Taking ownership key to successful reform

OWN IT: CharterCARE Health Partners CEO John Holiver, center, says patients need to be more involved with taking ownership of their health for better outcomes. / PBN PHOTO/RUPERT WHITELEY
OWN IT: CharterCARE Health Partners CEO John Holiver, center, says patients need to be more involved with taking ownership of their health for better outcomes. / PBN PHOTO/RUPERT WHITELEY

“The goal of an HMO is to put the primary care physician at the heart of delivering care to members. It’s about making sure members get high-quality, affordable care,” said Marc Spooner, president of Tufts Health Plan’s Commercial Products division, during the second of two panel discussions at the Providence Business News Health Care Reform Summit held at the Crowne Plaza Providence Warwick Oct. 20. He added that ACOs share the same goal.

Spooner’s panel focused on health maintenance organizations, accountable care organizations and preferred-provider organizations; the impact of self-insured companies on health care exchanges; and the future of the Affordable Care Act and HealthSource RI.

“An ACO takes a large group of primary care physicians and aligns them with a large system of care, [such as] Lifespan,” said Marc Proto, corporate vice president of contracting for Lifespan. “We have a relationship with a large, 170 primary-care- physician community.”

Proto said payment methods need to evolve, as well as the appetite to take on risk.

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John Holiver, CEO of CharterCARE Health Partners, agrees that alternative payment methods are necessary, as they promote interaction with programs, providers, physicians and patients.

“[ACOs] should have upside risk and downside risk, as hospitals do,” said Holiver, whose joint-venture company operates two hospitals, an elder-care-services network, a cancer treatment and research center, a behavioral-health program, a home health agency and an independent practice association.

“With the right cocktail, I think we can put together horizontal integration and become better partners with providers and physicians,” he said.

Holiver said one of the ways CharterCARE ensures coordination of care is through the use of a call center.

“We have a call center with a 1-800 number that is used by both consumers and physicians,” he said. “The referral goes to the call center to put the consumer at the right level, with the right care, for the right outcome. This has been very successful for CharterCARE,” he said.

In addition to integration between providers and health systems, Holiver said, “We need to get the patient involved.”

Eric Swain, vice president of sales and account management for UnitedHealthcare of New England Inc., agrees.

“Plans need to integrate how they interact with providers, and we need to get [patients] taking ownership of their health to make better decisions for better outcomes,” he said.

With a PPO plan, patients can choose any provider they want but will pay less if they use an in-network provider. Unlike an HMO, no referral is needed to see a specialist. In order to keep that freedom, employees are paying for plans with increasing deductibles.

Swain said rising deductibles aren’t necessarily a bad thing.

“It’s a way to get members to take more ownership,” he said.

From an insurer’s perspective, Spooner said the goal is not to drive an employer into a specific product.

“The first goal is to have clear information upfront regarding the different products available,” he said. “We have an obligation to educate the consumer and show them the value a product can offer.”

Swain added, “Employers need to see plan designs as attractive and things that work.”

With UnitedHealthcare pulling out of health care exchanges in all but three states in 2017, Swain was asked about the impact of such a move on exchanges, as well as the impact self-insured companies have on exchanges.

“United is participating in states where there is a viable, competitive business model,” he said, adding that the self-funded model can be especially helpful for larger employers by allowing them to save money and be more flexible.

“The best byproduct is the employer mindset changes from, what is my rate, to what is my underline cost,” he said. “How does an employer help employees become healthier and make better decisions?”

Wendy Kagan, senior vice president and director of Employee and Community Engagement for BankNewport, said the self-funded model can be a scary proposition from an employer perspective.

“We can only control the costs so much,” she said. “It can also be difficult for employers that take on a whole family because it’s harder to impact the behaviors of a family than an individual employee.”

Calling it “an incredible achievement,” Spooner said Rhode Island deserves tremendous credit for the reduced percentage of the state population that is uninsured, dropping to 5.7 percent in 2015 from 11 percent in 2013, with the implementation of HealthSource RI.

“The driver was enrollment in Medicaid. More than 90,000 became Medicaid-eligible and took advantage of it,” he said, adding that half of those still uninsured qualify for Medicaid and the challenge becomes how to let people know about the benefits available to them.

“There are systemic reasons why that’s challenging,” he said. “Some individuals feel they are healthy and don’t want to pay out of pocket; cultural and language barriers make it difficult to sign up through the system; and purchasing coverage can be extremely expensive if people don’t qualify for Medicaid.”

Addressing why the Rhode Island Free Clinic is as busy as ever, even with more people becoming insured, Swain said one of the contributing factors could be that people don’t understand their health plan and where to go to get the best care.

Holiver added, “We need young and healthy members putting premiums into the pot along with the older members who are pulling from that pot at a greater rate.”

Spooner said when the ACA was introduced, some saw it as the precipitating act for employers to get out of the business of providing health care, but he feels that hype was largely unfounded.

“Providing health care benefits is important to employers. We’ve not seen them anxious to give up that tie to employees,” he said.

Kagan added, “Employers feel it’s part of their responsibility to provide health care benefits.”

The concern on the employee side is, “They want everything to be the same. They don’t like change,” said Matthew Reeber, a partner and member of Pannone Lopes Devereaux & West LLC’s employment and litigation teams. “How does an employer answer questions when an employee asks, ‘Why is this being done?'”

During a Q&A session, an unidentified man in the audience said, “The way I see it, either we move forward to single payer or we move backward to competitive. What are your opinions on both?”

Spooner said single payer sounds attractive, “but when you look at the cost and the effect it has, it quickly becomes unattractive.”

“Vermont attempted it, but the payroll tax became so high that they couldn’t afford it,” he said.

Spooner said the public option is attractive because you can standardize what providers are paid, however he doesn’t see it as the cure because “you will get strong resistance from the provider community.”

Another audience member, David DeBlois, a benefits consultant with Starkweather & Shepley Insurance Brokerage Inc., said he felt the summit was very informative.

“It was good to see a number of individuals from the business community, brokers and consultants in the marketplace in order to understand the changes from a provider and employer standpoint,” he said. •

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