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You are here: Home / Anderson On Health Insurance / High but narrow hopes

High but narrow hopes

by David Anderson|  June 15, 20158:12 am| 21 Comments

This post is in: Anderson On Health Insurance

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Provider groups are being asked to take on far more population health risk management under the Accountable Care Organization (ACO) model as well as in a variety of commercial Shared Savings/Gainshare arrangements.  Providers get paid if they can keep their patients either healthy or treated at the lowest level of appropriate care.  This means diverting broken bones to urgent cares and orthopedist follow-ups instead of the ER, this means minimizing congestive heart failure complications, it means better diabetes management.  An increasingly common response by providers to this increased risk management functionality that they are expected to perform is to have the providers become insurers.  Usually, these providers that become integrated payer-provider networks are hospitals, and even more frequently, hospital chains.  The logic is that a chain of hospitals is big enough to really capture the vast majority of spending internally.  Medium size hospital chains without a major academic medical center anchor might be missing a transplant service, or it might be missing a burn unit, or its high end psychiatric care is insufficient but most dollars can stay within the chain with a few contracted sub-specialities for high cost, low usage services for the rest of the typical services needed.

There is something unusual going on in New York:

More than 100 doctors in New York’s Hudson Valley have launched a new health insurance company, one of the most striking examples of the tolerance for high risk that has flourished in healthcare as the industry looks to capitalize on upheaval under the health care reform law.

Middletown, New York-based Crystal Run Healthcare….The new insurer’s early bids for business have lowered employers’ health benefit expenses by 8% to 12%, said broker Bruce Weil, senior vice president of sales and marketing at Capacity Benefits

They are offering a super narrow network on both the hospital and doctor side of the equation.  This is very unusual as the doctors don’t control the hospitals so they don’t control the biggest cost driver. The hospitals won’t have an incentive to reduce their pricing or utilization patterns for the docs who they don’t employ nor profit share from.  At the same time, if they can offer rates that are 10% below the market norm, they should be in a good spot to claim either the lowest Silver or second lowest Silver, so they will get a good size Exchange bump in enrollment.

This is an interesting experiment that I don’t think will work as the hospitals don’t buy into the provider-payer model, but if they can do the low cost pricing accurately, I’ll be happily wrong.

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Reader Interactions

21Comments

  1. 1.

    Face

    June 15, 2015 at 9:23 am

    Somewhat OT….any indication that SCOTUS will announce their decision today? Or is it a fait accompli that it’s coming on June 29th Fuck You Last Day Bitches Suck It Eat Shit and Die?

  2. 2.

    Omnes Omnibus

    June 15, 2015 at 9:28 am

    @Face: I’ve talked to someone with some DC connections who has been hearing that it will come out today. My expectations were that this decision and the same sex marriage one would be the last two that the Court released. We’ll see, I guess.

  3. 3.

    MomSense

    June 15, 2015 at 9:44 am

    @Omnes Omnibus:

    I’m nervous.

  4. 4.

    dr. bloor

    June 15, 2015 at 9:46 am

    “Increased risk management functionality” is MBAese for what we in the real world call de facto “capitation.” I don’t know who’s crazier here–the docs who think this might be a good idea, or the customers who will sign up for an insurance plan loaded with docs who have one eye on the blood pressure cuff and the other eye on their accounting statements.

    Doomed. To. Failure.

  5. 5.

    Omnes Omnibus

    June 15, 2015 at 9:51 am

    @MomSense: I am reasonably confident because I can’t imagine that Kennedy and Roberts would both sign on to blowing up a major rule of statutory interpretation. But I may be naive.

  6. 6.

    WereBear

    June 15, 2015 at 9:51 am

    @dr. bloor: sign up for an insurance plan loaded with docs who have one eye on the blood pressure cuff and the other eye on their accounting statements

    My thoughts exactly. That is what crashed the reputations of so many HMOs. It gets rid of unnecessary procedures and tests, but also some necessary ones…

  7. 7.

    raven

    June 15, 2015 at 9:54 am

    @Omnes Omnibus: SCOTUS blog has neither I think.

    eta, somebody else look

    http://live.scotusblog.com/Event/Live_blog_of_orders_and_opinions__June_15_2015

  8. 8.

    MomSense

    June 15, 2015 at 9:59 am

    @Omnes Omnibus:

    That the case is such a stinker is what has me so spooked.

  9. 9.

    richard mayhew

    June 15, 2015 at 10:11 am

    @Face: Probably the 22nd or the 29th, whatever day the gay marriage case is not announced.

  10. 10.

    rikyrah

    June 15, 2015 at 10:12 am

    Glad to see you back and giving us information that most places look past.

  11. 11.

    Richard Mayhew

    June 15, 2015 at 10:24 am

    @rikyrah: Useful information #2: Don’t drive 38 hours in a week with two kids in the backseat — but that is something most people already knew.

  12. 12.

    Punchy

    June 15, 2015 at 10:26 am

    @Omnes Omnibus: I cant imagine these will come out anytime before the last day. Both decisions are going to wreak havoc (depending on your point of view), and I think they want these announced as they hit the door, not to be seen again for some time.

  13. 13.

    piratedan

    June 15, 2015 at 10:26 am

    Richard, I wonder if what the docs are doing is a first step to cut out the hospitals out of the equation. With the rapid expansion of urgent care clinics happening as we speak and their model of every ER clinic being treated as a de facto OP care clinic, it’s possible that they could handle a large chunk of business without getting into the logistical nightmare that a lot of the high end hospitals have become with all of their inherent problems. Sure, you farm out your serious patients to a hospital for long term recovery issues, but hell, PCP do that when they come across someone with a serious issue anyway.

    I know more than a few docs that are chafing under the directions of say… the Catholic Church or the corporate boondoggle that is/was the Columbia Health Care System (courtesy of the dark one, Governor of Florida because I refuse to name him specifically because I usually end up spitting afterwards).

  14. 14.

    Omnes Omnibus

    June 15, 2015 at 10:32 am

    @Punchy: they are the two “big” decisions of this term. I always expected that they would come out on the Monday and Thursday of the last week in June. It is the way the Court normally operates.

  15. 15.

    WereBear

    June 15, 2015 at 10:45 am

    @piratedan: That’s a great point… I just discussed that situation with someone who had a hormone problem and was referred to a specialist who is under Catholic doctrine.

    Which means she won’t get treated properly there.

  16. 16.

    Mary G

    June 15, 2015 at 10:57 am

    Glad to see you survived the expedition, Richard! I’m sure the grandparents appreciated it.

  17. 17.

    Richard Mayhew

    June 15, 2015 at 12:08 pm

    @Mary G: very much so

  18. 18.

    Stella B

    June 15, 2015 at 1:38 pm

    Something like Crystal Run Healthcare was tried in the 1980s in San Diego. It was called “Greater San Diego” something-or-other and it crashed and burned quite spectacularly, putting a fair number of medical groups out of business before being replaced by hospital based mega-groups.

  19. 19.

    jacel

    June 15, 2015 at 1:39 pm

    Richard, have you seen the Affordable Care Act article in the July Harper’s by Trudy Lieberman, “Wrong Prescription?”? I’m livid over the lengths she goes to for blaming Obama for any real or imagined shortfall in the overall healthcare system.

    I have to ask how many years Trudy was in a coma to be able to write (after describing the Republican roots of a lot of aspects of the ACA), “Perhaps Obama’s admission accounted for what at first seemed to be minimal opposition from mainstream Republications as debate over the A.C.A. unfolded in 2009 and early 2010”. I recall the Republican opposition being widespread, and pushing every button to delay passage of ANYTHING in the Senate without using every drop of the Democrats’ supermajority. And the “Tea Party” approach in opposition to “Obamacare” involved unprecedented rioting at representatives’ town hall meetings. And the big money TV ads demonizing the ACA at every step of development. How can a writer such as Lieberman describe those conditions as “minimal opposition” and not lose all credibility?

  20. 20.

    piratedan

    June 15, 2015 at 2:56 pm

    @jacel: because they’re busy rewriting the narrative. Because no one personally lit a bag of shit on fire on Trudy’s doorstep, none of that registered with her. After all, the rest of us lived through months of mispelled signs, insurance companies busing folks paid to protest from town hall to town hall meeting. Lets not forget crap like Giffords HQ in Tucson being shot at and the fact that people were taking out ads to explain why they voted the way that they voted amongst Dem congress critters who were being lobbied by hard money from the other side, being marked (Palin’s “surveyor’s symbols) for their votes in swing districts.

    Really, much ado about nothing when you consider that you actually had US Senators praying for the death of their colleagues so they could delay the votes and the dog and pony show in denying the seating of Senator Frankin.

  21. 21.

    Scott

    June 17, 2015 at 8:06 am

    Hey everyone,

    I cannot speak to how Crystal run provided healthcare is because I have Oxford. However I can tell you that the service at Cyrstal run is a great experience for the most part. I’m on Oxygen and I use quite a bit of healthcare. CR is where all my primary specialists are located. The wait times for appointments are not very long and the wait time after you arrive for most doctors and procedures is also short. I think the longest I ever had to wait was a little over an hour and that was once for the most/best cardiac doc. on staff. I did also wait once for nearly an hour for my pulmonologist but that’s because her car broke down on the way in. Other than that wait times are generally under ten minutes. They are expanding quite quickly and they have a very good reputation among users. They offer many locations and have a couple of urgent care centers as well. They use electronic records and some of their doctors still practice at multiple locations through the week. The thing I really like about them is they have a lot of choice for hours for things like cat scans, echo, blood work, and whatnot. They start at 7am and I’ve had appointments as late as 6:15pm.

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