For the first time in this area, a health care provider and an insurance company are working jointly to provide a group plan between a commercial insurer and an Accountable Care Organization.
Essentia Health and Medica are collaborating on the program. Called “Essentia ChoiceCare with Medica,” it will be available Nov. 1, in Minnesota, North Dakota and Wisconsin for large employers . Group plans for small firms will be available beginning Jan. 1. They will be available in Minnesota and North Dakota.
“We feel healthcare is just becoming more and more expensive. We know that families and employers are looking for a way to reduce healthcare costs and also get more quality out of their healthcare,” said Dr. Michael Van Scoy, medical director of population care management for Essentia Health.
Want to publish your own articles on DistilINFO Publications?
Send us an email, we will get in touch with you.
Simultaneously achieving both goals is a considerable challenge. According to an Aug. 10, story in Forbes magazine, employers’ costs of providing health benefits are expected to increase by about 6 percent next year while employees should expect about a 5 percent increase.
Collaboration is key
“For us as a health plan to be effective at delivering a lower cost point, the obvious start is to think more collaboratively about our business relationships, our provider relationships and how we can together make them more effective as opposed to us and them doing things more independently,” said Scott Reid, vice president, product and operations at Medica Health Plans.
Both organizations already have accumulated several years of experience.
In 2013, Essentia Health became one of six healthcare providers nationwide to become accredited as an Accountable Care Organization for Medicare. The designation signifies that Essentia coordinates care among doctors, clinics and hospitals. A key element is sharing electronic medical records throughout its system. Essentia already has Accountable Care relationships with Blue Cross Blue Shield of Minnesota, Blue Cross Blue Shield of North Dakota, Health Partners and UCare.
Medica was a pioneer in tailoring commercial insurance to Accountable Care Organizations. In 2012, it launched a commercial product with Fairview Health Services in Minneapolis. Medica later developed similar relationships with Park Nicollet, Ridgeview Medical Center, HealthEast Care System, North Memorial Medical Center, all in the Twin Cities metro, Rochester-based Mayo and Altru Health System in western Minnesota and North Dakota. The insurer, however, doesn’t work with all healthcare providers. It has qualifications regarding geographic coverage and the quality of the organization, Reid said.
Although Medica sells policies in the individual market, the accord with Essentia currently involves only group plans. That’s an important factor in making the arrangement successful, Dr. Van Scoy said.
“We’ll have a defined community and a relationship with the people who enroll,” he said. Through that relationship, Essentia wants to identify high-risk medical conditions, then monitor and treat them to ensure patients don’t require expensive emergency room visits.
“If we notice somebody is not taking their asthma or cholesterol medications, we can reach out to them to get their prescriptions refilled or get their condition re-evaluated to assess the need for a medication. We’d much rather have somebody with well-controlled asthma than somebody struggling with it on a day-to-day basis and then needing 11th hour medicine,” Van Scoy said. “We’re getting more and more experience and more comfort by being pro-active about finding patients who have gaps in care or high-risk conditions and more pro-actively reaching out to them.”
Two goals are achieved by doing so: The costs of care are reduced and patients live a better life, he said.
Another element also comes into play: Providing a product that encourages members to seek nearly all of their care with the ACO provider, which is Essentia.
“That’s a great advantage for a provider because they have a full view of your healthcare within their electronic medical record. It’s very different than an open access model,” Reid said. In an open access model, he explained, patients might receive 30 to 40 percent of their care through a single system, then see a variety of specialists with different providers.
“That creates a lot of financial inefficiency within a system and makes it really hard for a provider to really understand how to deliver care effectively,” Reid said.
Staying within the network will offer some advantages to participants, Essentia said in unveiling the plan:
• They’ll be able to schedule same-day primary care appointments.
• They’ll receive direct access to specialists.Patients can see any primary or specialty care provider in the Essentia Health network without a referral.
• They’ll have access to Essentia MyHealth,a secure online tool that helps members track their health information and stay connected with their physician.
• They can call a patient navigator 24/7. The service provides assessment by a nurse and appointment scheduling.
• Using a single phone number, patients can contact either Essentia Health or Medica.Service advisors can answer questions about health plan benefits, billing and care.
Although Essentia Health operates 15 hospitals and 68 clinics, providing members access to care in 50 communities, will present challenges. There will be times when patients must travel outside of the system’s footprint.
“We realize people travel, so we don’t want see them penalized for needing urgent care. We estimate we will control over 70 percent of their medical activity and we accept that,” Dr. Van Scoy said.
Brave new world
A decade ago, many of the healthcare and health insurance concepts being employed today did not yet exist. That changed as the Affordable Care Act gradually rolled out. It substantially increased the number of people insured but also shifted their cost of care to other people who have a better ability to pay. Now, there’s a growing outcry to contain those costs and the rate of their growth.
“The cost has been preventing companies from hiring more people, preventing families from investing their money somewhere else. If communities are not spending money on healthcare resources, then they have money for other things. This could build stronger communities in the long run. People are expecting more from us. This is one way to make it happen,” Dr. Van Scoy said.
Success is not guaranteed. Reid said healthcare providers that work with Medica must be willing to “think strategically and differently about how we provide care together.” They also must be willing to share the financial risks.
“It’s a new era for us. We’re learning and growing with it,” Dr. Van Scoy said.
Date:October 28, 2016