September 2, 2014
Dr. Nancy Van Vessem

"We try to detect and fix problems before they become a real emergency," says Dr. Nancy Van Vessem, chief medical director at Capital Health Plan (with Dr. Robert Chapman)

Photo: Colin Hackley

Mary Pankowski

"Not for one moment did I worry that the best care wouldn't be provided."  - Capital Health Plan customer Mary Pankowski (with husband Joe)

Photo: Colin Hackley

Health Care Trends

Capital Gains

Tallahassee-based Capital Health Plan is a rare bird in the health world: An HMO that has both held down costs and kept its customers happy.

Lilly Rockwell | 9/11/2012

Six years ago, Nancy Van Vessem, chief medical director for Capital Health Plan in Tallahassee, was sifting through federal data on back and neck surgeries and noticed that the HMO was paying for more surgeries than other providers. “We were at the 90th percentile nationally for back surgeries here locally,” Van Vessem says.

Physicians in Tallahassee typically recommended costly MRIs for back pain, then prescribed surgery — despite evidence that most people get better without operations, she says.

To curb the reliance on surgery, Capital Health launched an aggressive effort to educate doctors and patients about back pain and the benefits of physical therapy. In face-to-face meetings and newsletters, the firm encouraged physicians to delay ordering costly MRIs and send patients to six weeks of physical therapy unless there was a red flag. “It gave primary care doctors the ‘easy’ button,” Van Vessem says.

Capital Health Plan’s Customers

2012 enrollees 125,000

2012 Medicare enrollees 13,054

Biggest customer State of Florida

Counties Calhoun, Franklin, Gadsden, Jefferson, Leon, Liberty, Wakulla

Accolades Rated best HMO in the nation and third-best private health insurance plan in the nation by National Committee for Quality Assurance

Source: Office of Insurance Regulation, Department of Management Services, National Committee for Quality Assurance

It worked. Most patients’ pain lessened after physical therapy, and back surgeries decreased 24%. Now, Capital Health Plan says the incidence of back surgery among its customers is in the 90th percentile nationally only among 45- to 64-year-old males. The goal is to get that group to the national average.

Intensive use of data and technology to track everything from knee surgeries to colon screenings is one of the hallmarks of Capital Health’s operations. Founded in 1982, the firm is part insurer, part provider. It employs 37 doctors and has a total network of 560 doctors and specialists who accept reimbursement from Capital Health. For customers who need help outside Capital Health’s service area, the company has an agreement with the National Blue Cross Blue Shield Association.

This year, Capital Health’s average premiums stayed flat, compared to the national average of a 7% increase. Members of one plan, for instance, pay an average $271 in monthly premiums for family coverage, and individuals pay $102, both below the national average of $426 for the same plan, according to the Milliman Medical Index.

Capital Health covers on average 90% of health benefits, says Capital Health Plan President and CEO John Hogan.

Notably, the company has implemented electronic records even as most doctors and HMOs elsewhere struggle with the new technology. Patients and their physicians — both staff and affiliated — can see claims, laboratory results and pharmacy history online.

The National Committee for Quality Assurance rates Capital Health’s insurance plan as the third-best in the nation, using data from claims, prescriptions and prevention measures. Capital Health — executives prefer to call it a “delivery system” rather than “insurer” or HMO — is the only Florida-based health insurer to make the list.

Tags: Healthcare, Insurance

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