Inside New York’s successful health exchange

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Affordable Care Act

Inside New York’s successful health exchange

On February 19, 2014 we held a panel discussion on the state of New York’s health exchanges. The following is a summary of the key points made during the discussion. Thanks to writer Heidi Reinberg for capturing the essence of the conversation so well.

Whatever you call it – ACA, the Affordable Care Act, Obamacare – there has been (and there will continue to be) much debate over the rollout of what is arguably the biggest sea change in healthcare in this country in decades. What is not in dispute, however, is the success of New York State’s healthcare exchange as part of this groundbreaking piece of legislation.

New York not only ranks #2 in the country in terms of enrollees, but as panel moderator Cooley LLP partner Wendy Goldstein  pointed out, the state’s exchange offers more provider options – at seventeen – than any other state. Panelist Dr. Amanda Parsons, Deputy Commissioner of the New York City Health Department, attributes the success of the state’s marketplace (as of February, statewide enrollment was at 35% of its goal) to a couple of factors: 1) the state did not “spend a lot of time hemming and hawing over whether or not they were going to expand Medicaid” and 2) there was no “big brouhaha over whether we were going to run our own exchange – we’re New York state, and we like to do things our way!” Thus, says Dr. Parsons, the state was actually able to jump start its planning process much earlier than many states, some of which are still stuck in a debate as to whether or not to expand Medicaid.

Panelists representing new marketplace entrants – Debra Friedman of Health Republic and Mario Schlosser of OSCAR – are bullish on New York’s healthcare marketplace. Though “we never forget they’re a regulator,” Ms. Friedman called the leadership of the agency “really experienced, intelligent, responsive, best in class — you just couldn’t have a better business partner.” Schlosser concurred, dubbing the exchange “incredibly responsive.” In fact, he continued, “I cannot praise them highly enough.”

The New York State Marketplace
New York’s healthcare exchange serves both individuals and families and small businesses (via the SHOP program). Through the online exchange, interested parties can shop for and compare Qualified Health Plans (QHPs); check their eligibility; find out if they qualify for Medicaid or subsidies/tax credits; and, finally, enroll in the plan of their choosing. There are various plans offered – platinum, gold, silver and bronze.

According to Dr. Parsons, it is estimated that half of the 1.1 million uninsured New Yorkers will gain insurance through the marketplace (the other half comprises undocumented individuals, ineligible, or just plain un-interested). Of these, half of the state’s enrollees will end up receiving coverage through Medicaid, with the remainder being served by QHPs like those offered by Health Republic and OSCAR. (Note: as of March 31st when open enrollment for 2014 ended, over 908,000 had enrolled.)

Health Republic
With a background as an insurance executive, Debra Friedman is CEO of start-up insurer Health Republic, which, with 67,000 members and 70,000 providers, is the second largest plan on the New York exchange behind Wellpoint.

Health Republic is a not-for-profit member-led coop health plan, the only one for which members comprise 51% of the board and whose members vote on such crucial decisions as rate increases and benefits offered. All profits are reinvested back into benefits and services.

The organization’s mission is to be the high-quality, highly affordable choice in New York state. According to Ms. Friedman, “We hold as a core value that, when members get the right care at the right time, that is the highest-quality care and the most affordable care.” Currently in 32 counties, Health Republic reaches 92% of New York’s population.

Central to Health Republic’s value proposition is the organization’s flexible, highly delegated business model, which allows the organization to “pivot on a dime in terms of operational support,” says Ms. Friedman. In the first month of operation, Health Republic processed a robust 55,000 members through its system. “Because we have a number of different vendors in our model, we can be flexible geographically — at call centers, at claims-processing centers, at ID card centers — enabling us to be highly scalable and cost efficient,” she explained.

Health Republic encourages its members to undertake a health-risk assessment early on so that the organization can understand their exact needs and provide customized care. A key component of Health Republic’s member benefits package is its user-friendly Smart Access program, which provides enhanced member engagement through such services as primary-care-physician engagement, and Smart Engage, a suite of online services that includes a robust healthcare library and other healthcare and wellness tools. In addition to Smart Access and Smart Engage, Health Republic benefits also include 24/7 telemedicine and co-pay structures that go down to zero once a primary care physician is selected.

OSCAR

Created two years ago by a group of Harvard MBA-technologists frustrated with the healthcare system, Oscar is definitely not your parents’ health insurance. Panelist Mario Schlosser (along with his two co-founders ) set out to create an insurance company that would meet three main goals:

  1. make things simple
  2. guide people through a complex system
  3. put a doctor “in the family”

 

“One of the big bets we made coming in is that people want their insurance company to be there before they go to the doctor and not just after when you have to pay the bills,” said Schlosser. The Oscar search box is “smart” enough to process colloquial phrases, so if users type in “stomach ache,” the system will give them not only the information they need to determine possible causes, but also to decide on whether a trip to the drugstore, their primary care physician, or even a gastroenterologist is warranted. The system will further give the customer probable courses of treatment and related costs. And of course, Oscar’s online portal will even help users find the closest doctor or pharmacy (and will even submit the prescription for them). Should a patient so desire, they can request an “appointment” with one of Oscar’s free teledoctors, who will generally call them within an average of seven minutes. The goal? “You become a bit more educated as a patient before you even go in [to the doctor],” says Schlosser.

With a provider network of 40,000, Oscar is seeking to make things easier for doctors as well. “Let’s just help them with things they are already doing and that they’d like to do,” says Schlosser, like calling patients with lab results or following up via e-mail. The insurer is developing aps that will allow physicians to more easily and efficiently reach Oscar patients.

However, Schlosser is quick to note that many physicians are already utilizing high-tech tools in their practices – and he’s not looking to reinvent the wheel. “The best role we can play is just as an orchestrator of smart things that other people do,” he explains. “There are smart doctors out there that do very innovative stuff, very smart vendors out there, there are other Silicon Valley-based start-ups that do aspects of this. The best thing we can do is to make sure that the smart people float to the top.”