CoxHealth: A Case Study in Launching a Co-Branded Medicare Advantage Plan

Solution Snapshot


$1.3 billion, five-hospital system in the Midwest with an integrated physician network


  • Differentiate the system in a highly competitive market
  • Focus on MA as part of a population health strategy
  • Engage physicians in developing value-based care capabilities


  • Launched a successful co-branded plan: CoxHealth MedicarePlus garnered 14 percent market share in its first year
  • Exceeded target contract performance across quality metrics
  • Reduced unnecessary medical costs
  • Completed over 60 percent of target Enhanced Encounters®
  • Implemented a multi-pronged physician engagement approach


  • Lead with an MA strategy derived from a proven model. Partnering with a collaborative payer can support the transition to value-based care delivery and mitigate the upfront risks of starting a new plan.
  • Communicate the strategic value of change to align stakeholders. Everyone—from the leadership team to the physicians—needs to understand how value-based care impacts them.
  • Align a strategy with a collaborative partner. Health systems moving to value will benefit from a strategic operating partner who can guide their organization to develop value-based capabilities.

Download the full case study.

The Challenge

CoxHealth is a five-hospital system with an integrated physician network in southwestern Missouri. Like many other health system leaders, CoxHealth leadership faced several challenges:

  • Understanding how internal and external factors—regulatory, market and organizational—impact the system’s strategy;
  • Maintaining market share in a highly competitive market;
  • Building a sustainable care delivery and business model for population health management; and
  • Retaining an engaged physician network and rewarding necessary behavior changes.

The leadership team decided to focus on Medicare Advantage (MA) as part of its value-based care strategy. To proceed, CoxHealth had to evaluate the option of launching its own provider-sponsored MA plan or partnering with a collaborative MA payer. In the end, the system chose to enter into a value-based MA contract as a vehicle to catalyze the move toward a population health model.

To be successful in value-based care delivery, physicians need the right tools, information and incentives to provide high-quality care. However, guiding physicians through the change is just as important strategically as it is tactically. As CoxHealth learned, clearly communicating the vision and strategy is crucial to aligning leadership, physicians and patients within this new model of care.


“CoxHealth knew that in order to achieve success in launching an MA plan in a very competitive market, we had to find a collaborative partner that would allow our health system to alleviate some risk, while focusing on what we do best—care delivery.”

– Steven Edwards, President and CEO, CoxHealth


The Solution

In evaluating potential partners, CoxHealth turned to Essence Healthcare, operated by Lumeris. As a long-term operating partner, Lumeris powers Essence Healthcare by providing value-based care services and technology to enable a collaborative payer-physician model that drives improved healthcare outcomes.

CoxHealth could now partner with Essence Healthcare (enabled by Lumeris’ operational infrastructure and expertise) to execute its MA strategy, as described in the following activities:


  • Design and launch co-branded plan:
    • Launch CoxHealth MedicarePlus, a narrow network HMO with rich member benefits; and
    • Institute PCPs as the gatekeeper for managing care.
  • Implement a value-based contract and physician engagement:
    • Identify a subset of PCPs to initiate engagement;
    • Implement a full risk, value-based contract for the system;
    • Employ a stair step contracting methodology to support physicians moving to full risk contracts, focusing on cost and quality targets;
    • Recommend new internal physician compensation model;
    • Train physicians and care teams on The Nine C’s;
    • Provide access to Continuing Medical Education (CME) courses and physician boot camps to help physicians learn key behaviors and concepts for delivering value-based care; and
    • Mentor clinical leadership.
  • Perform differentiated payer operations that support physicians:
    • Manage core health plan operations (e.g., claims processing, medical and pharmacy management, sales, marketing, enrollment, customer service); and
    • Implement a variety of programs that more effectively leverage the provider network.
    • Implement clinical programs using actionable information:
    • Deploy the Accountable Delivery System Platform® (ADSP), a payer-agnostic platform that provides 360-degree visibility into patient and population level information;
    • Provide dedicated analytical and clinical resources for identifying improvement opportunities;
    • Develop a centralized Care Management team to support population health activities; and
    • Launch the Enhanced Encounter® program to engage physicians in understanding revenue management.

Benefits of a Lumeris Operating Partnership

+ Excellent quality ratings with 4.5-5 Stars for the last six years

+ Existing payer infrastructure through Essence Healthcare, including subject matter expertise, CMS and state licensure with the associated capital requirements, regulatory functions and operational efficiencies

+ Knowledge of the MA market and consumer trends

+ Robust physician engagement programs based on the Accountable Primary Care Model–The Nine C’s®

+ Actionable information for managing patients and populations in the ADSP

+ Supportive clinical resources to aid physicians in managing appropriate care

+ History of collaboration to enable physician-led success


“As physicians, we want to make a difference in the lives of our patients. Lumeris’ training and education in value-based care delivery has been invaluable in helping us achieve that goal.”

– Dr. Julia Flax, MD, CoxHealth

The Outcomes

CoxHealth launched its co-branded product in January 2015. To date, the organization has demonstrated strong results and continues to perform highly as it builds its capabilities for value-based care.

Lumeris seeks to enable its partners to achieve the Triple Aim +1™ One: better health outcomes, lower unnecessary costs and improved patient experience plus physician engagement.


Unprecedented Enrollment Growth
CoxHealth’s co-branded product exceeded growth expectations upon launch. During its first Annual Enrollment Period (AEP), the plan exceeded its membership projection by 300 percent. In its second year, the plan grew from 14 percent market share to 22 percent, becoming the second largest plan in the market and displacing several national MA payers (Graph 1).


Graph 1: Enrollment. CoxHealth MedicarePlus enrollment grew rapidly during its first years in the market, exceeding expectations and displacing entrenched market players.


Improved Quality
CoxHealth exceeded target contract performance across a variety of metrics, and improved the quality of care for its MA patients, as illustrated in Figure 1.


Figure 1: Improved Quality.CoxHealth demonstrated immediate quality improvements across a variety of metrics in the MA population.

Reduced Unnecessary Costs
In its first year, CoxHealth outperformed its target Medical Cost Ratio (MCR) prior to surplus distribution by 4 percent and reduced leakage by more than 25 percent between 2015 and 2016. In addition, the system continues to demonstrate improved medical expense management (Graph 2).


Graph 2. Reduction in PMPM costs. CoxHealth continues to demonstrate cost improvements over time.

Ongoing Revenue Management
CoxHealth continues to drive accurate documentation and coding with the Enhanced Encounter Program. Physicians have already completed 65 percent of the target Enhanced Encounters and anticipate achieving their target of 70 percent (Figure 2).


Figure 2. Revenue Management. The Enhanced Encounter program has helped CoxHealth physicians more accurately document and code their patient population.

Engaged Physicians
Enabling physicians to succeed in accountable care was a core strategy for CoxHealth. These key elements cannot be overlooked when guiding physician transformation (Figure 3):
  • Multi-pronged clinical leadership and education;
  • Accountable primary care focus; and
  • Care team resources and processes adapted for value-based care.


Figure 3. Physician Engagement. Keys to success in enabling physicians and care teams.

“This partnership aligns with our strategy and was our first step toward value-based care. In our quest to continue being a top-performing system in the market, we have now begun to develop the right capabilities, infrastructure and behavior changes to drive success.”

David Raney, Vice President, CoxHealth Network