Strategies to Improve Access to Care and Drive Cost Efficiencies

In today’s rapidly evolving healthcare landscape, employers and organizations continuously seek innovative ways to reduce costs while improving access to care. Traditional healthcare models often create barriers to high-quality, affordable care due to complex insurance structures, provider network limitations, and rising medical expenses. However, organizations can take control of their healthcare spending and provide better outcomes for employees by adopting alternative network solutions, such as Direct Primary Care and Direct Specialty Care.

With this in mind, Captive Resources’ Brian Gagne, VP of Health and Wellness Services, hosted Drew Kallestad — Chief Strategy Officer and Co-Founder at Agility Innovation Partners — during our March Health Risk Management Webinar. During the webinar, the two explored key strategies to achieve cost efficiencies in healthcare while improving access, leveraging data-driven approaches, and implementing real-world solutions that drive tangible results.

The Importance of Primary Care

Access to primary care is a crucial determinant of health outcomes and healthcare costs. Gagne cited studies that have shown:

• Patients who regularly see a Primary Care Physician (PCP) experience 33% lower healthcare costs and are 19% less likely to die prematurely than those who primarily see specialists.
• PCPs help patients navigate the healthcare system effectively, ensuring appropriate referrals and early intervention in disease management.
• Increased primary care utilization reduces costly emergency room visits and hospital admissions, helping to avoid unnecessary medical claims.

By strengthening primary care access, employers can ensure their workforce receives preventive care, ultimately reducing long-term healthcare expenses.

The 3 Elements of a Direct Contracting Strategy

According to Kallestad, most healthcare plans today follow a PPO-centric model, where large carriers negotiate provider networks and unit costs through opaque contracts. While this has long been the norm, it’s an indirect approach that leaves employers and employees with little visibility or control over pricing and provider selection.

Direct contracting offers an alternative approach by eliminating intermediaries and directly connecting buyers (employers and employees) with sellers. The most prominent categories where this happens are Direct Primary Care, Direct Specialty Care, and Clinical Care Navigation.

Direct Primary Care

Direct Primary Care is a membership-based healthcare model where employers pay a flat monthly fee directly to a physician for unlimited primary care services. This model eliminates copays, insurance claims, and hidden costs, providing immediate benefits such as:

• Same-day or next-day appointments (virtual or in-person).
• Longer, more personalized visits with a doctor.
• Avoidance of expensive insurance claims for routine care.

Direct Specialty Care

Direct Specialty Care is a patient-first healthcare model where patients pay specialists directly, without insurance or referral barriers. According to Kallestad, this results in:

• Upfront pricing for transparent costs.
• Faster access to specialists.
• High-quality care through memberships or direct pay pricing.

Clinical Care Navigation

Even with cost-effective care models in place, patients often struggle to find the right providers at the best prices. Clinical Care Navigation helps bridge this gap by:

• Providing personalized guidance to help employees access high-quality, cost-effective healthcare.
• Steering employees toward low-cost, high-value providers and facilities through direct pay platforms.
• Enhancing the overall member experience by reducing administrative burdens and improving health outcomes.

Steps for Employers to Transition to a More Efficient Healthcare Model

Assess Current Costs and Utilization

• Analyze medical and pharmacy claims data.
• Identify cost-avoidance opportunities.

Introduce Direct Contracting Strategies

• Implement Direct Primary Care for routine health needs.
• Explore Direct Specialty Care options for high-cost procedures.

Leverage Clinical Care Navigation

• Partner with care navigation vendors to guide employees to high-value care.
• Educate employees on cost-effective healthcare choices.

Adopt a Fiduciary Mindset in Healthcare Purchasing

• Work with fiduciary pharmacy benefits managers (PBMs) to reduce drug costs by 40-60%.
• Utilize transparent healthcare pricing models.

Communicate and Educate Employees

• Engage employees with clear communication on plan benefits.
• Provide tools and resources to navigate the new healthcare model effectively.

Takeaways for Employers

According to Kallestad, the future of healthcare lies in cost transparency, direct contracting, and data-driven decision-making. Employers who embrace these strategies will reduce expenses and enhance access to high-quality, affordable care for their employees. By shifting away from traditional insurance models and leveraging Direct Primary Care, Direct Specialty Care, and Clinical Care Navigation, businesses can control their healthcare spending while ensuring better health outcomes.

To learn more about Agility Innovation Partners, visit their website.

About the Webinar

This presentation was part of Captive Resources’ Medical Stop Loss Webinar Series — regular installments of webinars to educate medical stop loss group captive members. The thoughts and opinions expressed in these webinars are those of the presenters and do not necessarily reflect Captive Resources’ positions on any of the above topics.