by Wendell Potter
Health care provider organizations that are working directly with employers like Boeing -- and cutting out the insurance company middlemen
-- believe they can do more than save money for those employers.
They're confident they can also improve both health care quality and
service for workers and their families in ways that insurance companies
cannot.
Employers are starting to realize that insurers might
not be, as they have claimed, "part of the solution" to achieving a
more patient-centered health care system. In fact, in some ways they
have been part of the problem.
Providence-Swedish Health Alliance,
a not-for-profit, hospital-based accountable care organization (ACO),
will soon be providing both coverage and care to many Boeing employees,
along with UW (University of Washington) Medicine -- without an
insurance firm. Officials at Providence-Swedish told me Boeing chose to
work with them directly in part because of the firm's desire to ensure
their employees had a "better patient experience." While cutting costs
and improving quality of care were priorities, improving service and
reducing hassles that have become synonymous with insurance company
interactions was equally important to Boeing.
So
Providence-Swedish has committed to a number of assurances and is even
establishing a "concierge center" for Boeing employees. Among other
things, the ACO has promised same-day or next-day appointments for
urgent primary care visits and acute care, proactive support for
preventive care and chronic disease management. The hub for all of this
will be the concierge center, which patients can reach by phone, email
or the Web.
While Boeing is contracting directly with
Providence-Swedish and UW Medicine, the ACOs will have their own deals
with insurance companies to provide back room services like claims
processing. Dr. Joe Gifford, CEO of the Providence-Swedish ACO, told me
his organization is working with Blue Cross of Illinois for that work.
The federal government works with insurers in the same way to handle
claims for Medicare beneficiaries.
Gifford also told me he's in
discussions with a number of other employers in the region that could
result in similar deals -- and even some that will include insurance
companies, to some extent. And he noted that government entities,
including Medicare and state governments, are following a similar path.
It's
a path that leads to what is often referred to as value-based care, a
term that encompasses a spectrum of arrangements. What is common to all
of the arrangements is a movement away from paying doctors and hospitals
for individual treatments and diagnostic tests. In the deal with
Boeing, for example, the aerospace company has given the ACOs a budget
to provide all the care Boeing employees and dependents are likely to
need in 2015.
In that sense, he said, "Boeing is treating us like
an industrial supplier... and we are fully accountable" for costs and
outcomes. That means that the ACOs will by necessity need to focus on
keeping patients healthy and managing chronic conditions in the most
cost-effective ways so as to prevent complications and reduce
unnecessary hospitalizations.
Other hospitals are also taking on
responsibilities that once were the complete domain of insurance
companies. One example: the Community Hospital of the Monterey
Peninsula in California, which earlier this year began offering its own Medicare Advantage plan
to serve area seniors through a subsidiary called Aspire. "We think we
can do a better job of meeting local needs than having a national
company come in and tell us how to do it," the company's CEO, Scott
Kelly, told the Monterey County Weekly.
This trend is not
new. Many hospitals in the 1980s began operating their own HMOs to
compete with insurance companies, but most of them failed, in large part
because they didn't have the actuarial and claims management expertise
in-house they needed to stay solvent.
Learning from past mistakes,
many of the hospitals and physician-led groups that are moving back
into the health insurance market are hiring companies like Chicago-based
Valence Health, a fast-growing firm that offers services ranging from
claims adjudication to patient care coordination to more than 120
hospitals nationwide.
The number of employees at Valence has
doubled to 325 over the past two years and is expected to grow by
another 500 within five years. According to Kevin Weinstein, Valence's
chief marketing officer, that growth has been fueled by the movement
away from fee-for-service medicine to value-based care in which health
care providers are finding they have no alternative but to be more
accountable for both cost and quality.
While the Affordable Care
Act has been a catalyst for much of this change, employers like Boeing
and other big payers of health care, including federal and state
governments, will continue to drive it.
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