Dr. Health Plan Will See You Now

The lines have already gotten increasingly blurry between payers and providers as payers have moved to buy or partner with a variety of providers, especially those delivering primary car. And the trend may pick up speed because of the COVID-19 pandemic. Many independent providers have run into cash crunches because of declining patient volumes that may never return to their pre-pandemic levels. Meanwhile, payers are eyeing control of primary care as a way to manage costs and perhaps address healthcare disparities.

“Plans and providers are looking for lower-cost sites of care,” says
Kulleni Gebreyes, M.D., a principal with Deloitte Consulting in Charlotte, North Carolina. As a result, “payers are moving from being financers of care to providers of care.”

“Insurers are going really, really deep into primary care,” says Heidi Leeds, sector leader for health insurance with health insurance consultancy Korn Ferry. “Before they dabbled. Now it’s front and center.” Although some payers “are looking to expand their footprint” by acquiring primary care providers, others are getting involved in the primary care sector through partnerships and joint ventures, Leeds says.

“It’s part of a longer-term strategy,” says Fred Bentley, managing director at Avalere, a healthcare consulting firm in Washington, D.C. Teaming up or acquiring a primary care provider is a means for health insurers to have “even more control and influence over members’ care and engage with them.” The move also is designed to control costs, as “primary care is the gateway to the patient healthcare journey,” Bentley says.

Large insurers are involved

The country’s largest insurers have definitely developed a strong appetite for the insurer-primary care mashups. Humana, for example, announced in March that Conviva Care Centers, one of its wholly owned subsidiaries, was buying a primary care physician network in South Florida that includes 12 health centers and 40 physicians. Earlier in the year, the company announced that another subsidiary, Partners in Primary Care, would add up to 20 new primary care centers in 2021, with locations in the Atlanta and Houston areas, Louisiana and Nevada. Humana said in the press release announcing the Conviva deal that the company now owns 170 “senior focused” primary care centers that are “payer agnostic” — people don’t need to be in Humana Medicare Advantage to be patients at the centers.

CVS Health, which acquired the health insurer Aetna in 2018, has been in the primary and urgent care business for 15 years. The first MinuteClinics in CVS retail outlets opened in the Twin Cities and Baltimore in 2006. Then in 2019, company launched its HealthHUBs, which provide a broader array of services than MinuteClinics and are geared toward chronic disease management. Despite the pandemic, CVS aims to have 1,500 HealthHUBs open by the end of this year.

The company also introduced the Aetna Connected Plan this year in the Kansas City area. Members of the plan don’t get charged at MinuteClinics and HealthHUBs. CVS says the premium is 20% lower than other preferred provider organization products in the market.

UnitedHealth Group CEO David Wichmann said during an earnings call in January that the company’s Optum division started this year with 50,000 physicians and 1,400 clinics and had a goal of adding “at least” 10,000 employed or affiliated physicians this year. In March, the company made a splash in Massachusetts when its Optum division announced that it was acquiring Atrius Health, the largest independent physician group in the state. State and federal regulators need to review the deal before it goes through.

In Florida, Florida Blue, a part of GuideWell, has partnered with Sanitas Medical Centers to offer primary care with no copays for members of some of its medical plans. For emergency care, the company has partnered with Crucial Care to create GuideWell Emergency Doctors. The offices are staffed by board-certified emergency doctors, and some plan members have no copayments for the first two visits.

These kinds of partnerships and acquisitions will be a “strategic priority for many (health) plans,” Bentley says, but he doesn’t expect them in every market. Instead, it will depend on the size of the payer and whether there are primary care practices with which to form strong relationships. “We’re still in the middle innings with this,” says Bentley.

Zeroing in on seniors

Humana began its push into senior-focused primary care in the Kansas City area, establishing four Partners in Primary Care standalone clinics in 2017, and then setting up two clinics at Walgreens drug stores the following year.

The insurer now has four clinics at Walgreens in the Kansas City area and one in South Carolina, says Renee Buckingham, president of Humana’s care delivery organization. After initial concerns over whether consumers would understand that the Walgreens clinics were offering full-service primary care, rather than just urgent care, and whether doctors would be willing to work at a clinic located at a drug store, Humana has been “pretty happy about the retail experience,” says Buckingham. And consumers, particularly those who have mobility or transportation issues are happy to get their healthcare where they can also do some shopping, she says.

Many of Humana’s senior-focused clinics are in Sun Belt locations that have large senior populations. When identifying clinic locations, Humana looks for communities where seniors are underserved by primary care providers, Buckingham says. Care coordination for chronic conditions can suffer where there’s a shortage of providers, she notes, adding that seniors are “one of the most vulnerable populations in the country.” The COVID-19 pandemic has made that even more apparent. About 80% of the deaths from the disease have been among those ages 65 and older, according to the CDC.

Closing healthcare disparities is on many agendas these days.
Although insurers have plenty of purely business reasons for moving into primary care — containing costs, capturing a chunk of the premium dollar, forging tighter, multifaceted relationships with members — they also see primary care as a way to address healthcare disparities, says Leeds at Korn Ferry. Through their primary care practices, payers can “serve segments of the population that may otherwise have been left behind,” she says.

Primary care practices with staffs that include behavioral health providers and social workers are in a position to address mental health problems and social determinant of health, says Gebreyes, noting, “They treat the whole person.”

Primary care is also feeling the effects of the shift to some version of capitated, value-based care. Prior to the pandemic, many primary care practices relied on fee-for-service payment. That made sense. “They knew volumes were going to go up,” says Bentley, “That’s not true anymore.” With a shift to value-based care, “the financing and delivery of care are becoming more interlinked,” notes Gebreyes. It has become something of a truism that physicians who had adapted to value-based care have fared better during the pandemic. Older physicians who have spent their careers in a period when payment was fee for service may be more willing to sell their practices now that value-based payment is taking hold.

For consumers, the shift to value-based care should result in better access to quality care, Gebreyes says, and Leeds says that should benefit insurers: “Every health plan wants to do everything it can to keep the patient out of the emergency room.”

Susan Ladika is an independent journalist in Tampa, Florida, who covers healthcare and business.