Col­lab­o­rat­ing on health­care

In­sur­ers, physi­cians see value in part­ner­ships

Modern Healthcare - - THE WEEK IN HEALTHCARE - An­dis Robeznieks

Physi­cian prac­tices that pi­o­neered in­te­grated de­liv­ery models have taken dif­fer­ent paths to find some­one to buy the in­no­va­tion they’re sell­ing. The Greater Rochester (N.Y.) In­de­pen­dent Prac­tice As­so­ci­a­tion, formed in 1996, has 917 mem­ber physi­cians af­fil­i­ated with Rochester Gen­eral Hospi­tal and Ne­wark Wayne Com­mu­nity Hospi­tal, both in New York. In Septem­ber 2007, it was only the sec­ond clin­i­cally in­te­grated IPA to get a fa­vor­able ad­vi­sory opin­ion from the Fed­eral Trade Com­mis­sion. But even af­ter the FTC deemed GRIPA’s col­lab­o­rat­ing physi­cians weren’t vi­o­lat­ing an­titrust statutes, lo­cal health plans shunned GRIPA and its in­for­ma­tion tech­nol­ogy-aided busi­ness model.

So GRIPA looked else­where for busi­ness, and it slowly and steadily grew its client base with self-in­sured com­pa­nies in the area. Although some fi­nal de­tails still need to be worked out, it is forg­ing ahead now with what’s de­scribed as an “ac­count­able care part­ner­ship” with Ex­cel­lus Blue Cross and Blue Shield.

Hous­ton’s Kelsey-Sey­bold Med­i­cal Clinic was founded in 1949 and achieved fame in 1966 for be­ing named the med­i­cal provider for NASA. But, last De­cem­ber, the 370physi­cian mul­tispe­cialty group made head­lines for be­ing the first ac­count­able care pro­gram to be ac­cred­ited by the Na­tional Com­mit­tee for Qual­ity As­sur­ance. While ACOs are seen as a new con­cept, the clinic’s ACO pro­gram started in 2007 as a part­ner­ship with in­surance car­rier Cigna. The pro­gram, KelseyCare Pow­ered by Cigna, em­pha­sized low­er­ing costs through pre­ven­tive ser­vices and IT-as­sisted co­or­di­nated care.

Now, lev­er­ag­ing pro­vi­sions in the Pa­tient Pro­tec­tion and Af­ford­able Care Act, KelseySey­bold is sign­ing on small busi­nesses with self-funded in­surance plans. Last month, the prac­tice en­tered into an agree­ment with Austin, Texas-based Boon-Chap­man, a third­party em­ployee ben­e­fit ad­min­is­tra­tor, to of­fer health ben­e­fits for par­tially self-funded com­pa­nies with 50 or more cov­ered em­ploy­ees. (Em­ploy­ers in par­tially self­funded plans carry stop-loss in­surance.)

Matt Horn, Kelsey-Sey­bold’s man­ager of sales and busi­ness devel­op­ment, noted that self-funded in­surance plans are not sub­ject to the Af­ford­able Care Act’s med­i­cal-loss ra­tio pro­vi­sions—which re­quire health plans to spend most of ben­e­fi­cia­ries’ pre­mi­ums on health ser­vices—and will not have to pay the an­nual fee some health in­sur­ers will be re­quired to pay start­ing in 2014. Com­pa­nies with 50 or more em­ploy­ees will, how­ever, be sub­ject to a new rule re­quir­ing them to pro­vide health in­surance or pay a perem­ployee penalty.

An­other as­pect of KelseyCare that will be at­trac­tive to em­ploy­ers, Horn said, is that 45% to 50% of their costs will be cov­ered by a flat per-mem­ber, per-month fee that will take away

much of the un­cer­tainty of health­care ex­penses.

“We do think the ACA will ac­cel­er­ate self­fund­ing,” said Dr. Spencer Berthelsen, Kelsey-Sey­bold board chair­man and man­ag­ing di­rec­tor.

Berthelsen also said that Kelsey-Sey­bold is well-po­si­tioned be­cause it can point to six years of im­pres­sive qual­ity and cost data from KelseyCare that’s been ver­i­fied by a third­party bench­mark­ing study.

The num­bers show Kelsey-Sey­bold de­liv­ered care at 15% to 30% be­low com­pa­ra­ble plans. The bulk of the sav­ings were at­trib­uted to keep­ing “cat­a­strophic” health claims of more than $50,000 at about half of what was shown for non-KelseyCare Cigna health plan mem­bers.

While KelseyCare started with one big payer, Cigna, and is now branch­ing off to do busi­ness with self-in­sured em­ploy­ers, the GRIPA Con­nect Clin­i­cal In­te­gra­tion pro­gram started by con­tract­ing with large em­ploy­ers in­clud­ing the Rochester Gen­eral Health Sys­tem, LiDestri Foods and Pay­chex, the pay­roll and hu­man re­sources out­sourc­ing com­pany that has some 3,500 em­ploy­ees in eight lo­ca­tions around Rochester.

GRIPA got its foot in the health plan door in 2011 with an ac­count­able care pro­gram that in­cluded 4,500 em­ploy­ees, de­pen­dents and pre-Medi­care re­tirees of the County of Mon­roe who were al­ready cov­ered by Ex­cel­lus Blue Cross and Blue Shield.

On Jan. 1, it launched the “Care for Health” ac­count­able care part­ner­ship with the Rochester Gen­eral Health Sys­tem and Ex­cel­lus Blue Cross and Blue Shield.

Although the pro­gram is un­der way, an Ex­cel­lus spokesman de­clined to com­ment on it, ex­plain­ing the deal is not yet fi­nal. Dr. Joseph Vasile, GRIPA’s pres­i­dent and CEO, ac­knowl­edged that some de­tails still need to be worked out. But, he added, “We have an agree­ment, and we’re in the live pe­riod.”

He de­scribed the pro­gram as a “Medi­care ACO-type” agree­ment with qual­i­ty­im­prove­ment and shared-sav­ings in­cen­tives. “It really is a part­ner­ship be­tween the in­surance com­pany, the health­care sys­tem and our physi­cians,” Vasile said.

Based on claims ex­pe­ri­ence for the 110,000 pa­tients cov­ered by Ex­cel­lus, the five-year pro­gram be­gins with a $520 mil­lion bud­get for 2013, with three par­ties split­ting any sav­ings or losses based on a qual­ity-score for­mula. There are 18 qual­ity mea­sures re­flect­ing care in di­a­betes, coronary artery disease, hy­per­ten­sion and other con­di­tions.

Vasile said that Pres­i­dent Barack Obama’s re-elec­tion and the U.S. Supreme Court de­ci­sion up­hold­ing the Af­ford­able Care Act have helped GRIPA’s ef­forts but also that “the move­ment would have gone for­ward no mat­ter what oc­curred in Washington.”

Af­ter sev­eral years fail­ing to cul­ti­vate much in­ter­est from health in­surance com­pa­nies, Vasile said the pro­gram with Ex­cel­lus could be the first of many fu­ture work­ing re­la­tion­ships with pay­ers. “It’s a very sig­nif­i­cant next step,” he said. “And, I hope, a next step to other ways we can part­ner.”

Dr. Eric Nielsen, a former GRIPA chief med­i­cal of­fi­cer and now a vice pres­i­dent with the Cam­den Group con­sult­ing com­pany, agreed.

“We see pay­ers around the coun­try en­cour­ag­ing provider groups to pro­vide clin­i­cal in­te­gra­tion,” he said. “I think the Af­ford­able Care Act had some­thing to do with it,” he added. “But be­cause of the high cost of health­care, we had to do some­thing.”

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