Jane Anderson | March 2016 Volume 7 Issue 3
Large employers contracting directly with providers are finding that stellar employee experiences are driving better-than-expected uptake of accountable care organization-based health benefits and bundled payment-driven medical tourism for high-dollar procedures.
Employers trying this approach, which include The Boeing Company and Lowe’s Companies, Inc., are very focused on providing high-quality care. But benefit design and patient satisfaction are turning out to be key in the success of these initiatives, company executives told attendees Feb. 19 at the National Value-Based Payment and Pay for Performance Summit in San Francisco, sponsored by Global Health Care, LLC.
“The goal is to work with the providers to do the right thing at the right time for the right price,” said William Kramer, executive director for national health policy at Pacific Business Group on Health (PBGH), which is working with large employers on a value-based bundled payment initiative. “The early returns on this have been very good. We can drive innovations through direct contracting and high standards for care delivery.”
PBGH’s National Employers Centers of Excellence Network includes six medical centers nationwide that offer world-class joint, spine and bariatric surgeries. Employers joining the PBGH Health Negotiating Alliance can send their workers to those centers for surgery.
Lowe’s, Walmart Stores Inc. and other large employers joined the alliance in order to improve quality and save money, Kramer said. The project took lessons from both accountable care organizations and patient-centered medical homes, but settled on a prospective episode-based bundled payment approach, he added.
Value-Based Plans Draw Members
The program is voluntary. Employees who choose to have their procedures done at a center of excellence receive consultations and care covered at 100% without deductibles or copayments. They also receive travel, lodging and living expenses for the patient and a caregiver. “The benefit design encourages the patient to choose the center of excellence,” Kramer said.
Payments to the medical centers are based on diagnosis-related groups and include all procedure-related care from onsite pre-op through the “clear to travel” visit, which usually takes between seven to 10 days in the medical center’s city. Labs and diagnostics; physician, anesthesia and hospital fees; durable medical equipment; and outpatient or home health physical therapy all are included, Kramer said.
For the first year of the program, “there’s been great take-up,” he reported. “This has been a very popular program. Quality has exceeded our very high expectations, and financially, this has been a real win.”
The financial benefits haven’t come so much from savings on the procedures themselves, Kramer said. Instead, they’ve come from avoided surgeries. “A significant percentage of patients referred to the centers of excellence — when you put their cases through the appropriate criteria, they’re told, ‘you don’t need this surgery.’”
The employers who are offering the centers of excellence option for certain surgeries have made it an add-on to their insurance options and medical networks, as opposed to requiring the use of it, Kramer said. This has helped with employee satisfaction, since no one is forced into medical tourism for their surgeries.
Enrollees Praise Service
However, the employees who have tried it absolutely love it — and they come back and tell their co-workers how wonderful it was, he said. “People have come back and said, ‘This was great,’” he said. “That has really helped on take-up. Employees have come back and told co-workers, ‘I love Lowe’s. They flew me and my family to Baltimore, and I went to Johns Hopkins.’ It’s absolutely an intangible employee benefit.”
Johns Hopkins Bayview Medical Center does joint replacement surgery for the program. The Employers Centers of Excellence network also includes Virginia Mason Medical Center in Seattle (joint and spine surgery); Mercy Hospital in Springfield, Mo. (joint and spine surgery); Kaiser Permanente Irvine Medical Center (joint surgery); Geisinger Medical Center in Danville, Pa. (spine surgery); and St. Vincent’s Medical Center in Cleveland (bariatric surgery).
“If we’ve put together a package that’s not just built around quality but includes the patient experience, it could be a real winner,” Kramer added.
Boeing also emphasizes member experience, said Theresa Helle, Boeing’s manager for health care quality and efficiency initiatives. “We want member experience to be different,” she said. “Not just quality — we want the experience to be noticeably different.”
The Boeing Company’s Preferred Partnership program has grown from two ACO partners in the Puget Sound region (VBC 7/14, p. 1) to four partnerships, including two that have just started in St. Louis and in Charleston, S.C., Helle said.
Boeing is very careful with its employee benefits, Helle said. “That’s the reason we didn’t take away an existing benefit” when starting the ACO programs. Many employees already were getting care from providers at the organizations forming the ACOs, but Boeing management wanted them to choose the ACO programs voluntarily, not be forced into them, she said.
The company focused on educating its workforce about these new plans, she said. “We spent a lot of time helping members understand what was different. It is a significant investment, obviously.”
The investment paid off: In 2015, the program’s first year in Puget Sound, about 30% of the eligible population chose an ACO-based insurance product. In 2016, another 5% chose an ACO-based product. This has exceeded Boeing’s expectations, Helle said.
Currently, Boeing contracts with ACOs organized by:
•UW Medicine Accountable Care Network (Puget Sound area);
•Providence-Swedish Health Alliance (Puget Sound area);
•Mercy Health Alliance (St. Louis); and
•Roper St. Francis Health Alliance (Charleston, S.C.).
About 30,000 employees, dependents and retirees are eligible to join the ACO in Puget Sound, which is where Boeing makes its commercial airliners and is the company’s biggest market, Helle said. Another 15,000 ACO-eligible employees, dependents and retirees are in St. Louis, where Boeing has much of its defense business, and around 8,000 are in Charleston, S.C., the site of Boeing’s newest manufacturing plant, Helle said.
Financial reasons drive most employees to switch into the ACO-based plans, Helle said. Employees who choose the ACOs don’t pay as much for their share of the coverage, receive more for their company-funded health savings accounts, and — perhaps most importantly — pay nothing for primary care office visits and generic prescription drugs.
The plans are designed so that employees have lower out-of-pocket costs in exchange for being required to receive care within the ACO network to get the highest benefit level. Emergency care is always covered at the highest benefit level, regardless of site of care, and having a primary care physician is encouraged but not required, Helle said.
However, employees also were drawn to the ACO networks themselves, especially since many already were receiving care from those health systems, she said. The ACOs must provide excellent member service, including:
•Quicker access to physicians,
•Treatment decision support,
•After-hours care,
•A call center for triage, scheduling and issue resolution, and
•A website for medical records and provider searches.
In addition, following a Seattle-based pilot of a high-risk patient-centered medical home that delivered 20% per-member per-year savings, Boeing now requires ACOs to incorporate such a medical home into their designs, Helle said, adding, “this is exactly the group of patients the ACOs need to pay attention to.”
Quality improvement measures are embedded in the contracts, with a special emphasis on member experience and member satisfaction, she said.
Boeing continues to work toward integrating carve-outs such as disease management, behavioral health and pharmacy benefits into the ACOs, Helle said, noting that proper management of these services is critical to the success of ACOs.
Source: AIS Health