Two teams with very totally different concepts about what drives the price of medical insurance each have their eyes on Garfield County, the place residents pay considerably greater than comparable individuals dwelling on Colorado’s Entrance Vary.
At a neighborhood assembly this week, Garfield County Commissioner Tom Jankovsky stated residents have instructed him for years that they cannot afford the price of medical insurance premiums, that are among the many state’s highest, within the particular person market. Most Coloradans get insurance coverage from their employers, Medicare or Medicaid, however those that aren’t eligible for these have to purchase a person plan on the Join for Well being Colorado market, or go with out protection.
The state’s reinsurance program — basically, a backstop that limits how a lot insurance coverage corporations lose when protecting individuals with costly wants — helped some, as did Rocky Mountain Well being Plans’ entry into the person market, Jankovsky stated. Nonetheless, about 14% of the county’s residents are uninsured, which is considerably larger than the statewide common.
“They’ve been priced out in lots of circumstances,” he stated.
Valley Well being Alliance, which operates in Pitkin and Garfield counties, thinks the answer is in getting individuals to make use of essentially the most cost-effective type of care — going to a main care physician as a substitute of an emergency room if they’ve the flu, for instance. It additionally has inspired hospitals, medical doctors and others to work collectively to maintain sufferers out of the hospital.
Peak Well being Alliance, which began in Summit County and expanded into the southwest nook of the state final 12 months, thinks altering sufferers’ habits is not sufficient to dramatically decrease prices. The group focuses on what hospitals cost for care, and whether or not insurers are passing alongside financial savings.
Valley Well being Alliance already works with a well being insurer promoting plans in Garfield County. Peak can be a newcomer, after COVID-19 threw off negotiations to enter the market final 12 months.
Success in southwest
Peak started in Summit County, and later expanded to Lake, Grand, San Juan, Dolores, La Plata and Montezuma counties. Shiny Well being administers the plans it helped negotiated in these counties, although a unique insurer has proven curiosity in working with Peak in Garfield County.
Negotiations begin primarily based on what hospitals would want to cost to cowl any shortfall in what Medicare and Medicaid pay, whereas making an affordable revenue, stated Claire Brockbank, Peak’s CEO. An actuary then determines what an insurance coverage plan would want to cost, primarily based on these charges and the way a lot care individuals use, she stated.
“The very last thing we would like is a hospital that goes bankrupt,” she stated.
In some circumstances, they discover hospitals are overcharging, Brockbank stated. In others, the hospitals’ costs are affordable, however insurance coverage corporations aren’t passing financial savings on to clients, she stated.
A Peak plan has the bottom premiums in Summit County, costing about $400 much less yearly than the most cost effective choice from different well being insurers for a 40-year-old nonsmoker. The financial savings are bigger within the different counties the place it operates, although the plan with the bottom premiums is not the precise selection for everybody.
There are some trade-offs for decrease premiums. Summit County clients cannot go to Vail Well being’s Steadman Clinic for routine orthopedic issues, and people within the southwestern counties cannot cross into New Mexico, as a result of Peak and the suppliers there haven’t got an settlement.
The proposed Garfield County community is not excellent, as a result of Valley View Hospital, in Glenwood Springs, hasn’t proven curiosity in taking part, Brockbank stated. Valley View did not reply to questions on its partnership choices.
Folks in Garfield County aren’t sicker or utilizing low-value care any greater than the common Coloradan, indicating one thing else is driving prices, Brockbank stated.
“It’s not actually utilization,” she stated.
“Proper care, proper place, proper time”
Chris McDowell, govt director of Valley Well being Alliance, disagrees. Solely after tackling the issues of getting the precise care to individuals, and on the proper place and time, does it make sense to begin speaking about costs, he stated.
Valley Well being Alliance began with just a few giant employers attempting to make their workers more healthy by way of wellness teaching, however they realized that bringing prices down required inappropriate care, McDowell stated. For instance, workers visiting emergency rooms for what gave the impression to be chilly signs value about $500,000, he stated.
Hospitals and first care suppliers from Aspen to Parachute agreed to work collectively to coordinate sufferers’ care, with incentives in the event that they hold sufferers wholesome, McDowell stated. For instance, a main care physician who checks most diabetic sufferers’ long-term blood sugar ranges quarterly would get a reward for decreasing the chances these sufferers can be hospitalized, he stated. They then invited Rocky Mountain Well being Plan to promote insurance coverage choices primarily based on the construction of paying for worth.
Hospitals and insurers each have their very own enterprise fashions and need to make cash, McDowell stated, however he considers Valley Well being’s mannequin much less adversarial than Peak’s. Decreasing well being care costs would require a long-term “transformation,” he stated.
“Premiums are a symptom, not the issue,” he stated. “We’re lastly on the level the place we’re beginning to have significant conversations about value.”
The bottom-priced choice in Garfield County, supplied by Rocky Mountain Well being Plans, prices about $133 much less yearly than the lowest-priced plan supplied by Anthem.
Jankovsky, one of many three Garfield County commissioners, stated that whereas Valley Well being’s method has helped scale back costs some, the advantages have been restricted. He hopes negotiations between Peak and the hospitals that have not reached an settlement bear fruit quickly, so residents have one other insurance coverage choice for 2022.
“Once I began this, I did not know the way exhausting it will be to work with the hospitals. I assumed they’d be extra community-oriented,” he stated.