St. Luke’s dips toe into ‘accountable care’ insurance model

Dec. 02--St. Luke's University Health Network has joined Lehigh Valley Health Network in offering a new form of health care management called "accountable care."

The partnership between St. Luke's and Kentucky-based Humana gives members of the insurer's Medicare Advantage plans in-network access to St. Luke's hospital network and its physicians.

Humana announced the prevention and outcomes-based accountable care partnership Monday.

Earlier this year, Cigna announced a similar deal involving about 5,500 of its members who are patients of Valley Preferred, a managed care organization aligned with Lehigh Valley Health Network.

"More and more health systems, payers and Medicare are moving this way," said Neil Steffens, Humana's vice president for Pennsylvania. "We all know it is important for the long-term sustainability for our health care system. What the member could expect is hopefully an improved health care experience."

The plans factor patients' health outcomes into reimbursement in an effort to encourage better coordination among patients' health care providers and emphasize prevention with a goal of reducing costs while improving patient health.

Humana, the nation's second-largest provider of Medicare Advantage plans, covers about 5,000 Lehigh Valley seniors and hopes the new arrangement with St. Luke's will increase that number, Steffens said.

Particularly well-suited to large health networks, accountable care plans are only going to become more common, said Dr. Forney Fleming, a professor in the University of Texas at Dallas' health care management program.

"This type of organization, whether an [accountable care organization] or a variant of it is really the wave of the future," Fleming said. "You are going to have to integrate your care and make it a whole lot more efficient and effective."

The deal is St. Luke's first foray into accountable care, but the hospital is in talks with other providers, said Francine Botek, the hospital's vice president of finance.

"St. Luke's accountable care arrangement is a partnership with Humana that is centered around providing the highest-quality care to the Medicare population," she said. "St. Luke's strives for continuous care improvement which ultimately translates into reduced costs as a result of lower readmissions, reduced complications, fewer trips to the emergency room and other unnecessary testing."

At its heart, the accountable care model strives to put the brakes on medical costs while improving patients' health. It does this by giving doctors and their staff incentives to keep people healthy and addressing their health conditions before they become more serious or chronic ailments.

Once the patient needs care, the emphasis is on providing appropriate care and following up afterward to ensure the patient has a positive outcome.

In some ways, the plans resemble a more sophisticated version of an HMO, said Dr. Gus Geraci, chief medical officer of the Pennsylvania Medical Society. "At the end of the day, the overarching concept is to provide better quality for more people with less money," he said.

Who can argue with that, he said. But whether they work depends heavily on the criteria used to evaluate patient outcomes and providers' and insurers' willingness to make patient care a priority over manipulating the system to maximize profit.

"Sadly, in large part it depends on the purity of heart of the participants," he said.

Humana's accountable care arrangement with St. Luke's will pertain to Humana's PPO and a newly offered HMO through Medicare Advantage, a federally funded private alternative to Medicare, Steffens said.

Despite funding cuts included in the Affordable Care Act, enrollment in Medicare Advantage plans has continued to grow. Steffens said Humana's decision to introduce the new HMO plan and enter into an accountable care partnership with St. Luke's was not a reaction to the funding cuts.

People who enroll in either of Humana'sMedicare Advantage plans in eastern Pennsylvania will be included in the accountable care model if they choose St. Luke's as their provider. The 2014 Medicare Advantage enrollment deadline is Saturday.

What will it mean for Humana patients? Primary care doctors and their staffs will be expected to do more to promote preventive services such as colonoscopies and to check to make sure they are taking and refilling prescribed medications, Steffens said.

Doctors will be given Humana-developed analytical tools designed to predict and hopefully head off future health issues, and their patients will get health club discounts though the company's Silver Sneakers program, among other benefits, Steffens said.

[email protected]

610-820-6745

___

(c)2013 The Morning Call (Allentown, Pa.)

Visit The Morning Call (Allentown, Pa.) at www.mcall.com

Distributed by MCT Information Services