Serving Low-income Patients Inland Empire Health Plan’s PPACA Strategy
One of the most contentious issues associated with the Patient Protection and Affordable Care Act (PPACA) has been the creation of health insurance exchanges (HIEs), which must be composed entirely of private health insurers. While many states have resisted participation, others, like California, have begun building an exchange.
In a bid to better cover low-income patients, the exchange umbrella also allows nonprofits such as the Inland Empire Health Plan (IEHP), a group with more than 565,000 members, all of whom reside in the sprawling Riverside and San Bernardino counties of California. As IEHP prepares to dive into the exchange, CEO Bradley P. Gilbert, MD, will continue to focus his energies on the subsidized lower-income market.
It’s a sound strategy, considering that health insurance exchanges are expected to yield more than 30 million newly insured patients in America, with a sizable percentage falling into the low-income category. Gilbert’s considerable experience with this population gives him a strategic edge that could benefit all payors and providers.
Gilbert cautions that there is often a lot of income volatility with people at 100% to 200% of the federal poverty level. The expansion of Medicaid under PPACA will encompass all individuals earning up to 133% of the federal poverty level, which translates to about $30,000 for a family of four, and the rest will be required to purchase insurance, some with subsidies. For IEHP, HIEs represent an undeniable opportunity thanks to 58,000 Healthy Families children who are already on board.
“Every single one of their parents, if they are not covered by their job, will be eligible for coverage through the exchange—subsidized coverage," Gilbert notes. "So that’s an immediate potential of 100,000-plus members for IEHP. We have been taking care of their kids for 13 years.”
Building on the Network
As one of only two joint powers agencies in California, IEHP does independent practice association contracting, as well as direct physician contracting to serve its Medi-Cal, Healthy Family, and Medicare patients. In recent years, IEHP has ended up covering a lot of individuals who previously had commercial insurance. These people lost their jobs, ending up at the Medi-Cal level. The phenomenon contributed to growth of 75,000 members last year, and a similar amount the year before. These same individuals will likely end up in the exchange. “Families will have an exchange-eligible adult, they may have a Medi-Cal kid, and a Healthy Families kid,” Gilbert told an audience at the annual American Health Care Congress, December 5, 2011, in Anaheim, California. “We see that all the time. But they would be able to enroll in one health plan if entities like us are in the exchange.”
It all adds up to a solid foundation that the insurer intends to build on in its marketing messaging via billboard and radio to attract new members in the commuter culture of Southern California: network stability during income transition and family continuity.
“That ability for individuals to stay in one health plan and retain their doctors is significant,” Gilbert says. IEHP will continue to rely on its familiar physician networks filled primarily with safety net providers that include federally qualified health centers, clinics, traditional Medi-Cal physicians, and other providers familiar with serving low-income patients. It also is considering broadening its network to include what Gilbert refers to as “more commercial providers.”
Additionally, IEHP will expand partnerships with community-based agencies, including schools and businesses that already provide services to this population, to market its offerings.
Engaging low-income patients who are struggling to pay for the basics is admittedly difficult, but Gilbert’s IEHP has found ways to improve the situation. “We have ‘navigators’ who go into people’s homes to do one-on-one education, and we do a ton of wellness programs,” he says. “Even so, our no-show rate is terrible. Our compliance rate is terrible. If you extrapolate that to the exchange population at the lower end, it is going to be really difficult.”
Currently, the navigators also assist patients in enrolling in the programs they are eligible for, but specific language in PPACA prohibits health plans from being navigators, Gilbert says.
Gilbert is hopeful, however, that bringing patients into the system through health insurance will improve engagement and compliance. “They have no motivation whatsoever because they are getting episodic care in an unstructured system,” he notes. “You hope by bringing them in and having a primary care physician that they will embrace a structured process for care.”
Price Is the Object
If the exchange ultimately works like it is supposed to, people will be able to go to a Web site or to a person to enroll. From there, Gilbert envisions four levels of benefits, plus a catastrophic plan. Price and network will be easily found in a way that is not necessarily true today.
“The tricky thing is that if multiple benefit plans are allowed within the actuarial value, that is going to be a nightmare,” Gilbert says, “because you are going to have four benefit plans with 17 variations. If health exchanges do what I want them to do, they will have just the four benefit plans, and you just price them across the actuarial boundaries.”
Ultimately, Gilbert says simply that the number-one criterion for low-income patients will necessarily be price, a phenomenon already widely seen in Massachusetts. “Because price is going to be number one, it is a challenge, because if you underprice, you put yourself at risk of getting everybody,” he says. “We like the idea of using our current providers as a marketing tool, and actually competing on price and quality—although unfortunately I’m not sure how many people really use quality when choosing a health plan.”
Nonetheless, IEHP’s retention rate in its Healthy Families population bodes well for the plan. Last year, the plan retained 100% of its Healthy Families patients and boasted a 90% HCAHP score for customer service, although its physician satisfaction scores were quite a bit lower.
Maintaining close ties with its provider network and the community agencies and businesses that serve the lower-income population will be central to its strategy in approaching the 300,000 new patients that will be eligible for HIE coverage in IEHP’s market, only some of whom will be subsidized. “It’s not rocket science,” Gilbert says. “If you are not delivering excellent customer service, people will leave you.”Greg Thompson is a contributing writer for HealthCXO.
In a bid to better cover low-income patients, the exchange umbrella also allows nonprofits such as the Inland Empire Health Plan (IEHP), a group with more than 565,000 members, all of whom reside in the sprawling Riverside and San Bernardino counties of California. As IEHP prepares to dive into the exchange, CEO Bradley P. Gilbert, MD, will continue to focus his energies on the subsidized lower-income market.
It’s a sound strategy, considering that health insurance exchanges are expected to yield more than 30 million newly insured patients in America, with a sizable percentage falling into the low-income category. Gilbert’s considerable experience with this population gives him a strategic edge that could benefit all payors and providers.
Gilbert cautions that there is often a lot of income volatility with people at 100% to 200% of the federal poverty level. The expansion of Medicaid under PPACA will encompass all individuals earning up to 133% of the federal poverty level, which translates to about $30,000 for a family of four, and the rest will be required to purchase insurance, some with subsidies. For IEHP, HIEs represent an undeniable opportunity thanks to 58,000 Healthy Families children who are already on board.
“Every single one of their parents, if they are not covered by their job, will be eligible for coverage through the exchange—subsidized coverage," Gilbert notes. "So that’s an immediate potential of 100,000-plus members for IEHP. We have been taking care of their kids for 13 years.”
Building on the Network
As one of only two joint powers agencies in California, IEHP does independent practice association contracting, as well as direct physician contracting to serve its Medi-Cal, Healthy Family, and Medicare patients. In recent years, IEHP has ended up covering a lot of individuals who previously had commercial insurance. These people lost their jobs, ending up at the Medi-Cal level. The phenomenon contributed to growth of 75,000 members last year, and a similar amount the year before. These same individuals will likely end up in the exchange. “Families will have an exchange-eligible adult, they may have a Medi-Cal kid, and a Healthy Families kid,” Gilbert told an audience at the annual American Health Care Congress, December 5, 2011, in Anaheim, California. “We see that all the time. But they would be able to enroll in one health plan if entities like us are in the exchange.”
It all adds up to a solid foundation that the insurer intends to build on in its marketing messaging via billboard and radio to attract new members in the commuter culture of Southern California: network stability during income transition and family continuity.
“That ability for individuals to stay in one health plan and retain their doctors is significant,” Gilbert says. IEHP will continue to rely on its familiar physician networks filled primarily with safety net providers that include federally qualified health centers, clinics, traditional Medi-Cal physicians, and other providers familiar with serving low-income patients. It also is considering broadening its network to include what Gilbert refers to as “more commercial providers.”
Additionally, IEHP will expand partnerships with community-based agencies, including schools and businesses that already provide services to this population, to market its offerings.
Engaging low-income patients who are struggling to pay for the basics is admittedly difficult, but Gilbert’s IEHP has found ways to improve the situation. “We have ‘navigators’ who go into people’s homes to do one-on-one education, and we do a ton of wellness programs,” he says. “Even so, our no-show rate is terrible. Our compliance rate is terrible. If you extrapolate that to the exchange population at the lower end, it is going to be really difficult.”
Currently, the navigators also assist patients in enrolling in the programs they are eligible for, but specific language in PPACA prohibits health plans from being navigators, Gilbert says.
Gilbert is hopeful, however, that bringing patients into the system through health insurance will improve engagement and compliance. “They have no motivation whatsoever because they are getting episodic care in an unstructured system,” he notes. “You hope by bringing them in and having a primary care physician that they will embrace a structured process for care.”
Price Is the Object
If the exchange ultimately works like it is supposed to, people will be able to go to a Web site or to a person to enroll. From there, Gilbert envisions four levels of benefits, plus a catastrophic plan. Price and network will be easily found in a way that is not necessarily true today.
“The tricky thing is that if multiple benefit plans are allowed within the actuarial value, that is going to be a nightmare,” Gilbert says, “because you are going to have four benefit plans with 17 variations. If health exchanges do what I want them to do, they will have just the four benefit plans, and you just price them across the actuarial boundaries.”
Ultimately, Gilbert says simply that the number-one criterion for low-income patients will necessarily be price, a phenomenon already widely seen in Massachusetts. “Because price is going to be number one, it is a challenge, because if you underprice, you put yourself at risk of getting everybody,” he says. “We like the idea of using our current providers as a marketing tool, and actually competing on price and quality—although unfortunately I’m not sure how many people really use quality when choosing a health plan.”
Nonetheless, IEHP’s retention rate in its Healthy Families population bodes well for the plan. Last year, the plan retained 100% of its Healthy Families patients and boasted a 90% HCAHP score for customer service, although its physician satisfaction scores were quite a bit lower.
Maintaining close ties with its provider network and the community agencies and businesses that serve the lower-income population will be central to its strategy in approaching the 300,000 new patients that will be eligible for HIE coverage in IEHP’s market, only some of whom will be subsidized. “It’s not rocket science,” Gilbert says. “If you are not delivering excellent customer service, people will leave you.”Greg Thompson is a contributing writer for HealthCXO.