Get to know Dr. Rachelle Scott of Eden Health.

PLAN PROVIDER BENEFITS

HOW SPECIALTY CARE MANAGEMENT BENEFITS DIFFER AMONG PLAN PROVIDERS.

THIRD-PARTY ADMINISTRATORS TPAs benefit most from SCM’s integration processes (which save time and reduce complexity), cost savings, and increased plan retention and membership.

MANAGING GENERAL UNDERWRITERS MGUs have shown higher profitability and decreased risk exposure, helping to increase persistency.

BROKERS Brokers can reduce high-dollar claims and engage in partnerships between networks due to SCM’s flexible policies.

CARRIERS Predictability from fixed-rate costs, ease of use, and flexibility enable carriers to increase profits and satisfy partners.

“Our programs look to remove out-of-pocket expenses for members, so there is no copay, coinsurance, or associated deductibles for the benefit of outpatient dialysis.” – CRAIG CLEMENTE

tackle risk from a first dollar up approach, meaning the emphasis is on what discount is being achieved. Instead, SCM focuses on the comprehensive nature of financial risk.

“We don’t classify ourselves as cost containment, as that is from a first-dollar approach,” Clemente says. “We’re looking to provide something with a larger scope and more tangible value by managing claims with a costup approach in pricing strategy.”

Aside from its approach to coverage, SCM differentiates itself with a flat rate and fixed costs. The goal of SCM isn’t just to make health care more affordable for members; it also wants the plan to be affordable for employers.

“Any product or service that is based in nuance is going to have values that pile up to create a truly unique value proposition, and that’s how SCM has been built since Day One,” Clemente says. “We want to make sure we’re providing a true risk management tool through predictable, quantifiable costs.”

SCM’s plans apply to the entire spectrum of self-funded health plans, from more traditional insurance networks to small out-of-network companies. The only other requirement is a minimum of four members in the plan. Although its plans apply to all self-funded insurances, its niche offerings create some challenges.

“Our No. 1 challenge is the rarity of the risk,” Clemente says. “Dialysis outpatient care is not something that every plan experiences, which is actually a good thing for the market. But our biggest obstacle to overcome is finding where those risks are happening.”

The other, Clemente says, is the amount of time and effort that goes into customized solutions. “Our plans are tailor-made solutions, which is part of the expertise we bring, but it takes a lot of review and analysis on our end.”

QUANTIFIABLE SUCCESS

When it comes to success, SCM takes a bilateral approach. The main measurement is whether the health plans can preserve funds in a way they weren’t able to do before. And ideally, those funds can be allocated in a more impactful and meaningful way. The quantifiable measurement, though, is the volume in which that value is provided.

“As we’re able to provide that value on a larger spectrum across someone’s block of business, we maximize results every time on first dollar and the final payment process,” Clemente says. “It’s really special when we have an opportunity to provide that over time and across multiple beneficiaries. That’s the exciting part for us — knowing what we’ve built really provides value through a sustainable risk solution.”

Dialysis, in particular, is in the worst quadrant of risk for selffunded health plans because of its cost, volatility, and ongoing nature. SCM’s dialysis plan includes 33 months of exposure for financial risk. A partner of SCM with a member undergoing dialysis recently saved 89% of costs associated with that member’s care. Before enrolling in SCM’s dialysis plan, the member’s treatment was running about $2.4 million annually; this was trimmed to around $264,700 through SCM’s Renal Re-Pricing Program.

Looking ahead, SCM might expand into other niche health coverage plans. In March 2022, Argosy Healthcare Partners purchased a majority of SCM, paving the way for greater resources moving forward.

“We’re looking at expanding both inside of our outpatient risk management dialysis market and different ways to deliver that to market and assume risk,” Clemente says. “But outside of that, we want to diversify our top line through some existing programs like data analytics and oncology — and perhaps other verticals.” 