How to de-risk your good ideas and earn carrier support.
Overview
Carriers and risk partners want clarity and proof—not just enthusiasm. This playbook helps you replace “trust us” with evidence. Score your idea across eight risk areas from 1 (high risk / unproven) to 5 (low risk / proven & operating), and package the proof so a carrier can say yes faster. The more questions you answer up front, the smoother the path to approval.
To illustrate, let’s use a common challenge: getting a new Direct Primary Care (DPC) program across the finish line so the carrier supports it with the right pricing. And remember—success comes easier when all stakeholders are engaged from the start, not just Sales and Clinicians. Bringing in operations, finance, compliance, and IT early eliminates surprises and builds carrier confidence.
Rating Guide: 1 = High risk / unproven • 3 = Partially de‑risked • 5 = Low risk / proven & operating
The DPC Risk Readiness Scorecard
1) Problem–Market Fit (Is There Real Demand?)
- 1: “We think employees will love DPC.” No data, no employer interest documented.
- 3: A few employers sign Letters of Intent (LOIs) or agree to pilot at a reduced price; engagement goals unclear.
- 5: Employers commit real dollars. Ideally, these are unaffiliated, paying clients rather than free or low‑cost pilots. ≥70% of eligible employees have access, ≥50% engage within 180 days, and third‑party validation adds weight.
2) Solution & Experience (Does It Work for Users?)
- 1: Concept only; clinics “in discussion.”
- 3: Signed agreements with clinics; published Service Level Agreements (SLAs) for wait times and 24/7 access.
- 5: Clinics live; same‑day appointments available for most needs; high Net Promoter Score (NPS); clear escalation to specialty or urgent care.
3) Team & Delivery Readiness (Can You Run It?)
- 1: Program manager only covers sales; operations and data overlooked.
- 3: Outside consultants fill some gaps; playbooks drafted but untested.
- 5: Clear accountability for clinical operations, employer communications, data/analytics, and Third‑Party Administrator (TPA) integration; tested playbooks in use.
4) Go‑to‑Market & Distribution (How Will It Spread?)
- 1: Overly aggressive Per Employee Per Month (PEPM) program pricing assumptions; no sales track record.
- 3: Early broker relationships; first employer win, but long sales cycles.
- 5: Consistent broker pipeline; realistic pricing; references from unaffiliated, paying employers (true third‑party validation).
5) Addressable Opportunity (Is It Worth Doing?)
- 1: “Midwest employers want this.” No sizing.
- 3: Total Addressable Market (TAM) calculated by metro; employee participation rate assumed but unproven.
- 5: Bottom‑up sizing validated by pilots showing actual conversion rates in target cities or markets.
6) Economics & Pricing (Sustainable Unit Economics)
- 1: Assumes success requires 60%+ employee employee participation without evidence.
- 3: Guardrails in place; breakeven plan shows the program can still deliver positive ROI at 30–40% employee participation.
- 5: Actual utilization and savings data available; analysis proves positive ROI even at 15–40% employee participation rates. DPC providers should be reimbursed in ways that reflect age, utilization, and service mix—not a flat community rate. Clear documentation of covered services and reimbursement is critical so carriers can price accurately. Incentives should align so providers are rewarded for access, engagement, and outcomes—not just enrollment.
7) Integration & Operations (Will It Fit?)
- 1: No plan for eligibility feeds or claim reporting.
- 3: Draft workflow with a TPA or medical management partner; referral rules outlined, sample reports available.
- 5: Live eligibility feeds and claim reports; referral and attribution rules active.
8) Differentiation & Defensibility (Why You?)
- 1: Looks like any other DPC pitch.
- 3: Claims differentiation on access or analytics but untested.
- 5: Locked‑in clinic capacity in constrained markets; data loop proves value; employer references highlight uniqueness.
Evidence Pack for Carriers
When you approach a carrier, bring a clear, packaged story:
- Snapshot — population, geography, program costs, SLAs, engagement plan
- Validation — LOIs, Purchase Orders (POs), pilots, references, satisfaction data
- Data — baseline claims, modeled steerage, impact on high‑cost claimants
- Operations — workflows, governance cadence, reporting mockups
- Network — signed agreements, panel capacity, after‑hours coverage
- Compliance — plan‑doc excerpts and regulatory stance
- Financials — unit economics, employee participation scenarios, breakeven scenarios, downside guardrails
- Covered Services & Documentation — clear description of what’s included in the DPC scope, how services are reimbursed, and any carve‑outs so carriers can adjust pricing
How to Use this Scorecard
Reminder: Involve all stakeholders early—not just Sales and Clinicians. Bringing in operations, finance, compliance, and IT avoids surprises and builds carrier confidence.
- Score yourself across all eight risk areas. Use a trusted skeptic or intermediary as a sounding board.
- Pick the next two moves to lift each weak spot.
- Sequence quick wins (next 90 days) vs. longer plays (6–12 months).
- Send your evidence pack with your first outreach for faster, cleaner carrier feedback.
Partnership Note
At Magellan, we are committed to supporting program managers and their broker partners every step of the way. We bring underwriting expertise, operational flexibility, and practical tools like this scorecard to help turn good ideas into sustainable programs. If you’d like a second set of eyes on your readiness package, Magellan is ready to provide professional, collaborative support to ensure your program is packaged clearly and positioned for success.
Attribution
This framework is adapted from the 1–5 “risk spectrum” concept by Leo Polovets (How to De‑Risk a Startup). It has been tailored here to help DPC program managers secure carrier support faster.
