by Kent Bottles

First posted on Kent Bottles’ Private Views on 7/6/2012

Kent Bottles Host of Kent Bottles' Private ViewsNow that the Supreme Court has upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA), health insurers are scrambling to reinvent themselves for an era of health care reform.  In Part I, we quoted Aetna CEO Mark Bertolini as saying he wants to create a business model that makes sense under the new rules and regulations.  Bertolini in a speech stated, “We need to move the system from underwriting risk to managing populations.  We want to have a different relationship with the providers, physicians and hospitals we do business with.”  Starting with Aetna, Part II will examine the ways that insurance companies are trying to reinvent themselves for a reformed health care delivery system that often wonders why we need health insurers at all.

Early this year, Aetna decided to evolve “’from an insurance carrier to a health solutions company.”” The head of brand and consumer marketing at Aetna stated, “’More and more, the end consumer is who we need to focus on.’” Aetna has developed Care Pass Platform, an agnostic tool that all consumers can use to aggregate and organize their fitness, medical, insurance and nutrition data. Aetna is also partnering with Medicity to provide smartphone apps for providers and iTriage to provide apps for consumers.

Aetna has conducted 57 pilot programs to test ways to decrease per-capita cost and increase the quality of the health care they deliver; the company is participating in 10 accountable care organizations (ACO) and has plans for 17 more ACO experiments.  One successful diabetes pilot in Pennsylvania resulted in acute sick days dropping by 31% with the use of case managers. ()

Aetna also spent $1.6 billion in 2011 to buy health care companies, including Medicity, Prodigy Health Group, Genworth Financial’s Medicare supplement business, and PayFlex Holdings.

Aetna’s partnership with Northern Virginia’s Inova Health System to create a health plan where both partners will share costs and profits is perhaps the company’s most innovative experiment. The partnership will provide incentives to encourage physicians to not over utilize tests and procedures and will also measure and reward quality of care.  Companies will get a rebate if the cost of the care of their employees is lower than expected. 

A different innovative approach to responding to health care reform is Highmark’s merger with West Penn Allegheny Health System (WPAHS).  When first announced in June 2011, the idea inspired Hoover’s health care industry team to create the following headline:  “Bizarre Pittsburgh proposal:  will Highmark – West Penn merger work?”  A year later in June 2012 Moody’s rating service cited dropping patient volumes and continued operating losses at WPAHS in reaching the conclusion that the $475 million infusion of Highmark funds will not be enough to save the struggling health care system; Moody’s still rates $737 million of WPAHS debt as junk bonds.

The Highmark WPAHS merger is complicated by Highmark’s unsuccessful attempt to merge with Independence Blue Cross and failed contract negotiations between Highmark and University of Pittsburg Medical Center (UPMC), the major health system in the Western Pennsylvania market that has its own insurance plan that competes with Highmark.  As if dueling advertising campaigns and lawsuits were not enough excitement, the plot thickened when Highmark fired its CEO Dr. Kenneth Melani, the architect of the merger, after he fought with his Highmark employee girl friend’s husband.  Assault charges were dropped against Melani after he successfully completed an anger management program.   One wonders if new Highmark CEO William Winkenwereder, Jr., MD will continue to support the merger plans.

The Highmark WPAHS merger is an attempt to create “what health-care thought leader, Clayton Christensen, in The Innovator’s Prescription, describes as an integrated, fixed-fee provider system. As such, Highmark and West Penn Allegheny are undertaking a tremendous change agenda.”  Other observers are watching the merger with interest because such vertical mergers have not been extensively studied or investigated.  The Western Pennsylvania region clearly needs to try something new because the status quo is not working: the largest hospitals and health insurers are engaged in a legal battle; WPAHS, the second largest hospital system, is on the brink of failure; and health care costs in Pittsburgh are substantially higher than in similar markets, relative to the quality of care.

Wellpoint, which covers about one third of the nearly 100 million Americans who receive their insurance from a Blue Cross plan has been investigated by Congress for canceling policies retroactively in order to achieve at least a $128 million profit. Wellpoint has also been criticized for having 39 executives who each make more $1 million a year and for spending $27 million on staff retreats at resorts in 2007 and 2008.  Reform advocates point out that such overhead costs contribute to the $400 billion a year in administrative costs that would largely disappear under a single payer system.  Wellpoint’s response to health care reform has been to spend $100 million on technology upgrades and to buy Medicaid provider Amerigroup for $4.46 billion and CareMore for $800 million.  Angela Braly, Wellpoint’s CEO said, “First and foremost there are significant growth opportunities ahead in the Medicaid marketplace resulting from economics, demographics, budgetary issues, as well as healthcare reform. We expect Medicaid spending under managed care programs to increase by nearly $100 billion by the end of 2014.”   At least one critic has wondered about the wisdom of this purchase, based on two future possibilities: 1) if Romney becomes president and the GOP takes control of the Senate, then the Medicaid expansion in the PPACA might be overturned and 2) the Supreme Court ruling left the door open for GOP governors to refuse to participate in the Medicaid expansion.  Braly, of course, is the health insurance executive who stubbornly defended proposed 2010 premium increases in California that President Obama attacked during the debate over the passage of the PPACA. Anthem Blue Cross, a unit of WellPoint, attempted to increase premiums for individual insurance policies in California by an average of 25 percent, with some rates going up as much as 39 percent.

CIGNA has developed a new ad campaign “Go You” that focuses on consumers for the first time. The chief communications officer at CIGNA states, “’It is a shift, it’s an important shift.’”  In the past insurers addressed their advertising campaigns at wholesale business accounts, not individual consumers.   To bolster this consumer strategy, CIGNA bought Kronos Optimal Health to obtain their health coaches, health education programs, and lifestyle management systems.   CIGNA also spent $3.8 billion in cash to buy HealthSpring and its 340,000 Medicare Advantage participants in 11 states and its 800,000 member Medicare prescription division.  The company is also expanding their Medicare Advantage position in Texas and Arkansas ().

Humana, like Aetna and CIGNA, is concentrating on the individual health care consumer with television ads showing “a family reunion at a summer home, complete with giggling children, cooing grandparents, bonfires, and swimming at the lake.”  In addition to the consumer oriented ad campaigns, Humana has a new program that rewards members for losing weight or quitting smoking with points that can be redeemed for hotel reservations, electronics and clothing.

Humana’s Patient Centered Medical Home Partnership with WellStar Health System has seen decreased inpatient and emergency room expenses by 12% and 17%, respectively, and a decrease in emergency room visits by15%

On the mergers and acquisitions front, Humana has acquired Concentra, for $790 million in cash. Concentra provides occupational medicine, urgent care, physical therapy and wellness services at more than 300 medical centers in 42 states.   The insurer has also completed the acquisition of Arcadian Management Services, a Medicare Advantage health maintenance organization.

UnitedHealth Group was one of the earliest converts to evolving from a health insurance company to a health care data mining company.  As early as 2007 their subsidiary Ingenix bought The Lewin Group, a respected health policy think tank in Northern Virginia. A Lewin report in 2009 claimed to show that a public option would force 119 million Americans out of their private health plans and into the government sponsored plan. Although the Lewin report was shown to be faulty, the GOP used it to great advantage in excluding the public option from the final PPACA bill.

UnitedHealth Group has also been active in exploring private sector payment and delivery system pilots. Their Patient Centered Medical Home model provides primary care providers a prospective care management fee as well as a performance incentive payment.  Their ACO pilot with Tucson Medical Center includes a spending target based on three years experience by each physician group or hospital and shared savings and bonuses are given to those that meet their goals. United Healthcare is also experimenting with bundled payment programs with oncologists in Georgia, Missouri, Ohio, Tennessee, and Texas.

Whether these branding and advertising campaigns and payment and delivery system pilots will be successful is an open question.  An Edelman global survey about trust found insurers, banks, and financial service companies at the bottom of a ranking of 16 industries.  They found that corporate reputations were determined by high quality products, transparent and honest business practices, and how companies treat their employees.  They also discovered that when a company is distrusted, 57% of people will believe negative information when they hear it once or twice and only 15% of people will believe positive information.  Of all the players in health care, insurers routinely rank last in terms of consumer trust.  “They are among the most disliked industries in the United States.  The nature of the business is that they really are not that eager to O.K. every expense,” said Professor Regina Herzlinger of Harvard Business School.

Another expert, Fred Karutz of Silverlink Communications, thinks that health care insurance companies have a long way to go because they are new to the retail environment. “As people become consumers, they seek out value. In the group space, health plans could never hear the consumer scream, but in the retail space everybody can hear the consumer scream.”

The PPACA and the health care reform movement offer tremendous retail opportunities for health insurance companies.  There may be as many 30 million Americans seeking insurance through the exchanges.  There will be about 15 million Baby Boomers who will eligible to sign up for their preferred plan, Medicare Advantage.  The Medicaid expansion could cover as many as 17 million citizens, despite the reservations of many governors.

Whether health insurance companies can overcome the mistrust that many consumers feel and whether they can truly add value to a reformed system remains to be seen.  They might want to listen to Dr. Elliott S. Fisher, the ACO guru at Dartmouth:

“Their future is going to depend on their ability to demonstrate value to patients and to employers. No one any longer questions the fact that health care is unaffordable and that the current way we are doing business isn’t working.”

Patricia Salber MD, MBA (@docweighsin)
Patricia Salber, MD, MBA is the Founder and Editor-in-Chief of The Doctor Weighs In. She is also the CEO of Health Tech Hatch, the sister site of TDWI that helps innovators tell their stories to the world. She is also a physician executive who has worked in all aspects of healthcare including practicing emergency physician, health plan executive, consultant to employers, CMS, and other organizations. She is a Board Certified Internist and Emergency Physician who loves to write about just about anything that has to do with healthcare.


  1. “Give me Liberty, or Give me Death!” – Patrick Henry

    What a brilliant ruling by the United States Supreme Court on the affordable health care act (Obamacare). Stunningly brilliant in my humble opinion. I could not have ask for a better ruling on a potentially catastrophic healthcare act than We The People Of The United States received from our Supreme Court.

    If the court had upheld the constitutionality of the individual mandate under the commerce clause it would have meant the catastrophic loss of the most precious thing we own. Our individual liberty. Thank you! Thank you! Thank you! Supreme Court.

    There is no mandate to buy private for-profit health insurance. There is only a nominal tax on income eligible individuals who don’t have health insurance. This is a HUGE! difference. And I suspect that tax may be subject to constitutional challenge as it ripens.

    This is a critically important distinction. Because under the commerce clause individuals would have been compelled to support the most costly, dangerous, unethical, morally repugnant, and defective type of health insurance you can have. For-profit health insurance, and the for-profit proxies called private non-profits and co-ops.

    Equally impressive in the courts ruling was the majorities willingness to throw out the whole law if the court could not find a way to sever the individual mandate under the commerce clause from the rest of the act. Bravo! Supreme Court.

    Thanks to the Supreme Court we now have an opportunity to fix our healthcare crisis the right way. Without the obscene delusion that Washington can get away with forcing Americans to buy a costly, dangerous and highly defective private product (for-profit health insurance).

    During the passage of ACA/Obamacare some politicians said that the ACA was better than nothing. But the truth was that until the Supreme Court fixed it the ACA/Obamacare was worse than nothing at all. It would have meant the catastrophic loss of your precious liberty for the false promise and illusion of healthcare security under the deadly and costly for-profit healthcare system that dominates American healthcare.

    As everyone knows now. The fix for our healthcare crisis is a single payer system (Medicare for all) like the rest of the developed world has. Or a robust Public Option choice available to everyone on day one that can quickly lead to a single payer system.

    We still have a healthcare crisis in America. With hundreds of thousands dieing needlessly every year in America. And a for-profit medical industrial complex that threatens the security and health of the entire world. The ACA/Obamacare will not fix that.

    The for-profit medical industrial complex has already attacked the world with H1N1 killing thousands, and injuring millions. And more attacks are planned for profit, and to feed their greed.

    To all of you who have fought so hard to do the kind and right thing for your fellow human beings at a time of our greatest needs I applaud you. Be proud of your-self.

    God Bless You my fellow human beings. I’m proud to be one of you. You did good.

    See you on the battle field.


    jacksmith – WorkingClass :-)

  2. DealBook: Investors in Health Care Seem to Bet on Incumbent
    Aetna’s decision to buy Coventry Health Care is interpreted as meaning that Mark T. Bertolini thinks President Obama will get re-elected and that the ACA will not be repealed.


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