No matter what the Supreme Court rules on the federal law mandating universal coverage, here is what virtually all of the HealthPartners employees will have to start doing differently:


At HealthPartners, health care reform has been underway since well before a young senator from Illinois began his run for president.

HealthPartners in Bloomington enjoys a structural advantage that sets it apart. It has a medical care side of doctors, clinics and hospitals -- and a health plan side, too. In other words, it offers health coverage and delivers care with an eye on keeping costs in check. That's what the Affordable Care Act of 2010, whether you agree with it or not, was written to do.

HealthPartners' structure wasn't always that much help in the market, as historically one of the main functions of a health plan is to beat down prices for the services a clinic or hospital provides. Hard to pound yourself. But along comes the federal health law, and it was clear to most observers in the Twin Cities that HealthPartners was well-positioned for changes coming to the market.

Health care reform efforts share the common goals of increasing access and reducing the rate of cost growth. At the national level, most of the debate has been about access and coverage. The core argument before the Supreme Court, which is expected to rule this week, is about an individual mandate to carry insurance. There has been relatively little talk at all about cost and payment structures -- critical elements in the federal law or any reform initiative.

Ongoing work to slow growth in the "total cost of care" is what dominated my interview last week with HealthPartners CEO Mary Brainerd. She said HealthPartners is "absolutely" working within with the concepts outlined in the reform law that will pay providers for health and wellness rather than paying for more medical procedures.

In a nutshell, the Affordable Care Act authorized the Centers for Medicare & Medicaid Services to allow a hospital or clinic system to completely take over all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years. And then be held accountable financially for results.

That program is, as of today, only about Medicare beneficiaries, but the concept is clearly on its way to the Minnesota commercial market. HealthPartners is perfectly OK with being held accountable for the overall health of 5,000 folks, and the costs incurred to keep them healthy. So are Park Nicollet, Fairview Health Services, Essentia Health of Duluth, and Allina Health, which are all among the health care providers that are developing this accountable care model.

HealthPartners has an advantage because it is integrated in a way that none of those other systems are. If a provider like Fairview wants to be accountable for a population, it will have to figure out how to enroll those people, keep track of them, underwrite the group for anticipated claims, and so on. HealthPartners already does that in-house.

For Brainerd, moving forward has far less to do with structure and more to do with how HealthPartners has approached its day-to-day execution of improving total cost of care. She described a milestone moment at HealthPartners that predated the health reform law's passage by three years. It was when the organization adopted what it calls the "Triple Aim," meaning simultaneously improving the quality of care, improving the experience of the patient population and lowering the cost of care. The primary tool has been a pretty simple one, and that is the electronic health record.

Old-paradigm thinking, Brainerd said, is that a chart recorded what a physician did when a patient came in and was treated. Now, "we have all this information, and what should we be doing to support the health and well-being of a population?" she said.

HealthPartners has just crossed the 10 million mark in delivering lab reports over the Web. Sound trivial? No way, said Brainerd. If the doctor controls release of lab results, he or she owns that lab data. If the patient sees it first, then the patient is far more engaged with the data. And if HealthPartners plans to be held accountable for the health of a population, then it needs its patients to be far more engaged in their own health.

Another idea was to drop a decision-making guide right into the electronic health record when the doctor was ordering a high-tech screen. If they order a "low-utility" test, the system presents some better alternatives based on the data. That saved 7,000 scans in the first 12 months and since has been adopted by other care systems in Minnesota.

HealthPartners has about 1.41 million health and dental plan members in Minnesota and western Wisconsin, up from about 872,000 at the end of 2005. Its approach has been working, clearly, but Brainerd credited many other players for driving change in Minnesota, and including head-to-head competitors like Medica Health Plans and several of the care provider groups.

Brainerd also acknowledged that change in health care can be frustratingly incremental, and the best she could say about cost is that the growth curve is flattening. The cost increase trend for HealthPartners commercial members was 2.6 percent in 2010 and 3.3 percent in 2011. From 2007 through 2009 it was about 7.5 percent per year.

There is plenty of evidence that the old ways still linger. For example, physicians at HealthPartners are compensated in part on the basis of relative value units, a straightforward pay-for-production model that is procedure- and patient-volume-based. Will HealthPartners have to adjust compensation to better align staff with overall cost-of-care objectives?

"You have got to be able to live in today's model and still make change," Brainerd said. "We are on the borderline between the old system and the new."

Indeed, Brainerd said, Medicare needs to "get moving" on reforms, because Medicare patients are such a large part of any system's revenue.

"Eighty percent of our members now receive their care from a system that is paid at least in part on total cost of care," Brainerd said. "I don't know what I would call that," she added, pausing for a bit. "I guess I'd call it progress." • 612-673-4302