On June 15 Cleveland Clinic and Oscar Health announced that they will offer co-branded health insurance plans to consumers in northeast Ohio, marking Oscar Health’s expansion into Ohio and Cleveland Clinic’s first entrée into the health insurance market with a product bearing its name.
Pending regulatory approvals, consumers in five northeast Ohio counties—Cuyahoga, Summit, Lorain, Medina, and Lake—will be able to purchase Cleveland Clinic/Oscar individual health plans. It is anticipated that they will be sold on the Ohio health insurance exchange as well as off the exchange, with coverage beginning January 1, 2018.
According to Steve Glass, Cleveland Clinic’s chief financial officer, the plans will break down the complexities between providers and insurers, allowing patients to easily navigate the healthcare and health insurance systems, get the highest quality care at a reasonable price, and improve their overall health.
Every member will be matched with both a Cleveland Clinic care team—a dedicated primary care doctor and care managers—and an Oscar concierge team, with a nurse and three care guides. These clinical and concierge teams will act as one unit, sharing data across the continuum of care to ensure that the patient's health and wellness needs are proactively met and unnecessary hospitalizations are reduced. Members will also have free, 24/7 access to telemedicine. Out-of-network costs will only be covered in an emergency, says Thorsten Wirkes, vice president of Strategic Partnerships, Oscar Health. What should else MCOs know about the partnership? Healthcare analysts offer their insight.
Possible challenges could emerge. “The challenge will be having these systems work collaboratively and not at cross-purposes,” says Andrew Demetriou, managing director, Health Analytics, Berkeley Research Group, a healthcare-focused management consulting firm. For example, Oscar’s systems for determining the appropriate locus for care will need to fit within Cleveland Clinic’s clinical guidelines. In addition, the success of Cleveland Clinic’s care team concept will depend upon key providers maintaining focus on the assigned patient cohort and having access to a robust electronic health records systems to avoid inefficiency in diagnosis and treatment, particularly because the Oscar system relies heavily on patient use of technology to interact with providers. “There is a precedent for improved patient outcomes through the use of dedicated patient teams at other health systems, and certainly Cleveland Clinic has the resources and experience to implement such a system.”
The pairing hopes to buck a trend reported by the Robert Wood Johnson Foundation that stated that of 37 provider-sponsored health plans formed since 2010, only four were profitable in 2015. Another five have gone out of business.
Another challenge will be to make sure the systems work harmoniously, Demetriou says. “This will require blending the traditional culture of Cleveland Clinic with Oscar Health’s very different technological culture,” he says. “Both organizations will say that the objective is ‘putting the patient first,’ but the issue is whether they have a common understanding of what that means. Since Oscar Health has evolved very differently from major health plans and has built its brand on developing a more consumer-friendly portal for patients, there may not be the same tension between it and Cleveland Clinic that has characterized other provider ventures into plan markets.”
John Hansel, vice president of healthcare provider solutions, MedeAnalytics, a provider of healthcare analytics tools, believes success will require a truly integrated experience for patients. “This means leveraging shared technology and data to help patients navigate the healthcare system, help patients gather health information, understand costs, and generally improve patient communication beyond the typical fragmented process in a traditional payer-provider-patient relationship,” he says. “Both Cleveland Clinic and Oscar have a reputation for using technology to be patient centric, which is a good sign that this arrangement may be more successful than other payer-provider owned health plans.”
Expect some limitations. Oscar has promoted itself on the basis that its interface and concierge approach make patient access to providers easier and more likely to direct patients to the appropriate provider more quickly than other plans, Demetriou says. The affiliation with Cleveland Clinic furthers Oscar’s strategy of aligning with top-tier provider organizations. Other plans have excluded or limited access to organizations such as Cleveland Clinic for cost reasons, while this plan does the opposite by focusing on Cleveland Clinic and limiting access to other providers. Consequently, the Oscar/Cleveland Clinic plans may offer broader access to Cleveland Clinic’s services, but with limitations on provider choice.
Process integration will need to occur. The Cleveland Clinic-Oscar plan will leverage both technology and provider network design to go beyond traditional health plan offerings. “From a technical perspective, the program will use telemedicine and virtual health tools to connect with patients, as well as specialized software to communicate costs and improve the financial experience for patients,” Hansel says. “This is particularly important for high-deductible plans offered on the exchange. From a process perspective, the program will be designed like an ACO with a focus on population health management,” Hansel says. “The care team structure will enable primary care providers and care managers to proactively manage each patient’s total health. But all of this depends on the successful integration between Cleveland Clinic provider tools and Oscar health plan tools to create a seamless experience for patients. This technical and process integration will be a major undertaking and will likely take several years to implement.”
It’s hard to predict plans’ popularity. Demetriou says it’s difficult to estimate how popular the new plans will be. Oscar’s model has focused primarily on individuals who are purchasing care through state and federal insurance exchanges. Many traditional plans have recently declined to participate in Ohio’s exchanges, so Oscar’s entry into the market may provide a new choice for individual consumers. In addition, potential enrollees may view access to the Cleveland Clinic as valuable, given its reputation. “Whether it’s attractive will depend upon Oscar’s delivery on its promise of improved patient experience, which in turn depends upon the success of Cleveland Clinic’s patient teams,” he says.
Hansel says the plans will likely be popular, primarily driven by Cleveland Clinic’s brand name and high-tech collaboration tools to improve the patient experience. “Of course, popularity will depend on plan pricing in the individual/exchange market,” he concludes.
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.