Colorado HealthOP: An alternative to the traditional

Sunday, September 01, 2013 12:12 PM

New insurance cooperative empowers patients for better health

Kate Alfano, CMS contributing writer

Leading up to Oct. 1, 2013, when Colorado’s new health insurance exchange opens for enrollment, Coloradans can expect to see an explosion in health insurance marketing and new plans coming online hoping to gain market share among the large number of patients newly eligible for health insurance and subsidies under the Affordable Care Act (ACA).

Many of these plans will be offered through the ACA-authorized Connect for Health Colorado marketplace, but one new plan, also authorized by the ACA and opening for enrollment on Oct. 1, hopes to stand out in its effort to provide its members an alternative to traditional health insurance and a more engaged experience.

Colorado HealthOP, Colorado’s first statewide nonprofit health insurance cooperative, is an independent health insurance plan governed and operated by members. Under the CO-OP structure, members have a voice in operations including deciding what is covered under benefit plans. Members can be elected to the CO-OP’s board of directors and, according to Colorado HealthOP CEO Julia Hutchins, when revenues exceed costs, the surplus will go back to members through lower premiums, expanded benefits and quality improvements.

“Colorado HealthOP offers a radically different solution and business model for improving access to high-quality, affordable health care,” Hutchins said. “As a CO-OP, we are committed to working with consumers, providers and employers to support local solutions to local health care problems. We are a new collaborative vehicle for payment and clinical reform in Colorado. The potential for innovative disruption is significant.”

HealthOP was formed in March 2012 and approved for federal funding in July 2012. But while the insurer was born under the ACA, this is not a federal or state program; HealthOP will pay back the Health and Human Services loan it received for startup within five years and its solvency loan within 15 years.

Jack Westfall, MD, MPH, is a family physician and Colorado HealthOP’s chief medical officer. He is leading the efforts to support member health needs by building a robust statewide network of primary care, developing an integrated care model and population health programs, and optimizing the CO-OP’s clinical effectiveness.

He previously spent 21 years with the University of Colorado School of Medicine practicing family medicine, providing rural clinical care and leading rural programs – a great fit for a company that strives to focus on prevention, wellness and rural health care. Westfall said one factor that led to his career change was his frustration with implementing patient care programs that demonstrated improved outcomes, but that then had no mechanism for long-term sustainability beyond the life of the research grant.

Westfall gave the example of providing home blood pressure monitors to patients with hypertension, which he studied extensively in both urban and rural Colorado through the primary care practice-based research networks at the university. He found this patient empowerment tool to be an effective way to manage and improve blood pressure, decreasing the risk of heart attack and stroke in the long term. But when funding ended, so did the program – there was no way to continue providing this service as no insurance company paid for home blood pressure management at the time.

“One of the things that helped me make the decision to move over to HealthOP was the ability to take some of that scientifically proven, locally-relevant programming and implement it as a member benefit,” Westfall said. “So instead of providing these benefits on a programmatic standpoint for two or three years, we can make them part and parcel of how HealthOP provides care.”

Good for patients
Hutchins said patients should choose these insurance products because HealthOP is focused on people, not profits, and the insurer strives to encourage healthy behavior rather than simply paying for care when a member is sick or injured.

For example, HealthOP designates a list of prescribed “health actions.” If members meet the requirements, they can qualify for an “enhanced benefit” – lower co-pays, lower coinsurance, lower deductibles and a health incentive account that they’ll be able to use to pay for medicine or visits. There are three health actions patients can meet in the first year: participating in a primary care wellness visit, having their biometrics recorded and completing a health risk assessment so providers can help identify areas of potential improvement or preventive measures to prevent illness. In future years, the company plans to add measures related to diabetes, asthma and other chronic diseases.

“The goal is to engage patients in taking some responsibly for their health and facilitate that relationship with their physician to make those prevention and health actions easier,” Westfall said. “Our goal is to help people, to make it easier for them to be healthy.”

HealthOP expects to attract members who are interested in ways to improve their health and who are interested in health education and preventive measures that their primary care provider will suggest to them, Westfall said. And the company wants the yearly wellness visit to be one where the patient and provider develop a comprehensive health action plan for getting healthy and staying healthy.

Even patients with other health care coverage can benefit from HealthOP through a free affiliate membership. Westfall said it’s for people who are committed to the values of HealthOP as a consumer-driven health plan and healthy living resource, but who don’t necessarily want to purchase the insurance. These members will have access to some of the resources members have, such as discounts with partner organizations and healthy living tips.

Good for physicians
HealthOP also wants to interact differently with physicians and other providers, improving their experience by providing “common-sense customer service,” decreasing paperwork and administrative hassles, and encouraging strong communication between physician and patient.

“Instead of an insurance company that denies claims, our goal is to partner with patients and providers,” Westfall said. “We want to engage them in conversations and we want to enhance the relationships between patients and their primary care providers because we think that if we’re really going to bend that cost curve, we have to promote the benefits of primary care that will save lives and costs downstream because of decreased ER visits, decreased hospitalizations and decreased poor outcomes from chronic disease.”

HealthOP will experiment with alternative payments models such as claims-free primary care, bundled payments and risk sharing, striving to implement systems that are fair, patient-centric and that appropriately fund health maintenance and improvement.

From the start, providers will be eligible for financial incentives for keeping patients healthy. In the example of blood pressure management, the member will receive a home blood pressure monitor and the provider will receive a yearly fee to work to help keep the patient’s blood pressure under control, whether in person, over the phone or through protocols with a nurse.

“Making this move from the beginning can significantly reduce overhead costs for consumers and for providers who are committed to making practice changes to support a new, more flexible way of getting paid for patient care,” Hutchins said. “We want to work with providers who are committed to this vision and to making the transition over time. And, for those providers who want to get paid the traditional way, our rental networks are already experts at that, so it’s not a capability we necessarily need to or want to develop internally.”

While Colorado HealthOP is currently pursing direct contracts with physician and provider organizations that are delivering patient-centered, coordinated care or want to pursue innovative health care solutions in their communities, the majority of provider relationships in 2014 will be through existing, statewide commercial networks, Hutchins said. Providers who are part of these networks will be able to see Colorado HealthOP patients without having to establish a direct contracting arrangement.

Building to the future
There is still much work to be done leading up to Oct. 1 and then to Jan. 1, 2014, when benefits start. Westfall said the biggest challenge is getting the word out that there’s an opportunity for individuals and small groups to purchase a reasonably priced plan, “whether it’s our plan or not.” He also stressed the importance of understanding how Colorado HealthOP differs from traditional health insurance and the value added by a cooperative model that’s making decisions based on the benefit to the individual member and provider.

“At the end of the day, we really expect that the way HealthOP is managed, the recognition of the importance of primary care and the administrative simplicity of HealthOP will provide an opportunity for healthier, more engaged patients,” Westfall said. “Patients, because of their experience with HealthOP, will be more engaged in their own health and engaged in working with their primary care provider and that will improve their health. A nonprofit committed to bending the cost curve, this model is going to result in a healthier Colorado.”