There is an interesting insurance pilot project that is going on in Atlanta and Chicago:
UnitedHealth Group’s new Harken Health subsidiary is trying to grab that niche, in a modified way, with a clinic-based plan that offers unlimited primary care and behavioral visits at no charge.
The health plan, which offers services with no coinsurance charge and copays only for prescription drugs, will be available at four neighborhood office locations in Chicago and its suburbs and will open six centers in the Atlanta area….
members have access to UnitedHealth’s wide national network of hospitals and specialists, including Northwestern Memorial HealthCare, University of Chicago Medicine and Advocate Health Care in Chicago. That runs counter to the strong trend for plans to offer narrower hospital networks….
The clinics, which opened this month, are staffed by Harken-employed primary-care physicians, nurse practitioners, behavioral-care specialists and health coaches….
There is same-day scheduling for appointments and 24/7 telehealth access to staff providers. Exam rooms feature patient data screens allowing the member, doctor and health coach to go over all medical information with full transparency.
This is very interesting benefit design for what is otherwise a fairly straightforward Exchange plan. I am looking at the Silver Harken Health for Atlanta zip code 30301 on Healthsherpa.com right now and the rest of the schedule of benefits looks typical. There is a $3,000 deductible and a $6,000 out of pocket maximum where the out of pocket above deductible looks to be prescription drug co-pays. For a Silver, this is pretty typical. Pricing wise this is middle of the pack as the Atlanta price leader is a narrow network based on a Medicaid managed care organization that spammed the exchanges with insubstantially dissimilar designs.
The bet in Atlanta and Chicago is a bet on avoidance. Primary care and behavioral health care are dirt cheap compared to acute crisis care. The bet is that removing any cost barrier to care will see people use a lot more primary care and behavioral health care to catch problems earlier. Furthermore, if the hours of these clinics are pretty good (evening and weekends), these clinics should serve as emergency room and urgent care diversion locations. A PCP visit at an office is, from an insurer point of view, significantly cheaper than the same services at an urgent care center, and way cheaper than an ER visit.
The first level of the short term bet is a utilization management bet. The longer term bet of this plan design is that expensive chronic conditions can be managed approrpiately and effectively which transforms them into somewhat expensive chronic conditions and some proportion of future expensive conditions can be averted or at least delayed by better and/or more frequent primary care.
I am very curious about the results of this experiment as it is an insurer going into the care management business at the PCP end and not the hospital side. It is a narrow slice of being an integrated payer-provider system and a fairly unique (to my knowledge) twist on the model.
japa21
I have mixed feelings. I would have to do some research on this, but I seem to recall that patients who have some financial investment in care seem to do better than those that don’t. Trying to get work caught up on before going on a lengthy (and well deserved) vacation, so may not have time to do the checking on that now.
However, back in my days of being a behavioral health provider and finishing my masters, I interned with the Chicago health department in one of their MH clinics. When I first started, the services were free, but then switched to a $5 co-pay. The assumption was that patients would work harder on their self-care. I did check back a year later and they did have some evidence that outcomes improved and there was not a reduction of utilization due to the slight increase in cost.
scav
@japa21: So another experiment wouldn’t hurt, as results are not so universal and unequivocal as to be automatically present with appropriate citations?
Richard Mayhew
@japa21: It is worth the experiment …
japa21
@Richard Mayhew: Not disputing that. This is definitely a case of “it can’t hurt to try.” Just musing on my part.
RSA
@japa21:
I’d like to know what people were thinking, because that sounds pretty irrational to me.
scav
@RSA: Um, (ETA: look around you) rational doesn’t exactly seem a good assumed first baseline for human behavior, does it? Hence the need for experiments, and more than one, with relooks over time as, while the critters do seem to enthusiastically return to their own vomit, they also learn new tricks regardless of age. Tricky critters.
Kylroy
@RSA: I can see why a token payment (like $5) might make people more responsive; folks tend to be more acutely aware of getting their money’s worth when they actually make a payment.
Problem is, a more-than-token payment will discourage people from visiting, and the breakpoint that defines a significant payment will be different for every patient. I think whatever benefits accrue from a small copayment aren’t worth inevitably driving off some patients, and this experiment will test that.
Capri
I have been directed to and then experienced “life coaching” or whatever the term one uses to talk to a nurse about excercise and eating. And my take is that adding a $5.00 co-pay so that the patient literally “buys in” is not likely to affect results at all. Because even though the coaching was free for me, it wasn’t without a cost. I met with my coach during business hours – she didn’t come to my office or home nor did she take folks before 8:00 or after 5:00. So every time I saw her I had to leave my building and drive to the health center. It took about 2 hours total (commute time plus appointment) out of my day. It was the reason I stopped going – I didn’t have the time during my working day to do this week after week.
mtiffany
Removing barriers to the least expensive forms of care so that people can resolve health problems early rather than them waiting to seek care until it is an absolute necessity (and orders of magnitude more expensive)? Why, it’s almost as if these health insurance companies are selling a service that keeps people healthy! Revolutionary!
If there weren’t perverse incentives in our current ‘healthcare system’ would insurance companies have found it necessary to test the Olive Garden buffet strategy as a pilot program? “Why don’t we let them fill up on bread? Bread is dirt fucking cheap. Give them all the bread they want and when we finally let them get to the buffet, they’ll be to full eat too much of the expensive stuff.”
Jeffro
OT but here is a list of things GOP candidates are proposing the wake of a single attack (yes a big one, but a single one…and overseas…and not on US targets or citizens but those of a nation conservatives typically like to make fun of)
– America should stop accepting Syrian refugees fleeing ISIS (you know, our enemies?)
– or at least, the Muslim ones
– even if they are 5 year old orphans
– and oh by the way we ought to close mosques in this country, too
In. Sane.
They have found their issue, and it is not climate change, or jobs, or education, or gay rights: it’s just plain old fear.
Folks better push back hard on this…
RSA
@scav: Right, I should have been more specific, now that I think about it. I wonder which of the myriad forms of irrationality/cognitive biases that have been identified in human thinking account for this behavior? :-)
@Kylroy:
That seems plausible; it further suggests to people, “What I’m getting must be worth something if I have to pay for it.”
It still seems weird to me, though, that $5 would make a difference. They’re already “spending” the time to visit a healthcare provider; they already know that they’re exchanging their time for some expected benefit, reducing the possibility of an illness getting serious. And a nominal charge is enough to change people’s behavior.
beltane
@Capri: $5 for a weekly session, plus transportation costs, etc. will be equated to “hassle” in the minds of many people living from paycheck to paycheck, especially if the visits are scheduled right before payday.
beltane
@RSA: I guess the hundreds of dollars a month people are paying for insurance premiums doesn’t count as paying for a service? A few years ago I was prescribed weekly physical therapy for an extremely painful frozen shoulder. The $25 copay for a treatment that didn’t provide instant relief meant that I only went twice before deciding I’d rather deal with the pain and use the money to pay other bills.
beltane
@Jeffro: Well, the Democratic governor of NH, Maggie Hassan (surname sounds suspicious), has jumped on the Republican bandwagon of cowards. When it comes to pants pissing and lack of moral backbone, both sides do it.
richard mayhew
@beltane: @RSA:
Under a pure cost accounting measure, Beltane, you’re right. Under a behavioral economics money bucket framework, RSA is right. People mentally budget money in buckets, and they seldom shift buckets unless they are specifically forced to. There is a monthly premium bucket and a day to day expense bucket. 2 very different things.
Another Holocene Human
@Jeffro: That’s not fear, that’s hate.
Another Holocene Human
@beltane: My insurance company is trying the gambit of having a nurse nuisance call me for not following up on making needed preventative healthcare appointments. I don’t want her to nag me, so that’s a motivation.
I don’t think paying/not paying nuisance copay is affecting my decisions much. I use a credit card and sometimes an FSA card, which a lot of people get through their employers (it’s mostly for that deductible in January).
There are people with, er, personal problems who waste healthcare providers’ time and since care is rationed, everyone is trying to discourage them or otherwise make them go away. Nuisance payments are meant to dissuade them.
I think all this crap about “taking ownership of your health” and “having buy-in” is post-hoc rationalization.
Another Holocene Human
@RSA:
This phenom kicks in when you’ve been gulled into paying a LOT though*. It’s how luxury brands “work” for the consumer. It has nothing to do with the psychology of a fritter-your-cash-away nuisance payment.
*-that is, paying more than the normal, average amount … so again, if everyone else pays 20$ copays your 15$ copay or 30$ copay is nothing special
ps: another analogy, consider the person who drives a mile to get .04$ lower gasoline/gallon, vs person who pays .20$ extra per gallon for “high octane”–one is price shopping and the other perceives some sort of enhanced value that causes them to let go of that deathgrip on their dollars. Nothing about an insurance company tweak is going to set off that “but this dial goes to 11/but NuGlo has active particles in it” marketing bullshit magic that makes people happily pay more and psychologically double down.
piratedan
If rational were part of the equation then we wouldn’t have the good people of Kentucky voting to deprive themselves of a functional health care system.
At least someone is trying to look at the twofer, early treatment to equate to lower costs… seems like they took the Oregon State health system of prenatal care and are expanding it to this model to see if they can have the same cost reduction with beneficial outcomes….
RSA
@beltane:
Of course it does! I’m sorry to hear about your shoulder. I was expressing surprise that a nominal charge has an effect in the opposite direction I’d expected (i.e., according to japa21 it didn’t reduce utilization, but it did improve outcomes).
beltane
@RSA: After losing six years of my life to intense pain, the problems with my shoulder miraculously resolved when a seemingly unrelated thyroid issue was taken care of.@Another Holocene Human: I just brush off those calls. Now that we’re on the PPO plan there’s nothing less than an acute emergency that would induce me to deal with the health care system. I’m still paying of credit card debt from a series of previous encounters with “the beast”.
RSA
@beltane:
Wow. I can imagine it did feel like a miracle.
One my close friends is dealing with a complex set of symptoms that the doctors can’t figure out, and over the past couple of years he’s gotten kind of down on the GP-then-referral-to-specialists path he’s followed. Each of the specialists he sees has hypotheses about what’s causing his symptoms and a set of tests and remedies they try. What my friend seems to need is a super-generalist who can put together knowledge from lots of specializations to figure out his problem, but that person hasn’t come along yet.
WereBear
Because such a beast does not exist in the age of specialization.
At this point, he’s better off typing all his symptoms into a search engine and see if any syndromes surface. Lots of people with tricky conditions have found this does wonders for them… eventually.
It’s certainly cheaper.
I can say that I was able to find two possible things my own condition could be. One was genetic and was not me. The other was acquired and I got a treatment plan, free on the Internet, that considerably helped me.
The idiot who was a specialist did nothing but ramp up the bill. And the tests he ran were done wrong.
hylen
Terminology question (not too off-topic, I hope): “20% coinsurance” means the consumer pays 20% of the cost. Whereas “100% coinsurance” means he or she pays 0%. Is that correct?
Richard Mayhew
@hylen: 20% co-insurance, the individual pays 20% of the contracted rate until they hit the out of pocket maximum.
100% co-insurance is an odd construction. Typically that means the consumer pays everything, but for CMS guidelines, that means the insurer pays everything… a lot like bi-monthly progress reports (every 2 weeks or every 2 months, it is context dependent)
hylen
Thanks, Richard. Appreciate it.
100% co-insurance is an odd construction.
Agreed. If I did the link correctly, this is what had me wondering. It’s from the Covered California website (pretty handy but mighty slow).