To HMO or PPO, that’s the question. Orange County’s top health maintenance organizations experienced growth in the former and decline in the latter during the 12 months through July.
The HMOs are ranked on the Business Journal list by local membership. Ranked plans combined for 1.3 million local members, up 4% year-over-year.
One HMO plan and two PPO plans declined to submit enrollment figures; United HealthCare didn’t separate out OC numbers or HMO from PPO. The Business Journal estimated the membership of the remaining plans.
HMOs
Kaiser Permanente continues to lead the pack but with only a marginal gain, up 7,000 local members to 567,000. The self-contained integrated system—a health plan that bears insurance risk; a doctors group; and a hospital system—plans to drive down healthcare costs through technology, such as telehealth.
Executive Director of Kaiser Orange County Mark Costa told the Business Journal that use of its telehealth system has grown and that it plans to continue to expand the platform to provide patients with convenient, flexible access to care.
Services are available via telephone, email, video and text messaging. Kaiser said it plans to provide access not just to primary-care telehealth services but also specialty care services, its skilled nursing facilities and home health services. It said last year that it conducted over 133,000 video visits and over 8.5 million scheduled phone visits nationally.
• Anthem Inc., through its Anthem Blue Cross, continues to be the list’s No. 2 plan, followed by Blue Shield of California and Health Net of California Inc.
Third-place Blue Shield had significant increases locally—nearly 38% to 133,396 members—and nationwide—23% to 947,163. In June, the health plan announced a multiyear, $30 million technology initiative in collaboration with the California Medical Association. The plan is to develop technology to help independent doctor practices with administrative paperwork. The collaboration will start with pilot projects in Monterey and Butte counties.
• UnitedHealthcare fell one spot on the list to sixth, followed by Cigna Healthcare and SCAN Health Plan.
SCAN, one of the country’s largest nonprofit Medicare Advantage plans, is focused on keeping older people healthy and independent. Its offerings include programs and services targeting loneliness and isolation, which its research has shown is prevalent among seniors. More than 82% of seniors surveyed said they know at least one person who is lonely, and 57% said they wish they had more close friends in their lives.
Chief Medical Officer Romilla Batra said loneliness and isolation can have detrimental effects on mental, emotional and physical health. Socially-isolated seniors generate roughly $130 more per month in Medicare spending than those who are socially connected, according to a report from AARP Public Policy Institute.
• Aetna Health of California jumped two spots to fifth place, growing membership from 61,055 to 79,675. Its acquisition by retail pharmacy network CVS Health is scheduled to close this year. The $69 billion deal is intended to bring about more efficiencies, including a reduction in the cost of clinical care and emergency room visits by directing basic care needs to CVS MinuteClinic walk-in locations.
PPOs
The nine preferred provider organizations on the Business Journal’s unranked directory combined for a 908,184 local membership, essentially flat from a year earlier.
PPOs historically are more expensive than HMOs for users. The tradeoffs, however, include more options and flexibility on certain aspects of healthcare, including the right to see specialists without a gatekeeper primary-care doctor, as well as coverage of some elective procedures, such as weight-loss surgery, not covered by HMOs.
Beyond the binary system of HMO versus PPO, there are also exclusive provider organization health plans.
EPOs are similar to HMOs, as they don’t cover care outside of the plans’ provider network but are also much like PPOs in terms of flexibility, offering such member services as the ability to make appointments directly with specialists with no prior physician referral. EPO plans are typically cheaper than HMO and PPO plans but typically come with very limited provider networks and require 100% self-pay if members go outside the provider network.
• Irvine-based Cigna Healthcare’s membership decreased by 6.4% to 71,335.
