8 N.J. hospitals partner with QualCare to offer tiered health care plans

By Anjalee Khemlani | July 14, 2017

Eight hospital systems have partnered with QualCare’s network to offer a tiered network health care plan for small groups, an often underserved sector for health benefits in terms of options.

The Community Care Network soft-launched at the start of this year using employees of a QualCare affiliated physician group MEWA, and includes a value-based arrangement with 13 hospital providers.

The eight health systems that are part of the plan include: Atlantic Health System, CentraState Healthcare System, East Orange General Hospital, Holy Name Medical Center, Saint Peter’s Healthcare System, St. Joseph’s Healthcare System, Trinitas Regional Medical Center and Valley Health System.

The idea has been in the works for more than a year, according to Dawn Clessuras, QualCare’s chief operating officer.

John Gribbin, CEO of CentraState, said the conception dates back about three years.

“We sensed in our community a need to help, particularly the small businesses and small employers with a few hundred employees and less, deal with a very chaotic insurance market,” Gribbin said. “These are employers who usually have some of the fewest options available to them, and they’ve been experience very high annual increases. And they have difficulty in dealing with the way that the market was hitting them so hard.”

And so, the plan was crafted and launched.

It offers small employers rates from a value-based arrangement for the eight collaborating health systems, as well as various benefit levels from a high deductible to plans with 100 percent coverage, Clessarus said.

In addition, if a member wants to utilize the broader network, they can do so at normal rates.

Sound familiar? It should. It has some aspects of the Horizon Blue Cross Blue Shield’s OMNIA health plan.

Gribbin said the new plan is focused on the unmet needs of a small group that needs options regardless of the fate of the Affordable Care Act at the federal level.

“The small group market has been hit really hard over the past few years, been very volatile. Since a lot of employers in our service area are characterized as small groups … it seems to work better in that marketplace,” Gribbin said.

So, why is QualCare, which has traditionally served as an administrator of health plans for the state’s hospitals and providers, pushing its way into the public sphere?

Holy Name CEO Michael Maron said it had something to do with a shift in the market. Some of the state’s largest health care players who have traditionally used QualCare are moving to other payers and ways to handle the health benefits for their employees, he said.

QualCare used to be owned by a number of hospitals and health systems, and a sort of tiered network did exist at the time. That network included lower costs to employees of each of the owners when the employees went for care at their own hospital or another owner’s hospital, Maron said.

“What QualCare didn’t do was turn around and sell that (existing tiered network) to other companies,” Maron said.

Though they are now, Maron said it’s too little late since it comes as a result of some of the health systems parting ways with QualCare.

But Clessarus believes the plan meets an unmet need in the new world of consumerism health care.

“When you start getting some of these narrow networks, and I think they are important to help lower the cost (of health care), we kind of went from one end of the spectrum to the other,” Clessuras said.

“We started with HMO plans way back in the 90s and merged into these PPOs where you can see whichever doctor you want to see and we are seeing the impact of that with the cost of health care. So, you kind of have to swing the pendulum back a little bit and say, ‘OK, you need to be a better consumer of care if you want your premiums and health care costs to go down, or not increase by double digit increases.’ “