As managed care has become the dominant form of health coverage in the U.S., the practice of medicine has undergone an almost complete transformation. Today, in order to provide the highest quality health care in the most cost-effective manner, physicians must be fundamentally involved in health care cost management.
By its very design, managed health care works only with the support and cooperation of physicians. Primary Care Physicians (PCP) have particular influence over health care costs because they are often the main source of referrals to specialists and other health care providers. Appropriate use of PCPs in the role of coordinating care and managing referrals, in close cooperation with specialists, has proven to be the most effective method of providing high quality care at the most reasonable cost. The business strategy at Fort Wayne-based Three Rivers Medical Associates (TRMA) recognizes this fact, and realizes that given the opportunity, physicians will gladly manage costs and continuously improve quality, provided they have appropriate information, tools and support.
"I was a board member of the medical organization that was in existence before TRMA became an independent physician led group," says Date Sloan, M.D., Indiana Surgical Specialists, and member of both the TRMA Board of Directors and the Lutheran/TRMA joint Venture Board. "Over the years, I have learned a great deal about the insurance end of medical care. There have been many changes in the attempts to provide cost-effective medical care throughout the country. At TRMA, the emphasis has always been on providing cost-effective care, as well as how we can do things better for our patients and their physicians. Because we are not only board members, but also provide care for our patients, we have to live with the decisions we make. Our goal is to have Three Rivers Medical Associates recognized as the area's leading innovator in all aspects of the delivery of medical care. This should benefit all segments of the community - from the employer-purchaser of medical care through the patient who needs treatment."
TRMA, along with its hospital partners within the Lutheran Health Network, is poised to make this goal a reality in 2002 and beyond.
TRMA is a physician-owned organization comprised of 765 physician partners most of whom are also shareholders in the corporation. As shareholders, these physicians have a vested interest in the organizations' ongoing success, and realize the key to this success is the ability to provide quality health care services at a reasonable cost. Three Rivers Medical Associates functions as an Independent Physician Association, or IPA. As such, TRMA's participating physicians remain in their independent office settings while sharing the responsibilities of leadership for the organization. TRMA is unique in this market because it is the only IPA that continues to contract with HMOs on a fully capitated basis; that is they execute contracts with insurer(s) and accept a fixed monthly fee from the insurer(s) to pay all physician-related expenses. This responsibility is not taken lightly, and requires significant physician commitment as well as a high level of operational expertise in order to achieve a successful outcome.
"Over the past five years of my involvement with Three Rivers Medical Associates - first as a board member and now with the privilege of serving as its Board Chairman - I have been impressed by the commitment of my fellow physicians to this organization," says John S. Mohrman, M.D., a family practice physician with Brooklyn Medical Associates. "Both on a board and committee level, there has been consistent interest and participation in developing physician leadership skills in the many facets of the health care industry. I feel the community can benefit from the expertise of local physician involvement in health cost management, just as patients benefit from the strong medical care provided by the many doctors our group represents. We would like to continue to offer a local product that provides the total management expertise that northeast Indiana needs."
While TRMA's success is derived primarily from it's independence, a strong alliance and shared decision-making with the Lutheran Health Network via the Lutheran/TRMA, LLC joint venture has positioned TRMA group health products for future growth. While TRMA physicians have always worked closely with the Lutheran Health Network, this strategic alliance was significantly enhanced in November 2000 when TRMA's Board of Directors agreed to merge TRMA operations with the operations of the LutheranPreferred PPO network. The LutheranPreferred PPO is wholly-owned by the Lutheran Health Network, and is one of the largest PPOs in northeast
Indiana, with membership exceeding 60,000. Merging the administrative functions of TRMA's HMO operations with those of the LutheranPreferred PPO created a win-win situation for employers and patients.
"Integrating physician and hospital managed care strategies for these products has had a tremendous impact on our ability to help employers contain medical costs," says Paul Moss, CEO of Lutheran/TRMA, LLC. "The merger allowed us to identify new areas for creating efficiencies and savings that are then passed on to the consumer. Aligning our interests through the joint venture has provided significant flexibility in working with employers and payors in the development of innovative and cost-effective group health offerings."
By blending the strengths of the TRMA governance structure and physician oversight with the operating expertise of the LutheranPreferred PPO, the Lutheran/ TRMA joint venture is ideally situated to provide employers an array of group health products. Managed by local providers instead of large insurance companies, Lutheran/TRMA offers a potential winwin situation for employers and their employees. Primary Care Physicians, as coordinators of patients care and referral patterns, are uniquely qualified to enhance the quality of advanced care for their patients, while providing employerpurchasers of health care benefits with optimum savings.
The dominant goal of the Lutheran/TRMA joint venture is to increase the quality of health care while working with employers to contain the cost of providing medical benefits to their employees. Another significant goal of Lutheran/TRMA is to create efficiencies beyond those which insurance companies are usually willing to provide local physicians, in terms of the referral and credentialing processes. A hallmark of the Lutheran/TRMA organization has been its ability to decrease the "hassle factor" for physician offices by streamlining the credentialing and referral processes, thus allowing physicians more time to focus on patient care.
Lutheran/TRMA, LLC
The Lutheran/TRMA organization has evolved dramatically since the merger in November 2000. Numerous operational efficiencies have been identified and new processes implemented, all with the primary objective of being able to provide employers with a variety of cost-effective options from which to choose a group health plan for their employees. According to Paul Moss, CEO of Lutheran/TRMA, "Our intent is to effectively manage a variety of plans so that we can confidently say to an employer - no matter what your needs may be from an employee benefit or financing perspective, we can provide a plan that will meet your needs." Lutheran/TRMA currently contracts with two HMO health plans that can be accessed by area employers. Partners National Health Plan, an HMO with headquarters in South Bend, Indiana has provided group health benefits to area employers by utilizing the Lutheran/TRMA network for over ten years. Partners continues to be a viable option for employers seeking HMO benefits for employees. M-Plan HMO, headquartered in Indianapolis, has utilized the Lutheran/TRMA network since 1997 to offer area employers group health benefits. M-Plan continues to grow in this market, as its membership base with Lutheran/TRMA has more than doubled in the last two years.
The LutheranPreferred PPO is the flagship product of the Lutheran/TRMA network, showing steady growth since its inception in 1995. LutheranPreferred maintains a broad geographic presence in northeast Indiana, and has a large provider network of over 3,000 physicians and 38 hospitals in 28 counties. LutheranPreferred has a strong reputation for physician and member satisfaction, as well as for its ability to be offered within a variety of benefit plan designs and financing structures, while providing significant savings to the employer.
Three Rivers Medical Management
In order to maximize opportunities for enhancing the health care of Lutheran/TRMA patients, while ensuring costeffectiveness, TRMA provides medical management services to employers accessing the Lutheran/TRMA HMO and PPO products. This service is provided by Three Rivers Medical Management (TRMM), a division of the Lutheran/TRMA joint venture and is designed to evaluate and direct the costeffective and medically appropriate utilization of healthcare services delivered to those individuals covered by an employers health plan. Administrative oversight is provided by one fulltime, and two parttime local practicing TRMA physicians who serve as Medical Directors. Three Rivers Medical Management (TRMM) offers a variety of utilization management strategies to help employers control costs, while enhancing opportunities to improve the quality of care provided.
New Product Development
The Lutheran/TRMA joint venture has developed into an organization that is able to provide a variety of high-quality, costeffective group health options to employers. This is clearly evidenced by Lutheran/TRMA's ability to effectively manage and grow two HMO plans, as well as the LutheranPreferred PPO product in northeast Indiana. Employers are however always looking for new methods of controlling the increasing costs associated with providing health benefits to their employees. As a result of this interest, Lutheran/TRMA has developed a new product over the course of the past year, in partnership with Employee Plans, Inc., a local Third Party Administrator (TPA) that will provide employers with an additional option for offering group health benefits to their employees. Three Rivers Preferred is unique in this market in that it will be the only plan available to self-funded employers that provides a Physician Care Coordinator component, as well as an optional risk-sharing component in which Lutheran/TRMA essentially guarantees a maximum level of claims expense for the employer. These two elements are unheard of in the northeast Indiana group health arena, and are expected to generate significant interest among employers when this product is launched in June.
Solid management structure and sound business techniques have moved Three Rivers Medical Associates and the Lutheran/TRMA joint venture to the forefront in their ability to provide area employers with a variety of high-quality, costeffective group health options for their employees. Whether an employer finances health benefits on a self-funded basis, or they prefer a fully-insured option, the Lutheran/TRMA network can exceed their expectations by providing a plan that meets their needs for cost-containment and quality. "The wonderful and unique feature about the joint Venture partnership is that it is just that-an equal partnership between TRMA and Lutheran Health Network," says Michael Schatzlein, M.D., executive vice-president and chief operating officer of Lutheran Health Network (LHN), and a member of the JV Board. "I've been involved in the organization since TRMA's inception and from my perspective, I can tell you that this is a vehicle that we've struggled for over 10 years to build. Rather than either party having a controlling role, we've come together as equals. We're now poised to move forward into a whole new phase of costcontainment and quality improvement, to work together to provide better and more affordable healthcare for people in our community. That's unprecedented in this market."
