Despite those inherent advantages, not all health systems that own an insurer are rushing into the market. “We're being cautious,” said Juan Serrano, senior vice president for payer strategy and operations at 55-hospital Catholic Health Initiatives. The Englewood, Colo.-based health system, one of the nation's largest by revenue, has launched an ambitious strategy to diversify into insurance markets.
CHI may sell exchange health plans, but not until 2015 at the earliest. It plans to use next year to monitor which states create viable exchanges through robust marketing campaigns. “If others are able to successfully move in and operate, it stands to reason that we, too, could stand in and offer an alternative,” he said.
Serrano said the system does not yet see competing providers entering the insurance markets as a competitive risk. “I don't know if competitive pressure is something we're ready to try to understand in year one,” he said. Markets will stabilize and mature in coming years, he said, and competition will become clearer.
At 10-hospital Sentara Healthcare, in Norfolk, Va., officials say consumer demand will be far less than originally projected in the markets thanks to new rules about what benefits must be included and limits on how widely premiums can vary between the young and old, said Michael Dudley, president ad CEO of the system's insurer, Optima Health.
Health plans sold through exchanges must include benefits across 10 categories of benefits under the Patient Protection and Affordable Care Act. New rules also limit the amount insurers can vary premiums between the youngest and oldest customers by a ratio of 3-to-1, which insurers have argued will raise premiums for young, healthy customers in order to stay within the narrow range.
“I am beginning to wonder about the affordability of the Affordable Care Act,” Dudley said. Plans will be too costly for low-income households, even with subsidies to buy insurance, and some will choose instead to pay the law's penalty for skipping coverage. Optima projects demand from 10,000 to 15,000 new customers instead of initial projections of 40,000 to 60,000 in the Norfolk market.
Sentara will sell an exchange health plan, but not establish a narrow network that limits customers to its providers in exchange for a lower price. Dudley said Sentara cannot risk possible financial losses by marketing a plan that may be priced too low to cover patients' medical expenses and would squeeze payments to providers. Any growth in market share under those conditions would lead to mounting health system losses, he said.
Indeed, consumers' preference for the narrower network that comes with the lower price remains unclear, said Mark Hansberry, senior vice president of strategy, marketing and communications for six-hospital Fairview Health Services, a Minneapolis-based health system. Hospitals have largely been shielded from competing for consumers based on individual shoppers' preferences because so many receive insurance from an employer.
But in the fall, the exchanges could generate a sizable consumer market for price-sensitive healthcare. Fairview owns half of insurer Preferred One, which will compete on the exchange with a narrow network against other health plans with broader networks and higher prices. “It's what you do as a consumer in almost every other element of our lives,” Hansberry said.
Hansberry says Fairview will be competitive on the exchange because the health system is investing in cost-reduction programs such as prevention and wellness in an effort to prevent unnecessary care. By gaining more patients, the health system hopes to capture more revenue to offset losses from those prevention efforts, he said.
Not all health systems looking to compete in the exchange say they will pursue a narrow network. “There's a few avenues that one has to be careful with wit0h a narrow network,” said Christopher Fanning, vice president of commercial sales at Geisinger Health Plan, Danville, Pa., which will sell broad-network options on the exchange. Narrow networks could potentially exclude providers based on cost, he said. “We are not comfortable restricting patient care on cost,” he said.
Not all provider plans to enter the exchanges are responses to anticipated drops in service revenue because of care-coordination efforts. “This is part of our growth strategy,” said Melissa Hayden Cook, president and CEO of Sharp HealthCare's health plan, which will enter the exchanges. The system's accountable care organization has increased Sharp's market share on its own, Sharp officials said.
Some system-owned insurers have invested in market research and marketing plans to compete for new consumers. Pittsburgh-based UPMC began 20 months ago and developed consumer profiles common among retailers that will help the health system's health plan effectively market and price its exchange options, said Kim Jacobs, vice president of consumer and product innovation. Western Pennsylvania shoppers in the new market are expected to total 412,000, he said. “For me, in my career, this is the largest open enrollment we'll probably see,” he said.