Safety-Net Provider Advances its Mission with Health Plan

MetroHealth Select was started as a more affordable pathway to healthcare for the employees of Cleveland-based MetroHealth System. Now it's being marketed to other organizations that are self-funded.

Cleveland-based MetroHealth System, a safety-net provider with 731 licensed beds and $905 million in fiscal year 2014 operating revenue, has a long history of striving to deliver high-quality, low-cost care while dealing with a difficult payer mix.

About 55% of the health system's patient population is either covered by Medicaid or uninsured, while another 22% is covered by Medicare. Only 23% of patients have commercial insurance coverage.

New Strategy for Lowering Costs

In 2009, the system launched its health plan, MetroHealth Select, as a continuation of its mission to reduce healthcare costs in the communities it serves, says Holly Perzy, MD, MetroHealth Select's executive director.

"We are a county hospital so, really, the initial onset of MetroHealth Select was a way to have us work with our parent, the county, to help lower their healthcare costs," she says.

"It started as a product to offer to county employees who utilize the county hospital and to make a more affordable pathway to healthcare for those employees. The county looked at it as a cost-saving measure and as a way of supporting the hospital."

Since then, Perzy says, the health plan has grown substantially and MetroHealth is now marketing it to other area employers.

"We are taking it to the market as a product offering that is beneficial for companies that are self-funded," she says. "When MetroHealth Select started, there were several hundred people on the plan and now we have six clients and over 20,000 covered lives, including our own health plan, a local university, and a union group."

Already Focused on Value
Perzy, who also serves as MetroHealth's vice president of care delivery and still practices medicine about 30% of the time, says the organization's long-standing focus on value as a safety-net provider has placed it in a good position to succeed on the payer side of the healthcare industry where cost containment is key.

"One thing I think I didn't really appreciated until I took this job—and I've been at MetroHealth for 26 years, and I trained here—is that we can lower costs because that is fundamental to how we practice medicine here. It goes back to our very significant mission as a county hospital," she says.

Part of the practice culture at MetroHealth, Perzy says, is to have each clinician assess the true need for diagnostic and therapeutic tests before writing an order.

"[If the] test isn't going to change the decision-making process, clinicians ask themselves if they really need to do it. In a fee-for-service market, people would [order tests] all the time… They would give people stress tests just to give them stress tests when really they weren't necessary," she says.

"Because we have never had huge margins at MetroHealth, we have always practiced value-based care. We have inherently decreased unnecessary testing. We have decreased duplication of testing, the prescribing of medications that are antagonistic, and the kinds of redundancies that exist all over the place. That has reduced our cost structure in and of itself."

Paying More Attention to High-Risk Patients
To help bend that cost curve even more, MetroHealth Select uses data to stratify patients and identify those who may incur high costs. The integrated system, Perzy says, can then provide interventions to prevent the overuse of expensive healthcare resources.

"Whenever anyone is looking at the healthcare of a population, you'll see… 30% to 35% of people are the rising risk, and they can go either way. Those people need a lot more coordination of care and a lot more hands-on touch to make sure they don't rise into the 5% to 10% of people who are using 50% or more of healthcare dollars."

MetroHealth takes "a holistic, comprehensive approach" to these patients by providing services such as disease management, care coordination, a wellness program, and telemedicine, Perzy says.

"Our approach takes all the facets of care and brings them together under one umbrella."

An Integrated Value-Based Network
While MetroHealth Select is built on a narrow network model, Perzy says she prefers the term "integrated value-based network" because it's less apt to deter consumers from becoming health plan members and is a better reflection of the level and amount of access that is available.

"There is so much misconception and negativity around the idea of a narrow network, even though we are giving members access to about 500 physicians, a couple hundred nurse practitioners, and 18 locations. We are constantly looking at making sure we are growing our network offerings to satisfy the needs of our clients," she says.

Narrow Networks Cut Costs, Not Quality, Economists Say

And because MetroHealth Select is part of the larger integrated delivery system, Perzy is able to work with people on the provider side of the organization to assure that capacity does not become an issue for members.

"The nice thing for us is as a network we are intimate with providers. I have lived for 25 years on the provider side of the system and can talk about capacity and demand to say, 'I have X number of new clients with potential members in the pipeline," she says.

"We can look together at the overall system for capacity for primary care and specialty care to serve the member better because we are in synch."

Designing Benefits to Improve Cost and Access
Because MetroHealth is able to control costs through its integrated value-based network and clinical protocols that eliminate substantial amounts of waste, the organization can design benefit plans that are highly competitive in the local marketplace, Perzy says.

"If you have a self-funded employer that is going to have a PPO offering, Select can be an option to have less premiums out-of-pocket, less co-pays, and less deductibles, if any at all. We can drive people into Select and that works fairly well because benefit design has a big impact," she says.

Lower costs for health plan members decrease the likelihood that patients will delay care due to financial considerations and, thereby, helps MetroHealth achieve its population health goals, Perzy adds.

"As employers move more toward high-deductible health plans and more co-insurance, I see people in the office who don't understand their coverage. They don't understand that they have a $3,000 or $4,000 deductible. When they realize that, they postpone tests, and as a doctor, I don't think that is a good idea," she says.

"My clinical background is about making sure we are trying to do the right thing for patients. We want to bring a product to the market that helps us provide the right service at the right time in the right place… I am rather biased about the benefits of that because I can witness first-hand all the issues that people have when they don't have enough health coverage."