Getting Health Care Right for Tri-State Employers

Getting Health Care Right for Tri-State Employers

By Mark C. Clement, President & CEO, TriHealth, and Dr. G. Stephen Cleves, System Chief for Primary Care, TriHealth

Health systems carry a unique responsibility to the communities they serve – particularly to the businesses and employers who fuel our local economy. In addition to caring for patients, health systems are major employers themselves, and partners in keeping workforces healthy and productive. Just as importantly, health systems influence one of the biggest expenses on every company’s profit and loss statement: employer-sponsored health care benefits.

At TriHealth, we recognize and embrace this responsibility. It’s why more than a decade ago, we began making investments into the infrastructure and care models needed to lower costs, improve health outcomes, and deliver real value to the businesses that keep Greater Cincinnati working. Over the years, we have partnered with the Business Courier through podcasts and regular guest columns to share our work, including the impressive outcomes we have achieved for patients and employers. Through our Corporate Health Division, we also bring employer workforce solutions related to prevention, occupational health, fitness, wellness, behavioral health, and even mobile services directly to the worksites of the thousands of local employers with which we partner. But our Corporate Health services aren’t standalone offerings – rather, they are an extension of TriHealth’s population health model of care, where employees benefit from a connected, coordinated, and proactive system of care focused on prevention, early intervention, and life-long wellness. These are services that support the whole person, as an integral part of our work to Get Health Care Right.

As a result, TriHealth’s approach is helping local businesses keep their employees healthier and more productive while lowering their total cost of care. Where others have often eliminated these comprehensive corporate health care services, we’ve doubled down because we know it is the right thing to do for our patients and our employers. And the results speak for themselves. By focusing on prevention and early detection, better management of chronic diseases, and providing the right care in the most cost-effective setting, TriHealth has been able to reduce the total cost of care and is now 12 percent below Ohio state average. And that represents a savings to our community of more than $100 million each year!

These numbers prove that when systems take on the hard work of improving care coordination, shifting to prevention, and accepting real accountability for outcomes, including cost, the entire community can benefit. But for employers to experience the full value of TriHealth’s care model, it requires health insurers to do their part, too.

This time last year, TriHealth invited each major insurer to explore how we could collaborate to bring greater value to our organizations and to the patients and employers we jointly serve. We were disappointed that UnitedHealthcare did not engage in meaningful dialogue or help build a path forward to align incentives aimed at lowering cost and improving the health of our shared patients and members. Unlike other payers, UnitedHealthcare chose not to advance these conversations to meaningful changes.

Today, as we approach the end of our three-year agreement with UnitedHealthcare, we are experiencing the consequences of these early choices and a lack of meaningful engagement. At a time when partnership and innovation between insurers and health systems are needed most, UnitedHealthcare has chosen a path that is creating barriers rather than solutions. 

For example, their slow response time of more than 100 days to our good faith proposal for a contract renewal, a less-than-serious counteroffer, and no real effort to address indefensible denials and delays in payment do not reflect a commitment to a true partnership. Last year alone, UnitedHealthcare denied more than $40 million in claims for needed care that was provided to your employees and other members of our community through TriHealth and our physicians. While TriHealth vigorously challenged these denials on behalf of our patients and providers, it cost us millions of dollars and lost physician time to do so, and still resulted in long delays in payment and denied reimbursements. 

It is a disappointing response from an insurer that has repeatedly recognized our system as a high-performing partner. In fact, in 2023, TriHealth was recognized by UnitedHealthcare as one of the nation’s top Accountable Care Organizations for early detection, which is a core tenet of our population health care models and is critical to saving and extending lives!

TriHealth’s unique care models, which focus on early detection, health promotion, and providing care in the most cost-effective settings, delivered more than $5.7 million in medical cost savings to the 41,000 UnitedHealthcare members we served comparing 2023 to 2024. And in 2024, UnitedHealthcare members who received care through TriHealth saw total health costs – medical and pharmacy combined – that were 14 percent lower than the national commercial average.

So, our ask of UnitedHealthcare is simple:

• Pay us fair rates comparable to what other insurers are currently paying TriHealth and what UnitedHealthcare is paying other health systems. 
• Recognize the value our system creates in lower overall cost of care for employers, employees, and their families.
• Stop creating unnecessary barriers to care and wasteful spending on administrative hassles due to excessive and indefensible denials and delays in payment.
• Immediately pay the current $18.5 million in claims that have aged more than 90 days, including many of which are greater than two years old.

With a 170-year legacy of care in Cincinnati through Good Samaritan and Bethesda North Hospitals, TriHealth has proven our dedication to delivering high-quality, compassionate, convenient, and affordable care to every member of our community. In fact, last year, nearly 40% of Cincinnatians turned to TriHealth for their care. No matter the challenge, TriHealth remains steadfast in our bold commitment and vision to transform health care for the better. And we will continue to do this – for patients, families, employers, and insurers alike – by delivering better care, better health, and better value, all in the name of Getting Health Care Right for all those we serve. We call on UnitedHealthcare to join us in this noble and important work!