jstartz26

I wouldn't necessarily say we're missing something that other countries have. Each system has strengths and weaknesses. Reform on this scale is difficult to do correctly even if your major political parties can compromise and work together on something.

Personally, I'm more excited about the potential of MFA than Mark; however, I'm equally frustrated by the national conversation around it. It's a political battleground and the public debate lacks nuance or depth. MFA, in my opinion, solves a set of problems and introduces a set of unknown problems while doing nothing for certain root issues (clinical variation, potentially avoidable events, etc.). The focus on who pays and taxes is a very small part of a much larger conversation and many of the voices talking about it lack industry knowledge or experience. But the same can be said about a bunch of different controversial issues right now and I'm off topic.

To actually get to your question - it's MFA+Medicare reform+a whole bunch of other reforms related to the delivery of care. MFA is not enough because it's just one piece of the puzzle. If we're missing anything as a country, is a political environment that would make this sort of widespread societal reform possible because it truly isn't as simple as switching to single payer.

Product comparison: that’s fair – only so much you can fit in an announcement post. We completely agree it is difficult to compare benefits (even for competent HR departments) but it is even more confusing for individuals. We try to make this clearer and transparent when working with employers during the quoting process. Benefit coverage gets boiled down to “actuarial value” and quantified as a number relative to the benefits mandated under the Affordable Care Act. This is presented alongside the financial quote and compared to competing bids. It also helps to actually read through our Schedule of Benefits Coverage– even at the individual level it is apparent what the differences are in our benefit plan vs every other SBC we have seen.

If you were to judge the quality only by price (all else equal), underwriting for this segment is done at the employer level – so savings can vary significantly from company to company. We’ve had quotes that matched other bids, and we’ve presented offers as much as 35% less (on a cash basis, not actuarial) than other insurer’s annual price hikes.

Overall, I cannot agree more with your comment that comparison is hard. There is not a lot of transparency in this market segment because of the unique considerations that go into underwriting each group. Plus, a lot of the companies (startups included) that people find appealing are playing games with coverage, especially playing around with deductibles and copays. It’s currently very difficult to make it super clear without just sitting down with the person/employer and talking through the benefits.

1. There is a $300 copay for an emergency room visit (both in-network and out-of-network). This is actually our only copay period. It is to encourage people to only use emergency rooms for emergencies. There are no deductibles for our primary plan though we do offer a HDHP as well (for employers with HSAs), so for the secondary product a deductible does apply. Emergency care is always covered as an in-network benefit and no copay would apply for inpatient care/admissions.

2. Payor ID is EH001. Yes to all except 276/277 for right now.

3. Naturally, this depends on the type of provider. We work with our providers to contract on a basis that is comfortable for them. Not all physicians are ready to accept something like capitation. We collaborate with physicians on the quality parameters to track. Some agreements are done as bundles for the entire episode of care. Some agreements are case rates or capitation payments. Some are still benchmarked off of Medicare but tied more closely to patient outcomes. For example, with primary care doctors we target avoiding poor control of diabetic A1C levels to be below 15% and to do depression or anxiety screenings for more than 80% (among other metrics).

4. Nope. We contract directly and do all the claims processing ourselves. Sometimes that means negotiations can take awhile (for large health systems) but it almost always means we reach favorable terms with a mutually beneficial structure.

Thank you!

Wyndly looks great. Allergies are a tricky problem to solve for a broad population. Why do you say it's not profitable? Is it because you are being asked by health plans for an expected ROI?