Open enrollment is underway, and millions of Americans are wrestling with patient loyalty versus price. While some consumers are switching carriers to ensure in-network status of their providers, many others are sacrificing their provider relationships for cheaper premiums and out-of-pocket expenses. Health insurance exchanges in many states are bare-boned with only one or two carriers, and carriers like UnitedHealthcare and Humana have removed themselves from the individual market entirely in select states.
Now more than ever, consumers are prey to the power of insurers, and insurers are using their leverage to nudge members toward, or away from, certain services. A broad examination of plan designs suggests insurers are beginning to see convenient care services as a way to lower costs, and consumers, faced with severely limited choice, higher-than-ever deductibles, and severed patient-provider relationships, are eager to oblige.
Services like retail clinics, urgent care and telemedicine can keep patients out of expensive emergency rooms, connect new patients to an in-network primary care physician for ongoing care, and provide patients a temporary “fix” for illness until their primary care physician becomes available. This could reduce complications, like an untreated cough turning into bronchitis, for example, or a bladder infection turning into a kidney infection. Many insurers equate these potential benefits with cheaper or fewer insurance claims.
Some insurers like Blue Cross and Blue Shield of North Carolina and UnitedHealth Group have invested in convenient care through front-facing means like partnerships or acquisitions, but others, like those listed below, are instead steering patients to convenient care services through educational products and plan designs.
- Anthem BlueCross BlueShield (available in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, Virginia and Wisconsin): Emergency rooms charge $150 to $200 for the same service that urgent care and retail clinic centers can render for $20 to $75, the pamphlet says. It also touts savings of up to $180, “enough to buy 52 lattes from your corner coffee shop.” The insurer suggests patients “take a look at why another option for medical attention can be a good idea” and directs patients to retail health clinics for flu shots or mild rashes, fevers, or colds.
- BlueCross BlueShield of Arizona: “When it’s not an emergency but your doctor isn’t available…isn’t it time to consider a retail health clinic or urgent care center?” The pamphlet suggests there are “other options for minor, non-emergency conditions that may help save time and money,” and adds that retail health clinic visits typically fall under the primary care physician benefit, though urgent care copays tend to be higher than that of a retail clinic.
- Health Partners (available in Minnesota, Wisconsin): The 2017 Open Enrollment Handbook has an informative “Know Where to Go” page that suggests patients utilize Virtuwell (a telehealth provider) or visit a convenient care clinic for bladder infections, pink eye, and upper respiratory infections. Patients needing diabetes management and vaccines are instead referred to their primary care physician.
- TRICARE, the universal healthcare program for military members, launched a three-year Urgent Care Pilot Program in May 2016. The program allows individuals to access urgent and convenient care services twice a year without a referral or prior authorization from their primary care physician. Prior to this pilot, individuals needed to access urgent and convenient care services either from their primary care physician or through a referral.
- CareSource (available in Ohio, Indiana, Kentucky, West Virginia): Retail clinic visits receive the same in-network benefits as primary care physician visits with no copay requirement for the Gold and Silver plans.
- Cigna (available in Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Maryland, Missouri, New Jersey, North Carolina, South Carolina, Tennessee, Texas, Virginia): In September 2016, Cigna added AMWELL telehealth services to its existing offerings with telehealth provider MDLIVE. For most Cigna plans, patients pay less than or equal to the primary care benefit for telehealth visits with contracted providers.
These insurers are experimenting with the true cost of convenient care, despite widely spread criticism that places like retail clinics may not reduce ER visits or lower overall healthcare costs. In fact, many—if not most —insurers remain cautious about championing the convenient care model because of the concern of overutilization and fragmented care. Some insurers like Humana, Aetna and Horizon Blue Cross Blue Shield of New Jersey dissuade consumers from visiting retail clinics by charging higher copays for retail clinics than less-accessible primary care physicians.
As value-based care comes more clearly into focus, however, providers are utilizing any and all access points of care to improve patient health and outcomes, and many are turning to retail clinics and urgent care centers to share electronic medical records and help improve patient outcomes. As long as providers keep inking deals and partnerships with retail clinics and urgent care centers, the future looks good for insurers to incorporate enhanced convenient care benefits into their products. Soon enough, convenient care could be more widely accepted as part of a new continuum of care, rather than a disruption of the old.
Follow Michelle La Vone Richardson on Twitter @mlavoneDRG