Like other hospital chains across the country, it’s under intense pressure from public and private insurers, as well as employers, to accept flat-rate payments for care, rather than reimbursements for every service. And that puts pressure on hospitals not just to manage costs, but to keep people well — in short, to act more like insurers.
“This is a huge, dramatic cultural shift,” said Dowling, president and chief executive of North Shore-LIJ, who expects it will take several years to market coverage to the general public.
Once the system becomes an insurer, picking up the tab for a hospitalization rather than generating revenue from it, more resources will be devoted to preventive care, Dowling said.
“The last place I’ll want you to be is in the hospital,” he said. “I’ll be doing everything to get you to take care of yourself.”
Hospitals from Colorado to Virginia are exploring similar strategies spurred by rising costs and incentives in the health law. An estimated 20 percent of networks market an insurance product, including MedStar Health, serving the Washington-Baltimore region with Georgetown University Hospital and eight other facilities.
Another 20 percent are exploring doing so, according to a survey last year of 100 hospital leaders by the Advisory Board Co., a research firm.
“This trend is definitely picking up steam across the country,” said Chas Roades, the firm’s chief research officer.
Impact on consumers
Proponents say consumers would benefit from streamlined care and possibly lower costs, but some also worry they could find themselves with fewer choices and limited access to outside experts and cutting-edge treatments.
“The idea of managing care for patients in a holistic fashion sounds great,” said Carmen Balber, who directs the Washington office of Consumer Watchdog. “The question is how it plays out. Are doctors given the freedom to make recommendations outside of cost calculations?”
Driving the change is the transition from fee-for-service payment schemes, which pay for each doctor’s visit, appendectomy or CT scan separately, to one that pays providers a lump sum per person per year. This will shift more of the financial risk of medical care from insurers to providers.
Once hospital systems are paid this way, “they’re sort of halfway toward being an insurance company,” Roades said. “The more hospitals take on risk and manage the care, the more they look like insurance companies. And ultimately you have to ask: Why do we even need an insurance company sitting between a health system and an employer?”
Of course, Americans rebelled against an earlier iteration of this model, known as managed care, when insurers ran the show.
“The big wild card is: How will patients view it?” he said. “Is it just going to be viewed as managed care 2.0 and engender the same kind of backlash, or will people engage with it because it can help them live healthier lives?
“I don’t think it’s a slam dunk one way or another.”
Managed care redux?
One change, experts say, is technology. Electronic medical records and a wealth of health databases that did not exist during the first wave of managed care can now guide appropriate medical treatment.
In the ’90s, “we were flying blind,” said Paul Keckley, executive director of the Deloitte Center for Health Solutions. “Now we’ve got a whole wave of clinical algorithms to know what’s an appropriate referral.”
Several large hospital networks — such as the Ford Health System in Detroit and UPMC in Pittsburgh — have entities that sell insurance policies.
But that can complicate relations with insurers, and health systems like North Shore-LIJ, which depend on contracts with commercial plans, would not want to jeopardize those. Dowling said he might partner with an insurer to market a North Shore-LIJ insurance product; he envisions a hybrid system that would continue to contract with numerous plans.
It can get tricky, though. UPMC, for instance, has been embroiled in a nasty legal dispute with Highmark, a large insurer, over its acquisition of a rival hospital network in Pittsburgh, though the parties reached an agreement in May. Texas Health, which experimented with health plans in the 1990s, found the business a distraction from its primary mission and have sold it off.
“Hospitals think this is a way to cut out the middle person, tailor care more closely and save a lot of extra money, but there’s a history to this and it generally doesn’t work,” said Howard Berliner, a visiting professor of health policy at New York University. “It winds up being incredibly complicated.”
Several Washington-area health systems already market plans or self-insure their employees. Besides MedStar, Sentara Health Care, a Norfolk-based health system that owns Sentara Northern Virginia Medical Center in Woodbridge, markets Optima Health, a health plan with 433,000 members. And Inova Health System, a hospital network based in Falls Church, Va., has announced it would partner with Aetna to establish a jointly-owned health plan that will sell insurance products in northern Virginia.
The transition is complex and fraught with risk for hospitals, experts say. Insurance is a different business from health care and requires its own mind-set and skills. Hospitals will have to change the way they are run and radically alter the way they take care of patients, possibly taking on powerful interests — such as doctors.
To become licensed as an insurer, a health system also needs to have millions of dollars in capital reserves and must run a regulatory gantlet to prove it has an adequate provider network and can deliver required benefits. And a hospital system cannot dip into the health plan’s reserves to fund new services.
“Many hospitals sold their insurance plans even though they were profitable because the hospital had better use for the money — the money sitting in insurance reserves could be better devoted to building the tower,” said Paul Ginsburg, president of the Center for Studying Health System Change.
‘GPS system for patients’
The North Shore-LIJ system has entered into several new full-risk contracts with Medicaid and Medicare to treat its neediest patients, who are elderly, poor or both (the two government plans make up the majority of hospital patients). Many struggle with chronic illnesses and require nonmedical support services, such as health education or nutrition and weight management programs.
Under the old model, there was little, if any, reimbursement for these services. As an insurer, North Shore could direct resources to them. Some of the new initiatives are basic, such as making sure patients get needed medicines, know which symptoms indicate a worsening condition and have a number they can call for advice 24-7 — and can get in to see a primary care physician before a crisis develops.
Others are high-tech. A team generates detailed color-coded maps of the service area that enable it to zero in on neighborhoods, even city blocks, that are hot spots of diabetes, hypertension, asthma and heart disease.
“I can look at a map and see the pockets of diabetes and where the patients come from and say, ‘Wouldn’t it be great if we had some educational resource close to them?’ ” said Tracy Breen, chief of endocrinology, who is recruiting diabetes educators to target these communities and translating the best patient materials into Russian, Spanish, Korean and two dialects of Chinese.
Another problem hospitals have is they usually see patients only during a crisis. So North Shore-LIJ computer analysts are developing a “GPS system for patients” to determine why some patients are admitted so frequently: Do they resort to the emergency room because the doctor isn’t available in the evening? Does the doctor need backup on weekends?
“We can wrap services around the physician to coordinate with patients and make sure prescriptions are refilled and there is coverage outside hours,” said Jeremy Boal, chief medical officer, who has started a house calls program for homebound and frail patients. “That would allow physicians to focus on what they do best — being at the bedside.”
As insurer, the health system may also have to make tough decisions that rub physicians the wrong way or reduce their income, Dowling said.
“If I find out that instead of surgery there is a more efficient way of doing something with better outcomes and less cost, I have to manage the doctors,” he said, referring to a study that found that inserting stents into narrowed arteries was no more beneficial for stable patients than standard drug therapy although it generates enormous revenues for doctors and hospitals.
“You can blame the insurance company now,” Dowling said, “but if you are the insurance company, now you’re the one telling your own doctors to do something they don’t want to do.”
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.