New Year, New Deals? Breaking Down Health Plan, Doctor Alliances

by Dan Diamond, California Healthline Contributing Editor

RELATED TOPICS:

The Washington Post's annual In/Out List doesn't crossover much with "Road to Reform." (Possibly for good reason; the latest edition says "wonks" are officially out this year.)

But this column is nothing if not occasionally gimmicky. So here's a one-time, two-line trend-spotting bonus for 2012:

  • Out: Physicians and insurance companies as mortal enemies.
  • In: Health insurers and physicians ... as partners.

Regular California Healthline readers know that several big payer-doctor deals were struck in 2011, disproportionately in the Golden State. UnitedHealth's Optum division acquired a handful of physician groups, most notably 2,300-member Irvine-based Monarch HealthCare. Other health plans teamed up with independent practice associations to launch accountable care organizations.

Are these deals an industry blip or the beginning of a boom?

Check back at year-end. For now, it's too soon to know.

The high-profile deals are garnering plenty of buzz, however. And given the rumblings, many other doctor groups and plans are scrambling to evaluate whether similar partnerships make sense.

Changes Afoot for Everyone

It's old news that industry players are taking on new roles.

Hospitals in 2011 ramped up the pace of physician acquisition, seeking to integrate care and gain reimbursement. More employers added responsibilities for their employees' wellness, hoping to cut costs.

But the physician and insurer deals are particularly striking because of the sectors' oft-contentious relationship. If doctors and health insurance plans aren't fighting over reimbursement, they're battling over paperwork or even public scorecards. Outside of Kaiser Permanente, many efforts at vertically integrated systems with insurers running doctor groups have largely failed.

Even the CEO of Monarch HealthCare is surprised by his own partnership with UnitedHealth.

"Not 10 years ago I would not have thought of something like this," Bart Asner told Modern Healthcare's Rebecca Vesely. But when seeking a partner, "[UnitedHealth] showed up on our doorstep."

What's Driving the New Partnerships

UnitedHealth's pursuit of Monarch -- and by extension, other plans looking to partner with physicians -- isn't a shock.

Given ongoing industry efforts to coordinate care, lock up primary care providers and cut costs, physician groups have many suitors.

But Vesely concludes that the reasons for physicians to team up with health plans, rather than merge with other doctors' groups or join a hospital, are less cut-and-dry.

One driver may be that national plans have much more financial wherewithal to meet the sales price for large groups, as well as their strategic ambitions. UnitedHealth projected profits of more than $5 billion in 2011. The average hospital clears about one-1000th of that per year.

Alternately, IPAs and health plans may be pushed together as dance partners while hospitals bulk up. The growing "dominance" of hospital-led health systems means that physician groups are losing market power and the ability to recruit new doctors, health care consultant Penny Stroud told American Medical News late last year, making plan ownership more appealing.

California at the Epicenter

These drivers can all be seen in the unlikely Monarch-UnitedHealth deal, which Vesely neatly breaks down in Modern Healthcare.

  • What UnitedHealth gains: Access to physicians for its members and better positioning in a new market of integrated care delivery.
  • What Monarch gains: Deep pockets to invest in electronic health records, clinical programs and its growth strategy.

A good share of these new physician-payer deals are unfolding in California.

That's partly because the state's long history with managed care offers fertile ground for such partnerships. The entrenched HMOs, large multidisciplinary physician groups and concentrated market have set up an ideal laboratory for attempting this kind of coordination.

CMS' efforts to reward integrated care also are pushing California's strong IPAs to the forefront. No state had more organizations named as Pioneer ACOs last month than the Golden State's six, which includes Monarch.

Reaction and Reassessment

Modern Healthcare calls the new deals a "marriage of convenience" -- and there's certainly little romance and a lot of number-crunching to the proceedings.

Monarch also leaves behind a pair of jilted ex-partners.

Blue Shield of California will end its contract with Monarch in May, citing the IPA's new relationship with UnitedHealth. Anthem Blue Cross has pulled out of the physician group's planned ACO pilot.

That ACO effort may become an early litmus test for the UnitedHealth-Monarch relationship. Other payers are watching how smaller-scale initiatives, like regional insurers' efforts to acquire physician clinics, are unfolding.

If the partnerships prove successful, expect a flurry of activity across 2012 as more payers and physicians make sure they're dealt in -- and not left out.

Here's what else to watch as the new year begins.

In the States

  • CMS on Dec. 20, 2011, approved a new three-year, $26.75 billion Medicaid waiver for Massachusetts that allows its 2006 health insurance law to continue and provides hospitals with incentives to offer quality-focused and cost-efficient care. The waiver will expire in June 2014 (Baker, "Healthwatch," The Hill, 12/20/11). The waiver is vital to the state law's primary goal of ensuring that most residents have health insurance (Conaboy, "White Coat Notes," Boston Globe, 12/20/11).
  • Texas Democrats in a recent letter urged HHS Secretary Kathleen Sebelius to reject the state's request for a waiver from the medical-loss ratio regulations under the federal health reform law (Pecquet, "Healthwatch," The Hill, 12/22/11).
  • The advocacy group Progress VA recently filed a petition seeking to pressure state lawmakers to disassociate with the American Legislative Exchange Council, a conservative, pro-business group that authored the state's lawsuit against the federal health care reform law (Pecquet, "Healthwatch," The Hill, 12/28/11).

Challenges to Reform

  • After more than a year of vowing to "repeal and replace" the federal health reform law, Republicans still have not developed a plan to substitute for it. Republican presidential candidates have proposed new tax credits and allowing residents to purchase health insurance over state lines as an alternative to the reform law. However, some conservative experts said the ideas might not work as intended and even if they did, they would be only the beginning of a true replacement for the Affordable Care Act (Fahrenhold, Washington Post, 12/24/11). In related news, a Kaiser Family Foundation survey shows that among opponents of the current reform law, most want the ACA repealed, but not replaced (Kliff, "WonkBlog," Washington Post, 12/26/11).

Inside the Industry

  • Health insurers in 2012 will start paying the federal government a $1 fee for each insured person to go toward funding the Patient-Centered Outcomes Research Institute, which aims to determine which medications, medical procedures, tests and treatments work best. While the Treasury Department said the fee would not likely be collected this year, insurers will still owe the federal government the amount. The fee rises to $2 per insured person in 2013 and rises with inflation each year thereafter (Alonso-Zaldivar, AP/Washington Times, 12/27/11).
  • CMS on Tuesday announced the names of 73 health care experts who will participate in its Innovation Advisors Program, which will support individuals who seek to pilot and refine innovative payment and delivery models.  After an orientation phase, advisers will work with the CMS Innovation Center -- established through the health reform law -- to pilot health care delivery models in their local communities and create partnerships that can foster and disseminate successful ideas. Each adviser's organization will receive up to $20,000 to support his or her activities during their participation (CMS release, 1/3). The Innovation Advisors Program will select up to 200 participants within its first year. The agency is expected to reopen applications in Spring 2012 and select remaining advisors by June (CMS fact sheet, 1/3).

On the Campaign Trail

  • President Obama's re-election campaign is creating videos to promote the federal health reform law. On its website, the campaign asks supporters to "[r]each out to five folks who are affected by this reform and ask them to stand with the" law. In one video, a 21-year-old student at the University of Nebraska-Lincoln explains how the federal law allowed her to stay on her parent's insurance plan while she experienced a serious illness. In another video, viewers are asked to "[s]pread the news about how health care reform is working for seniors," a reference to the law's provisions closing the gap in Medicare prescription drug coverage (Jackson, "The Oval," USA Today, 12/21).

to share your thoughts on this article.