Blurred Lines
Late last year, in the upscale
The clinic is neither a freestanding medical practice nor an extension of a local hospital chain. GuideWell is the parent company of Florida Blue, the state's largest health insurer. And the clinic is a beachhead in Florida Blue's move into providing primary care as well as paying for it.
The clinic, with 18 exam rooms and equipment ranging from CT scans to IV fluids, is staffed by board-certified physicians who can treat everything from heart attacks and strokes to ear infections and broken bones.
Prices are posted in the lobby:
A GuideWell spokesman points out that customers pay urgent care rates rather than emergency care rates. Typically, Florida Blue members who visit the clinic pay one-third less than they'd pay to visit a hospital ER.
In today's health care landscape, the old "fee for service" model in which insurance companies pay providers for each individual procedure a consumer needs is giving way. In its place, a value-based or pay-for-performance approach is emerging in which insurers pay providers a set amount to care for each insured patient.
The shift has forced both traditional insurers and traditional health care providers to focus intently on controlling costs.
One sign of that focus is the increased emphasis by both providers and insurers on preventive care. The changing reimbursement model also creates incentives for hospitals and health insurance companies to encroach on each other's territory as they scramble to claim a larger share of any savings they can generate.
"All of this ties back to the overarching trend we're seeing in the industry: Costs are going up at an unsustainable level, so you really have all parties looking for ways to dramatically change their models," says Yulan Egan, a counsultant with
GuideWell partnered with
Strategically located in an affluent area, the
"We have seen, unequivocally, some of the highest customer satisfaction surveys that we have ever seen" from patients who use the clinic. "And they don't have to go the emergency room, where they're going to get charged a heck of a lot more."
Business is strong enough that GuideWell opened another Emergency Doctors clinic this summer, less than 10 miles from the first, near
GuideWell has also struck a deal with Latin American hospital and clinic operator Organizacion Sanitas Internacional to open primary care clinics in south
Patel says the new clinics are important planks in the company's overall move to value-based care models. In addition to providing some services itself, Patel says 25% of Florida Blue's medical spending is now through value-based contracts with providers - up from "almost zero" three years ago.
Meanwhile, as insurers gravitate into medical practice, some traditional health care providers are moving into insurance.
In 2013,
Health First is the only health system in
The deal calls for
"I think hospitals, as health care moves to more of a value-based system, will be increasingly looking for ways to hold first dollar risk (premiums) so they can be responsible for that," Rector says. "Lowering our costs and our prices and transferring that savings from our hospital systems to our health plan and enrolling members is a really strong value proposition. We want to hold the premium dollars, and we want to be responsible for the service, outcome and overall cost."
Some other hospitals appear to feel the same way. A 2013 survey conducted by
Insuring their own patients gives hospitals a much fuller picture of their health care history and what, if any, preventive programs they follow, allowing them to better manage care. And in an environment where providers are paid for the quality of care they provide - rather than the number of tests they order or surgeries they perform - it allows them, rather than third-party insurers, to capture the bulk of any savings.
"It's up to them to manage against a number and, if they keep costs down, they're actually rewarded for that," says Egan, of the Advisory ,Group. "Hospitals see a nice convergence there."
The Obamacare Factor
While much of the debate and controversy surrounding
An important component of the law, Egan says, is how it pushes
That shift is accelerating: At the start of this year, the
What's more, by establishing public exchanges where consumers can shop for insurance plans, the law has made it easier for hospitals to market any new insurance plans they launch, reducing a key barrier to entry.
Focusing on the Core
Not every hospital is racing to get into the insurance business.
"Our focus is developing our models to better manage our population and developing a very strong network of primary-care physicians - because you always hear that there's a shortage of primary-care physicians and people want convenience," he says.
"Being in the insurance business is not our core business," Sonenreich adds. "Our core business is health care."
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