Ever­green’s mis­sion

Our view: We need all the com­pe­ti­tion we can get on Mary­land’s health ex­change but also the in­no­va­tion the state’s lone health co-op has pro­vided

Baltimore Sun - - FROM PAGE ONE -

For the sake of com­pe­ti­tion in Mary­land’s Oba­macare mar­ket­place — par­tic­u­larly for those who buy in­sur­ance as in­di­vid­u­als, not through their em­ploy­ers — Ever­green Health needs to sur­vive. CareFirst BlueCross BlueShield had 80 per­cent of Mary­land’s in­di­vid­ual in­sur­ance mar­ket in 2014, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion, up from 74 per­cent three years be­fore. Ever­green, with nearly 40,000 mem­bers and grow­ing fast, is ex­pand­ing in the state at a time when other car­ri­ers are pulling back. Though still rel­a­tively small, it pro­vides an­other op­tion for con­sumers and puts pres­sure on the dom­i­nant car­rier to in­no­vate and con­tain costs.

But for the sake of cre­at­ing a more ef­fec­tive and af­ford­able health care sys­tem, Ever­green needs not only to sur­vive but to main­tain its mis­sion and iden­tity. Ever­green isn’t just an­other health in­surer; it was set up as a co-op with a unique model for de­liv­er­ing health care in a way that heav­ily em­pha­sized pri­mary care and well­ness. It main­tains its own pri­mary care of­fices in which doc­tors’ caseloads are lim­ited, al­low­ing them to ad­dress pa­tients’ health much more com­pre­hen­sively than tra­di­tional in­sur­ance re­im­burse­ment mod­els af­ford. Ever­green has in­vested in be­hav­ioral health spe­cial­ists to help its mem­bers with nu­tri­tion, fit­ness, sub­stance abuse and men­tal health and co­or­di­na­tors to help them fol­low treat­ment plans and man­age care with spe­cial­ists. Its em­pha­sis on ev­i­dence-based prac­tices and its com­mit­ment to put pa­tients ahead of prof­its made it just the kind of ex­per­i­ment Oba­macare was in­tended to foster.

As such, we can’t help but be con­cerned at the news that Ever­green has agreed to be ac­quired by pri­vate in­vestors who will con­vert it from a co-op to for-profit sta­tus. Dr. Peter Beilen­son, the for­mer Bal­ti­more City and Howard County health com­mis­sioner, will still be in charge, and he says the con­ver­sion won’t al­ter Ever­green’s care model but will im­prove fi­nan­cial sta­bil­ity and al­low in­vest­ments in new pro­grams and tech­nol­ogy. Even so, the in­tro­duc­tion of a profit mo­tive raises the con­cern that Ever­green’s pri­or­i­ties could even­tu­ally change so that it re­mains a com­peti­tor in Mary­land’s mar­ket­place but less of an in­no­va­tor.

The im­me­di­ate im­pe­tus for Ever­green’s move is the ex­tra­or­di­nary “risk ad­just­ment” pay­ment the co-op has been forced to make un­der ACA rules de­signed to com­pen­sate in­sur­ers who take on higher-risk pa­tients. Car­ri­ers whose pa­tients look health­ier un­der al­go­rithms de­signed by fed­eral reg­u­la­tors are re­quired to com­pen­sate those whose pa­tients look sicker, and for 2015, that ef­fec­tively meant Ever­green had to fork over a quar­ter of its rev­enue — $24 mil­lion — to CareFirst. Oth­er­wise, Ever­green was in the black. The com­pany is su­ing over the im­ple­men­ta­tion of that rule, but even if it suc­ceeds, re­lief will come too late.

The root of the prob­lem, though, is Congress, which has failed to take even the most rudi­men­tary steps dur­ing the last six years to make the ACA work. Congress was sup­posed to pro­vide “risk cor­ri­dors” pay­ments to help make up for the dif­fi­culty in pre­dict­ing costs un­der the new health care reg­u­la­tions, but it has not au­tho­rized any funds for the pur­pose, so in­sur­ers like Ever­green are only get­ting a tiny frac­tion of what they’re due. The Cen­ters for Medi­care and Med­i­caid Ser­vices may have found a work-around to al­low full “risk cor­ri­dors” pay­ments, but that’s too late for Ever­green, too.

Ever­green isn’t alone in fac­ing dif­fi­cul­ties — al­most all of the co-ops es­tab­lished un­der the ACA have failed al­to­gether — but the stakes for see­ing an en­tity like Ever­green suc­ceed are higher in Mary­land than else­where. The state is oper­at­ing un­der an ex­per­i­men­tal waiver to tra­di­tional Medi­care rules that al­lows Mary­land to main­tain higher re­im­burse­ments for hospi­tal costs pro­vided that it strictly limit the growth of health care spend­ing. By the end of this year, the state is sup­posed to sub­mit a plan for ex­tend­ing those sav­ings from just hospi­tal costs — which have a long his­tory of strict reg­u­la­tion in Mary­land — to all health care ex­pen­di­tures. Mak­ing that tran­si­tion is go­ing to re­quire sub­stan­tial im­prove­ments in pri­mary care, pre­ven­tion and co­or­di­na­tion of care — the very things Ever­green was de­signed to do.

Dr. Beilen­son says that the con­ver­sion is not a course he would have cho­sen but that it is nec­es­sary to en­sure the com­pany’s sur­vival. He said Ever­green had a choice of in­vestors and was able to pick those most com­mit­ted to its mis­sion. Their iden­ti­ties and the terms of the deal are con­fi­den­tial for now but will be­come pub­lic in Novem­ber when Ever­green sub­mits its ap­pli­ca­tion for con­ver­sion to the Mary­land In­sur­ance Ad­min­is­tra­tion, which, like the fed­eral govern­ment, will have to ap­prove the trans­ac­tion. A process for such con­ver­sions es­tab­lished af­ter CareFirst’s botched at­tempt to go for-profit in the 2000s re­quires Mary­land In­sur­ance Com­mis­sioner Al­fred W. Red­mer Jr. to find that the deal is in the pub­lic good. Mr. Red­mer has been strongly sup­port­ive of Ever­green as an im­por­tant ex­per­i­ment in trans­form­ing the de­liv­ery of health care, and we urge him to eval­u­ate the pro­posal care­fully. It’s im­por­tant that Ever­green pro­vides an­other choice on the state’s health in­sur­ance ex­change. But it’s cru­cial that it con­tin­ues its legacy of in­no­va­tion.

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