news Why St. Luke’s Created a Unique HMO Style Insurance Plan for Idaho

St. Luke’s Health System has grown rapidly over the past decade, acquiring and trading medical practices and hospitals in Idaho and Oregon. As it grew, St. Luke’s executives laid out a master plan to keep medical costs in check and ensure that medical care actually makes people healthier.

One of the milestones of this plan arrived last fall. A new insurance company called St. Luke’s Health Plan.

Matt Wolff, President of St. Luke’s Health Plan, said: “I think it’s a big hurdle that creates a lot of friction and frustration. Frankly, I don’t think it helps build trust in the community.”

The plan is similar in some ways to HMOs like Kaiser Permanente. Holders of St. Luke’s Health Insurance Cards may only receive medical services from facilities and providers that are part of the St. Luke’s network. St. Luke’s Network includes St. Luke’s and other independent healthcare providers. It is also different from other HMOs. For one thing, a patient doesn’t always need a referral from her primary care provider to see a specialist, he said, Wolff said.

He said St. Luke’s health plan promises to be more streamlined to prevent patients from getting bogged down in Kafka-esque bureaucracy when trying to get healthy.

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Patients aren’t stuck between health insurance companies and doctors when they disagree, he said.

According to Wolff, the primary way to do this is to leave the decision of what is medically necessary and what is not to the healthcare provider. Eliminates the process of approving or rejecting

But there are internal controls in those decisions to control spending, he said. Healthcare providers themselves are fully responsible for the financial and health outcomes of their patients.

St. Luke’s Health Plan concept to be tested in 2023

Ten years ago, St. Luke’s system brought another insurance company to Idaho called “Unique Strategic Alliance.” We partnered with Select Health, a Utah nonprofit insurance company, to launch a St. Luke-centric plan. This plan from Select Health has been and continues to be popular with consumers.

The overarching idea of ​​this plan was to reward St. Luke’s and their providers when they make wise decisions. If we could keep patients healthy without hospital stays and expensive prescription drugs, if we could keep everyone’s costs down, St. Luke and her providers would get a financial return. can do.

Five years after that plan, an Idaho politician reported: Luke’s has yet to realize the premium savings it promised. ”

Officials said in 2017 that it was “too early to tell if we could achieve our goals by changing how we pay for health care,” but they believed they were on the right track, politicians said. reported.

According to Wolff, the outline of the new health insurance scheme, which was a somewhat novel approach in 2012, is now very common in Idaho, with such “value-based” policies becoming more commonplace. Lesson learned.

“Some may talk about integration where providers make decisions, but literally our model is. “It’s what determines whether a visit is necessary,” Wolff said. It doesn’t mean you have to necessarily do things that aren’t in line with care, but it does mean population quality (which assesses health care), population outcomes, along with financial responsibility.”

St. Luke’s: Health insurance is not a prelude to shutting out competitors

A decade ago, St. Luke’s came under fire and even faced an antitrust lawsuit for its growing share of the Treasure Valley healthcare market.

According to Wolff, St. Luke’s does not intend to become a closed system accessible only to those with a St. Luke’s insurance card. Nearly all of the insurers that competed with St. Luke’s Health His plans on the exchange last fall had St. Luke’s Health His providers and hospitals on their networks.

“Our strategy will continue to be, and always will be, a multi-payer strategy because no single payer or single such arrangement has enough momentum to really change the market. Because we don’t think we have,” said Wolff.

How long will it take? it depends.

St. Luke’s Health Insurance premiums vary depending on age, area of ​​residence, and whether you are eligible for income-based subsidies. The out-of-pocket cost for each person depends on the type of medical care they need and the plan they choose. The ‘Bronze’, ‘Silver’ and ‘Gold’ plans represent trade-offs between monthly premiums. What you pay out of pocket to use the insurance.

All St. Luke’s plans feature $0 for some basic costs, including primary care office visits, on-demand virtual care, outpatient mental health care, and prenatal care. They can prevent more costly and complex health problems in the future, Wolff said.

Other health insurance companies in Idaho follow the same philosophy and offer no-cost medical services.

The Affordable Care Act requires insurance companies to cover some preventative care for patients free of charge. As of 2020, an estimated 862,000 people in Idaho received $0 out-of-pocket preventive care through private insurance, according to a report by the U.S. Department of Health and Human Services. Some benefits of the St. Luke’s Health Plan go beyond these basics.

However, a $0 out-of-pocket doesn’t necessarily mean that the patient doesn’t have to pay a dime. For example, the copay for obstetric care is $0. However, as explained in the St. Luke’s Health Plan brochure, that copay applies to bills of obstetrics and gynecology or other obstetric care providers. This does not apply to facility-specific labor and delivery fees, which can cost thousands of dollars or more in hospitals.

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