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The once-plentiful population of health plans owned by physician groups, hospitals or integrated health systems has dwindled steadily in the last decade. The demise of those plans has continued with acquisitions by larger plans over the last year, experts say.

No one has specific numbers on the rate of consolidation, except to say that new physician- and hospital-owned plans are not popping up to replace those that have been bought.

Large plans, both for-profit and nonprofit, have been eager to buy up health plans that hospitals and medical groups are ready to sell.

There are good reasons for that eagerness, said Peter Kongstvedt, MD, author, professor and managed care consultant based in McLean, Va. "The larger the acquisition, the more time it takes and the more it costs."

Dr. Kongstvedt added, "Smaller provider-owned plans do not command a high price."

Large plans also know that hospital and physician-owned plans sometimes have a hard time competing with them and therefore make good targets for acquisition.

"You need the scale, you need a lot of things to get by to build the capital ... to be able to provide the service," said Humana Chief Financial Officer Jim Bloem. "These kinds of increasing challenges give smaller plans ... the impetus to take a real look at the economics of the plan, the relationship of the plan with other entities they might own."

Experts say the reasons hospital systems and physician groups are ready to part with their insurance business include state regulations requiring large reserves, patient preference for large networks, and limited resources for marketing that would allow the smaller plans to compete with the national giants.

A recent example of the continuing trend of smaller plans being gobbled up by larger plans came in October, when Coventry Health Care, based in Bethesda, Md., purchased Preferred Health Systems, a health plan owned by Wichita, Kan.-based hospital group Via Christi Health System. If approved, the merger would add about 120,000 people to Coventry's current membership of 5.2 million. Terms of the deal were not disclosed.

Pam Carbiener, MD, a Daytona Beach, Fla., ob-gyn, was on the board of commissioners for Halifax Health at the time its Florida Health Care Plans subsidiary was sold to BlueCross BlueShield of Florida in August 2008.

She was torn, she said, because as a clinician she worried about losing a physician-friendly, patient-centered, local health plan. Eventually, she came to believe that the hospital needed to sell the health plan to remain financially healthy. The $85 million deal was finalized in January.

Physician- and hospital-run plans are challenged with keeping down medical spending while the practices and facilities need patient volume. A.M. Best found the median medical loss ratio for a physician- or hospital-owned plan was 89.3% in 2007, an increase of 3% since 2004, and higher than the overall health insurance market.

"It's hard to take off one hat and put on the other," said Linda McMullen, director of medical economics and associate general counsel at the Florida Medical Assn. "You're member-benefit driven, so you're trying to say 'yes' to members, but trying to run a business on the other side, saying, 'We've got to raise your premiums by 25%.' "

Beating the odds

There are some plans, however, that are not only surviving, but look to be thriving.

For example, Hometown Health, the insurance arm of Reno, Nev.-based hospital system Renown Health, has turned away interested buyers. Even in the midst of a recession, the plan has kept up its market share with about 120,000 members, said Ty Windfeldt, director of sales and service.

He said Hometown Health has done well by offering the same things larger plans do, including wellness programs and sophisticated claims reports for employers, but has combined it with customer service anchored in local relationships.

"Rates are one thing; rates drive the main decision, but the premiums employers are paying are so substantial, they're demanding they get a certain level of service and quality," Windfeldt said.

The print version of this content appeared in the Nov 9, 2009 issue of American Medical News.

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