Nothing Narrow About It:
PBGH’s Primary and Specialty Care System of Excellence Offers Broad Array of Features and Benefits  

PBGH’s Primary and Specialty Care System of Excellence (SOE) represents a powerful new approach to health benefits that allows purchasers to contract directly with vetted, high-performing primary care and specialty practices.

But while designated groups of providers delivering cost-effective, high-quality care is central to the SOE, it’s critical to understand that the approach differs fundamentally from the “narrow network” model many insurers have adopted in recent years.

Freedom of Choice 

Narrow networks typically restrict patient access to a limited panel of doctors, hospitals and treatment facilities willing to accept lower reimbursements in exchange for the expectation or promise of higher patient volume.

PBGH’s SOE imposes no such limitations and patients are free to continue using the  provider of their choice. That said, the SOE’s rigorous emphasis on quality and efficiency, plus a range of patient-friendly features, make it more likely patients will vote with their feet and voluntarily embrace the SOE.

More Key Differences 

Other key distinctions between the SOE and the narrow network model include:

• Quality – All SOE network doctors are selected based on strict PBGH quality standards. In addition, compensation is directly tied to value and health outcomes. Narrow network physicians, in contrast, usually are included strictly for economic reasons and have limited incentives to enhance the quality of care.
• Access – Employees enrolled in SOE are guaranteed clinician access and receive assistance in scheduling appointments. Narrow networks offer no such guarantees and wait times for appointments frequently can be extensive.
• Continuity of Care – Seamless information-sharing and coordination between the primary care physician (PCP), specialist and other providers is a cornerstone of the SOE. Most narrow networks have no mechanism to ensure the PCP remains engaged with care.
• Employee Support – The SOE provides ongoing support and navigation to the patient throughout their care journey, including scheduling, transportation and other capabilities. Most narrow networks offer no such assistance.
• Health Equity – A narrow network restricts the providers employees, and their families can access, which can exclude a patient’s choice of clinics that are aligned with needed language or cultural competencies. The SOE, by contrast, incorporates these critically important elements as part of the patient-reported experience to increase the visibility of clinicians and practices that patients feel comfortable with. In addition, typically it is hourly wage workers who cannot afford or find time during their workday to arrange follow-up care. By handling this task on their behalf, seeking and obtaining appropriate care becomes increasingly available, and therefore, more equitable. 

Advanced Primary Care 

Perhaps the most significant difference between the SOE and the narrow network model is both philosophical and practical: Unlike most insurance networks, narrow or otherwise, SOE puts advanced primary care – and the primary care physician — squarely at the center of the care process. This also means that referrals are made by primary care physicians with direct knowledge of a patient’s medical needs, not health plans. This not only ensures clinical appropriateness, but all evidence shows patients are most likely to follow guidance from their care team. Advanced primary care is a codified, patient-centric approach that incorporates quality metrics, interdisciplinary care, seamless integration with other care elements, including behavioral health, expanded patient access and a recognition of underlying social determinants of health (SDOH).

Lower Costs, Improved Retention and Recruitment 

Building a care system around primary care is essential for lowering employers and employees’ total cost of care. Adults who regularly see a primary care physician have 33% lower health care costs and reduced odds of dying prematurely than those who see only a specialist. Every $1 increase in primary care spending produces $13 in savings. And if everyone used a primary care provider as their principal source of care, the U.S. could save $67 billion annually.

Access to preventative and primary care likewise plays an important role in employee retention. Companies that establish effective wellness programs are considerably less likely to lose employees due to voluntary attrition. At the same time, the majority of workers say their level of satisfaction with healthcare benefits plays a major role in deciding whether to stay at a job or move on.  

An Innovative Approach

Here’s how PBGH’s SOE works: 

• Find the best providers – We use multiple data sources, including claims, clinical and patient reported,- to identify and vet the best performing providers in specific metropolitan regions for both primary and specialty care. We look at cost-of-care, qualifications, outcomes, patient experience and other variables to ensure providers meet or exceed our standards.

• Develop master contracts – We then enter into a single, shared master contract with selected providers, one that reflects our expectations but that can be tailored to your priorities. In all instances, payment is tied to value and health outcomes. 

• Manage referrals – Through the APC practice,we’ll provide your employees with a simple referral mechanism that helps ensure they engage with vetted, high-quality specialists. Patients receive a VIP access card that triggers benefit incentives and gathers data to encourage use and improve the patient experience. We also help with scheduling to reduce patient burden and wait times.

• Strengthen patient engagement – Our patient engagement experts are available to interact with your employees to help streamline access and to bolster adherence to medications, treatment and disease management.  We also ensure that the APC practice receives all the data, so patients know their care is coordinated by people they trust.

Back to the Future 

PBGH’s System Of Excellence marks a critical evolution in the delivery and payment of health care. At the same time, it represents a return to a time when care was patient-focused and quality-oriented, a time before monopolistic systems with strong incentives to overtreat regardless of quality came to dominate the system. That doesn’t mean we begrudge profitability among providers –in fact we want to pay our selected provider partners more and differently. But in return, we expect and demand the highest quality and cost and outcome accountability. The SOE provides a vehicle for achieving these objectives and in so doing, fundamentally alters the misaligned incentives and unsustainable trajectory of the current system. Most importantly, it gives patients and families easy, trusted access to the very best care.