Philadelphia-based Jefferson Health is targeting growth for its health plan and working closely with commercial payers to deliver high value care for the community as part of an integrated delivery and financing system.
Healthcare billing is often confusing, with complex explanations of benefits hard for healthcare workers to decipher and even more challenging for patients. It's difficult for clinicians to know what is covered and what isn't, and communicate that to patients. But Jefferson hopes to simplify as much as possible by aligning more closely with commercial insurers around a common goal: better quality and cost-efficient healthcare.
"Healthcare providers and insurers need to work together more closely to make a more consumer friendly system that allows people better transparency around cost," said Joseph Cacchione, MD, CEO of Jefferson Health, on a recent episode of the "Becker's Healthcare Podcast." "I think there's going to be changes to payment models. It's going to force us to work together. If we don't, we're going to end up even more fractured, in a more divisive system."
Many health systems have contentious relationships with commercial insurers because insurers are getting into the provider business. UnitedHealth Group owns Optum, the largest physician network in the U.S. Aetna employs clinicians through CVS Health and Cigna has Evernorth.
"They're now competing for the same business in a lot of ways," said Dr. Cacchione. "There are many disruptors in healthcare right now that are not necessarily looking to take on Medicaid patients or the uninsured. They're really looking to take on the profitable parts of it, and they're attacking it through the premium dollar, whether it be Medicare Advantage or through commercial contracts. I don't think that relationship is all good, but I do think we can find common ground."
The focus on reducing utilization is a good place to start for hospitals and commercial insurer partnerships, said Dr. Cacchione. Jefferson is working on reducing utilization with its own health plan and eliminating pre-certifications in many instances. For example, members requiring nursing home placement don't need Jefferson's health plan to re-certify the transfer; they're able to go straight to the nursing home.
"We're able to get people to a nursing home on a Friday afternoon, when previously they would've sat over the weekend waiting to get the pre-certification from the insurance company," said Dr. Cacchione. "So we're trying to break down those barriers, and when we talk to some of the insurers, in particular our Blue Cross folks, they're willing to work on things like that where we take out [re-certifications] and become more efficient together."
Not all insurers are willing to work with health systems on partnerships, but Dr. Cacchione encourages healthcare leaders to collaborate when possible for better patient care.
"We have such an opportunity to make something different from a consumer standpoint if we can do this together rather than separately," said Dr. Cacchione. "The idea that these two industries have been so separated has made such a bad consumer experience, and I think it's contributed to the excess cost we have in this country on healthcare."
Jefferson is also focused on creating a more integrated patient experience with its own health plan. The plan focuses on government payers, with its major business being Medicaid. It also has a Medicare Advantage and a Part A plan. Dr. Cacchione doesn't anticipate moving into the commercial space with the system's plan in the future.
"We think the governmental payers are a place where we can compete in a more level playing field, and we think there is opportunities to pull people up that are getting left behind in healthcare by creating solutions that are, whether they be Medicaid or whether they be for people that require government subsidies for private health insurance," he said. "We think that's a better way for us to help attack the whole issue around health equity."