State of the Industry 2009: Challenges

The spinning economy has hit the pocketbooks of health plans as reflected in their top two challenges for 2009: competing in the marketplace (27.7%) and enduring national economic lows (20.8%).

Three health plans-CDPHP in Albany, N.Y., Blue Cross and Blue Shield of Minnesota and Blue Shield of California-have definite ideas about what they each plan to tackle in 2009.

"With increased costs and a bad economy, we have to make sure that healthcare is affordable," says Bruce Nash, MD, chief medical officer for CDPHP. The solution behind the objective is a medical home model, which would promote primary care as a specialty, develop a new compensation system for primary care physicians (PCPs), increase access to PCPs, enhance chronic condition care, decrease redundancy of care and increase value to both patients and providers.

At the beginning of 2009, CDPHP will introduce a two-year pilot for three physician practices. The objective is to give physicians an opportunity to increase their reimbursement by treating higher risk patients and offering more comprehensive care.

"If a physician can decrease his or her average cost of care by 2%, that will pay for enhanced reimbursement," he says.

NEW DM MODEL

"We want to change the role we play as a health plan in member health support," says David Plocher, MD, chief medical officer of BCBS of Minnesota, in outlining his main challenge of creating value for customers. "We have turned our health support model upside down with our Whole Person Health Support Program, which evaluates every member with the use of software, sizes up their needs and opportunities and delivers the support they need."

Along with customer service, the health plan launched a program this month that relies on a single administrative fee for employers rather than on a piecemeal system that looks at one disease at a time.

"[The program] is the way we do business now," he says. "We are no longer classifying a single disease. We are looking at each member's concerns and unmet needs and deploying outreach to fill the gaps."

BCBS of Minnesota also is collaborating with providers to change the way disease management services are delivered. Dr. Plocher says the plan paid certain clinics-those using advanced technologies such as electronic medical records, disease registries and e-prescribing-to provide disease management instead of outsourcing the services. Not only were physicians ready to step in, he says, but patients served by these clinics also experienced fewer gaps in care.

THREE-PRONGED PROGRAM

Tom Epstein, vice president, public affairs at Blue Shield of California, says his plan is working with providers to deliver quality healthcare at an efficient price.

Blue Shield has forged ahead by creating a pay-for-performance program founded on evidence-based medicine; expanding its prevention/wellness program offered to employers; and implementing complex care management, which is designed to reduce costs and improve care for patients with chronic disease. At the heart of the program are nurses who work with the patients and their families to provide the right care in the right setting and to decrease hospitalizations.

In addition, Blue Shield has piloted a program for its 4,700 employees, which offers a health day-off for participation; biometric screenings; access to health coaches; and a $200 reward for filling out a health risk assessment and utilizing the tools of Healthy Lifestyle Rewards, the plan's interactive, online program that helps members maintain healthy lifestyles.