Hospitals as insurers: potential, and pitfalls

Sarah Kliff / The Washington Post /

Published Jul 11, 2013 at 05:00AM

In 2012, MedStar Health, like many large employers, struggled to keep up with rapidly rising health care costs. For three years, the company held down premiums for its 19,000 employees by absorbing the increases itself.

Most employers would have had no choice but to raise premiums — in this case, by about $550 for a family — and cope with frustrated employees. MedStar, one of the Washington, D.C., area’s largest health systems, saw another option.

It would launch its own health insurance plan, offering it first to its employees. Patients would be limited to MedStar-affiliated providers, and as a result pay lower premiums. In time, MedStar could compete with the Aetnas and Blue Crosses of the world, offering insurance to the public.

All of a sudden, the health system did not just send out insurance claims — it also received them. This was, for the health industry, revolutionary.

“By putting in the new health plan, we had the ability to give them an option that actually allowed savings,” said Eric Wagner, a MedStar vice president. “People who enrolled in MedStar Select got a lower premium than they had the year before.”

Insurance plans and hospitals are typically at loggerheads. They squabble over claims that the hospitals submit and insurers sometimes deny.

“They make their money by not paying for health care to be delivered,” Wagner said of health insurers. “We make our money by delivering care. There’s always been a natural tension.”

For years, hospitals have accepted that tension as a cost of doing business. Insurers have decades of experience in the complex work of setting premiums, which requires anticipating how much care patients will need in the coming year.

Now, a growing number of large hospital systems are betting that, with a little help, they can do that just as well — or even better.

“These organizations believe that they’re really good, can capitalize on their brand and get people to enroll in it,” said Paul Ginsburg, president of the Center for Studying Health System Change. “They see a different way to capture these gains.”

Seeing health insurance companies as the middlemen, these hospitals are only too eager to squeeze them out.

To do so, hospitals are turning to a small startup in Northern Virginia named Evolent Health. It promises to teach them everything they need to know about building a health insurance plan from the ground up.

Leading the way

Twenty minutes outside Washington and across the Potomac River, the Arlington County offices of Evolent Health could be a movie set for a Silicon Valley startup — the kind that starts with millions in venture capital funding, not in a founder’s grungy garage.

An immaculate micro-kitchen, stocked with sodas and fruit, opens to a lounge with a plush white couch and big-screen TV. Two treadmill desks nearby are decked out with laptop workstations.

On a Wednesday morning, though, no employees were using any of these amenities. They were working, many with headphones on, at long rows of gleaming metal desks. Evolent has no offices, not even for its top executives. Glass conference-room walls are covered in scribbles from red, blue and green markers.

“We wanted a sort of Steve Jobs feel,” Evolent co-founder and president Seth Blackley said, explaining the open landscape.

With Frank Williams and Tom Peterson, Blackley launched the company two years ago while they worked at the Advisory Board, a hospital consulting firm. As legislators on Capitol Hill were debating health reform, Blackley was flying around the country, hearing from hospitals what they thought the future of medical care would look like.

“I had spent a lot of time talking to health systems and provider groups that were looking at their role in the future, given the cost pressures of the health-reform law,” he said.

That’s where the idea of helping hospitals launch their own health plans started. If hospitals could collect premiums directly from patients, the thinking went, they would have more freedom.

“The biggest advantage for hospitals is that they can take all the premium dollars and invest them in the most logical ways, instead of getting paid for each claim by an insurer,” Blackley said. “If they do this well, they’re going to stay viable and have a chance to deliver higher quality.”

Launching a health insurance company, however, is no small task. It requires physical infrastructure, including an army of call-center agents to handle claims and replace lost insurance cards. It also demands the ability to predict the future: One of insurers’ most crucial tasks is setting a monthly premium that will cover subscribers’ costs.

If a health insurance plan sets its premiums too high, the price tag may scare away consumers. If it sets the price too low, it could come up short, with revenue not covering the medical bills.

At the time, Blackley didn’t know much about running a health insurance company. But he did know that a growing number of hospitals wanted to get into the market.

Affordable options

With health insurance premiums growing by 8 to 10 percent annually, employers have begun to look for less expensive options. Restricting patients’ choice to a small number of providers affiliated with one health system is one way to bring down costs.

President Barack Obama’s health care law has also pushed large systems in this direction. In 2011, it began funding “accountable care organizations,” in which a big network of doctors accept a flat fee to care for Medicare patients.

If doctors do a good job of managing care, the hospital and the health insurer — in this case, Medicare — share the amount left over as profit. More than 400 hospitals have signed on as accountable care organizations, or ACOs.

Hospitals such as MedStar are pushing the model even further; some health care consultants describe these hospitals as “ACOs on steroids.” Instead of sharing the profits with insurers, they think they can run the plan themselves and keep all the profits.

“Some hospitals are saying they don’t see much upside in the ACO model,” Ginsburg said. “Instead, they’re saying, let’s create our own plan where we have a much greater upside if we do a good job. That’s the big change, this big opportunity for plans to be built around a health system, that did not exist before.”

In 2014, the health law will create another big incentive for hospitals to get into the insurance business: Millions of Americans will begin buying health insurance coverage using federal tax credits.

Twenty-eight percent of hospitals expect to launch their own health insurance plan within the next five years, according to a survey conducted last month by the Advisory Board, a co-owner of Evolent. Currently, 18 percent of hospitals own such insurance companies.

“Particularly for hospitals where the systems have a prominent name and prominent physicians working for them, this will be attractive to them,” Ginsburg said.

Holding down costs

Three years ago, Blackley was crisscrossing the country, looking at the handful of hospitals that ran health plans successfully.

“We went around and studied a number of the health delivery models that exist, from Kaiser Permanente in California to University of Pittsburgh Medical Center,” he recalls. “These folks have taken on full risk, meaning they have big upside and downside for making this work.”

University of Pittsburgh Medical Center’s plan stood out. Launched in the early 1990s, UPMC Health Plan is the nation’s second-largest hospital-owned health plan.

Perhaps most impressive, though, is its ability to hold down medical costs. Among UPMC’s employees, most of whom use the hospital-run health plan, the cost of medical services has increased annually by about 2 percent. The rest of the country, meanwhile, typically sees increases of 5.5 to 7 percent each year.

“This might sound mundane, but a lot of what this comes down to is building the right technology,” says Diane Holder, president and chief executive of UPMC Health Plan. “The health care system is so fragmented. Most of the time, doctors don’t know where their patients have been. We’re in the hospitals, and we’re able to follow patients.”

Over two decades, UPMC went from a tiny startup to the dominant health plan in western Pennsylvania. It, in many ways, proves that a hospital can successfully launch its own insurance product.

UPMC Health Plan and Advisory Board co-founded Evolent in 2011, investing $20 million in the venture. UPMC Health Plan had proprietary software that it could license to other hospital-run plans, alongside the infrastructure to run a health plan.

Advisory Board, meanwhile, worked with a network of potential customers. Over the past two years, Evolent has signed up 14 hospitals across the country as clients.

MedStar Health was one of the first clients and came on board after executives took a trip to Pittsburgh to get a better sense of UPMC’s plan.

“We spent the whole day with the group there,” Wagner recalled. “We left very excited.”

Two hospital systems in Atlanta, Piedmont and WellStar, were also among the company’s first clients. Since they cover different parts of the city, the two are partnering to launch a insurance product together in 2014.

At first, they tried to engage local health insurance plans.

“We evaluated partnerships with national health insurers in our local markets to see if we couldn’t work closer together,” WellStar chief financial officer Jim Budzinski said. “In our conversations, almost all payers were not interested in having those kinds of relationships.”

Together, Piedmont and WellStar could blanket most of the Atlanta region. They brought on Evolent to help them handle the back end of running a health insurance plan.

“You can have the right strategy, but you also need the right tools,” Budzinski said. “That’s where Evolent comes into play. We had a choice to create our own infrastructure, hire staff and build out the system. That would take a longer period of time and you’d have more risk.”

The new health plan will launch by year’s end. Unlike MedStar’s, it will immediately become available to the public and may soon be offered on the Affordable Care Act’s health insurance exchanges.

Success rate

Not everyone is confident that these hospitals will succeed. Insurance plans are especially skeptical that hospitals have the know-how to compete against plans that have been in this business for decades.

“I always take pause when people talking about doing something better that they’ve never done before,” said Karen Ignagni, president of America’s Health Insurance Plans. “Maybe that’s just the mother in me.”

Ignagni’s trade association includes hospital-owned health plans that successfully transitioned into a new business segment. But she’s also familiar with the hospitals that have failed because they did not set their premiums quite right or have a big enough network of doctors to meet patients’ needs.

“There is a very significant regulatory structure, and they have to meet all those requirements,” Ignagni said. “They need to make sure that they are able to offer an array of services and have an adequate network. How do you approach that in a provider-based system?”

At a recent American Hospital Association conference in Washington, Kylanne Green echoed a similar sentiment. As the chief executive of managed-care services at Inova Health Systems in Northern Virginia, she had also explored the possibility of launching an insurance product.

In the end, Inova settled on partnering with an existing health insurance provider, Aetna, to build a hospital-branded health plan.

“We were not an insurance company,” Green told hundreds of hospital executives attending her panel on hospital and health insurer partnerships. “We needed to get closer to being an insurance company, but we didn’t need to reinvent that wheel ourselves.”

Hospitals have especially worried about how patients will react to a more limited network. Many hospital-run health plans folded in the mid-1990s, when patients revolted against the bureaucracy and the special authorizations necessary to see a specialist or go outside the network.

At MedStar, Wagner acknowledged those pressures but contended that his hospital system would penalize patients only when they sought care that wasn’t necessary or could have been provided within the MedStar network.

“You can’t ignore them,” he said. “If you don’t need to go to the emergency room, but you go, and they send us a bill, we’re going to deny that bill. Every payer will, and we can’t be different from other payers. It’s not good for your health to get your care through the emergency room. That’s part of the signal we need to send people.”

Overall, Wagner describes MedStar’s experience working with Evolent and launching a health plan as positive. While it has only a small fraction of MedStar’s employees enrolled now, they’re expecting higher takeup in the open-enrollment period this year. The plan may soon sell to the public or enter the new insurance marketplace under the Affordable Care Act.

“We’re not going to do it in January 2014 since the waters seem way too unsettled,” Wagner said. “We’re continuing to look at that. We’ve had some good discussions with Maryland and D.C.”

Evolent, meanwhile, is quickly expanding. It expects to grow from 150 employees to 450 by year’s end. One challenge Blackley expects to tackle is how hospitals can communicate to their employees, and the public, as an insurer.

“When everyone is buying Blue Cross, they know what that is,” he said. “This is a new concept and that tends to require a huge communications effort.”

Before it can take over the health insurance market, however, Evolent needs to address a more immediate concern: Taking over another floor of its building, to make room for hundreds of new employees.

comments powered by Disqus