Health Care Trends to Watch: How insurance carriers are evolving to prepare for ACA

January 11, 2012

At Extend Health we like to keep an eye on trends in the health care and insurance industries, and lately one big trend is erosion of the clear boundaries between providers and payers – specifically, insurance carriers who are positioning their businesses to cope with the cost-control challenge they face as MLR requirements of the Affordable Care Act (ACA) start to kick in.

The trend of hospitals expanding into regional super-providers, buying up physicians groups and ancillary service providers, has been going on for some years now. But recently there has been a spate of activity among carriers who are expanding into new areas, buying companies or forming partnerships to offer new services both to patients and providers. Carriers are also investing in ways to educate patients and increase compliance with preventive and wellness measures, improve patient care coordination among their provider networks, and help patients find the services they need. A few examples follow:

  • Aetna recently announced Whole Health, a new insurance plan available to employees of small businesses. Employees who are covered under the plan receive lower co-pays if they get their care through Arizona’s Banner Health Network, Aetna’s ACO partner on the plan. The Whole Health plan is built on the ACO model of care, using electronic medical records (EMR) technology to allow providers to share patient information and data so they can better coordinate care. Employees will also have access to technology in the form of on-line tools that will help them do a better job of managing their health.
  • UnitedHealthcare (UHC) purchased XLHealth Corp., a Baltimore-based provider of programs for managing Medicare beneficiaries with chronic conditions such as diabetes. XLHealth’s model includes a variety of interventions enabled by health information technology to address the needs of its Medicare membership. For example, XLHealth members may be provided with advance home monitoring tools used to gauge their health status on a daily basis.
  • UHC also recently opened a consumer storefront, dubbed a “comprehensive health benefits store” in Flushing, New York. The store is meant to serve as a prototype for future consumer-support centers around the country. The center gives UHC plan members access to customer service representatives who can explain benefits, resolve claims issues, and help with other insurance-related matters. Specially-trained staff will also be available to help both UHC plan members and nonmembers find and apply for state and federal financial aid for such things as prescription drugs, food stamps, and heat and electric subsidies. Visitors to the center will be able to use available computers and iPads to find and print health-related information, and a health-screening kiosk will measure blood pressure, pulse and body mass index. Finally, the center will host an ongoing series of free-to-the-public seminars on topics such as nutrition and exercise, disease management, and financial planning.
  • Taking another tack, Humana has acquired Anvita, a health care analytics firm – a move that will allow Humana to give actionable clinical data to health care organizations, which they can use to improve patient outcomes and reduce costs. Humana will offer Anvita’s suite of software to hospitals and physician practices within its network.
  • Humana also recently bought a company that employs care managers for seniors with chronic illnesses. SeniorBridge, a clinical care company based in New York, provides in-home care for chronically ill patients. According to SeniorBridge, its beneficiaries have fewer unnecessary hospitalizations, falls, and emergency department visits.
  • CareFirst BlueCross BlueShield in Ohio has teamed up with Cardinal Health on a clinical pathways program for Rheumatoid Arthritis (RA). The partnership engages nearly 70 rheumatology practices who will participate in a “treat-to-target” approach to RA care – testing different treatment options until a patient’s symptoms are in remission. The goal of the program is to find ways to standardize the way rheumatologists treat RA patients.

Many of these programs are targeted at Medicare beneficiaries for several reasons, not the least of which is the funding and support provided by the ACA-instituted Center for Medicare and Medicaid Innovation (CMI). Seniors are also a good target for finding care improvements and cost efficiencies – older people generally need more health care services, and are far more likely to suffer from one of the 15 chronic conditions that account for 44% of total U.S. health care expenses.

There are many other examples; these are just a representative few. Looming MLR target requirements, along with the economic downturn, are making it imperative that carriers push for efficiency. It’s encouraging to note that so many carriers are looking for ways to improve efficiency by also improving patient care, enlisting both providers and consumers in improving health and managing chronic conditions.

Visit Extend Health — the nation’s largest private Medicare exchange.

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