Medicare Advantage plan run by doctors

Essence coverage bypasses insurers

By Patrick Howington
The Courier-Journal

Doctors often say health care would be better if insurers didn’t interfere in medical decisions. Now some Louisville and Lexington physicians have a chance to prove it.

They have designed and will run a Medicare managed-care plan, Essence, that will start providing coverage Jan. 1. It is enrolling members now and has signed up more than 700.

Essence’s plan stresses preventive care and low out-of-pocket costs for members. There is no monthly premium other than the standard Medicare Part B charge, $96.40 for most people. Co-pays for office visits are $5, and the plan pays to transport members to 10 doctor visits a year.

The plan has the second-lowest member costs among the more than 30 Medicare Advantage plans in the Louisville area, behind a plan offered by Louisville’s Humana, according to estimates by Medicare.

Despite collecting relatively little from members, Essence will pay participating doctors more than other Medicare plans do, said Dr. Greg Ciliberti, a Louisville internist who helped design it.

That will be possible because the emphasis on preventive care should keep members from developing illnesses requiring more expensive treatment, he said.

“Having practiced medicine 22 years, I can tell you — the best care you can get … is preventive care,” Ciliberti said.

Essence is available to residents of Jefferson, Bullitt, Fayette and Woodford counties in Kentucky and Clark County in Southern Indiana.

Essence Kentucky, the organization operating the plan, is part of St. Louis-based Essence Healthcare, founded by a physician group in 2003.

The company offers only Medicare Advantage plans, an alternative to traditional Medicare. The federal program pays Medicare Advantage plan operators — typically insurers such as Humana — to cover members. Plans must meet certain quality and reporting requirements.

Debra Gribble, president of Essence Healthcare, said the St. Louis physicians were tired of “hassles” from insurers that operate Medicare plans — for example, having to get approval before doctors could provide certain drugs or services to patients.

The physician group decided to “basically cut the big insurance companies out of it” and deal with Medicare directly, Gribble said.

The Kentucky plan has fewer than 1,000 primary-care doctors and specialists in its network of providers, according to Medicare’s Web site. That is fairly low compared with other Medicare Advantage plans, but that’s by design, Gribble and Ciliberti said.

They said Essence only wants primary-care doctors who will aggressively pursue preventive care — for example, by calling patients who haven’t had regular exams or prescribed treatments.
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