Healthy Signs of Success

Health New England has been moving up in the national rankings of health plans — all the way to No. 1 in one agency’s ratings for customer service. While such scores are generating headlines, it’s what’s behind the attractive ratings that constitutes the real story — specifically, the company’s strong focus on wellness, healthy communities, and strong growth, and not simply the bottom line.

Peter Straley says there are a host of quantitative methods for measuring the relative success of a health care plan such as Health New England — and by that he doesn’t mean the bottom line, but rather efforts to effectively serve clients.

There are numbers, and lots of them, said Straley, the company’s president and CEO, such as those awarded in national rankings of health insurance providers, and for HNE, they’re getting lower, which is the direction of choice in such matters. On Nov. 17, U.S. News & World Report, collaborating with the National Committee for Quality Assurance (NCQA), placed the company at number six out of 239 commercial health care plans; it ranked 11th three years ago and 9th in 2007. And in NCQA’s own annual report — the Quality Compass 2008 — Health New England was ranked No. 1 in terms of customer service among 160 health plans evaluated.

Meanwhile, there are some numbers that are rising — again, the desired trend — such as the totals for members (more than 100,000) and companies (more than 5,000) being served by the 22-year-old venture, and even in the number of physicians’ offices stocking a series of educational pamphlets, or comic books, created by the health plan.

They teach young people about everything from asthma to diabetes to the importance of weight control, said Straley, and they speak to the general operating philosophy that has enabled Health New England to score so well in those national rankings.

Summing it up, Straley said HNE has always focused on creating healthy communities — in every way that word can be defined — and not on the perceived role of an HMO, simply deciding what gets covered and what doesn’t.

“The true HMO was designed to take a holistic view of the person,” he explained. “It wasn’t about denying care or paying bills; it was about trying to engage you in what will make your life fuller and richer — which you can’t do unless you’re healthy, or as healthy as you can be.”

Overall, Straley attributed HNE’s success in the national rankings to its ability to listen and learn. In the case of the former, this means hearing from a host of constituencies, from individual members to business owners; from doctors to hospital administrators. And with the latter, it means observing what has worked and what hasn’t when it comes to health-plan administration and employing best practices.

In this issue, BusinessWest talks at length with Straley and others at HNE about why the company is turning heads on a national level, and how it certainly isn’t satisfied with the glowing approval ratings it has earned to date.

A Cover Story

Indeed, Pat Scheer, HNE’s Quality Operations manager, says the company wants to continue the current trend and do better than sixth in the next U.S. News/NCQA ranking. He and Straley believe that number will continue to fall due to the common denominator known as passion that they say permeates the company of some 240 employees.

These individuals, including Straley himself, know and live among the people they insure; this lack of corporate distance means feeling a personal responsibility for how well providers, employers, and consumers are treated.

“What differentiates HNE,” Straley said, “is that we really want to help people get the benefit of their health plan. Because, what’s your biggest fear? That something has just happened to you or a family member, and they’ll say, ‘oh, we don’t take that insurance here.’ We want to make sure that people are confident that, if they need their benefit, they’re going to get it. Because we’re going to see these folks on the soccer field or in the grocery store, we take it really seriously.”

It’s been this way since HNE was created in the mid-’80s amid concern from area doctors that Blue Cross’ new HMO would drain patients away from their practices—and potentially deliver lower-quality care.

A group of physicians collaborated with Michael Daly, then-CEO of the system now known as Baystate Health, and other administrators to integrate their own financing and delivery of health care through creation of a new HMO.

The result of that collaboration, said Staley, is that HNE remains sensitive to both the doctors providing the care and the employers who choose HNE for their employee insurance. “The ultimate goal is to provide high-quality health care,” he explained, “and we don’t think you can do that with a sledgehammer from either vantage point, because that’s been tried, and that’s failed.”

How these efforts to strike a needed balance and promote healthy communities become visible to the national organizations that rank health plans is another story — and Scheer’s bailiwick.

“Managed-care organizations have a choice whether or not to seek the NCQA accreditation or not,” he explained. “Back in 1991, HNE was actually the first health plan in the country to seek that accreditation level, and we’ve been accredited ever since.”

There are dozens of standards by which a health plan is judged, he said, including whether a company has a quality care committee; whether it collects data and how that data is used; how medical necessity is determined; how quickly a company responds to a patient appeal; and how the appropriateness of a provider is determined. The NCQA also asks for an additional 74 measures called HEDIS — the Health Care Effective Data and Information Set — as well as customer service surveys.

“It’s not something where we can say, ‘hey, everybody, NCQA is coming in three months, so get ready,’” Scheer explained. “They look back for a two-year period to be sure that you have quality-committee meetings. They say, ‘show me the minutes for the last 24 months. Show me that you’re taking action.’ There’s no possible way you can bluff anyone.”

All health plans are required to have the collection of their data audited, to make sure they’re adhering to the technical requirements. So while accreditation happens every three years, Scheer says documenting their efforts is a rigorous process that begins again the minute the current accreditation process is complete.

Well Done

Behind those attractive rankings are programs and operating philosophies grounded in imagination, innovation, and a commitment to the broad subject of wellness.

“I love wellness … it’s all about behavioral change, and doing what your mother said you ought to do all along,” Straley joked, adding that one of HNE’s successful wellness initiatives is that series of comic books that educate young people on health-related issues.

During their creation, the books were reviewed by medical personnel — and kids. The comic books have been distributed to pediatricians’ offices and offered to schools, and several have won National Health Information Awards.

“What we’ve found,” Straley said, “is that the pediatricians are doing a great job of explaining to mom and dad what the condition is and what the kids should do. And the kid is standing beside them getting some of it, but then they’re out on the playground and have an attack and wonder what to do.”

It’s an instance, he noted, where improving health care does not involve new science or treatment methodologies — just providing practical information in an accessible format.

It also means providing members with options, and plans specifically tailored for their changing needs.

Thus, in January of 2009, HNE will begin offering Medicare Advantage coverage for the first time. For people who are 65 and older, the Advantage plan allows them to remain within the system of their current HMO with Medicare coverage and the option to purchase additional benefits. On a day-to-day basis, the switch to some Medicare-paying benefits will be invisible to the consumer; they will experience the same health care package they had before turning 65.

“The individual who’s 64 years old and has our insurance through her employer is still the same person at 65,” said Straley. “She’s still seeing the same doctor. She still has the same issues. Nothing has changed.”

Enrollment levels in Massachusetts in Medicare Advantage plans are currently below the national average, but with HNE’s entry into the arena, that’s likely to change.

Meanwhile, HNE’s focus on overall wellness extends well beyond what would be considered traditional health care. Indeed, the company participates in the larger health of the community by supporting cultural institutions like the Springfield Symphony and museums, and helping fund and organize kids’ programs with the Urban League.

“Quality of life,” said Straley, “is not just are you coughing, but are you healthy physically, mentally, and spiritually?” It’s not just the right thing to do, he added — it also makes financial sense to support other businesses and the quality of life in Springfield and surrounding areas.

The company has become involved in the issue of homelessness for both reasons, helping raise money for a new resource center that will break ground next spring, eventually providing around-the-clock counseling, medical care, and other support services to homeless individuals.

“I think that it’s a failing of society when we don’t take care of people who are most in need,” Straley told BusinessWest. “This is not something you should blame people for — you need to provide help. But I’m also interested in economic development, and if we have people panhandling on the streets, it does not reflect well on Springfield.”

Turning again to the challenges being faced on a national level in caring for people’s health and well-being, Straley said HNE is already confronting the central issue that health plans will face as more people are insured: how to change the delivery of services to accommodate demand. “As you get more experienced, you literally can do more with less,” he said, offering an example: “If you do group information sessions rather than individual sessions, you’re dealing with 80% of the solution for 10 people all at once, and that creates capacity. There are pieces that you want to keep individual, but there are behavioral pieces that could be done differently.”

As a self-described “walking billboard for the company” (he often wears HNE logos), Straley expects people to approach him with questions. He listens, gives them his card, and says he’ll get somebody on it. It’s part of his belief that communication is at the core of the company’s success. “We try really hard to communicate clearly. We’ll try anything. We’ll write comic books! We’ll send you a memo! It doesn’t mean we’re always successful, but it’s the way you’d want a friend sitting across the table to tell you, ‘well, here’s how it works.’

“As you can tell, I’m so proud of what the people in this company do,” he continued, “and how connected they are to the communities that we serve, and just how passionate they are about not wanting to be the big, bad HMO the way the industry gets painted. We’re really different, and they care about that. We’re committed to what we do, and we know how important people’s health is. At the end of the day, if your health isn’t good, the rest doesn’t matter a whole lot.”

The Bottom Line

Returning to the subject of numbers, Straley said HNE passed the 100,000-member plateau two years ago, and has been enjoying steady, controlled growth since — a pattern he desires.

“I don’t want explosive growth,” he explained. “I want steady growth where we can manage the quality of the product we deliver.”

If one does that, he said, the numbers, including those in the customer service rankings, should take care of themselves.