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Managed Care Payor Solutions

Creating the Transparent Advanced Imaging Network Strategy to:

• Increase quality throughput of advanced diagnostic imaging services by providing state of the art equipment and sub-specialty radiologist reads.

• Substantially lower costs to HMO payors while shifting payments to a fixed p.m.p.m. basis.

• Virtually eliminate the compliance hassles of an area of managed care that has been laden with physician self-referral and violations of the Federal Anti-Kickback Statutes

This is a network solution that is designed to simultaneously satisfy the CFO, the Chief Medical Officer and the Chief Compliance Officer, whereas most so-called network solutions are primarily aimed at satisfying the CFO.  Our solution finds the “managed care sweet spot” in a specialty area that is high cost, high trend, and tends to have inconsistent quality as a result of imaging equipment proliferation.

Quantum Care, LLC has studied the operating methodologies of several large RBMs (Radiology Benefit Managementcompanies) with the goal of building a better mousetrap.  While it’s common in the industry for RBMs to offer HMOs moderate savings in exchange for the RBM taking over the HMOs’ diagnostic imaging network, Quantum Care, LLC is taking a refreshing new approach to address an area that is burdened with high cost, high trend services.  Here’s how:

Transparency: 

Quantum Care, LLC works on a set margin with 100% of the funds pre-allocated for professional and technical costs being channeled to the providers who perform the medical services.  Full transparency is needed to eliminate managed care gamesmanship that is typically seen in any company that refers to itself as a “benefit management” entity.  There are no hidden pricing arbitrage formulas designed to benefit the management entity at the expense of the providers or the HMO payors.  Quantum Care, LLC provides proof of all downstream payments to the HMO payor and it provides full transparency between network participants.  While Quantum Care, LLC does establish a geo-specific payment pool from which its network providers are paid, Quantum Care eliminates the typical criticism that’s associated with pre-paid services; that criticism being as follows: pre-paid arrangements are specifically designed to encourage providers not to perform requested services.  To address that concern, Quantum Care, LLC’s payment methodology allows for providers who performed more services or high acuity services to make more money than peers who perform less services or lower acuity level services.

Here’s a simple question:  Why is it that HMOs aggressively attack Rx costs and they have been less aggressive at managing Advanced Diagnostic Imaging Costs (which could trend at 4x, 5x or higher the trend of Rx).  The answer has to do with transparency as well.  Irrespective of what specialist (PCP, Cardiologist, Oncologist, etc.) writes a script for the patient, the Rx flows through an PBM (pharmacy benefits management company) as part of the order fulfillment process.  In turn, those costs are separated away from the core specialty, and those costs are viewed in a stand-alone silo of costs.  That does not happen in the world of diagnostic imaging.  Those costs tend to remain buried within the specialty costs of multiple specialties rather than being fully transparent.  Bean counters within the HMOs often analyze p.m.p.m. specialty reports while commenting….Hmm Cardiology, Neurology, Orthopedic, Oncology, etc. costs are up….but they miss the common driver among these cost increases.  The common thread is physician self-referral of advanced imaging services and the costs get buried within the specialty rather than being isolated as advanced imaging costs.  It is well evidenced that physicians who self refer are roughly 2x to 8x more likely to order a diagnostic test than would be a peer who did not engage in self-referral.

Advanced Imaging:

Quantum Care, LLC applies an old fashioned “stick to the knitting” philosophy to a high tech area.  Advanced Diagnostic Imaging Services have had a modality increase of about 38% per Medicare beneficiary compared to about a 4% modality increase per Medicare beneficiary for lower-level diagnostic services.  It’s not uncommon for advanced diagnostic costs to trend at over 20% per year.  With that being the case, Quantum Care, LLC focuses its attention on fixing what is most broken…..areas such as CT, PET, MRI, MRA, CTA, and nuclear medicine.

Networks:

At Quantum Care, LLC, we’ve always found it laughable when a “management” entity would approach an HMO with the following prospect: let us take over your network and we’ll save you money via more effectively managing your network.  Here’s a clue: when a management entity makes such a claim, they do so because they use questionable Prior Authorization standards in an attempt to tell their inherited network “no” over and over again.  Why is it that most disease state management companies provide only marginal improvements?  It’s because they feel as though they can manage anybody’s network.  In order to truly impact bottom line improvements, we at Quantum Care, LLC believe that one must “own” the network and correctly align incentives by using inarguable and non-ambiguous Prior Authorization standards…..and that’s exactly what we’ve done.  We have network ownership because we’ve created the network.  We can control what we’ve created, we’d be pompous to say that we can control that which we did not create.  Also, by developing the network ourselves, we bake in a quality imperative due to the fact that we’re more highly selective than is a typical HMO when developing an imaging network.  We seek to partner with accredited IDTFs (Independent Diagnostic Testing Facilities) and we ensure that our Prior Authorization criteria is in synch with the expert panel developed criteria of said IDTFs’ accrediting body.

WE HAVE BUILT THE BETTER MOUSETRAP:

Please contact us so that we can help you to substantially lower your bottom-line costs while enhancing quality and creating a compliant network.  We stress that we are not an RBM.  We have shifted the paradigm completely by becoming the first and finest Transparent Advanced Imaging Network.

New Strategies

We strive to find new ways to make managed care more manageable. Your unsolved cost issues are not problems to us; they are solutions waiting to be implemented. Let us solve the managed care puzzle for you. It's what we do!

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