Open access agreements bring patient choice

Springfield boasts two large health systems – Mercy and CoxHealth -– but for patients with private insurance, choosing which to use has long been an either-or decision.

Just more than a year ago, CoxHealth began bridging that divide, announcing in March 2011 that it had entered open-access agreements with two national managed care networks, Multiplan/PHCS and First Health Network.

Prior to the agreements, companies and employees enrolled in those networks were directed to Mercy providers or faced penalties – often in higher out-of-pocket costs – for going out of network. But now, with open access, that’s no longer a threat.

“They would’ve only had access to Mercy,” said Heather Swearengin, CoxHealth director of sales and business development. “This was just an opportunity to allow people to have an option (with) CoxHealth they didn’t have previously.”

When managed care first hit the health care sector in the 1970s, with the formation of health maintenance and preferred provider organizations.

Typically referred to as HMOs and PPOs, these groups connected patients to certain hospitals and doctors, with specific rules and regulations that limited choice and costs. In return, members paid less and doctors had steady streams of patients.

For example, New York City-based MultiPlan/PHCS and Bethesda, Md.-based First Health were both connected to Mercy, with similar plans, Swearengin said.

Patients have historically pressed networks for more personal choice in health care, however, and CoxHealth was answering that call, said Audra Lesly, senior director of CoxHealth Network, which negotiated the health system’s managed care contracts with Multiplan and First Health.

Swearengin said MultiPlan/PHCS had been willing to extend open access for some time. First Health had worked with CoxHealth until First Health’s parent company, Coventry Health Inc., bought Mercy Health Plans in 2010, and the contract had to be modified or terminated, she said.

Neither Multiplan nor First Health officials could be reached for comment, but Dr. Rob Steele, chairman of the board for Mercy Health Plans, said it was at that point that Mercy stepped in and allowed both contracts to change to open access. He noted that Mercy had been looking into open access for a few years.

“We felt that there was significant desire in the community to have access to both systems,” Steele said. “What we’re trying to do is to get to the endgame of health care and keep people as healthy as possible.”

Since the open-access plans have been in place, response has been positive, Lesly said. Though CoxHealth doesn’t track the number of people who have switched to Cox via the open-access agreements, she said it’s likely not a large number.

“We haven’t hit any big snags or hurdles,” Lesly said. “It does give us an opportunity to see patients we would not normally see.”

In a still-tepid economic recovery, employers have often had bad news for employees regarding their benefits, Swearengin said.

Those realities, however, can be countered by giving employees more choices through open-access plans, she said, noting, “That is something positive they can offer.”

Lesly said open-access networks often work with large employers with self-funded health coverage. She said the networks also will contract with other managed care companies that want to broaden their networks.

She noted, however, that plans with already-established networks in a given market aren’t likely to join open-access networks just because they become available in that market.

“They would use (open-access plans) for areas where they don’t have coverage,” she said, adding that open-access plans also are attractive to smaller carriers for network enhancement.

As an example, she pointed to Starmark, which is enrolled in Multiplan.

Lesley recommended that employers interested in open-access coverage should work with their brokers to figure out the best way to gain it, though she reiterated that it might mean having to switch health plans.

While open-access plans allow participants to choose between multiple health systems, patient fees are not necessarily equal, and Swearengin said costs will vary depending on the plans in which the patients are enrolled.

Lesly said CoxHealth has talked to other large payers about open-access plans and may forge new agreements with other networks in the coming months.

That’s welcome news to Mercy’s Steele, because it will help the local health care market to continue opening up.

“We’re hoping that there will be reciprocity,” he said. “We hope that catches fire.”