 

As an entrepreneur, she’s owned and operated several successful firms, and currently serves as the Chief Transformation Officer (part time) of SurgeryShopper.com which was launched in May and currently sees 2000 to 4000 daily visitors to the site from consumers, employers, brokers, TPAs, competitors and other researchers searching for information and sources for surgery prices, transparency and bundled prices. They come from all over the world. They also visit the company’s two Facebook company pages – one targeted to US visitors and another targeted to Canadian visitors and snowbirds planning to escape the winter in Canada and access surgery they might otherwise face 2-3 or 4 years waiting time to address their problem and reduce pain.  In only a few months, each Facebook page has attracted thousands of likes as proof there’s interest in the marketplace. Revenue comes after awareness, brand recognition and earned trust. The new company is certainly on its way to those four success indicators using her roadmap. The destination for providers is “revenues”. The destination for the employer is “cost containment and high quality service.” One road map gets both parties where they want to go.

Fair price is when the buyer pays a price they feel is reasonable and doesn't feel as if they were taken advantage of, and the seller collects a fee without feeling taken advantage of.

Recently, it was announced that one of the Fiat/Chrysler robotic brand Comau, decided to pursue BCBS Michigan in federal court for breach of fiduciary duty.  It is alleged that Blue Cross Blue Shield of Michigan knowingly paid improper and inflated medical claims, according to the Detroit Free Press.  This is neither rare, nor new.

The payments came out of Comau’s funds — not out of Blue Cross’s coffers — because companies that have self-insured health plans pay most claims out-of-pocket, with insurance companies responsible for administering those plans and processing the claims in exchange for fees. Companies buy separate “stop loss” coverage to protect against extraordinarily large claims. Sometimes they buy if the stoploss from the company paying the claims. If that’s the case in this one, racketeering may also be charged because if you pay higher fees and then the claims amount to threshhold for stoploss and you sell the stoploss, you are accused of creating the problem so you can sell your solution. Not cool.

Self-insured health care coverage, also known as self-funded coverage which is what employers and unions usually elect, is a different type of arrangement regulated under the federal US Department of Labor and the IRS under the Employee Retirement Income Security Act of 1974 (ERISA) instead of insurance laws that vary state to state.  Companies can also opt to pay premiums to insurance companies for full coverage, but there comes a point when self-funded is actually less expensive than fully insured. But it takes more active management on the part of the employer or union.

For example, in this court filing, it was alleged that BCBS paid for routine urine tests that cost $10 or less to perform, but one medical provider billed for $5,000 to $15,000, according to a whistleblower’s qui tam lawsuit in Wayne County Circuit Court. The lawsuit did not name the test provider. 

The whistleblower alleged further that billing records for two other Blue Cross customers demonstrate  similar overcharges totaling $75,000 and $125,000. But when he notified Blue Cross, he was told to “stand down” and not alert the customers that were hit with the excessive charges. A similar occurrence happened in 1991 when Todd worked for a large HMO. That’s why she’s so passionate about fixing this broken system in a broken marketplace.

Fraudulent overcharging and overpayments are widespread and cost employers significant funds to when their TPAs and ASOs pay inflated charges and fraudulent charges – and in some cases get kickbacks for doing so. Employers are in the best position to stop this nonsense, but they don’t seem to be prepared or knowledgeable about how to improve.  Maria can train an employer’s task force in a matter of a single, one-day workshop for which she charges a flat fee plus expenses to conduct at the employers’ chosen location.

On the other hand, the providers don’t know how to market, advertise and tell the employers they’re ready and willing to help the employers save cash in exchange for steerage or special designation.  She often conducts a workshop for the healthcare executives to draw the roadmap and survey their readiness status on-site and identify any gaps. Then she details what needs to be done to fill the gaps and starts helping with introductions to employers. She calls upon her clinical and administrative experience and education and hands on operational knowledge to guide the process with actionable strategies and measurable results. She then leverages her experience in these contracts from the past 27 years to draft and mediate the negotiate of terms between the parties for a mutually beneficial relationship for years to come.