The New York metro area is seeing another resurgence in healthcare delivery systems attempting to sell their services directly to employers offering benefits programs. These systems are looking to work with their existing medical insurers or even bypass them entirely – getting into direct competition for insured members and patients.

Viewpoints from Adam Okun

Kaiser Permanente pioneered a new model for healthcare financing and delivery 60+ years ago in California.

They created a healthcare system for their workers, later opening their insurance product to other employers using the Kaiser network and securing a captive member base for its doctors and hospitals. And while the model still comes with certain drawbacks around access to a broader range of doctors and hospitals, it has proven remarkably effective at maintaining lower healthcare spending and is currently available in eight states and our nation’s capital.

The approach, however, has not traveled well to other parts of the country.

It seems far more challenging to reorient an established decentralized healthcare system than build that structure from scratch. But that doesn’t mean others haven’t tried. Among recent notable efforts in the Northeast was Northwell Health’s launch of Care Connect (which subsequently closed due to lack of adequately managing the risk). And Mount Sinai took some risk in pursuing bundled payments with employers for a variety of outpatient surgeries. Brighton Health Plan Solutions (backed partially by Goldman Sachs) launched a product called Create, designed to sell employees access to a specific health system as their network. And it also struggled after failing to persuade the reinsurance to backstop the product and demonstrate a sufficient ceiling on costs to self-funded employers.

Fast forward to 2022, and the healthcare systems are at it again.

Northwell Health is taking a stab at building an insurance program, giving its employees access to its doctors and looking to drive all utilization to its network of providers (instead of the previous UnitedHealthcare coverage). Ironically enough, the product will be utilizing much of the infrastructure of Brighton Health Plan Solutions as it attempts a go-it-alone strategy towards tackling costs and driving utilization to its network.

Montefiore Health, after an ugly battle with UnitedHealthcare, has been working directly with employers to construct a direct care model. It would reduce rates for members who have now fallen “out of network” and provide premium service through exclusive partnerships.

Mount Sinai has officially launched its “members only” health center in New York City’s Hudson Yards. It offers concierge access and service to the Mount Sinai ecosystem of providers on a direct contract basis with employers. In addition, Mount Sinai is working with some employers to establish onsite facilities that would further entrench its brand with employers and their membership. Of course, UnitedHealth Group – through its Optum subsidiary – has fully engaged in delivering care by purchasing more provider groups directly, taking the fight to the healthcare systems.

With all the recent consolidation of the major metro New York hospital systems, it seems they are fully ready to go to war with one another for control over patient care.

But they have realized the true aggregators of patients are at the employer level – and the only way to gain access to the employers may be to work with or even around the insurers. As the lines between provider and payer continue to meld, it will be interesting to see who is left standing. And most importantly, whether the employers ultimately benefit.

 


EPIC offers these opinions for general information only. EPIC does not intend this material to be, nor may any person receiving this information construe or rely on this material as, tax or legal advice. The matters addressed in this article and any related discussions or correspondence should be reviewed and discussed with legal counsel prior to acting or relying on these materials.

 

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Adam Okun

Northeast Region Employee Benefits Practice Leader – New York, NY