Blue Cross and Blue Shield’s retail outlets have been so successful that the insurer has expanded the concept.

With more consumers buying insurance on their own, some health insurers are turning to brick-and-mortar retail stores to snag their business. Blue Cross and Blue Shield of Florida debuted its first “Florida Blue” retail location in Jacksonville in 2007 and followed that with a store in Pembroke Pines. The pilot storefronts proved so successful that Blue Cross recently opened two larger stores in Tampa and Miami. Customers can buy policies, get answers to questions about their coverage, get help with a claim, research a medical condition and even get a health assessment. They can also compare provider prices: An MRI might cost anywhere from $400 to $1,500 depending upon the provider. At the Florida Blue store, consumers can comparison shop before scheduling their scans. “The days of the consumer being shielded needed to come to an end,” says Craig Thomas, vice president and chief marketing officer for Blue Cross and Blue Shield of Florida. The company plans to open another location in Orlando later this year.

Humana, meanwhile, has 15 “guidance centers” in the United States, including four in Florida.

— Amy Keller

Humana has four “guidance centers” in Florida.

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Telehealth

UnitedHealthcare connects patients in underserved areas to doctors miles away through state-of-the-art videoconferencing software.

In certain rural (and some urban) areas, access to doctors and specialists can be as big a challenge for consumers as the cost of care. UnitedHealthcare has teamed up with Cisco to connect patients in underserved areas to primary care physicians, specialists and hospitals via state-of-the-art videoconferencing technology. At a recent demonstration in Tampa, UnitedHealthcare workers showed how a physician can conduct a virtual examination of the patient in real-time via a two-way video screen, interacting with the patient and an on-site nurse who performs medical tests. UnitedHealthcare plans to begin implementing its new “Connected Care” this year in Colorado.

— Amy Keller

Engaging the Consumer

To contain costs, many employers are switching to so-called consumer-directed health plans — high-deductible plans that marry health savings accounts (HSAs) with a tiered benefit plan that kicks in once a deductible (generally in the $2,000 to $3,000 range) is met. As individuals pay more out-of-pocket for their own care, health insurance providers are introducing new tools to help them make informed healthcare decisions. Aetna members, for instance, can go online to research the costs of more than 30 common medical procedures, the rates charged by doctors and other healthcare professionals and the costs of prescriptions filled at retail drugstores or through Aetna’s mail order program.

UnitedHealthcare, meanwhile, operates a Premium Physician Designation program to “help consumers identify better healthcare providers.” The program uses actual utilization data and cost, identifying physicians and facilities that meet either the “quality only” or “quality and cost efficiency” criteria. Consumers access the information online. Surgeons in the company’s network who are designated as “premium” have 59% lower complication rates and 15% lower costs.

— Amy Keller

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The Medical Home

Dr. Darla Broderick’s Palma Ceia office in Tampa serves as the medical home for her patients under a pilot program between Humana and JSA Medical Group. [Photo: JSA Healthcare]

In the fragmented world of healthcare, the doctors and specialists who treat a patient may never communicate with each other in the process. Tests are often repeated, money wasted and the quality of care impaired. Each doctor “is just looking at a piece of you, and no one sees the whole picture,” says Dr. Scott Latimer, Humana’s market president for senior products in central and north Florida.

Humana is now conducting a “medical home” pilot project in Florida with physician practices that are part of JSA Medical Group in Tampa Bay and MetCare on the east coast. Medicare Advantage patients who go to those practices are seen by a team of people, with a primary care doctor serving as the medical home — overseeing and coordinating all the other physicians and making sure the patient follows treatment regimens and gets regular checkups.

If patients need to see a specialist, the primary care doctor helps them find the appropriate doctor and makes sure that all the providers — using electronic medical records — stay informed of what the others are doing. Patients who are part of a medical home are able to access the doctor by phone in the evening or over the weekend.

Dr. Scott Latimer, Humana’s market president for senior products in central and north Florida

During its first year of operation as a “medical home,” MetCare’s 30-day hospital readmission rate for Medicare patients was 33% below the average Medicare readmission rate in Florida. The rate of female patients receiving mammograms, meanwhile, was 50% higher in the medical home population than in a similar population in primary care centers not organized around the medical home.

UnitedHealthcare and Cigna also are trying out the concept elsewhere in the U.S. Humana’s Latimer says the key to making medical homes work is doctor buy-in. “If we can show physicians in the community that this is actually a better model as a business proposal that works for them ... it will become more popular.”

— Amy Keller

Getting a Handle on Costs

Mail-order pharmacies often cost employers much more for generic drugs than retail pharmacies, says Dan Ross.

After 20 years in the employee benefits industry, including 17 years at Cigna, Dan Ross is using his expertise to help private companies and other large employers find ways to trim their healthcare expenses.

Consider, he says, prescription drug coverage. Most employers assume that retail pharmacies cost significantly more than mail-order pharmacies, but thanks to hidden fees and other costs imposed by pharmacy benefit managers (PBMs), the mail-order prescriptions often cost employers significantly more for generic drugs than they’d pay using a community pharmacy. “There’s no reason you should let an insurance company handle your prescription drug benefit because they mark up the drugs like you wouldn’t believe. You can figure an extra $10 to $15 per employee, per month,” says Ross, CEO and founder of MedVision, a Tampa-based consulting company that helps self-insured companies get more bang for their healthcare dollar.

Dan Ross, CEO of MedVision, helps self-insured companies save on healthcare expenses.

Ross recommends that clients farm out some options like prescription drug benefits to providers other than insurance companies. Ross also gets his clients to focus on preventive healthcare and managing chronic disease, which he notes is the No. 1 driver of healthcare costs. MedVision has also partnered with companies like North Carolina-based Biologics, which provides strategies to elevate cancer care while lowering cancer costs — a key considering that cancer can absorb 15% to 25% of an employer’s annual healthcare budget.

In the year since Manatee County schools hired MedVision, ER visits are down 70%, breast cancer claims and expenses are down 20%, back pain claims are down 20% and preventive office visits are up 66%. Other clients include the Archdiocese of Miami, Sarasota County government and Moffitt Cancer Center.

— Amy Keller

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Multicultural Marketing

United-Healthcare’s PlanBien targets the more than one-third of Hispanics who don’t have insurance.

Of all major racial/ethnic groups, Latinos have the lowest rates of health insurance coverage; more than one-third of Hispanics in the U.S. are uninsured. To bridge that gap, UnitedHealthcare recently rolled out PlanBien in south Florida and other heavily Latino parts of the country, including Arizona and Colorado. The plan provides bilingual online provider directories that list physician offices with Spanish-speaking doctors and staff, Spanish-speaking customer service representatives who can help participants locate Spanish-speaking doctors, and specialized educational materials in Spanish.

The company has created similar products for other ethnic groups. UnitedHealthcare’s “Generations of Wellness” initiative offers African-American members an online directory of African-American doctors, health tip fliers about conditions that disproportionately affect African-Americans, such as high blood pressure, high cholesterol, diabetes and obesity, and an online wellness center with exercise suggestions and healthy recipes.

— Amy Keller

Healthcare Banking

Noting the popularity of health savings accounts (pre-tax contributions into an account used to pay deductibles and out-of-pocket medical expenses), UnitedHealthcare chartered its own bank, Optum Health Bank, exclusively to support the HSAs. Today, the company administers 400,000 such accounts. Those with HSA accounts in the bank can invest a portion of their deposits in a dozen separate mutual funds. The bank also recently partnered with Intuit to produce a healthcare expense tracker that automatically organizes healthcare expenses online, says David Lewis, CEO of UnitedHealthcare of Florida.

— Amy Keller

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Cheaper Alternatives

Wolf Shlagman’s Consult A Doctor sells 24-hour access to doctors.

Minor conditions that send many people to the doctor’s office often can be handled by phone or e-mail — a child’s earache, a question about a symptom, a traveler who left his prescription pills at home. Entrepreneur Wolf Shlagman, 40, pitches his Consult A Doctor as an answer for employers and insurance companies looking to cut costs. He sells, for as low as $1 per employee per month, 24-hour access to doctors via phone and e-mail who can provide information or a diagnosis and prescription. His service saves 50% on an office visit cost and also cuts workplace absenteeism, he says. Next up: Consult a Specialist.

— Mike Vogel

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Onsite Care

Rosen Hotels and Resorts’ 4,500 employees have access to the company’s in-house clinic. [Photo: Megan DelMonte/DPR]

Sarasota Mayor Richard Clapp says the city may join the ranks of employers who provide healthcare for their employees via an onsite clinic. “People could come in without making an appointment, and they could get routine things done with no cost at all to them, and our costs will really be held at a minimum,” says Clapp.

The clinic approach was pioneered in Florida by Rosen Hotels and Resorts, which launched its in-house model 19 years ago and covers each of its 4,500 employees at an average cost of around $2,500 a year. Rosen’s 4,000-sq.-ft. medical clinic employs two full-time primary care physicians, two nurse practitioners, a full-time social worker, a part-time podiatrist and a part-time dietitian. The company provides access to specialists through an agreement with Florida Hospital.

Ashley Bacot, risk manager for Rosen and president of ProvInsure, Rosen Hotels’ insurance agency, says the key to savings for Rosen was cutting out the middleman — the insurance company. While most companies use onsite clinics only for convenient/occupational care and continue their contract with large insurers, Bacot negotiated directly with the hospital group and got “better rates than the large insurance companies.”

The company recently launched a business called Rosen Healthcare Solutions, which provides customized advice and assistance to companies that want to build their own on-site medical facilities. Bacot says clients are charged a “small percentage” of the savings that result from the new on-site healthcare model.

— Amy Keller

Hospital Infection Rates: Mayo’s Solution

Mayo Clinic follows a five-step procedure to help reduce patient infection rates. It’s aiming to eliminate hospital-bourne infections entirely. [Photo: Mayo Clinic]

Between 1998 and 2006, some 48,000 Americans died from two of the most common hospital-acquired infections, sepsis and pneumonia, according to a study of 69 million patients in 40 states published earlier this year in the Archives of Internal Medicine. One study put the costs of treating preventable cases of sepsis and pneumonia at $8.1 billion in 2006.

At Mayo Clinic Florida in Jacksonville, CEO William Rupp is spearheading a project intended to reduce the clinic’s rate of hospital-borne infections to zero. The initiative comes down to standardizing a process, Rupp says. In cases of pneumonia associated with patients on ventilators, Mayo follows five steps that cut the incidence of infection if performed daily. “We’re making sure that our patients on a respirator get those five items every day,” he says. Similarly, to cut down on the incidence of blood stream infections, Mayo now uses a small team that follows a rigorous set of procedures to insert all IVs. Since implementing its new standards, Mayo has cut its infection rates by about a third to a half, depending on the type of infection. Rupp intends to get to zero eventually. “My feeling is you can’t get to zero unless you at least set that as a goal.”

— Amy Keller

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Innovation Through Diversification

CEO Jeffrey Freimark has helped Miami Jewish Health System diversify its operations.

A change in Medicare reimbursement formulas has hammered Miami Jewish Health System’s original nursing home operation since the 1990s — it projects an $8 million loss on the 462-bed facility this year. In the meantime, however, the non-profit has diversified; it now serves 8,000 patients and has pain, rehab and other centers.

“The nursing home model, the way it’s been operating and the way it is today, is broken,” says CEO Jeffrey Freimark. “The point of my discussion is not, ‘Woe is me.’ It is what it is. How do we deal with it?” MJHS projects it will break even in 2012, though Freimark wants tort law changes to lower costs and reduce defensive medicine.

— Mike Vogel

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Insurance Market Share

Blue Cross and Blue Shield of Florida’s Jacksonville headquarters [Photo: Kelly LaDuke]

Among the dozens of companies that sell health insurance in Florida, two providers dominate. Blue Cross and Blue Shield of Florida, headquartered in Jacksonville, serves approximately 4.2 million members, giving it a 30% share of the Florida market. Aetna serves more than 1.2 million Floridians, controlling about 15% of the market.

Top Florida Health Insurers
Insurer	Florida Business
Blue Cross and Blue Shield of Florida	$4,628,635,539
Aetna Health	2,045,154,213
UnitedHealthcare	720,182,287
AvMed	659,875,132
Humana Medical Plan	628,371,429
Health Options	601,948,242
Vista Healthplan	541,114,525
Neighborhood Health Partnership	423,921,863
Capital Health Plan	407,450,183
Humana Health Ins. Co. of Florida	388,304,927
Source: 2009 annual report, Florida Office of Insurance Regulation

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Out of the Courtroom

Linda Quick.

In 2004, 81% of Florida voters passed Amendment 7, a patient “Right to Know” amendment, allowing them access to any adverse hospital incident reports. That gift to plaintiffs’ attorneys had a “chilling effect” on the peer review process by which doctors and hospitals try to prevent future mistakes by reviewing their procedures, says Linda Quick, president of the South Florida Hospital & Healthcare Association.

A year later, Congress passed legislation that trumps Amendment 7 by allowing the creation of patient safety organizations (PSOs), whose records of incidents and subsequent reviews would be kept from disclosure in court cases. PSOFlorida launched in January, a collaboration of the Florida Hospital Association and the south Florida group, and has 32 hospitals onboard with 50 more interested, says Bruce Rueben, president of the Florida Hospital Association.

— Mike Vogel

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Treatment

Researcher Hiroshi Komine examines a B16 melanoma cell line at Moffitt. [Photo: Nicholas Gould/Moffitt]

Researchers at Moffitt Cancer Center and Scripps are using genes to create “designer” lymph nodes that may help rebuild the body’s immune system and restore its ability to fight both cancer and other diseases. They have a nearly $2-million grant from the National Cancer Institute. A clinical trial involving melanoma is under way. “We anticipate we will be able to create fully functioning, designer lymph nodes at will in the human body,” says James Mulé, executive vice president of Applied Research at Moffitt.

— Amy Keller

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Healtchcare Rationing?

Entrepreneur Mike Fernandez recommends reinsurance for the 5% of people he says are responsible for 90% of claims. [Photo: Eileen Escarda]

Healthcare entrepreneur Mike Fernandez has made a couple of fortunes owning companies in managed care, retail pharmacies and the like. Last year, after a non-compete agreement from selling his last managed-care company expired, he gathered $100 million to start SimplyHealthcare, a Medicaid-focused managed-care company. “There’s more money flowing into it now then when I got out of it,” Fernandez says. Fernandez believes the state could cut Medicaid fraud in Florida by hiring a company — he happens to be shopping for one — to verify that treatments are medically necessary. For the nation, he recommends some type of reinsurance for the 5% of people responsible for 90% of claims. He says future rationing of healthcare seems likely. The population, he says, now sees the most expensive healthcare as a right divorced from cost — he likens it to wanting to dine at the most expensive restaurant at fast-food prices. Meanwhile, costs soar to the neglect of infrastructure and other investments the country should be making. “The percentage of GDP that is spent on healthcare is an obscene amount, and nobody wants to be the first one to take a reduction”

— Mike Vogel