Health Co-op Offers Model for Overhaul
Stuart Isett for The New York Times
Dr. Harry J. Shriver III meeting recently with one of Group Health’s patients, Eleanor L. Riley.
Published: July 6, 2009
SEATTLE — As Dr. Harry J. Shriver III examined 70-year-old Eleanor L. Riley one recent morning, he seemed in no hurry. He asked about her phlebitis and her gall bladder, and whether her gout was acting up. They discussed her blood pressure readings and whether she was getting any exercise.
“I surprise my patients by asking, ‘Is there anything else you want to talk about today?’ ” said Dr. Shriver, chief of a clinic near Seattle run by Group Health Cooperative of Puget Sound. “They’ve never heard a doctor say that.”
Dr. Shriver has the time because Group Health, one of the country’s few surviving health insurance cooperatives, has recently embraced electronic medical records and a collaborative model of primary care, allowing him to practice proactive medicine for the first time in years.
On Capitol Hill, those innovations have made Group Health a prototype for a political compromise that could unclog health care negotiations in the Senate and lead to a bipartisan deal. After a month of brainstorming, including briefings from Group Health executives, the Senate Finance Committee seems poised to propose private-sector insurance cooperatives — instead of a new government health plan — as its primary mechanism for stoking competition and slowing the growth of medical costs.
But state officials say Group Health’s impact on holding down costs has been mixed. And its successes may have less to do with its governance — by a board that is elected by patients — than with its ownership of a vast network of clinics and specialty care centers.
Above all, Group Health’s physicians are paid a salary and can earn bonuses of up to 20 percent for high-quality performance. Unlike most doctors, who are paid by the visit or procedure, they have little incentive to churn patients through and order unnecessary tests and operations.
At Group Health, doctors are rewarded for consulting by telephone and secure e-mail, which allows for longer appointments. Patients are assigned a team of primary care practitioners who are responsible for their well-being. Medical practices, and insurance coverage decisions, are driven by the company’s own research into which drugs and procedures are most effective.
As Congress and the White House debate a national health care overhaul, many in Washington agree that one reason health premiums have grown at four times the rate of inflation this decade is a dearth of competition. In 40 of 42 states studied by the American Medical Association last year, the two largest health insurers claimed at least half of all enrollment.
The question is how best to invigorate the system. Republicans and some moderate Democrats are concerned that competition from a government-run insurance plan would eventually drive private companies out of business and leave government as the sole insurer.
If the bill now being finalized by the Finance Committee includes cooperatives, it could set up a confrontation with the Health, Education, Labor and Pensions Committee, which has written legislation to create a government plan along the lines of Medicare.
House Democrats also prefer a public plan, as does President Obama. But Mr. Obama has signaled that he might settle for cooperatives if it would gain Republican support for the broader legislation.
There is much about the Group Health model that Congress and the White House would like to replicate. Whether that requires a cooperative structure is open to debate.
A number of company officials acknowledged that it is Group Health’s ability to directly manage its doctors that really drives innovation. The cooperative structure’s primary contribution, they said, is to create a consumerist ethos that keeps the company focused on patient care.
“There’s a kind of accountability to the patients in our system,” said Scott Armstrong, president of Group Health. “And when you bring the principles of a cooperative to bear, patients feel responsibility for holding the system together and for their own health.”
But Carolyn A. Watts, a health economist at the University of Washington, said the cooperative structure made little difference. “In the end, it’s not about who owns the place,” she said. “It’s about the incentives.”
Technically, Group Health Cooperative was misnamed when it was founded by trade unionists and Grange members in 1947. Structured as a not-for-profit corporation, its revenues ($2.6 billion last year) are reinvested rather than distributed among members. But it is governed like a cooperative — and calls itself one — because its board consists of and is elected by members.
With 550,000 enrollees in Washington, Group Health is the smallest of three major insurers in the state, with a 9 percent market share. It often does raise premiums by less than its competitors, but that does not mean the increases have been insignificant. Annual increases for individual policies have averaged 12.3 percent since 2000, peaking at 24.2 percent in 2003.
Mike Kreidler, formerly a Group Health optometrist and now Washington’s insurance commissioner, said governance by consumers had sometimes translated into generous benefits. “They haven’t had the dramatic impact on cost in this market that you might have anticipated,” he said.
Group Health is a rare survivor among the hundreds of rural health insurance cooperatives that formed in the 1930s and 1940s in the face of fierce resistance from organized medicine. But there is a feeling in Seattle that it has endured only by becoming more like its competitors.
In the 1980s, it ended the practice of charging all enrollees the same premiums, regardless of their health status, and it has since introduced deductibles, co-payments and out-of-network benefits. Only seven-tenths of 1 percent of enrollees voted in the last board election.
Senator Kent Conrad, a North Dakota Democrat who first proposed cooperatives as a compromise last month, said the Finance Committee was debating how a national network might be structured and how much seed money would be needed for state and regional branches. Mr. Conrad has said it would take up to $4 billion, while others have projected $10 billion.
Mr. Conrad estimates that cooperatives would need at least half a million members, about the size of Group Health in its 62nd year, to wield meaningful leverage. That scale will be possible, he said, if the Democrats succeed in bringing tens of millions of the uninsured into the market by mandating coverage and subsidizing premiums.
But supporters of a public plan argue that it will be a challenge to form pools that large any time soon. They predict that cooperatives will become dumping grounds for the sickest patients, and that they will have difficulty forming networks of physicians.
“The idea that these things will spontaneously erupt all over the country is just completely a dream,” said Timothy S. Jost, a law professor at Washington and Lee University.
