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They seem like odd couples: Aetna, one of the nation’s largest health insurers, is in talks to combine with CVS Health, which manages pharmacy benefits. The Cleveland Clinic, a highly regarded health system, joined forces with an insurance startup, Oscar Health, to offer individuals a health plan in Ohio.
Aetna also has new partnerships with large health systems that include hospitals and doctors’ groups in Northern California and Virginia.
These established players are venturing beyond their traditional lines of business, now that federal officials have quashed the mega-mergers proposed by the biggest insurers and blocked a deal between two large drugstore chains.
Former adversaries are banding together, girding against upheaval in a rapidly changing health care environment. They are also bracing for the threats posed by interlopers like Amazon eyeing a foray into the pharmacy business or tech companies offering virtual medical care via a computer or cellphone.
“There’s been a strong trend for health organizations to want to broaden their footprint, especially on the part of insurers to get more direct contact with the individual,” said Dr. John W. Rowe, a former hospital and insurance executive who is a professor of health policy at Columbia University.
Given the uncertainty over the Affordable Care Act and the potentially limited appeal of the core insurance business, insurers are looking to follow the strategy pursued by UnitedHealth Group. The big insurer, which acquired a chain of outpatient surgery centers this year, has a wide array of profitable health care businesses like its own pharmacy benefit manager and various consulting arms through its Optum unit.
While the companies promote these partnerships to employers and consumers as one-stop shopping, they could also put customers at a disadvantage by limiting their choices and increasing medical costs.
Under these arrangements, people may not be able to see doctors outside the organization’s own medical group. In addition, patients may worry that their doctor will decide not to order an expensive test to exact savings for the business partners — the insurer and the health organization. An in-house pharmacy benefit manager could direct customers to certain drugs because its manufacturer offers hefty rebates even if the medicine is more expensive or does not work as well as a competitor’s.
And the combined clout of the companies could push consumers’ expenses higher.
Employers that purchase coverage on behalf of their workers may also have difficulty determining how much they are paying for a given medicine or a particular service, said Edward A. Kaplan, a senior vice president at Segal Consulting. There’s a lack of transparency when it comes to drug prices, and employers may have even less information if the insurer and the pharmacy benefit manager are the same entity. “It’s going to be harder for us to get behind the curtain,” Kaplan said.
Companies are actively looking for partners that will provide an entrée into new businesses or a new supply of customers. CVS Health, which started as a drugstore chain, operates a large pharmacy benefit manager as well as walk-in clinics in its drugstores. By combining with Aetna, which covers about 22 million people, CVS would be able to direct members to its own mail-order and pharmacy business and to its walk-in clinics, located in its drugstores, for much of their care.
“It’s a sign of the continued integration in health care,” said Tom Robinson, a partner for Oliver Wyman, a consultant that estimated there have been about 200 partnerships created between insurers and large health groups in the past five years. By sharing in the profits or losses of these ventures, the parties say they work more closely to make sure a patient gets the right medicine or has access to a doctor at a nearby clinic instead of resorting to an emergency room.
The savings can be tangible. Anthem, which recently announced that it plans to start its own pharmacy benefit manager, estimated it could save $4 billion a year, the bulk of which it said would result in lower drug costs for customers.
These partnerships can also represent a dramatic departure from the status quo. In many situations, an insurer and a hospital group would barely talk to each other outside a meeting every year or so to haggle over how much to pay for a knee replacement or an overnight hospital stay. The discussions rarely include how to better manage the care of a patient whose asthma goes untreated or has back pain that would be better treated with physical therapy.
The contract negotiations between insurers and hospital systems tend to be “a zero-sum game,” said Brigitte Nettesheim, a senior executive with Aetna. Once the contract is signed, and a conflict arises over the cost or choice of a treatment, the patient is the one often caught in the middle.
Aetna started offering joint plans with Inova, a large organization in Northern Virginia, in 2013. The partnership covers more than 193,000 people. Patients see a doctor who belongs to a special network of primary-care physicians and specialists, most of whom are not employed by Inova but work together closely with the system to coordinate care for patients.
Both sides say these arrangements remove the insurer from the business of second-guessing the doctor. At the Cleveland Clinic, the doctors have established guidelines about how to treat various conditions so that when a patient has breast cancer, for example, the doctors can proceed without first getting approval from the insurer, said Kevin Sears, an executive with the clinic. Oscar Health, which is jointly offering a health plan in the individual market with the clinic, doesn’t “feel the need to authorize every single step along the way,” he said.
Large hospital groups view these partnerships as a way to hold onto their patients and to deal with pressure from the government and private insurers to reduce costs. “Health systems are feeling more pressured around price than they ever have before,” said Dr. Lisa Bielamowicz, an executive with the Advisory Board, which consults with hospitals and doctors. As more care is delivered outside the hospitals, they are intent on developing alternatives to walk-in clinics and telemedicine, where a nurse or doctor offers care via text or phone call.
Over the last several years, there have been a flurry of initiatives. They include accountable care organizations, which team up providers to coordinate care for a group of people, and are joining with large insurers like Aetna and Cigna.