Two groups with very different ideas about what drives the cost of health insurance are looking at Garfield County, where residents pay significantly more than similar people living in the Front Range, Colorado.
At a community meeting this week, Garfield County Commissioner Tom Jankovsky said residents had been told for years that they could not afford the cost of health insurance premiums, which are among the highest in the state, on the market. individual. Most Colorado residents obtain insurance from their employers, Medicare or Medicaid, but those who do not qualify for this need to purchase an individual plan in the Connect for Health Colorado market or be left without coverage.
The state’s reinsurance program – essentially a barrier that limits how much insurers lose by covering people with expensive needs – helped some, as did the Rocky Mountain Health Plan’s entry into the individual market, said Jankovsky. Still, about 14% of county residents are uninsured, which is significantly higher than the state average.
“They have been eliminated in many cases,” he said.
The Valley Health Alliance, which operates in Pitkin and Garfield counties, believes the solution is to get people to use the most economical form of care – going to a primary care doctor instead of an emergency room if they have the flu. , for example. It also encouraged hospitals, doctors and others to work together to keep patients out of the hospital.
The Peak Health Alliance, which started in Summit County and expanded to the southwest corner of the state last year, believes that changing patient behavior is not enough to drastically cut costs. The group focuses on how much hospitals charge for care and whether insurers are passing on savings.
The Valley Health Alliance already works with a health insurance company that sells plans in Garfield County. Peak would be a rookie, after COVID-19 destabilized negotiations to enter the market last year.
Success in the Southwest
The peak started in Summit County and later expanded to Lake, Grand, San Juan, Dolores, La Plata and Montezuma counties. Bright Health manages the plans it helped negotiate in those counties, although a different insurer has shown an interest in working with Peak in Garfield County.
Negotiations begin based on what hospitals would need to charge to cover any deficits in what Medicare and Medicaid pay, while making a reasonable profit, said Claire Brockbank, Peak’s CEO. An actuary then determines what an insurance plan needs to charge, based on these rates and the amount of care people use, she said.
“The last thing we want is a hospital that goes bankrupt,” she said.
In some cases, they find that hospitals are charging too much, Brockbank said. In others, hospital prices are reasonable, but insurers are not passing on savings to customers, she said.
A Peak plan has the lowest premiums in Summit County, costing about $ 400 less annually than the cheapest option of other health insurers for a 40-year-old non-smoker. The savings are greater in the other counties where it operates, although the plan with the lowest premiums is not the right choice for everyone.
There are some compensations for lower premiums. Summit County clients cannot go to Vail Health’s Steadman Clinic for routine orthopedic problems, and those in southwestern counties cannot cross over to New Mexico, because Peak and the providers there do not have an agreement.
The proposed Garfield County network is not ideal, because Valley View Hospital in Glenwood Springs has shown no interest in participating, said Brockbank. Valley View did not answer questions about its partnership decisions.
People in Garfield County are no longer sick or using low-value care any more than the average coloradan, indicating that something else is driving costs, Brockbank said.
“It’s not really use,” she said.
“Careful, right place, right time”
Chris McDowell, executive director of the Valley Health Alliance, disagrees. Only after facing the problems of getting the right care for people, in the right place and at the right time, does it make sense to start talking about prices, he said.
The Valley Health Alliance started with some big employers trying to make their employees healthier through wellness coaching, but they realized that cutting costs required looking at inadequate care, said McDowell. For example, employees who visit emergency rooms because of what appear to be symptoms of a cold cost about $ 500,000, he said.
Hospitals and primary care providers from Aspen to Parachute have agreed to work together to coordinate patient care, with incentives if they keep patients healthy, McDowell said. For example, a primary care physician who checks the long-term blood sugar levels of most diabetic patients on a quarterly basis would receive a reward for reducing the chances of these patients being hospitalized, he said. They then invited Rocky Mountain Health Plan to sell insurance options based on the pay-as-you-go structure.
Hospitals and insurance companies have their own business models and want to make money, said McDowell, but he finds Valley Health’s model less contradictory than Peak’s. Lowering health care prices will require a long-term “transformation”, he said.
“Awards are a symptom, not the problem,” he said. “We finally got to the point where we started having meaningful price talks.”
The lowest-priced option in Garfield County, offered by the Rocky Mountain Health Plan, costs about $ 133 less annually than the lowest-priced plan offered by Anthem.
Jankovsky, one of Garfield County’s three commissioners, said that while Valley Health’s approach helped cut some prices, the benefits were limited. He hopes that negotiations between Peak and hospitals that have not reached an agreement will soon pay off, so residents have another insurance option for 2022.
“When I started this, I didn’t know how difficult it would be to work with hospitals. I thought they would be more community oriented, ”he said.