The region consistently ranks among the top few on surveys of the nation’s most expensive health-insurance markets. Whether that’s due to the limited number of local medical facilities — which allows existing providers to maintain the increased rates they ask of insurers — or the higher operating overheads these facilities face due to the elevated cost of living, it’s likely some combination of both, and those expanded fees are in turn passed along to the insured by way of boosted premiums.
Adding to Summit’s health-care woes is the Colorado Division of Insurance’s (DOI) October announcement that the Colorado HealthOP, the state’s lower-cost, nonprofit insurance cooperative, would be forced to close its doors at the end of the year because it did not meet Colorado’s capital-reserve requirements. For background, the federal health-care law provided about $2.5 billion in solvency funding to 23 startup insurers nationwide, including a little more than $72 million to Colorado’s co-op. The guaranteed funding fell short, however, and consequently several of the nation’s cooperatives have had to fold.
The departure of the Colorado HealthOP leaves its more than 80,000 members statewide in search of new insurance plans with the turn of the calendar. Included in those losing their health care are approximately 1,500 full-time, year-round Summit County residents.
“It’s really disheartening because we were just starting to see progress with decreasing the number of uninsured,” said Tamara Drangstveit, executive director of the Family and Intercultural Resource Center, or FIRC. “Now that the HealthOP is no longer available, it will most likely mean an increase in uninsured again — and certainly in underinsured.”
Among the many community services it provides, FIRC offers free health-care enrollment assistance to residents, answering questions and helping them with the sign-up process for the state’s Health Insurance Marketplace as well as with Medicaid and Colorado Health Plan Plus (CHP+) eligibility for qualifying low-income families. FIRC cannot make recommendations of one health-care provider over another, but Drangstveit noted that of those residents who came through the organization for the standard health-care exchange, about 95 percent chose the state co-op because of its affordability.
“For most of our clients, the bottom line is definitely cost,” she said, adding that the consistency of care within the network and familiarity with their physicians is another key factor that weighs heavily on their decision for a provider. But with the cooperative now required to exit the exchange at year’s end and insurance costs in the area continuing to balloon, these low-income residents will have little option outside of the cheapest alternative, which is currently Kaiser Permanente
Even with potential subsidies, “there’s no choice in our market, really on that end of the spectrum,” Drangstveit said. “The only plan that’s remotely affordable is Kaiser.”
Kaiser is new to Summit County. The Oakland, California-based insurance provider has Colorado’s largest nonprofit health-care plan and will officially begin services for the mountain communities Jan. 4 of next year with the dual openings of facilities in Frisco and Edwards.
Both the Frisco location — in the Basecamp retail center at 226 Lusher Ct., across from the Whole Foods Market — and the one in downtown Edwards will start with a single permanent primary care physician, with rotating specialists from within the provider’s network of 1,100 doctors and “virtual care” video visits. Kaiser also plans to add permanent physicians down the road, as the community’s needs and requests warrant, in hitting its long-term membership target of upwards of 10,000 at each location.
The new provider has also been touting a recent deal it struck with Colorado Mountain Medical in Eagle County to offer expanded coverage through CMM’s staff of 30 medical practitioners who comprise some specialists and urgent care offerings, with offices in Vail, Edwards, Eagle and Basalt. That’s in addition to relationships already in place here in Summit with Dr. Christine Ebert-Santos, a pediatrician in Frisco, and Dr. Andrew Catron, an OB/GYN in Breckenridge at the Swan Mountain Women’s Center, and contract discussions ongoing with other physicians.
“Our mission is to bring down the cost of care,” said Brent Bowman, Kaiser’s executive director of Colorado’s mountain service area. “So that is going to be our kind of uncompromising position as it relates to our partnerships.”
The agreement both residents and health insurance experts are concerned about, in the meantime, is the lack of one between Kaiser and the county’s only emergency facility, St. Anthony Summit Medical Center in Frisco. It means that until an accord between Kaiser and the Centura-run hospital is reached — and at least for now that remains a big ‘if’ — a current or potential Kaiser patient is immediately on the hook for their entire deductible were they to suffer an injury of some significance, say, on the ski hill.
On Colorado’s health exchange, Connect for Health Colorado, Kaiser’s nine current plan options for Summit County are offered with a sliding scale of deductibles up to $6,000 and an annual maximum out-of-pocket expense of $6,850 for an individual. While the premiums associated with those plans are generally less expensive than packages from competitors such as Anthem, Cigna or Rocky Mountain, that still makes for a hard pill to swallow in terms of what happens to someone insured through Kaiser and has no choice but to take care at St. Anthony in an emergency.
Consider, as FIRC’s Drangstveit pointed out, many who choose the Kaiser plans are doing so strictly based on the affordability of the premiums for those plans, and that would be a notable financial liability for someone already in the low-income bracket and who selected a high-deductible, low- (relatively speaking) premium catastrophic plan. That’s already on top of her estimate that Kaiser premiums are still about a 20-percent increase from the Colorado HealthOP versus one of between 30 and 40 percent with all other plans.
At this time, it’s a tradeoff between cost and convenience, noted Bowman. And unless a Kaiser patient wants to pay extra to stay local — or what specialty care they need is not offered through Kaiser’s new primary care facilities nor with partnerships like CMM or another nearby supplemental relationship — the insured will have to make the trip to Denver. In the interim, Kaiser said it will foot the bill for its expanding Summit County membership — currently about 100 total but almost certainly to increase once Jan. 1 rolls around — to be transported back and forth, including overnight hotel stay for the patient and a caregiver.
Other local providers still say it’s a matter of “buyer beware.”
“A lot of people out there don’t know how to fully evaluate insurance,” said Chip Webb, CEO of Vail-Summit Orthopedics, which does not presently have a deal in place with Kaiser. “I’m not anti-Kaiser, but I worry, and my main message is that when people start searching on the exchange, look at the network because it’s important to understand what’s available in the community.”
“I cannot afford the liability associated with enrolling any insurance product that does not have proper contracts in place to handle patients,” added longtime insurance broker Stacey Gilbert of Denver Tech Insurance, “whether it’s M.D.s or hospitals missing from the provider list.”
For its part, Englewood, Colorado-based Centura, which also has a large presence in Western Kansas, said it’s also doing its part to lower insurance costs throughout the mountain community. However, it said that partnership discussions have not been held with Kaiser for between 10 and 12 months.
“It’s been many, many months,” said Mark Carley, Centura’s vice president of managed care and risk products. “We are not aware of any current interest by Kaiser to discuss and potentially formalize an agreement between Kaiser and St. Anthony Summit Medical Center. I haven’t received any inquiries or telephone calls asking for discussions.”
There is precedent for an agreement between Centura and Kaiser, of which one is presently in place in the Southern Colorado communities of El Paso, Pueblo and Freemont counties. Carley says Centura is still open to the idea of working with Kaiser on a mountain pact, but, when the initial conversation about it began, Centura made two requests: that Kaiser keep as much care as possible local instead of transferring patients to the Denver-metro area and use community physicians and clinicians already established in order to limit the number of Kaiser employees it would bring into the county.
At the time of these collaboration talks, Kaiser did not commit to the two stipulations, and so, for now, Centura has instead focused on other strategies with the aim of St. Anthony Summit Medical providing “viable, appropriately-priced” health-care offerings to the local community through different insurance carriers.
Kaiser continues to unfurl and introduce its mountain health-care plans and long-term blueprint, first focusing on individual and small group plans before making a stronger push into the larger group plans starting in 2016. With no new agreements in place for the time being, that means many will have to drive to Denver for specialty-care needs.
Bowman acknowledges he understands in some cases the trek to the metro area is not the most desirable, but that claims data show between 30 and 40 percent of care received by Summit County residents already occurs in Denver. Additionally, what Kaiser insurance looks like for mountain communities on Day 1 will likely be much different than down the road.
“Ideally, we’d have had contracts in place six months ago,” said Bowman. “We know that in the early stages that this might not be set up as the ideal state would be. We’re continuing to try to expand our network of choice, but in an affordable way.
“If we can bring down the cost of care over time,” he added, “we’re going to be successful, and I think our membership growth will reflect success in those areas.”