In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Nann Worel.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"It gets in your blood. You have to have a passion for it and it is my passion."
Park City, Utah, is a playground for movers and shakers. It is home to popular ski resorts that hosted events during the 2002 Winter Olympics. Each year its hosts the Sundance Film Festival, which attracts celebrities from around the globe and swells the population of about 8,000.
It is not the type of place where you would expect to need, much less find, a health clinic dedicated to the uninsured.
Nann Worel, executive director of the People's Health Clinic, is very familiar with that thinking. She notes that the workforce that supports the area's tourism industry—the gardeners, restaurant staff, maids, resort workers, musicians, and artists—are often among the uninsured.
She adds that with the economic downturn, sales managers, real estate agents, and other white collar residents have lost their jobs and healthcare benefits.
Last year there were about 9,500 patient visits to the clinic.
The People's Health Clinic was founded 13 years ago to serve the residents of Summit and Wasatch counties where the uninsured rate is 16% and 21%, respectively. The clinic began as a mobile service that set up shop in area parking lots. It eventually graduated to rental space and in December 2009 found a permanent home in a building it shares with the Summit County Health Department.
Worel has spent six years with the clinic but she has devoted much of her professional life to public health issues, especially access to and care for the medically underserved. "It gets in your blood," she says. "You have to have a passion for it and it is my passion."
After earning a graduate degree in hospital administration from UCLA, she was recruited for a one-year appointment at the University of Alabama-Birmingham and the Jefferson County Health Department. A Seattle native, Worel had never been to the South and decided to make the temporary move. But she met her future husband in Alabama and the one year stretched into more than 20.
Along the way they moved to the coastal city of Mobile where Worel was instrumental in the creation of Victory Health Partners, which provides primary care services to uninsured adults in the area. The idea for the clinic developed during a fireside chat among a group of medical and dental professionals on a 10-day mission trip to Venezuela. Worel remembers that the group began talking about the medical needs of the poor and uninsured back home in Alabama. "Once we looked into the needs, we realized there was a huge population with little access to care."
Worel and her friends rolled up their sleeves and Victory Health Partners opened its doors in 2003. Worel spent several years with the clinic, including time as the development director. Last year VHP treated almost 13,000 patients.
The move to Park City was meant to be something of a trial retirement for Worel and her attorney husband, who soon decided that he was too young to retire. Worel began as a volunteer at the People's Clinic. By 2008 she was the development director and a year later she was named executive director.
Today Worel manages an annual budget of $1.2 million, including $600,000 in in-kind donations. She oversees 35 volunteer medical providers, including physicians, physician assistants, and nurse practitioners. Two paid, part-time physicians help make sure important things like patient lab work don't fall through the cracks and the clinic's chronically ill patients get ongoing care they need.
The clinic also works closely with Intermountain Healthcare, which has 22 hospitals throughout Utah.
The clinic focus is primary care, although naturopathic physicians, chiropractors, homeopathic psychologists, licensed social workers, mental health counselors, acupuncturists, and physical therapists who volunteer at the clinic are available to the patients.
The People's Health Clinic requires appointments and patients are asked to contribute $20. Worel says it's important for patients to have some skin in the game. "I think people tend to comply better with medical advice if they pay a bit to help the medical care happen."
In recent years Worel has expanded to the national stage her advocacy for the medically underserved. She serves on the board of National Association of Free and Charitable Clinics for and is now the board chair. In addition to increasing the profile of clinics among elected representatives, the NAFC sponsors monthly webinars and maintains discussion boards for sharing ideas and best practices to improve patient care.
That's an important connection as Worel and the board of the People's Health Clinic explore their options to open the clinic beyond its current Tuesday through Thursday schedule. "The demand is there but we have to look at expansion from a budgetary standpoint," says Worel. "But if you don't feel good, Thursday to Tuesday is a long time to wait."
Amidst the healthcare.gov debacle, let's not lose sight of what is really important—access to affordable health insurance. Please start doing a better job of controlling your agency's message about the public's access to health insurance.
Kathleen Sebelius, Secretary of HHS
Dear Secretary Sebelius:
To paraphrase Shakespeare, if ever there was a season of discontent in our nation, this is it. Almost everyone is angry, and rightly so, about the kick-off of healthcare.gov. It is one big mess and it seems as if every day brings another startling revelation.
On Monday we learned that there were signs of problems on healthcare.gov way back in April. That's when McKinsey & Company sat down with officials from the White House, along with you and CMS administrator Marilyn Tavenner to discuss its report—written at the behest of the White House—about the potential shortcomings with the website. Many of which, as we all know, sadly came to fruition.
On Tuesday we were informed that now, seven weeks post-launch, technical development of the health insurance marketplace's website is still 30% – 40% incomplete.
Amid all the inevitable finger pointing and the calls for heads to roll, I am worried that folks inside the Washington, DC beltway may lose sight of what is really important to those of us out here in the everyday world: access to affordable health insurance.
Madam Secretary, I have some advice for you on how to stay focused on the goal of full implementation of the Patient Protection and Affordable Care Act while lowering the volume on all the political chatter.
Get Sappy and Connect with Someone Who is Uninsured
Millions of Americans live without health insurance. I count myself lucky that, like you, I am covered by employer-sponsored insurance. That's the case for about 90% of Americans who are insured. But there are plenty of people—entrepreneurs, artists, the unemployed—who are depending on healthcare.gov for access to insurance.
Reach out to someone uninsured, not for some media minute, but to put a name and face on this debacle. Become Facebook friends. Make that person your touchstone as your tech teams work their way through the 600+ repairs that must be made before your new BFF can begin the online process of getting insurance.
Take Control of the Media Message
The mainstream media loves the story, true or not, of the downtrodden who have been unable to either access healthcare.gov or who have discovered that their premiums will increase. You (and I mean you personally) have to counter those stories without getting into the weeds on things like subsidies or the differences among health plans. On the surface it's all about talking points. Ask Rep. Eric Cantor (R-VA), Sen. Mitch McConnell (R-KY), or House Speaker John Boehner (R-OH) for tips.
Take Control of the Congressional Message
You'll recall from your testimony before the House Energy & Commerce Committee Oct. 30th, that most Republican members are not fans of healthcare reform. Several times a week I receive e-mails from the committee detailing the latest Obamacare transgressions, which apparently threaten the very soul of America.
At times it is difficult to take these lawmakers seriously, but I have to admit that their message is simple and consistent: Obamacare is bad. There are some sharp Democrats on the committee, but they each seem to be doing their own thing in terms of messaging—they do not speak with a unified voice. As a leader, you need to do a better job of controlling the message.
Stop Condoning Stupid Stuff
I have to agree with the House E&C Committee on this one. You know who Henry Chao is, right? Officially he's the deputy chief information officer and deputy director of the Office of Information Services at CMS, but you probably know him as the project manager for healthcare.gov. Seems he never saw the McKinsey study about the website problems.
Yours is not an easy job, I know. Basically you are herding disparate stakeholders toward a fundamental shift in the healthcare delivery system that will ultimately reward value not volume. Along the way you are creating new insurance marketplaces where (we hope) millions of people can access affordable healthcare.
I am disappointed with how this is all playing out because I have friends and relatives who are depending on the healthcare.gov. About a month ago I wrote a column about the health insurance exchange being a marathon not a sprint. At that time I didn't think anyone could have imagined the range and depth of problems with the website that have surfaced. In fact my sources seemed to think any glitches would be quickly resolved.
Hospital readmission rates remain stubborn. Hoping to move the needle, Highmark Blue Cross Blue Shield has made its care transition program, which tracks readmissions indicators, mandatory for hospitals that have failed to meet a certain threshold.
To that end, Highmark Blue Cross Blue Shield has operated a pay-for-performance program called Quality Blue for many of its network hospitals since 2001. The program tracks 15 indicators of care quality and patient safety. Typically it allows the participating hospitals to select their focus indicators. Depending on their size, hospitals select between one and four indicators to help them track improvements each year.
Readmission rates remain stubborn, and there is some disagreement over to what extent hospitals can influence them. So in 2012, with CMS's 30-day readmissions penalty about to become a reality, Highmark decided to make its readmissions indicator mandatory for hospitals that failed to meet a threshold score.
Through the Pittsburgh-based insurer's "defect-free transitions of care bundle," 68 hospitals embarked on a program to reduce inpatient readmissions.
Highmark modeled the effort after a care transition program from the Physician Consortium for Performance Improvement. Page Babbitt, director of provider engagement at Highmark, identified these three steps as central to the success of the program:
Medication reconciliation process reviewed with the patient prior to discharge.
Detailed transition of care plan developed by the inpatient care team.
Transmittal of care plan provided to the patient at discharge and to their PCP or specialist physician within 24 hours of discharge.
Babbitt reports that the outcomes from this effort "have been fairly significant." Looking at the 68 participating hospitals over a three-year period, the overall compliance with all three steps increased from 12% in 2011 to 78% this year.
There was a 119% increase in the percentage of patients who received the medication list, a 425% increase in the percent of patients who received a transition of care plans, and an 87% increase in the percent of care transition plans that actually made it into the hands of physicians or specialists.
Meanwhile, there was a 2.8% decrease in seven-day readmission rates and a 5% decrease in 30-day readmissions. Overall, Babbitt says the participating hospitals saved almost 1,300 hospital readmissions.
Babbitt says the hospitals have implemented several additional interventions that contribute to reduced readmissions, including:
Patient Education Teach Back isan education intervention that has patients explain, in their own words, their care plans. "It's a way to find out if the patient really gets it," says Babbitt. She explains that when she speaks to a congestive heart failure patient, she talks about the importance of a low salt diet. Then she'll ask the patient to describe to her what they need to do, in their own words. "If they tell me that they're going to go home, stock their cupboards full of canned soup, and stick to their diet, well that's a learning opportunity. We course-correct them.
Health Team Huddle This is a multidisciplinary team that includes case managers, social workers, nurses, and pharmacy staff who meet every day to discuss patient discharges. Babbitt says the conversation often includes identifying patients with a high probability for readmission. "They talk about steps to take to prevent the readmission, transportation issues that might affect the patient's ability to get to a doctor's office, [and] issues at home that could affect recovery."
Outreach Beyond the Hospital Walls "[Providers] understand that readmissions is larger than the hospital itself and they have to involve their community," says Babbitt. Her staff works with hospitals to develop the outreach. Hospitals are particularly interested in partnering with skilled nursing facilities. They are sharing data, including the readmissions report care, and helping educate SNF staff about high-risk patients who might be readmitted over and over again.
Post-Discharge Dialogue Almost all of the hospitals are reaching out to patients with a post-discharge telephone call. The purpose is to have a chat with the patients about how they are doing and to pick up any signs that the patient may be in distress. The call may be followed by a visit from home health.
One unexpected side effect of this program has been the buy-in of hospital administrators.
Certainly there is revenue associated with readmissions, but Babbitt says the hospital leaders she speaks to understand that a readmission is not the right thing for the patient. "We're not getting push-back anymore on reducing readmissions. They realize this is something that they absolutely have to do."
Senior health plan executives sound upbeat about health insurance exchanges, Medicare Advantage plans, and collaborative risk-sharing agreements with providers.
Despite the well-publicized enrollment issues of healthcare.gov, senior executives at major health insurers were upbeat about the opportunities presented by public health insurance exchanges during their third-quarter earnings calls in October and November.
"We continue to believe that these emerging retail marketplaces can be successful over the long term," stated Mark Bertolini, Aetna's chair, CEO, and president. HIX—both public and private—as well as Medicare Advantage and payer-provider relationships were among the topics covered during the third-quarter earnings calls. Here are the highlights:
Public health insurance exchanges
Senior health plan executives say they were prepared for the difficult start of the HIX program and have their own resources in place to provide full-time exchange support. Still, payers are counting the days until Dec. 15, which is the last day to enroll in a plan that takes effect on Jan. 1.
They are worried that the time it will take to make the necessary repairs to the HIX system won't leave enough time for enrollees to be processed. They are also keeping a wary eye on Congress, which seems determined to intercede, perhaps in the form of extending open enrollment or delaying the individual mandate. Neither move is popular among health plan executives, who maintain that the program must cast a wide net to calibrate for adverse selection.
Most insurers are taking what Bertolini described as a "prudent approach" to the products they offer and the HIX markets where they participate. Cigna, for example, has HIX offerings in only five states (Arizona, Colorado, Florida, Tennessee, and Texas). Any expansions will be carefully considered.
Private HIX
Insurers say they are seeing a marketplace shift to private HIX as employers convert their self-funded plan memberships to defined contribution models and become fully insured plans. The upside for employers is that private HIX can be used by employers to transition to a defined contribution strategy where the employer puts a cap on how much to spend on employee healthcare benefits.
The upside for insurers is that fully insured membership typically generates four to five times the profit contribution of self-insured membership. In addition, large group employers are moving their retirees and Medicare-eligible employees into private exchanges for their Medicare benefits.
UnitedHealth expects to offer products on a private HIX, but also sees opportunities through its Optum subsidiary in providing a platform (myCustom Health) that can be used by payers, providers, state governments, employers, and other businesses developing exchanges.
Medicare Advantage
Despite rate pressures and a funding gap, insurers remain bullish on Medicare Advantage. To maintain their MA product revenue stream, insurers are embracing care coordination, investing in clinical quality improvements, and implementing value-based rewards for physicians and healthcare systems.
WellPoint is in the process of evaluating the MA markets it serves, capturing risk score revenue, and improving its star ratings.
The Medicare Advantage star program plays an important role in the MA strategy with insurers committing resources to improve their star ratings. Now in its sixth year, the ratings program was created by CMS to monitor health plan quality and performance.
Billions of dollars in bonus payments are shared by plans that achieve at least three stars because five-star plans—there are only 14 in 2014—can enroll members throughout the year rather than for the short, seven-week open enrollment period each fall.
Cigna, whose HealthSpring of Florida plan scored one of the elusive five-star ratings, cites its physician engagement model, which rewards improved health outcomes, customer value, and patient engagement.
Provider partners
As the delivery of healthcare services shifts from volume to value, payers and providers are forming collaborative risk-sharing agreements that focus on care coordination and the management of chronic conditions. For example, Aetna is building high-performance networks in several states, including one in Virginia with Bon Secours.
And Cigna just added nine new collaborative accountable care programs to its tally and now has 75 relationships in place across the country. UnitedHealth created an ACO in Wisconsin that includes a collaborative of four hospital systems and the Medical College of Wisconsin.
WellPoint CEO Joseph Swedish, reported that the giant insurer is seeing a lot of provider interest in payment reform and it is expanding its provider relationships based on value-based payment methodologies. It has more than 50 ACOs in place and more than 700 hospitals are part of its pay-for-performance system.
Among the significant perks of being a five-star plan is the ability of payers to enroll members throughout the year rather than only during the seven-week Medicare open enrollment period.
Finally there is some positive news about health plans coming out of Washington.
The federal shutdown earlier this month and ongoing problems with the healthcare.gov have overshadowed the annual announcement by the Centers for Medicare & Medicaid Services of the star quality ratings for Medicare Advantage health plans.
Now in its sixth year, the ratings program created by CMS to monitor plan quality and performance for beneficiaries. The program was greeted with a collective yawn among health plans until the Patient Protection and Affordable Care Act sweetened the pot with bonus payments.
Since 2012, health plans with at least a three-star rating have shared billions of dollars in bonus payments. With that kind of money on the line it comes as no surprise that health plans keep a watchful eye on those star ratings, which often play a strategic role in the development and growth of their Medicare Advantage book of business.
During a recent conference call with stock analysts, Mark Bertolini, chairman, CEO and president of Aetna Inc., stated that a "key component of Aetna's Medicare strategy includes the substantial investment we have made to improve our star ratings." He noted that based on the new 2014 ratings data, Aetna has over 60% of its Medicare Advantage members in 4- and 4.5-star plans.
This year, CMS awarded five-star quality ratings to 14 Medicare Advantage plans covering about 5.6 million enrollees. Among the significant perks of being a five-star plan: the ability to enroll members throughout the year rather than only during the seven-week Medicare open enrollment period. That means five-star health plans "are always open for [new] business," says Matthew Eyles, executive vice president of Avalere Health, a healthcare consulting group.
He explains that for many health plans the Medicare Advantage premiums collected tend to be higher than what they command in the commercial marketplace, so being able to market and enroll members throughout the year is attractive.
This year's 5-star plans:
Kaiser Foundation Health Plans; CA, CO, GA, HI, OR, WA and the Mid-Atlantic states
KS Plan Administrators; TX
Group Health Cooperative; WA
Gunderson Health Plan; IA, WI
HealthSpring of Florida
Providence Health Plan; OR and WA
Medical Associates Health Plan; IA, IL
Dean Health Plan; WI
One thing I noticed is the lack of for-profit national players among this elite group. Although these big players are willing and able to throw resources at the star rating program, it is simply not that easy to become a five-star plan, explains Eyles.
The CMS star rating system is based on 48 quality measures for Medicare Advantage plans with prescription drug programs (MA-PD) and 36 measures for MA plans without a drug plan. The measures fall into several broad categories, including health screenings, managing chronic conditions, and member satisfaction.
In addition, making the grade often depends on how common managed care is in a geographic area. "It's not just the actions by the health plans, although that's certainly the most important element," says Eyles. "But you have to have providers who are your partners, who understand what drives quality, and who do what they are supposed to do to drive those high star ratings."
Eyles says that overall the 2014 star ratings show improvement among the 3- and 3.5-star plans. "CMS is pushing plans and the plans are clearly responding. They have been making investments in quality and improving those star ratings. Their investments are paying off. It's an intensive effort to focus on improving and to actually be able to implement the systems, programs, and outreach with beneficiaries, to make a meaningful difference one year to the next.
For the 2014 plan year, the number of 4- and 4.5-star plans available increases to 151 from 116 the previous yea. Moving from three to four stars is important because in 2015 the minimum rating to qualify for a bonus will be four stars.
"The bonus can be the difference between an MA plan making money or not, says Eyles.
Six years after launching a dental medical integration program, Aetna reports that hospital admissions and claims costs are down, while diabetes control has improved by 45% among 1.5 million patients.
Much of the traditional focus of the care continuum has been to link pre-acute, inpatient, and post-acute healthcare in an effort to improve outcomes and reduce inpatient readmissions. While medical doctors and specialists have long been essential players, dentists are now being added to the mix as health insurers pay attention to the relationship between physical health and dental health.
In 2007 Aetna launched its dental medical integration program as part of a research program with the Columbia University College of Dental Medicine. The DMI program uses claims data to identify Aetna members who are pregnant, have diabetes or cardiovascular disease, and haven't visited a dentist lately. An outreach program connects with those members.
Six years and 1.5 million patients later, Aetna has released some results. DMI program members who visited the dentist have:
Lowered their medical claims costs by 17%
Improved diabetes control by 45%
Reduced their use of major and basic dental services by 42%
Required 3.5% fewer hospital admissions year-over-year compared to a 5.4% increase for non-DMI members
I recently spoke with Mary Lee Conicella, DMD, the chief dental officer at Aetna, about the DMI program, its place in the healthcare industry, and the program challenges.
Mary Lee Conicella, DMD
HLM: What's the relationship between periodontal disease and chronic disease?
Conicella: What has been concluded in the scientific literature is that there is an association between periodontal disease and several chronic conditions. The three conditions with the strongest evidence of associations are the three conditions in our program:
Diabetes
Heart disease
Pregnancy
For example, we know that the inflammation associated with periodontal disease can make it more difficult for a patient with diabetes to control her blood glucose. We have found that members in the program who have diabetes and have started going to the dentist have better control of their blood glucose in subsequent years.
HLM: How do you find potential DMI participants?
Conicella: All of our dental and medical member data is on the same platform. That provides us with the advantage of having all the data in the same place. Our system can easily identify members who have the medical conditions we include in the program. We use a fairly broad algorithm that includes many, many diagnoses codes for identifying those members.
We will also loop in members who have kidney problems associated with diabetes or heart disease, or hypertension. We use the categories of diabetes and heart disease somewhat generally, then we look at a broad grouping of members within those general categories.
We identify them from the medical data and look at their dental data to see if they have recent dental claims. If they have not, we proceed with the outreach.
HLM: Walk me through the DMI process.
Conicella: Once they are identified, the members receive a postcard to let them know about the enhanced dental benefits available to them. They can access a toll-free number to talk with one of our dental care coordinators who can help them find a dentist.
Keep in mind, these are members who have not visited the dentist recently. We continue to follow them for about three months. If they still haven't had a dental appointment then we follow up with a telephone call.
We find each year we are successful with getting more than 50% of those members identified to a dental appointment within a few months of our outreach. We have also found that they tend to have sustained use of dental services, so those members tend to keep going to the dentist once they get the encouragement and go for their initial visit.
HLM: Do electronic health records play a role?
Conicella: The EHR is available to the providers of services, to physicians and dentists. Where it can play a role is when a physician enters information about a patient into the EHR, and if the [patient's] dentist would also have access to that record, that would be another way to know more about the total health of their patient.
I see an advantage of having access to an EHR if you are a clinician, just to be able to have that bigger picture of your patient, rather than just the information that the patient might fill out on their dental health history form, for example.
We also have a health risk assessment that our members complete. It includes questions about their dental care and their dental health, so that's another way we can use data to get a picture of our members' total health.
HLM: Is DMI part of your ACO strategy?
Conicella: We would very much like to include dentists and dental services in our ACOs in the future. Aetna's ACO team is working with our dental group. Our ultimate goal is to find a way to use the ACO strategy to loop in dentists so all of the providers of care for a particular patient have an opportunity to coordinate with one another.
HLM: What challenges has the DMI program faced?
Conicella: When we first started the program, getting the medical team at Aetna, and physicians in general, on board was a bit of a challenge. I think dentists embraced it right away because of the research coming out in dental journals.
Physicians weren't reading about the connections. Now our chief medical officer at Aetna and the medical directors I work with have embraced the program and embraced the opportunities for integration.
I would say the main challenge now is how to motivate that segment of the population that despite our outreach, doesn't make a dental appointment. We're very happy with the success we have achieved, but we would love to find a way to motivate the rest of the members to start going to the dentist.
Medicaid and Medicare Advantage plans are the primary drivers of a resurgence in health maintenance organizations in the Lone Star state, where Medicare Advantage HMOs enjoyed double-digit enrollment growth in 2012.
After several years of membership losses, Texas health maintenance organizations are enjoying something of a resurgence with enrollment hitting a record four million members according to the Texas Health Market Review 2013.
The primary drivers? Medicaid and Medicare Advantage plans. Yep, although Texas officials may rail against government programs, HMOs there have been busy expanding their markets and setting up networks to grab a larger membership share of those government programs.
In terms of enrollment, the largest HMOs in the Lone Star state are national Medicaid plans—AmeriGroup (661,478 members) and Centene (410,512 members)—and the Texas Children's Health Plan (354,684), which covers members who are part of the federal Children's Health Insurance Plan.
What is happening in Texas?
Allan Baumgarten, a Minneapolis-based consultant who has studied the Texas market for more than a decade and is the author of the market review, says the state has been busy in recent years transitioning its elderly and disabled Medicaid recipients into managed care arrangements.
The program, which began as a demonstration project in Houston, "is creating significant enrollment opportunities" for the Medicaid HMOs says Baumgarten.
Of course, this opportunity pales somewhat compared to the two to three million Texans who were expected to become eligible for Medicaid under the expansion provisions of the federal Patient Protection and Affordable Care Act. Last year the U.S. Supreme Court gave states the permission to opt of the expansion. Texas officials decided to exercise that option.
Meanwhile, baby boomers are leading the Medicare charge. Medicare Advantage HMOs enjoyed double-digit enrollment growth in 2012. More than 500,000 Texas seniors are now in those plans.
Profitability is a mixed bag, though. While Medicare Advantage is the most profitable line of business for HMOs, Medicaid HMO plans lost a collective $74.3 million on their operations in 2012.
Baumgarten attributes the Medicaid losses, at least in part, to expansion costs. He notes that ramping up provider networks and operations to move into new markets is a costly undertaking. Also, to quickly build those provider networks the HMOs may have agreed to unfavorable contracts in terms of their commitment to payment arrangements.
Baumgarten is reluctant to make any guesses about future profitability. "Going forward will they have better success? Who knows? It's an open question."
In general, as a health plan's activities in a service area mature, it begins to post profits. Baumgarten says the same scenario could be applied to Medicaid HMOs in Texas but with two caveats:
From time to time Medicaid programs put the squeeze on HMO payment rates to see how low they can go before plans start to drop out. He has seen that happen before in Texas.
Baumgarten is also concerned about how much time it may take an HMO to recover from disadvantageous provider contracts signed in those early years. "Sometimes contracts are for multiple years. It's not something you can turnaround in 12 months."
He says the expansion in the state of the elderly and disabled Medicaid managed care program promises to boost profitability because the average per-member per-month revenue is in the $800 to $1,000 per month range.
With favorable contracts and discounts from major providers, and if the HMOs perform a better job of care coordination than now happens with fee-for-service payments, then Baumgarten says that should be sufficient to provide a return.
Health insurance exchanges
Despite a lack of support from the state of Texas, Baumgarten sees HIX as having "significant potential" that may even help kick start commercial HMO enrollment, which has dropped like a rock to around 500,000 members as employers have moved to PPOs.
For employers, most of the innovation in health plan product design is "happening outside of the HMO," says Baumgarten. That makes commercial HMOs a tough sell.
Patient-centered primary care is one part of WellPoint's strategy to shift provider reimbursements from volume-based to value-based care arrangements. A year into a multi-state rollout, the program is delivering as expected.
About a year ago WellPoint announced plans to expand its patient-centered primary care pilot throughout its 14-state market area. At that time I spoke with Jill R. Hummel, WellPoint's vice president of patient innovation, about what the giant healthcare insurer had learned from the pilot that could be applied to a national rollout.
Jill R. Hummel, vice president of patient innovation at WellPoint
Her list included the usual suspects: the role of payment reform in shifting from volume to value, the importance of providing actionable information to physicians, and increasing patient access.
PCPCs are one part of WellPoint's strategy to shift provider reimbursements from volume-based to value-based care arrangements. Fee-for-service reimbursements are replaced with fixed per-member, per-month payments and shared savings.
I recently touched base with Hummel to check on the status of the rollout and to find out how lessons learned in the pilot helped in the expansion.
Status of Expansion
The PCPC program has been rolled out to 12 markets so far with expansion planned for the two remaining markets by January 2014. To date, WellPoint has about 4,600 PCPCs in place. The emphasis remains on the primary care physician as the central player in coordinating patient care.
Physician Participation
About 20,000 primary care providers—or 20% of its PCP network—participate and provide care for two million WellPoint members. Hummel says the expansion is on track to have 25% of the network participating by the end of the year.
It plans to double its penetration/participation in 2014. And, it will pilot in 2014 the addition of specialists to the value-based care arrangement.
Hummel says the success of the pilot reflects ongoing collaboration with physicians. "This isn't something you do to physicians and providers, it's something you do with them."
Handholding
While there is general acceptance that healthcare needs to reflect value and patient outcomes, payments, Hummel says the transition is marked by physician uncertainty. "They worry about having the tools, knowledge, skills, and resources to be successful in the value-based environment."
Among the essentials is how to write a patient care plan. Hummel notes that most physicians did not learn how to write a patient care plan in medical school.
So WellPoint has a team of patient-centered care consultants to help physicians master the elements of patient-centered care. It also offers monthly 90-minute webinars to aid in the transition.
During the first year the webinars have focused on basics such as how to manage work flow, creating care coordination across the healthcare delivery system, and how to use data to improve patient care. Hummel says a second year of more advanced webinars is being developed.
Actionable Information
Incorporating claims data and predictive modeling, a hotspot report is developed for each PCPC. The report identifies members at high risk for an adverse event, a hospitalization or a readmission.
As an example of how the report is used, Hummel says one hotspot report identified a new patient with a history of diabetes, sleep apnea, obesity, and hypertension. Alerted by the hotspot report, the practice reached out to the patient, who had not received care in five years.
Providers worked with him to develop a care plan that included physician appointments every three months, self-management, and lifestyle changes. The patient now attends diabetic support classes, maintains a 1,500 calorie meal plan and is losing weight. And he takes his medications as prescribed.
Patient Engagement
Hummel notes that "there's really a talent to creating that personal readiness and receptivity in patients to embrace the changes they need to make to be an active participant in their health."
As part of the PCPC, physicians learn how patient outcomes can be driven by underlying behavioral issues. Access is critical in patient engagement, so incorporating e-mail and virtual, online visits with a physician practice is important.
Success Measures
Hummel says it will be another six months—probably the second quarter 2014—before cost trends emerge. For now, based on anecdotal, member-at-a-time evidence, she says the PCPC program is delivering "what we thought it would deliver."
The impact of health insurance exchanges will take months and years to assess. December 15, not October 1, is the big date; young invincibles aren't essential yet; and it will be 2015 before the viability of HIX is known.
Open enrollment for the health insurance exchanges is a marathon, not a sprint, and it will take months—and for some aspects, years—to assess the impact.
We've been hearing plenty of reports about long waits for HIX access, server problems, and other delays. But industry observers and stakeholders—who have the proverbial skin in the game—are looking well beyond those early glitches to the impact of HIX over the long term.
"I am certain that things won't go smoothly [at first], but I envision that any glitches will be resolved in the first couple of weeks. By the end of October, I think things will be running smoothly," says Caroline Pearson, vice president of Avalere Health, a consulting group that has studied HIX.
More than 2.8 million people tried to access the federal HIX site, Healthcare.gov, on launch day yesterday. People who don't have health insurance or who have serious health conditions are highly motivated to enroll. If they encounter problems early in October, Pearson expects that they will "come back and try, try again" until they are able to process their application and get enrolled in a health plan.
To take the long view on HIX, I spoke with Pearson, as well as Joe Mondy, spokesperson for Cigna, and Steve Wojcik, vice president of public policy for the National Business Group on Health. Here are some pointers.
Forget October 1, December 15 is the date to mark
That is the day when the enrollment period ends for policies that will go into effect on January 1. Many people will procrastinate or wait to see the initial uptake, so Pearson expects the first weeks of December to be busy ones for HIX.
Mondy agrees. Although Cigna is up and running with its HIX offerings in five states (Arizona, Colorado, Florida, Tennessee, and Texas) he expects potential enrollees to take some time to study the offerings and make their coverage decision. Cigna is providing online and telephone support 24/7 and has developed a five-minute video guide to help with the enrollment process.
The eventual importance of young invincibles
Many people have noted the need to attract so-called young invincibles—those hardy 20-somethings who rarely get sick—to HIX, in order to offset older and sicker enrollees. But Pearson says, "It is important to get healthy people in [HIX] during the first three years, but I don't know if it's that important for the first year."
In the short term, attracting young invincibles is important more in terms of PR than from a risk pool perspective. It is expected that young people will sit out the first year of HIX, which means the initial enrollment could be weighed toward a sicker population with more health needs. To protect health plans from potential losses in serving that population, the federal government has guaranteed risk corridors and reinsurance programs that will be in place for the first three years.
Welcoming newbies to the healthcare system
The millions of uninsured expected to purchase health insurance on the HIX will probably be unfamiliar with the basic mechanics of health insurance coverage. That means training will need to be ongoing. Cigna has developed an extensive education program for this audience and structured its HIX plans to be easy to understand and explain.
In addition, its surveys of potential members revealed that many have never had a family doctor. Mondy says the Cigna networks are primary care–centric. "We want to ease [enrollees] into a very complex healthcare system and help them navigate the system as they engage it."
The long-term viability of HIX
Wojcik says employers that are members of the National Business Group on Health are already familiar with the challenges of open enrollment and benefit changes. "They know there will be bumps in the road" over the short- term with HIX. But if things aren't running smoothly by 2015, "that could be a red flag."
He expects employers to look at what insurers do in the second, third, and fourth years in terms of participation, plans, and premiums. "If HIX can't sustain affordable coverage, if rates increase, or insurer choice is restricted," that will indicate long-term problems.
For now, large employers are eying HIX for their retirees, former employees on COBRA, and their part-time employees who are not eligible for company benefits. HIX rules prevent them from shifting full-time employees to the exchanges. That policy will change in 2017, and Wojcik expects employers to at least take a look then to see if a public HIX might fit in their benefit strategy.
Mondy says Cigna is looking beyond the initial enrollment period to member retention, which has always been a challenge in the individual market. It is expected that HIX will provide a similar type of competitive marketplace for individuals that is now enjoyed by groups. He is concerned, however, that loss leaders may disrupt the market, as individuals focus on the low monthly premiums rather than the full package, which may include high deductibles, copays, and small provider networks.
Extensive membership turnovers within HIX could affect market stability and make it more difficult for health plans to profitably manage members..
The first miles of the marathon
"This is a very heavy lift for everybody. It is much more than just putting a product out there," says Mondy. "That's why we're concentrating on markets we know and have the capabilities to serve. We'll have the opportunity to analyze things as we go along and as the health insurance exchanges mature."
Just in time for consumers to assess their coverage opportunities in the soon-to-be-unveiled health insurance exchanges, the National Committee for Quality Assurance has released its annual ranking of health insurance plans.
Just in time for consumers to assess their coverage opportunities in the soon-to-be-unveiled health insurance exchanges, the National Committee for Quality Assurance has released its annual ranking of health insurance plans.
This is the ninth year the NCQA has ranked health plans. For four consecutive years an HMO operated by Wellesley, Mass.–based Harvard Pilgrim Health Care has topped the list of commercial health plans. Harvard Pilgrim has four plans in the 2013 top 10: two PPOs and two HMOs. The health plan serves about 1.2 million members in Massachusetts, Maine, and New Hampshire.
The rankings are compiled by the NCQA, a nonprofit healthcare accreditation and quality measurement group. They are based on the Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) performance measures. Each plan receives an overall score between 1 and 100. Prevention and treatment account for 60% of the score, consumer satisfaction for 25%, and NCQA accreditation for 15%.
This year the NCQA ranked 1,020 health plans, including 484 commercial plans, 405 Medicare Advantage plans, and 131 Medicaid HMOs. NCQA accreditation is voluntary and health plans pay for the process.
So how does Harvard Pilgrim manage to fare so well year after year?
I had the opportunity a while back to interview Michael Sherman, MD, MBA, Harvard Pilgrim's senior vice president and the chief medical officer. He spoke then about the importance of partnering with provider systems to be "part of the solution" and talked about the innovations such as pay-for-performance, bundled payments, and patient-centered medical homes that the company has supported for several years.
Sherman stressed the importance of shifting physician relationships from a win-lose model, where most payer-provider discussions are about fee schedules, to a win-win model, where payers and providers work together to improve the delivery of healthcare.
That means spending more time talking to physicians about things like their infrastructure needs and developing payment systems that support improved healthcare delivery. Harvard Pilgrim also provides capabilities in analytics and care management programs to support physicians.
The health plan invests not only in outcome-based programs but also provides grants to help physician practices get the tools, develop the infrastructure, and hire the personnel needed to improve care delivery and reduce costs. Over 13 years Harvard Pilgrim has funded more than 190 initiatives totaling more than $14 million in its three-state service area.
The organization has also moved aggressively into healthcare cost transparency. Earlier this year it announced a partnership with Castlight Health to develop member access to cost and quality information about healthcare providers and common procedures, including out-of-pocket pricing and quality measures for all in-network healthcare providers.
Recently Harvard Pilgrim also announced that it is partnering with two New Hampshire provider organizations, Dartmouth-Hitchcock Medical Center and Elliot Health System, to offer a defined-network product focused on care coordination. The network includes more than 400 primary care doctors and 2,600 specialists, with an insurance premium that's about 10% less than Harvard Pilgrim's similar full-network plans.
Here's the NCQA top 10 results for 2013:
Top 10 Commercial Health Plans
Harvard Pilgrim Health Care (HMO, Maine and Massachusetts)
Kaiser Foundation Health Plan of the Northwest (HMO, Oregon and Washington)
Blue Cross and Blue Shield of Massachusetts (HMO, Massachusetts)
Harvard Pilgrim Health Care (PPO, Massachusetts)
Harvard Pilgrim Insurance (PPO, Massachusetts)
Tufts Associated HMO (HMO, Massachusetts)
Kaiser Foundation Health Plan of Northern California (HMO, California)
Tufts Benefit Administrators (PPO, Massachusetts and Rhode Island)
Harvard Pilgrim Health Care of New England (HMO, New Hampshire)
Kaiser Foundation Health Plan of Ohio (HMO, Ohio)
This is only the third year that PPOs have been included in the rankings, and they are making their mark. This year 274 commercial PPOs are ranked versus 204 HMOs. In 2012, two of the top 10 plans were PPOs; this year, three PPOs are among the top 10. There are 11 PPOs in the top 50 this year versus seven last year.
The three Kaiser Foundation Health Plans are the only health plans in the top 10 that are also part of an integrated health system. Kaiser employs its physicians and owns its hospitals, which gives the organization an advantage in delivering coordinated care as well as meeting cost and quality benchmarks.
For-Profit Health Plans
Among the major for-profit health insurers, only Anthem managed to crack the top 25. The HMO offered by Anthem Blue Cross and Blue Shield Maine is ranked at number 23. A Cigna PPO in Massachusetts is ranked 50, an Aetna PPO in Connecticut is ranked 59, UnitedHealthcare's PPO in Rhode Island is ranked 67, and Humana's PPO in Ohio is ranked 132.
Medicare Advantage Health Plans
An HMO from Kaiser Foundation Health Plan of Southern California claimed the top spot among Medicare Advantage health plans. In fact, Kaiser dominates that ranking, with six of its Medicare Advantage plans in the top 10.
Medicaid Health Plans
Fallon Community Health Plan of Massachusetts topped the Medicaid health plan rankings.
Andy Reynolds, assistant vice president for marketing and communications at NCQA, says the health plan participation in the NCQA rankings indicates that more and more insurers are committed to measuring their performance and accept that transparency—providing public access to their performance results—is a critical step in the process of improving healthcare.
He notes that the health plans at the top of the rankings have been committed to transparency for a long time.
Of course, the more plans that are transparent with their performance results, the better it is for consumers and employers, who are increasingly considering the value proposition in their healthcare insurance purchases.
