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Customer-hungry insurers offering free visits to physicians

By PHIL GALEWITZ

For Kaiser Health News

 

Health insurers in several big cities will take some pain out of  physician visits in 2016. The plans will offer free visits to primary-care physicians in their networks.

You read that right. Doctor visits without co-pays. Or co-insurance. And no expensive deductible to pay off first either.

In Atlanta, Chicago, Dallas, Miami and more than a dozen other markets, people seeking coverage through the insurance exchanges can choose health plans providing free doctor visits, a benefit once considered unthinkable.

The change is rolling out in a limited number of plans following reports that high co-pays and deductibles have discouraged many Americans who signed up for private coverage the past two years from using their new insurance under the Affordable Care Act.

Insurers say they hope encouraging visits to doctors will benefit members and their bottom lines by catching illnesses early before they become harder and more expensive to treat. For example, prescribing antibiotics promptly to a patient with pneumonia could avoid a lengthy hospitalization costing tens of thousands of dollars.

In addition, the policy could also cut down on the use of more expensive urgent-care centers and emergency rooms for cases that aren’t critical.

In most states, Dec. 15 was the deadline for coverage starting Jan. 1, though people have until Jan. 31 to enroll for 2016.

Two new health insurers, Harken Health, an independently operated affiliate of UnitedHealthcare, and Zoom+ are offering unlimited free primary-care visits at company-owned clinics. Harken operates in Chicago and Atlanta. Zoom+ is based in Portland, Ore.

Down South, Florida Blue, the state’s largest insurer, has health plans in Miami-Dade and nine other counties where low-income members buying plans can also get two free primary-care visits per year.

California-based Molina Healthcare, is offering not only free primary-care visits in some plans, but also free visits to specialists in Florida, Texas and five other states.

The no-fee visits go beyond the preventive services, such as immunizations and screenings, that all insurers must provide under Obamacare without charging a co-pay, even when a deductible hasn’t been met.

Health policy experts say the new approach sets the insurers apart in crowded insurance markets and may attract younger, healthier people who don’t have relationships with physicians.

“This is a great development … and shows how the market is trying to innovate,” said Katherine Hempstead, director of coverage for the Robert Wood Johnson Foundation.

“Consumers should find this very appealing. … It might be like ‘a spoonful of sugar helps the medicine go down,’ ” she said, quoting a line from the Mary Poppins song. “People are not going to grouse as much about cost-sharing later if they are getting something free first.”

Consumer advocates applaud the trend, which they say underscores why people need to look beyond the monthly premium when shopping for a plan. “It’s a smart move to reduce financial barriers to basic outpatient care to help patients manage their health,” said Lydia Mitts, a senior policy analyst at Families USA. “I hope other health plans will realize removing financial barriers to primary care doctors is a smart direction for patients and for the plans.”

The health plans offering free doctor visits are typically among the lowest-priced plans in many markets, according to a Kaiser Health News review of plans sold on the exchanges.

Some insurers can offer free visits because they operate health clinics staffed by salaried physicians. That’s the case at Harken Health, which has four primary-care clinics in Chicago and six in Atlanta for its members to use for unlimited visits. Harken also offers members access to a doctor by telephone and Internet. “We are creating unfettered access between the care team and the patients,” said Tom Vanderheyden, CEO of Harken Health. “We think it’s a significant differentiation.” Harken also offers free yoga and cooking classes.

Patients with easy access to Harken’s clinics should be able to avoid trips to urgent care centers, retail clinics and emergency rooms, and develop a deeper relationship with their primary care doctor, Vanderheyden said. “Better access … should mean better outcomes and happier people.”

Dave Sanders, M.D., CEO of Zoom+ and a physician, said offering free doctor visits at its modern clinics, should help attract young enrollees. “We are unabashedly focused on the millennial generation,” he said.

To that end, Zoom+ lets members make appointments using a smartphone app. The company’s  physician emphasize changing diets before prescribing drugs.

Dr. Craig McDougall of ZOOM+ talks about food as medicine with a patient visiting one of the insurer’s clinics in Portland, Ore.

Zoom+ has run clinics in the Portland area for the past year, but it has never offered an insurance plan before. Members can get free care at the clinics or Zoom’s freestanding emergency room.

Under the health law, marketplace plans must cover a certain percentage of a member’s health costs with the amount varying based on gold, silver or bronze tiers. “What we have done is to spend the resources on primary care,” Sanders said.

Zoom+ also offers free mental health visits and one free dental visit for a cleaning.

Florida Blue, the state’s Blue Cross and Blue Shield plan, developed a new product for 2016 called myBlue which offers two free primary-care doctor visits and then charges $1 a visit thereafter, $3 visits for specialists, free routine lab tests and free diabetic supplies. The myBlue plan was created to help people whose incomes qualify for the highest cost-sharing subsidies under the Affordable Care Act.

To offer such benefits, Florida Blue developed a smaller network of doctors, hospitals and pharmacies so it could better control costs. But to encourage enrollment in Miami-Dade County it recently partnered with three CliniSanitas medical clinics, which primarily serve the Hispanic audience in the area. The plan is also available across South Florida, and counties around Tampa and Orlando.

Jon Urbanek, a senior vice president for Florida Blue, said the new plan is intended to increase the insurer’s market share. He said participating providers in the myBlue products are not necessarily paid less than other doctors but their pay is more closely tied to reaching certain quality targets such as cancer and cholesterol screenings. In 6 of 10 counties where it’s available, the myBlue product offers the lowest premium. “We think our pricing positions us to do very well,” Urbanek said.

Molina Healthcare is offering zero co-pays for unlimited primary-care doctor visits for one of its silver-tier plans for 2016. Unlike Florida Blue, it says it offers free doctor visits in its plans without using a narrow network of doctors and hospitals. “We really want folks to get value from their premium dollar and not have any barriers for care,” said Lisa Rubino, senior vice president at Molina.

Molina offers the zero co-pay physician plans in Florida, Michigan, New Mexico, Ohio, Texas, Utah and Wisconsin.

This story was produced through collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health care policy research organization. Neither the foundation nor the news service is affiliated with Kaiser Permanente.


News about UnitedHealthcare and ACA called overwrought

 

Famed healthcare economist Henry Aaron says that  news stories about UnitedHealthcare’s Affordable Care Act insurance-exchange woes are overwrought and do not presage an ACA collapse. He notes UnitedHealth’s special problems:

  • Because UnitedHealth’s main business is employer-sponsored coverage, not individual plans,  it has less expertise in the latter market and so doesn’t offer the lowest-premium plans.
  • UnitedHealth has just a small amount of market share compared to Blue Cross/Blue Shield companies.
  • When UnitedHealth entered the ACA individual market in 2015, a year later than other insurers, it probably had particularly big start-up costs, enrolled fewer and sicker customers and thus had a particularly high attrition rate.

Testing bundled payments for chemo to stem costs

 

By JULIE APPLEBY

For Kaiser Health News

UnitedHealthcare said Thursday it will expand its high-profile test of whether bundled payments for chemotherapy can help slow rising cancer-treatment costs, part of a growing effort by insurers to find new ways to pay for care.

Results from United’s initial pilot test – reported last year – were puzzling: The overall cost of cancer care for patients in the study dropped by 34 percent, even as spending on chemotherapy drugs spiked significantly.

To try to find out why, UnitedHealthcare said about 500  more oncologists in Texas, Colorado, Florida and Oklahoma will join the study, bringing the total to about 650 physicians in seven states. Among other things, the pilot caps the profit the oncology practices can make on the chemotherapy drugs they prescribe, while adding a payment meant to cover physician care in the hospital, hospice management and to provide case management services to patients.

It’s a variation on so-called “bundled payments” that are becoming more common in health care, particularly for such things as joint-replacement surgeries. The idea is to bill and pay based on the overall treatment of a certain condition, rather than for each separate procedure and doctor visit. Because cancer treatment is so expensive, it is also now being targeted for bundled payments, but the complexity of treatment makes it harder to design bundles.

Meanwhile, United isn’t the only private insurer testing ways to try to slow spending on cancer care, while also improving care.

Still, results from three other efforts showed decidedly smaller savings compared with United’s stunning 34 percent drop, said Lindsay Conway, a managing director at the Advisory Board Company, a consulting firm.

Baptist Health South Florida, for example, reported savings of approximately two percent after the first year of its special oncology “accountable care organization,” while a partnership between oncology practices and insurer Priority Health in Michigan saw first-year savings of $550 per chemotherapy patient, Conway said.

“The big question is whether United’s results are replicable,” said Conway. “They’re working on that right now.”

While general efforts to control costs vary from creating so-called medical homes, where care is coordinated, to sharing savings with doctor groups that become more efficient, the ones drawing the most attention now are the bundled payments, said Kathryn Fitch, principal and health care consultant at Milliman. Medicare joined the effort to test bundles for cancer care this year with a pilot set to begin in the spring.

Among other things, the complex program will pay doctors an additional $160 a month per patient to provide extra support for chemotherapy patients, such as around-the-clock patient access to medical staff. Participating practices will have to meet specific requirements, including using electronic medical records, and they will  get financial incentives if they reduce their overall cost below benchmarks and meet quality targets.

“This is just going to get bigger – and Medicare is driving that,” said Fitch. “All insurers are adopting the same mantra. Even the pharmaceutical companies are doing more dealswith providers and payers.”

How United Tested Its Theory

In the UnitedHealth pilot project’s first phase, five oncology practices had their profits from chemotherapy drugs essentially frozen, said Lee Newcomer, United’s senior vice president for oncology, genetics and women’s health.

Rather than being held to any specific treatment regimen, each practice drew up its own and could add new medicines at any time. United reimbursed them the average sales price of the drugs given, plus a small amount meant to cover physician care in the hospital, hospice management and to provide case management services to patients.

That differs from how the insurer pays oncologists outside the study, where they are reimbursed the amount paid for the drug, plus about 22 percent to cover office costs. By comparison, Medicare reimburses oncologists for drugs administered in their offices average sales price plus 6 percent. Policy experts say such payment methods encourage the use of more costly drugs, even when just-as-effective – but less expensive and less profitable – drugs are available.

At the end of the three-year study, even though spending on chemotherapy drugs rose substantially, the cost of caring for the patients was $33.4 million less than costs for a control group of similar patients who were not part of the study. All patients had either breast, colon or lung cancer. United redistributed one-third of the savings with the physician practices by increasing their patient payments for a second round of the pilot, which is still ongoing.

What, exactly, led to the cost savings isn’t clear. But Newcomer said a reduced number of hospitalizations and use of radiation services clearly contributed, adding that the next round of its pilot program may offer more complete answers.

Still, the initial study wasn’t large enough to find statistical differences in quality measures, so whether patients in the study fared better or worse than those outside isn’t known.

“It’s not surprising the [payment pilot] reduced hospitalization if it provided an economic incentive for doctors to do so,” said professor Jerry Avorn at Harvard Medical School. “But you have to ask, was the control group using too much hospital care or was the innovative system using too little?  In the absence of outcome data, how would we know? It’s particularly important to define and measure outcomes carefully, especially in cancer patients.”

Also Thursday, United said it has launched a computer program  that all its cancer doctors can use – whether part of this pilot program or not — to determine if the treatments they’re prescribing fall within recommendations crafted by the National Comprehensive Cancer Network (NCCN), a nonprofit alliance of 26 cancer centers.

In the short run, the insurer says, the program will reduce the percentage of after-the-fact claim denials, which are frustrating and sometimes costly for patients. Over time, the program will also gather data about tens of thousands of patients, the drugs they take and how well they fare, so the system will provide head-to-head comparisons of chemotherapy treatments.

“Physicians will have a real world look at what is working and what may not be working as well,” said Newcomer. The insurer plans to make the aggregated results publicly available in about two years.


Optum adds new Mayo Centers of Excellence

 

 

mayoplummer

 

The Plummer Building on the Mayo Clinic’s main campus, in Rochester, Minn.

The Optum unit of UnitedHealthcare  has designated several specialties and service lines at Rochester, Minn.-based Mayo Clinic as Centers of Excellence, a bundled program for UnitedHealthcare customers and employers.

Becker’s Hospital Review reported that “Mayo has participated in Optum’s COE program for transplants for 11 years. Under the new agreement, the health system’s locations in Arizona, Florida and Minnesota will participate as COEs for cancer, bariatric surgery and heart failure.”

“Mayo’s providers in Rochester will also participate as a COE for congenital heart disease and infertility services.”

“When members and employers participate in the COE program, they pay negotiated, bundled rates for most services. Overall reimbursement is often capped at $10,000, according to the Minneapolis Star Tribune. Optum vets providers to choose high-quality hospitals and care teams that ultimately contribute to fewer unnecessary procedures and post-surgical complications.”

“Optum says its COEs yield tangible results. For example, the average length of stay for the transplant COE and clinical-management program was 21 percent lower than the national benchmark in 2013.”


The eyes have it: The growing role of optometrists

optom

In another sign of the increasing role of non-physician clinicians, Modern Healthcare reports, “o}ptometrists are working more closely with physicians and insurers to identify patients’ chronic conditions and make sure those patients receive appropriate medical care. They want to demonstrate that they have the training and skills to do more than just fit people for glasses and contact lenses.”
An example: “The Charlotte, N.C.-based Carolinas HealthCare System is working with Vision Source, a Kingwood, Texas-based network of 3,800 independent optometrists, to boost its performance in serving diabetes patients and raise its diabetes-care quality score.”
“Three white papers done at UnitedHealthcare found that eye-care professionals were effective in identifying patients with diabetes, high cholesterol, hypertension, juvenile rheumatoid arthritis and multiple sclerosis. ”

Big insurer to include phone and video consults in network

mobilephone

As insurers strive  to keep operating profits high, some are making it easier for patients to consult physicians by smartphone. This would presumably keep more patients out of the hospital.Consider UnitedHealthCare,  the huge Minneapolis-based company, which plans to include phone or video consults in its coverage network. Boston-based American Well, a telemedicine service,  is one of three providers approved for UHC’s system, reports The Boston Globe.The Globe reports that “UHC will also support visits through Doctor on Demand, based in San Francisco, and NowClinic, a mobile service offered by Minnesota-based Optum. At launch, UHC will only accept claims from people who pay for their own insurance, but the insurer says it intends to include health plans funded by employers next year.”

Thus the push to keep outpatients from becoming inpatients continues.

 

 


Getting big insurers to help the sick needy

By JAY HANCOCK, for Kaiser Health News

 

HARTSVILLE, Tenn. — Lynda Douglas thought she had a deal with Tennessee. She would adopt and love a tiny, unwanted, profoundly disabled girl named Charla. The private insurance companies that run Tennessee’s Medicaid program would cover Charla’s healthcare.

Douglas doesn’t think the state and its contractors have held up their end. In recent years she says she has fought battle after battle to secure essential care to control Charla’s seizures, protect her from choking and tube-feed and medicate her multiple times a day.

“If you have special-needs children you would not want to be taking care of these children and be harassed like this,” Lynda Douglas said. “This is not right. No way, shape or form is this right.”

State Medicaid programs across the country, which operate with large federal contributions, have outsourced most of their care management in recent years to insurance companies like the ones in Tennessee. The companies cover poor and disabled Medicaid members in return for a fixed payment from taxpayers.

That helps government budgets but sets up a fundamental conflict of interest: the less care these companies deliver, the more money they make. Nationwide, such firms made operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

In an attempt to manage that tension, Washington regulators are about to initiate theb iggest overhaul of Medicaid managed-care rules in a decade. Prompted by growth of Medicaid outsourcing, concerns about access to care and stories like Charla Douglas’, the regulations are expected to limit profits and set stricter requirements for care quality and the size of doctor networks.

“We want the enrollees to have timely access to integrated, high-quality care,” James Golden, who oversees Medicaid managed care for the U.S. Department of Health and Human Services, told a group of insurance executives in February. “There’s been some question about some of these issues.”

Tennessee Medicaid plans — operated by BlueCross BlueShield of Tennessee, UnitedHealthcare and Anthem — are among the most profitable Medicaid insurers in the country, according to data from Milliman, a consulting firm. The state, which runs one of the most respected Medicaid managed-care programs in the country, adopted that design in the 1990s and named it TennCare.

State officials point to quality data and survey results as evidence that the companies are doing a good job while allowing the state to spend far less on Medicaid than predicted. More than 90 percent of TennCare customers surveyed last year said they were very satisfied or somewhat satisfied, officials note.

“Our patient satisfaction scores are at the highest over the last five years they’ve been in 20 years of the program,” said TennCare director Darin Gordon, who worries new HHS rules could hinder states from improving Medicaid quality while controlling costs. “Don’t hamstring us from doing other innovative activities that are going to be able to help try to improve the health and wellbeing of our population.”

But doctors and patient advocates say state savings and insurer profits come at the price of inadequate physician networks, long waits for care and denial of treatments like the ones for Charla Douglas. Answering another question in the survey, 30 percent of adults said the quality of their TennCare care last year was only fair or poor.

“BlueCross is more organized and more strategic in its denials, and the other plans might be more careless, but the way it plays out for folks on the ground level is the same,” said Michele Johnson, executive director of the Tennessee Justice Center, a nonprofit law firm that helps TennCare members navigate the system. “What we find is that all three plans will deny care.”

Medicaid’s expansion in most states under the Affordable Care Act has obscured another big but more gradual change: More than half of Medicaid beneficiaries now receive coverage from private insurers, known as managed care companies, with incentives to limit care. The surge helped prompt inquiries by HHS’s inspector general last year that found widely varying state standards for access to doctors and poor information for members on where to find them.

In one nationwide study, half the doctors listed in official directories weren’t taking Medicaid patients. Among doctors who were, a quarter couldn’t see patients for a month.

In Tennessee views diverge sharply on whether the proposed federal rules, expected soon, are necessary. Many say the system is far from adequate.

Dena Deweese, who runs a primary-care practice in Knoxville, has problems finding specialists for her patients who are covered through Amerigroup, a TennCare contractor and Anthem affiliate that recently began operating in the area.

“I kept running into no, no, no,” she said. “I’ve still got lots of folks that are simply not taking it.”

Amerigroup says it only recently started covering TennCare members in the area and is still expanding its network. Since January “we have added more than 3,600 specialty physicians,” said company spokeswoman Cindy Wakefield.

TennCare’s member-per-doctor standard for primary care is among the worst in states that have such rules — one provider per 2,500 members. Even for urgent care, TennCare rules allow waiting times of up to two days for an appointment.

The state allows one neurologist per 35,000 TennCare members, although most states have no network standards at all for such specialists.

Even when children are having seizures, Crossville pediatrician Dr. Suzanne Berman often can’t get a TennCare neurology referral for weeks.

“I have a kid who urgently needs to see a specialist,” she said. “We call and we beg. ‘We can see you in three months,’ the neurologist’s nurse will say. ‘OK we can see you in two weeks.’ No, we can’t wait that long.”

Often she must send the child to a hospital emergency room to get the proper care — it’s “the only way I have found to jump the queue,” she said.

Dr. Douglas Springer, a gastroenterologist and, until recently, president of the Tennessee Medical Association, recognizes states’ need to control Medicaid expense.

“The cost in that population keeps going up and up and up,” he said.

But he favors new rules to ensure adequate doctor networks and limit insurer profits.

“If they can make it hard on [a patient], and make it so the networks are poorly funded or poorly populated, then nobody can go see anybody,” he said. “They don’t have to spend any money.”

Evelyn Manley said she had to fight to get TennCare’s insurers to cover even a portion of the behavioral therapy that doctors recommend for Christian, her five-year-old son with diagnoses of autism and Down syndrome.

“I’m grateful” for TennCare, she said. “But it could definitely improve.”

Lynda Douglas, 69, knew she wanted to adopt Charla a decade ago as soon as she took her for foster care from the state. Charla’s problems include cerebral palsy, a badly curved spine, frequent seizures and osteoporosis. She cannot speak and takes most food by tube. She is 16, weighs less than 80 pounds and loves Barney the dinosaur.

Douglas, who lives about an hour east of Nashville, says she has often struggled to get adequate treatment for Charla. But she was grateful that TennCare’s contractors sent daytime nurses to monitor her seizures, keep her from choking, activate an implanted device to control seizures, administer medicine and maintain a tube that delivers medicine or nourishment eight times a day.

Then more than a year ago UnitedHealthcare reduced the nursing to one hour a day even though Charla’s condition hadn’t improved. Douglas protested with the help of the Tennessee Justice Center and a pro-bono lawyer and won, but TennCare appealed. It took two more rounds of adjudication before a judge ruled in Douglas’ favor late last year.

The managed-care companies “are making a mint down here,” Douglas said. “They’re getting rich at the expense of the kids. This is not right.”

UnitedHealthcare made operating profit of $236 million last year on revenue of $2.8 billion in its Tennessee Medicaid business, according to state filings. Anthem’s operating profit for TennCare came to $53 million on revenue of $946 million. BlueCross’s operating profit for TennCare was $121 million on revenue of $1.8 billion. Those results do not include expenses for taxes, depreciation and other items not directly related to health coverage.

“Our care teams worked with the family and with [Charla Douglas’] physicians and other providers to assure that her services were appropriate for her special healthcare needs,” UnitedHealthcare said in a prepared statement. The managed-care plan followed TennCare’s contract and care guidelines, it said. 

This year Charla switched to the BlueCross TennCare plan to better coordinate her care with two other disabled children in the Douglas household, one foster and one adopted. In March the plan denied coverage of the seizure-control pump that Charla’s doctors prescribed, saying it was medically unnecessary.

BlueCross now says it will pay for the procedure. A spokeswoman blamed the initial denial on a “physician’s failure to provide the needed medical information.”

Like TennCare officials, the managed-care industry is urging HHS not to publish overly rigid regulations that bog plans down in paperwork and hinder them from making investments to keep members healthy.

“You’re dealing with a huge variation in population” covered by Medicaid from state to state, said Jeff Myers, CEO of Medicaid Health Plans of America, an industry lobby. “Each state has an insurance commissioner. Presumably they’re very good about making decisions about insurance regulation” to suit local conditions, he said.

Myers and other officials expect HHS to issue rules for “medical loss ratios” that limit profits and force plans to spend a minimum portion of revenue on medical care. Such restrictions already apply to other insurance under the health law.

Imposing blanket profit standards on diverse Medicaid programs “would be terrible policy,” he said.

TennCare director Gordon, who frequently advises other states on Medicaid, rejects suggestions that managed-care networks are inadequate or that contractors deny needed care. Third-party surveys show that 90 percent of Tennessee doctors take TennCare and most of them take new TennCare patients, he said, although consumer advocates dispute this.

TennCare members sometimes have trouble seeing specialist doctors, but so do patients in commercial plans, he said. Like many state Medicaid directors, he wonders how HHS can publish network rules for 50 states with widely varying geographies and health systems.

“We actually have a pretty solid network,” he said, with systems to closely track how contracted insurers are performing. The HHS investigation into Medicaid doctor networks “looked at it very narrowly” and “gives you a less complete picture of what’s going on in the states,” he said.

Written the wrong way, Gordon said, HHS limits on managed-care profits could discourage spending on coordinators who improve care quality at decreased cost.

“Yeah, we’re a little concerned,” about the proposed rules to be published by the Centers for Medicare & Medicaid Services, or CMS, he added. “There are some things that we think may have adverse effects.”

Other Tennesseans tend to oppose Washington decrees no matter what they say.

“We need to keep CMS out of our business. They have done nothing but screw everybody up,” said Dr. Iris Snider, an Athens pediatrician who praises the job Gordon and other officials have done with TennCare. “It really worries me … when we finally get a system that’s working reasonably well for my patients.”


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