In my 27 years in the health care industry, I've never seen more changes than I have in the last few years. In business communities such as San Diego that have a wide diversity of employers, both in terms of industry type and group size, providing quality, affordable health care remains a critical challenge. Finding the right health care solution amidst all of the changes in the market helps employers attract the right employees and improve productivity and profitability.
As health care continues to evolve in response to demand for more affordable access to care, one of the most significant shifts I've witnessed has been the way in which insurers and providers have begun working together. With these partnerships, keeping patients healthy creates a financial reward based on quality health care and fewer hospital admissions instead of the old model of payment per medical procedure.
New solutions to outdated models
In the past, providers and insurers negotiated rates cyclically, often with each party not completely satisfied in the outcome. HMO's and, more recently, narrow network options were a step in the direction of more efficiently managing costs and care. Meanwhile, providers received fee-for-service reimbursements that incentivized increasing the number of medical procedures performed as well as increasing hospital occupancy. All of this is changing now with new alliances and emerging health plans.
New programs use coordinated care partnerships between hospitals — even hospitals that compete — and insurance providers. How are these partnerships able to achieve such synergy where competition existed before? Surpluses are shared among partnering hospitals and insurance providers. And, if costs are higher than expected, the insurance company and the hospitals will share those costs too.
What you'll see in insurer-provider alliances
The goal of this type of alliance is to improve patient care, reducing redundancy and waste and keeping costs low. The ventures will aim to provide the following:
• A plan that provides a better quality of health care because it offers top hospitals and doctors working together , according to The New York Times.
• Patients will only have to pay a co-pay for prescriptions, doctors' visits and procedures rather than worrying about deductibles, coinsurance and other complicating factors.
• Fewer in-patient hospital admissions, greater coverage for nurse care for discharged patients, and increased help for people with chronic illnesses such as diabetes.
• Partner hospitals working together, leading to a common electronic health record system, common nurse hotlines and mobile access to doctor's visits.
• Top systems combining wellness programs, leading to less redundancy and more resources going toward improving patient health.
• Better quality health care at a lower price for employers.
One example of such provider innovations is the Enhanced Personal Health Care program, an Anthem Blue Cross initiative that is orienting primary care around prevention, chronic disease management, avoiding unscheduled hospitalizations and care coordination. This can help patients get healthy and stay healthy. Our Enhanced Personal Health Care providers are among the best in the industry and the list is growing. In the San Diego and greater south region, Anthem counts Heritage Provider Network, Sharp Community Medical Group and Sharp Rees-Stealy Medical Group among its participating providers in the Enhanced Personal Health Care initiative.
These new alliances mark the beginning of a shift in thinking for health care. Rather than competing, the best hospitals will work together to keep patients out of the ER and out of the hospital. If successful, red tape will decrease while community health improves. Health care costs will go down and at everyone wins.
-- Written by Paige Rothermel, vice president and general manager of the California Large Group at Anthem Blue Cross. Rothermel has held many leadership roles in her 27-plus years with the company. Rothermel and her leadership team support over 3,800 customers including underwriting, sales, account management and implementations.