Ohio’s largest state-based health insurer and one of the state’s largest safety-net providers are joining to provide a new health insurance product to serve Northeast Ohio, predicting improved quality of care and insurance premium savings of 15 percent.
CLECare will be a joint venture between Cleveland-based MetroHealth System and Medical Mutual of Ohio, also of Cleveland. The new health plan would initially serve Cuyahoga County alone, where Cleveland is located, with a break-even goal of under 25,000 enrolled members. CLECare is a full-risk HMO product under Medical Mutual’s license.
Medical Mutual, which covers 1.6 million lives and employs 2,500, dates its history as a health plan to 1934. MetroHealth began as the City Infirmary in 1837 and in the 1950s it became a county hospital. Last year, the 450-bed hospital that delivers care at 23 locations logged 1.6 million inpatient, outpatient and emergency visits, caring for 250,000 unique patients and employing around 7,000.
Dr. Akram Boutros, MetroHealth president and CEO, pointed out that neither party owns a controlling interest in the venture. Boutros said that MetroHealth has had successful experiences as a Medicaid expansion program and participated in several Medicare demonstration projects as patient-centered medical homes. In one pilot program the system covered 28,000 patients and came in 29 percent below the allowable costs, while improving health outcomes and reducing emergency department visits. He said those initiatives prepared MetroHealth for CLECare.
“We take a care management approach, providing early interventions and preventive services, managing unnecessarily duplicative tests and complementing the program with interventions intended to overcome social barriers like transportation and nutrition,” Boutros said. “We also sent a pharmacist to homes of patients using seven or more medications to insure their meds are in order,” he said.
He said the CLECare partners will share clinical and claims data to manage their patients in real time and a mechanism for integrating its Epic Systems electronic health record with patient records from home care, nursing home and hospice providers and Medical Mutual’s claims data.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Boutros said CLECare will offer its fully insured HMO product to employers with 51 or more employees and soon after to self-funded employers. He said few, if any, county hospitals offer similar products.
“We’ve been doing this for over 20 years and have extensive experience in managing population health across different payer groups, from the uninsured, to Medicare, Medicaid and now applying to commercial payers,” Boutros said. “MetroHealth decided not to pursue this alone, though, because there are specific skill sets that insurance companies provide that are not easily replicable at a provider level and also skill sets and value propositions that providers can deliver that insurers can’t. We believe that two organizations focused on partnership and the health of our communities could be more effective than a single system owning both pieces.”
The partners said that collaboration earlier this year sparked the idea of CLECare. Medical Mutual bought the insurance business from HealthSpan effective March 1, and MetroHealth began to treat HealthSpan’s 40,000 patients in Cuyahoga County as of April 1.
Medical Mutual officials did not respond to requests for comment at deadline. But in a news release, Rick Chiricosta, the insurer’s chairman, president and CEO, said: “We expect significant interest from former HealthSpan insurance purchasers and the growing number of employers and individuals in Cuyahoga County who seek better value for their healthcare dollars.”
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