The growing number of partnerships between hospitals, outpatient care providers, and academic medical centers has been attributed, at least in part, to the healthcare reform initiated by the Affordable Care Act (ACA), which rewards hospitals for improving patient health outcomes and reducing healthcare costs.1 For example, under the Medicare program for accountable care organizations (ACOs), any reduction in cost growth (as well as any losses) will be shared with Medicare, depending on the quality-of-care delivered.2 These reforms represent a departure from fee-for-service models, which incentivize payment for a volume of services, to value-based models, which reimburse based on qualityof-care measures. In response to various incentives and increased efforts to reform, many hospitals and health systems have opted to partner to distribute the risk and resources, increase coordination of patient care, and provide higher-quality services.3
Hospitals opt for mergers and partnerships for several reasons. The ACA’s healthcare reform stresses the Triple Aim goals, introduced by the Centers for Medicare & Medicaid Services (CMS), of improving patient care quality and satisfaction, improving population health, and reducing costs.4 CMS planned to cut payment to hospitals with poor patient outcomes by 1%, from October 2014 through September 2016, a decision that affects approximately 14% of hospitals in the United States.5 To meet these demands, hospital administrators have been seeking to diversify their patient populations, upgrade technologies, and increase access to capital through joint ventures.
A joint venture is a partnership in which 2 parties share risks and profits, as well as administrative power, to innovate.3 Joint ventures are more flexible than mergers, with the parties remaining more independent. A merger is a partnership in which 2 parties combine, sharing assets as well as debts, for a competitive market advantage. Mergers and joint ventures allow participating parties to combine clinical and/or management strengths and gain greater geographic coverage, which increases access to more patients for federal reimbursement.3,6 Restructuring, similar to repurposing assets, is a natural consequence of joint ventures and could reduce excess capacity at the city level, which would further reduce costs.
An ACO is a group of healthcare providers and/or suppliers of services (eg, hospitals, physicians, payers) that voluntarily work together to coordinate patients’ healthcare to improve overall patient health and healthcare while reducing costs, in turn producing a more streamlined method of healthcare delivery.2 A 2012 joint venture between Piedmont and WellStar healthcare systems resulted in the Georgia Health Collaborative, which focuses on ACOs and innovative healthcare delivery. This partnership was much aniticipated in the state7 and allowed for the formation of a new insurance plan—Piedmont WellStar Health Plan (PWHP)—to accommodate the increased population coverage and Medicare recipients.8
Medicare Shared Savings mandates reporting of quality measures to receive payment as preventive health, as well as requirements covered by PWHP’s wellness program, including immunizations, disease screenings, and disease management improvements.2 The administrators of the respective organizations at PWHP believed that partnering would allow the companies to meet ACA standards for improving clinical outcomes at reduced costs, and offer a greater financial buffer for future healthcare reform.8 PWHP also emphasizes that joint ventures will allow for implementation of disease prevention and care management programs, with higher quality at lower costs, which is funded by the Prevention and Public Health Fund of the ACA.7,9 With this goal of improving the health of patient populations, this joint venture is paving the way for a care model centered on patients and healthcare professionals.
In addition to improving patient care, specific ACA provisions have encouraged hospitals to focus on the well-being of their employees.10 Before the ACA was passed, some employers had wellness programs (ie, preventive measure activities) in which participants were awarded for adopting healthy lifestyles.11 However, these programs were not standardized and did not need to produce measurable results to comply with federal standards. The ACA encourages implementation of employee wellness programs by establishing the Prevention and Public Health Fund, which includes other preventive goals of funding community health services and waiving preventive service costs (eg, immunizations, cholesterol screenings, flu shots).9 In 2011, $10 million in ACA funds was distributed by the US Department of Health & Human Services (HHS) to help establish and improve employee wellness programs. The ACA also mandated quality reporting from health insurers to monitor the programs’ effectiveness.
CMS’s final rule, “Incentives for Nondiscriminatory Wellness Programs in Group Health Plans,” outlines the types of wellness programs and their incentive structures.11 In 2013, the US Department of the Treasury, the Department of Labor, and the HHS issued a joint final ruling that further increased ACA provisions for employee programs.11 The final ruling categorized programs by their type of incentives: participatory or contingent on health. Participatory programs are focused mainly on education and health screenings, and rewards (if any) are not tied to participants’ health outcomes.
Health-contingent programs offer incentives for participants to improve health factors and are subdivided into action-only incentives (rewards are issued for enrolling in activities such as diet and exercise) and outcomes-based incentives (rewards are issued for demonstrating improvement in health-screening results). For the latter type, the legislation has increased the amount of outcomes-based rewards from 20%, set by HIPAA regulations, to 30% of the employer employee’s cost for the health plan. For programs with tobacco-reduction goals, the legislation increases ACA’s incentives to 50% coverage of healthcare costs. These increased efforts to fund preventive efforts have increased the development of employee wellness programs.11
Although leaders of hospitals and health plans cite many benefits to partnering and the subsequent development of health and wellness programs,3,7,8 there is controversy about whether these structures, supported by ACA reforms, benefit all related parties (physicians, employees, and patients) by lowering costs and improving healthcare quality. Joint venture and merger deals have engendered noteworthy antitrust disputes within federal and state courts because of posited anticompetitive effects.12 Some economic studies based on outcomes of heightened consolidation activity in the 1990s and early 2000s suggest that such concentration of the healthcare market will result in higher costs for patients.13,14
For example, in 2013, the Federal Trade Commission (FTC) blocked hospital mergers in Illinois and Ohio,3 and would have blocked the merger between Palmyra Park Hospital and Phoebe Putney Health System in Georgia if state legislations had not nullified the federal mandate.15 For health and wellness programs, an investigation of UMPC MyHealth,16 and a review by the RAND Corporation,17 have demonstrated varying significance of health benefits and are inconclusive on cost-effectiveness.1 Although the trend toward partnerships between hospitals and health plans is increasing, as is the consequent development of health and wellness programs, it is unclear whether this trend is positive or negative.
The ACA reforms have incited rapid growth of joint ventures and mergers, as well as health and wellness programs within the healthcare marketplace. However, evidence is inconclusive on whether these partnerships and wellness programs are contributing to the Triple Aim of improving patient care, improving population health, and reducing costs.4 Piedmont/WellStar emerged as a novel entity in the shifting healthcare environment. It is one of the first vertical partnerships in the country between a hospital and a health plan that implemented a reformed employee health and wellness program. This combination represents a unique opportunity to promote health and wellness.
The primary objective of our study was to examine the impact of ACA-related reforms on the development of health and wellness programs once a joint venture is established between a hospital and a health plan. The secondary objective was to summarize the literature on effective health and wellness programs and provide examples of successful joint ventures and mergers.
We conducted a review to identify successful joint ventures, mergers, and health and wellness programs. Journal articles, newspaper articles, press releases, and legislative reports were collected from PubMed, Galileo, EBSCOhost, and Google Scholar. Key search terms were “employee,” “corporate,” “health and wellness program,” “health plan,” “insurance plan,” “hospital,” “vertical venture,” “joint venture,” and “merger.” Details for individual partnering entities and wellness programs were obtained by searching hospital websites. Articles selected for review were published between January 2007 and January 2015.
Articles pertaining to joint ventures and mergers had to be published online, in the United States, between 2007 (in anticipation of the ACA) through January 2015 (first-year benchmark of Piedmont/WellStar, a joint venture employee wellness program). Articles were excluded from the review of successful wellness programs if they involved topics related to acquisitions, wellness programs not tied to insurance plans, patients and nonemployee populations, studies conducted in nonhospital settings, and articles lacking a report on health outcomes. ACOs formed outside of joint ventures or merger agreements were not included in this study. The bibliographies of the articles were reviewed, and cited sources were obtained if relevant.
Data collected and analyzed included partnership location, partnership type, population size, partnership date, and demographics and program outcomes of the health and wellness programs.
A total of 44 articles met the inclusion criteria. Analysis of these articles showed that the rationale related to risks and benefits of joint ventures associated with market consolidation and anticompetitive effects have changed since hospital mergers of the 1990s.18 In addition, growth in hospital prices has been declining over the past decade, from 5.8% in 2003 to 1.5% in 2013.18
The number of hospital joint ventures increased substantially in 2010 and 2011, which was attributed in part to preparation for the ACA reforms.3 According to a survey published in 2013 of 306 hospital referral regions, 60% of hospitals in 2013 were affiliated with health systems, representing a 7% increase over 10 years.1 The increase in joint venture and acquisition activity correlated with decreased demand for inpatient services, as evident by reductions in the length of hospitalization.18 According to a 2013 study by the Center for Healthcare Economics and Policy, from 2007 to 2011 there have been 245 hospital mergers, with the majority consisting of the acquisition of 1 or 2 entities.19 Of the 333 mergers, approximately 33% were reported to the FTC, and only 4 were challenged in court. Furthermore, joint venture and acquisition activity overall only involved 12% of hospitals, contrary to the perceptions of “mega-consolidation” within the healthcare market.19
Most joint ventures and mergers can be categorized as either vertical or horizontal partnerships.1,12 A horizontal partnership is a consolidation of businesses that provide the same service (eg, a hospital partnering with another hospital). By contrast, a vertical partnership is a consolidation of businesses that provide different services.1,13 For example, a hospital and a health insurer launching a joint health plan, such as Piedmont/WellStar, represents a vertical joint venture. Vertical joint ventures had been unprecedented before the recent healthcare reforms of the ACA, because of conflicting interests (eg, hospitals bill insurance plans for patients’ charges). However, the ACA reform’s incentives to reduce costs and offer accountable care have fostered this unique collaboration.
Examples of Successful Joint Ventures and Mergers
In addition to Piedmont/WellStar’s partnership, 7 other entities have formed vertical joint ventures or mergers (Table 1), including Mount Sinai Medical Center and Continuum Health Partners (New York City); MedStar Health and Southern Maryland Hospital Center (Clinton); Highmark Health Services and West Penn (Pittsburgh); Aetna and Inova (Northern Virginia); Health First and Florida Hospital (Florida); Dartmouth-Hitchcock, Elliot Hospital, and Harvard Pilgrim Health Care (New Hampshire); Anthem Blue Cross plus 7 California hospital systems (California); and Tufts Health Plan and Granite Health (New Hampshire).6,20-30 Kern Medical Center and Kern Health Systems may establish a vertical merger in California.31
Innovation Health represents a novel type of joint venture between a hospital system and a health plan, Inova and Aetna, respectively.24,25 The joint venture was launched to enroll members in North Virginia, allowing them access to local Inova providers and to Aetna providers nationwide. Payment reform from the ACA was given as a motivating factor to form this partnership: a unique health plan that aligns incentives among physicians, patients, the health plan, and the health system to improve quality and lower cost of care.29
The health plan follows the traditional fee-for-service model by charging premiums per enrollee, and it incentivizes value-based care by sharing cost reductions with physicians. The aim of this incentive is to reduce patient premiums long-term by aligning incentives with healthcare providers. Furthermore, the health plan believes that joint ventures will allow for an easier transition from fee-for-service to accountable care payment models, combining resources to invest in information technology and communication infrastructure. This venture has been active for 3 years and provides coverage to residents of North Virginia.29
Similarly, the merger of Highmark with West Penn, known as Allegheny Health Network (AHN), provided the basis for Piedmont/WellStar’s partnership and joint health plan.7,32 This Pennsylvania collaboration initiated the Accountable Care Alliance and, through this initiative, physicians from AHN’s 7 hospitals worked with Highmark to set new standards for patient care and safety, identify best medical practices, and upgrade technology to improve care coordination.32
Highmark based the AHN’s model for patient care on its patient-centered medical home program, a collaboration with a separate ACO, in which providers communicate and share responsibility for a patient’s health quality. The Accountable Care Alliance is expected to expand to include Highmark providers outside of AHN, which would increase patients’ access to providers and specialists. The joint venture has benefited both parties, with the West Penn Allegheny Health System recently reporting its first profit in 3 years.33
The most recent joint venture, Tufts Freedom Health, involves the 5-hospital health system, Granite Health, and an insurer, Tufts Health Plan, to administer Tufts Freedom Health Plan exclusively to New Hampshire residents.30 Leaders from both entities aim to provide greater care coordination and quality care, with Granite Health’s initiatives centered on improving health outcomes through shared data-driven population health management and administrative efficiencies and product innovation from Tufts Health Plan. Representing one of the innovative services focused on improving quality care, wellness-focused health plans have been launched for employees and patients.30
Reflecting the trend of integrating provider and payer, some hospitals are planning to start their own insurance plans for their patient populations, either by self-insuring or through partnering.20 A 2011 survey of hospital leaders demonstrated that 20% of the 100 hospitals surveyed intend to market their own insurance plan. In 2010, approximately 10% of community hospitals nationwide either owned or were part of health systems that owned health plans.20 For example, Florida Hospital had planned to launch its own insurance, but because of cost and time barriers, it was believed that strategically partnering with Health First Health Plans would be more efficient, reflecting the advantage of shared resources within a joint venture.23 This partnership and others reflect the increasing interest of hospitals and health plans in becoming more patient-centered service providers. Entities also recognize the importance of improving care through wellness programs.
In recent years, more companies have been providing employee health and wellness programs. According to a 2011 report of the American Hospital Association, 86% of the nation’s hospitals have an employee wellness program and are promoting a “culture of health,” involving leadership, incentives, 2-way communication, program diversity, and/or outcomes documentation.10 Most employee wellness programs target obesity and smoking,10,34 the leading causes of preventable death in the United States, and the greatest cost to insurers. Depending on the type of incentive (participation-based or health outcomes–based), employee participation rates and health outcomes vary.11
A literature review conducted by the US Department of Labor and the HHS, “Current Use of Wellness Programs and Economic Impacts,” supports (but not definitively) the belief that most such programs contribute to lowering insurance costs and improving employee morale and health.11 However, a RAND study showed that results from these programs (only 50% of which were evaluated formally by employers) produce negligible savings and health improvements: in a 3-year period, the average weight loss was approximately 1 pound per employee.17 A 5-year observational study of a wellness program examined by the University of Pittsburgh Medical Center (UPMC) involved a matched-control analysis of more than 4000 employees.16 Although results showed an increase in overall costs, the cost reduction for the high-risk groups was significant. The majority of employees maintained or reduced their health risks.16
Table 2 and Table 3 summarize several examples of successful hospital wellness and health programs, including Cleveland Clinic, Nebraska Medical Center, and Sentara Healthcare–Optima Healthcare. Although they vary in size and activities, their best practices for profitable wellness programs are similar and include risk stratification of employees, targeted interventions, substantial monetary incentives, and employeecentered care.35-38
Smoking cessation and physical activity are among the areas targeted. Sentara and Cleveland Clinic demonstrated improved health outcomes, as measured by lower health risks, reduced smoking rates, and screening values. Sentara and Nebraska Medical Center realized cost-savings through their wellness programs. The Sentara-Optima partnership reflects the strategic advantages of joint ventures; Sentara wished to build on Optima’s existing MyLife and MyPlan programs with added care coordination to form the Mission Health wellness program.39 The clinical and financial success of Mission Health is evidenced by its disease management outcomes and the high ratio of return on investment (ROI) of 6:1.39
Approximately 7% of hospital wellness programs surveyed by the American Hospital Association have measured their ROI, and less than 50% have measured health outcomes.10 Therefore, because most programs are less than 3 years old and lack ROI data, controversy still exists on the effectiveness of these programs in improving population health and reducing costs.18 However, the average ROI ratio of successful programs ranges from 2:1 to 3:1 compared with 3:1 in corporate settings.34 Notwithstanding the dispute on the effectiveness of these employee programs, to mitigate rising healthcare and program implementation costs, a trend within the hospital community links employee wellness programs with health insurance.10
Several case studies of joint ventures and mergers suggest that anticompetitive effects increase costs for comparable services but that overall the cost benefits of merging are dependent on characteristics of the hospital and the market.1 Moreover, it has been suggested that price analyses based on healthcare consolidations in the 1990s do not accurately apply to the current healthcare environment, which is marked by emphasis on the Triple Aim goals and the shift of health stewardship to the patient.18 Moreover, antitrust actions from the FTC have not been a barrier: less than 2% of reported partnerships have been challenged in court.18 The novel partnerships between hospitals and health plans that are now emerging are very different from the horizontal joint ventures that occurred before implementation of the ACA.
Most vertical joint ventures and partnerships have formed since 2011. For the novel entities, health outcomes data are currently insufficient to determine their effect on improving patient care, improving population health, and reducing costs, especially within the context of joint wellness programs.18 For 1 Triple Aim goal, that of improving patient care satisfaction, the American Hospital Association recommends engaging employees first, and then tailoring program incentives and goals.10 Within the value-based payment model, improving population health and reducing costs are aligned, achieving patient population-based health goals by targeting high-risk, high-utilization groups.
However, given this trend of increasing partnerships and rising healthcare costs, healthcare executives believe that joint ventures prevent hospitals from trading-off quality and services for cost reductions and risk of closure.7 Therefore, these partnerships provide a structure to achieve the Triple Aim of improved patient care, cost containment, and population health.4 If these entities can meet these goals, especially through demonstrating cost-savings and improved health outcomes, they will be rewarded for their innovation through the ACA’s value-based payment models that share risks and cost-savings among healthcare partners.
Although ACA provisions for Medicare Shared Savings have incentivized employee wellness programs, other federal programs, particularly Medicare Part D, currently do not reimburse for wellness or preventive health interventions. Accurate and detailed documentation of the cost-effectiveness of Medicare Shared Savings may encourage Medicare Part D to expand to wellness reimbursement based on the joint stakeholder incentives. If well-structured incentives from Medicare Shared Savings are tied to wellness outcomes, health systems could use this model for future wellness programs, and more healthcare practitioners (including pharmacists) could have more opportunities to participate in wellness promotion.
Before the ACA, some employers had wellness programs, but these programs were not standardized and did not need to produce measurable results. The ACA encourages improvement of employee wellness programs by providing funding for expanded health services and mandated quality reporting. The increase in compensation of health-contingent programs from 20% to 30% of wellness program costs reflects the shifting paradigm toward value-based care.11 Employee wellness programs have implemented more patient-centered interventions, including health portals, counseling on lifestyle choices, and prospective referral services for at-risk groups.
Successful workplace health and wellness programs have varying incentive structures, but all include monetary incentives and documentation of costs and/or health outcomes. The Mission Health and UPMC MyHealth programs support the belief that disease management programs and targeted wellness services for high-risk populations can result in substantial cost-savings. Therefore, focusing on a select group of high-cost patients and designing methods of documenting cost-savings at the start of the wellness program is a best practice for achieving lower healthcare costs. Corporate wellness professionals and health outcomes organizations recommend best practices to establish a wellness program40 and to generate and synthesize healthcare evidence for adequate cost-effective analysis.41 These recommendations should be followed for merged organizations to adequately assess health outcomes, produce adequate ROI, and determine the true health values realized from health and wellness programs.
For the initial stages of their new health plans, hospital executives state that launching reinvented employee wellness programs represents an opportunity not only to adapt to new federal quality-based incentives and penalties, but also to test the efficacy and cost-savings of these interventions before expanding them to their patient populations.8 Piedmont and WellStar’s partnership and joint wellness-centered health plan represent a model that addresses the Triple Aim of improved patient care, cost containment, and population health. Although most wellness programs currently allow access to only local employee populations, the potential expansion of Aetna and Inova’s Innovation Health and the alliance of Highmark and West Penn indicate a trend toward integrated patient care among providers and insurers on a national scale.
The combination of funding from the ACA to offset initial investment costs of a wellness program plus incentives from CMS’s value-based payment models to realign care models and document quality measures have incited innovation in employee wellness programs within vertical joint ventures and mergers. Although there are start-up costs for providing employee wellness programs, partnering entities foresee increased value in providing more health benefits because of the lack of detailed documentation and the novelty of the models identified (incentivized employee wellness programs and vertical joint ventures and mergers): the degree of benefits realized from these costs is yet to be determined.
Future research on wellness programs of joint ventures or mergers should include high-quality study designs that focus on the Triple Aim objectives. Patient-centered goals and focus groups should be elicited for continuous feedback on program designs. These studies should include matched-control and intervention groups, stratified by risk, to assess the impact of wellness programs, and primary outcomes should entail documenting costs as well as health outcomes. In addition, studies should demonstrate cost-savings from meeting Medicare Shared Savings quality measures and document the impact of healthcare professionals on quality care for reimbursement purposes. Such research would help expand value-based care models and foster new opportunities to promote health and wellness.
Author Disclosure Statement
Dr White is a consultant to Baxter, Keryx, Prium, and GVK Biosciences. Ms Vu, Ms Kelley, Ms Kuca Hopper, and Ms Liu reported no conflicts of interest.
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