A partnership of four Western Pennsylvania hospitals is contracting with a commercial health insurer with the goal of improving care while reducing costs, and an eye toward inking similar deals with other insurance carriers.
Bridges Health Partners LLC of Warrendale has announced it will collaborate with Louisville, Ky.-based insurer Humana Inc. The deal will affect Humana’s Medicare Advantage members treated by doctors affiliated with the Bridges consortium.
Medicare Advantage plans provide government-paid health insurance through private insurers.
The Bridges hospital partnership, which was formed in 2017, represents Butler Health System, Excela Health System, St. Clair Hospital and Washington Health System.
The Bridges-Humana collaboration is among similar efforts nationwide to shift payment for services to the value of the care provided rather than number of procedures performed. Accountable care organizations, like the one Bridges created in 2017 for some 20,000 of its patients, are part of a nationwide effort to rein in costs through improved care coordination and closer case management.
“It’s really about managing the health needs of the individual,” said Joel Engelka, Pittsburgh contracting director at Humana. “At its core, it’s a shift away from fee-for-service to a value model that looks at the entire member. It’s really about coordinated care.”
Historically, the Medicare program paid doctors according to the services rendered. Under Medicare’s Advantage program, health care providers are paid a flat monthly rate per patient — regardless of costs involved with care. The result is an incentive to hold down costs while meeting quality metrics.
Under the partnership, Humana members will be screened for chronic health problems, such as diabetes and congestive heart failure, and whether they’ve undergone recommended preventive health screenings and taking prescription drugs appropriately. Duplicative medical tests and procedures will be eliminated.
A team approach, using local health care providers, is used to keep in touch with members and encourage healthy living habits.
Bridges Health Partners president Tom Boggs described the approach as “proactive case management,” which tries to limit avoidable hospital admissions and therefore higher costs, through preventive care.
“A big part is to keep people from getting into that high-cost category,” he said.
Medical costs for patients cared for under Humana’s value-based model were 15.6 percent lower than traditional Medicare plans, according to the insurer. Humana has 47,000 Medicare Advantage members in Pennsylvania, but it’s uncertain how many are also patients of Bridges doctors.
Bridges chief medical officer Robert Zimmerman said proper management of chronic health problems is a special concern.
“Managing chronic conditions is the best place to get the biggest bang for the buck,” he said.
John Grese, executive director of payor relations at Bridges, said the consortium is eyeing similar agreements with other health insurers.
The penetration rate for Medicare Advantage plans nationwide is about 34 percent, but over 60 percent in parts of Western Pennsylvania, which is among the highest rates in the country.
Kris B. Mamula: kmamula@post-gazette.com or 412-263-1699
First Published: February 19, 2019, 2:00 p.m.
