Many companies are finding that their traditional partners, such as health plans or TPAs are not able to deliver the desired product and network customization, member experience, or improvements to the quality of care for their people.
Direct contracting has evolved as a strategy to give companies more control over product design, pricing, provider selection, and greater insight into the quality of care. According to NBGH, 11% of large employers plan to have this approach in place in 2019 to improve pricing and create greater value on medical services, using a mix of centers of excellence (COE), ACO, and patient-centered medical home (PCMH) strategies.
Sprite health provides end-to-end support to self-funded employers in designing, implementing, administering and optimizing customized direct contracts with health systems. Whether the contracts are for specific services such as cardiac surgery, orthopedic surgery, oncology, and transplants or for comprehensive services (e.g. accountable care organization, or ACO).

Opportunity Analysis

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Sprite health helps companies identify gaps that are not adequately met by traditional health network, and explore the right provider partners in their particular markets.

Our sophisticated data management and analysis systems provide insights into your existing network to identify waste, gaps and improvement opportunities . This analysis provides the right foundation to curate a strong network of doctors and facilities dedicated to providing high quality, accessible care at a reasonable cost.

Post contract execution, the system provides real-time visibility into how provider partners are delivering against quality, cost and utilization metrics, and proactively flag issues in member engagement, delivery performance and quality.

Smart Contracts

Many companies continue to manage provider contracts with a mix of manual, paper-laden, and informal processes; relying on ex post facto audits and analyses. The resulting hodgepodge “strategy” limits visibility into contracts and performance, exposing companies to inflated costs, diminished negotiation leverage, missed savings opportunities and poor compliance.

Sprite health uses smart contracts, an application of the blockchain technology to create an independently verifiable, secure, permanent and fault-tolerant agreement designed for satisfying common contractual conditions.

contract. optimizationThis transparent approach ensures that both company and partner providers have access to the same information that is validated, verified and maintained. The individual transactions are tamper proof and cannot change outside of the knowledge of both parties. The claim repricing, validation and adjudication is automated in response to each validated transaction. Complete provenance details are available to review and analyze each transaction.

The smart contract can evolve to support growing business needs. The system allows both employers and partner providers to change or update agreement terms in a secure and dependable environment. This approach eliminates the risk that the contract has not evolved with the organization and now no longer delivers what the business needs. Understanding the difference between the reported expectation of value and the reality of value actually delivered provides leverage for rectification and cost recovery.

Dynamic Benefit Design

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Because direct contracts often fix the plan’s costs at a particular level, the company may want to incentivize plan participants to use the contracted providers. They may do this, for example, by having the contracted services covered by the plan without regard to the deductible. In the right cases, this can result in a win-win for the plan and the member: the plan gets predictability, often at a lower price, and the member receives care at a reduced cost.

Sprite health provides maximum flexibility in experimenting with benefit designs to align member and provider incentives.  For example, waiving co-pays and deductible for COE. This enables companies to implement new approaches such as value-based-insurance design (V-BID), reference based pricing, transparency tools, bundled pricing to align employee’s out-of-pocket costs with the value of the health services.

Pay for Value

Forward-looking companies like Boeing, Walmart, Intel, GM are shifting to alternative care and payment models focused on value. This innovative model compensate providers based on outcomes and not cost & activities. However, this transformation requires different capabilities uniquely provided by Sprite health.

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We utilize machine learning to assess which value based payment models best meet the company’s budget and address the quality and cost expectations. Because there’s no plan involved, the companies are not constrained by the plan’s reimbursement rates or fee schedules. They can pick and choose the right ‘Pay for Value’ payment models (Bundled, Shared Savings, Shared Risks, Capitated) that works best for their benefit strategy.

For example, a company may choose to pay the provider a bonus for achieving certain agreed-upon quality and/or member satisfaction metrics, such as customer service, preventive care, immunization rates, and ER visits. Alternatively, they may decide to go for “shared savings” or “shared risks” arrangements whereby the provider shares a portion of “savings” or “loss” generated against a baseline for spending.

Proactive Budgeting and Financial Management

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Sprite health budgeting and cost control provides the estimation of costs, the setting of an agreed budget, and management of actual and forecast costs against that budget.

Benefit administrators can define multiple budget strategies for specific services, benefit programs or incentives and can limit the budget scope to specific members, specific locations, zip codes or counties. The cumulative budget strategies define the baseline against which the actual expenditure and predicted eventual health spend is reported.

The dashboards provide  real-time visibility into how  actuals are lining up against the  forecast and budgeted amount and flag specific areas that  should be addressed to keep the projected expenses under budget.

The more precise control of budget makes it possible in to reallocate margins in accordance with the new and evolving needs of the population anytime of  the year.

Contract Administration

Higher Efficiency

Sprite health provides the complete administration infrastructure for direct contracting including processing payments and claims, answering phones, providing care management, helping employees through the benefit enrollment process and performing other administrative duties.

Our comprehensive engagement toolkit includes incentive design, custom communication campaigns, and integration with existing programs and channels.

Our dedicated Care Coordinators offer full-concierge service to covered members, assisting them with selecting physicians, scheduling appointments, transferring medical records, coordinating logistics and following up post-procedure, reducing unnecessary stress and improving the member experience. 

Member Portal

Engage members in their healthSprite health provides simplified experience that reduces the amount of effort required on the part of the members to access programs and information, and make it easy for members to engage in their health and take advantage of the programs available to them. Starting with open enrollment, the system provides members a simplified benefit shopping experience to better understand how their plan or program works; understand what their choices are, and what questions to ask to make the right choice for their family.

Whether they want to check their insurance coverage, care reminders, doctor appointments, medical history, HSA balance, claims, reward points – it’s all there. One place to go, and one number to call if they need help.

Member Engagement

Member engagement

We use performance analytics to identify the members most likely to engage at the lowest possible cost. Focusing on this population, we use behavioral health science, along with rewards and member incentives, to motivate members to actively engage with their health.

The system combines plan, demographic, and clinical data to create a personalized program for each member. By engaging the right member with the right message—and the right incentive—we motivate members to complete high-value activities.

The result? Better health outcomes. Stronger plan performance. And a valuable, trust-building experience for members.

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‘Pay for Value’ to drive better care at lower costs