Efforts in Sharing Risk
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"We'll be financing care from providers outside MetroHealth," says Corlett. "So we will reimburse them because they're augmenting our primary care services."
MetroHealth Care Plus, which is how the new initiative will be branded to consumers and providers, is also providing a pharmacy benefit, which is a new expense.
"We will have to learn over time how significant that expense will be," Corlett says.
The program requires MetroHealth to become an insurer in fact, if not in name, because it effectively must finance care and take on risk for a population of up to 30,000 previously uninsured, people who do not necessarily have to access care at MetroHealth.
"An actuary worked with us to develop per-member, per-month figures, but we'll have a better sense in three months of how much we're spending outside and how much stays inside," says Corlett, noting that initial projections indicate that about 25 cents of every dollar the system will spend on this population will go outside the system to federally qualified health centers and other ancillary providers.
The fact that MetroHealth Care Plus will be paying outside entities is early practice for the types of shared risk contracts many healthcare organizations will have to take on as both government and commercial payer sources look to force providers to take risk surrounding quality of care.
Corlett says state and CMS officials granted the waiver in part because they were intrigued with a program at MetroHealth called Partners in Care, which was essentially a patient-centered medical home for the uninsured. That program will now morph into MetroHealth Care Plus.
Corlett says although Ohio is expanding Medicaid, which means its waiver will be short-lived, he encourages safety-net hospitals in other states to look into something similar, if they have the wherewithal and meet the requirements.
"If a state chooses not to expand, the waiver exists, and I would think that in states that choose not to expand and that also have large urban public hospitals, it would be an alternative they might want to look at."
This article appears in the April 2013 issue of HealthLeaders magazine.
Philip Betbeze is senior leadership editor with HealthLeaders Media.
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