The health care business in Florida and across the nation is the midst of monumental change as insurers, hospital chains and even retailers begin to venture outside their traditional roles. Hospitals are getting into the insurance end of the business. Insurers, along with drug stores, are delivering front-line health care. And consumers, confronted with blurring lines and a host of new options, may need a scorecard to keep up. The shifting ground continues to change where and how they go to the doctor. BayCare, which operates 15 hospitals in Tampa Bay and the surrounding area, next month will become the second health system in the state to sell Medicare Advantage plans, the privately offered insurance policies through which many people receive their Medicare benefits. Two other chains, Florida Hospital and Orlando Health, are providing HMO insurance plans to thousands of Disney employees this year, with hopes of expanding the model to include other employers. Meanwhile insurance companies, from Florida Blue to UnitedHealth, are gobbling up physicians practices and creating large networks of doctors offices that offer clinical services under new company banners. And retailers like CVS and Walgreens continue to push more toward the front lines of health care, offering online doctors’ visits and an expanding list of other medical services. It all adds up to an industry in the middle of a shake out, executives and experts say, with players on all edges trying to stay relevant by expanding what they do. "This is a trend that’s been emerging over the last five years," said Peter Young, a hospital consultant. "It’s increasing each year as providers discover that they need to move up the food chain." Driving many of the changes is the Affordable Care Act, which helped usher in a shift in thinking about the cost of health care. Hospitals are penalized more often by insurance companies and the government when patients have more frequent stays. The focus now, Young said, is keeping patients out of the emergency room. "What we’re seeing is that ER visits are flattening or declining all over America as health systems begin to focus on prevention," he said. "They are redirecting non-emergent people to urgent care, and urgent care is perfect for that. That’s also why you see CVS and Walgreens getting into and expanding their clinic business." PREVIOUS COVERAGE: The future of Tampa Bay hospital care looks a lot like Apple and Amazon Young and other experts described a health care landscape that is changing rapidly to keep up with population growth, new technology, government rules and evolving patient preferences. "We’re designing everything around the patient," said Dr. Peter Schoch, senior vice president of population health for Florida Hospital. "Patients don’t want to get multiple bills they don’t understand, or have to get permission to be seen by a specialist. It really doesn’t sound that strange when you put it in those terms." • • • At the Florida Blue Center on Westshore Boulevard in Tampa, consumers can meet with insurance navigators to sign up for Medicare and Affordable Care Act plans during open enrollment. They can also participate in free yoga or tai chi classes, and get a health exam by a registered nurse or nurse practitioner. The staff can’t write prescriptions, but they can perform some routine blood tests and administer flu shots and shingles vaccines, among other examinations. The 5,000-square-foot center, with large windows and colorful banners, has the feel of an Apple store. From sleek tables lined with tech equipment, consumers can test the latest in health care technology, from learning how to refill prescriptions on an iPad app to taking a digital EKG reading. The vast majority of these services are free, even if participants aren’t Florida Blue members. "We were asked why we were getting into the brick-and-mortar business," said Christie DeNave, a spokeswoman for Florida Blue, which is the state’s largest insurer. "We wanted to be where people already were congregating in their community, around malls and in shopping plazas like near a Walmart." Just down the road at the Sanitas Medical Center, Florida Blue members can see a primary care physician, undergo routine imaging tests and still sign up or talk to an associate about their Florida Blue health insurance, DeNave said. The company has been forging new partnerships — like with the Hispanic clinic brand, Sanitas e_SEmD and formed an umbrella company, GuideWell, to couple their insurance services with more clinical ones, she said. "Because we’re an insurance company, there are many regulations in place what we can and can’t do," DeNave said. "And as the industry moves away from fee-for-service type pay, we want to lead by example. That’s why we created Guidewell, because it gives us more flexibility to come up with new, innovative ways to treat patients." The trend isn’t brand new. Florida Blue has been working with Sanitas since 2014. And in 2012, the insurer purchased Diagnostic Clinic Medical Group, an 80-doctor practice in Largo. Meanwhile, UnitedHealth continues to make similar moves across the country, buying up physicians practices under its Optum brand, which, like GuideWell, gives the insurer more freedom to see patients directly. "Insurance companies are having a longer-term relationship with their patients now, and the clear logic behind that is the value-based payment model we’re shifting to," said Troy Quast, a health care economist at the University of South Florida. "The lines are getting blurred. And for the insurance companies, it gives them a line into the patients they’re insuring. They have access to medical records more easily now and track what’s going on with them." • • • BayCare’s debut as a Medicare provider has been three years in the making, said Jim Beermann, the president of Baycare Select Health Plans. After jumping through the regulatory hoops, the hospital chain will offer two Medicare Advantage plans called "BayCare Plus" during open enrollment for 2019, which begins Oct. 15. The plans will be offered to an estimated 750,000 Medicare-eligible consumers in Pinellas, Polk, Pasco and Hillsborough counties. PREVIOUS COVERAGE: Attention Publix shoppers, the doctor will see you now In putting the plans together, BayCare set up a network that included physicians and specialists from its rivals in the Tampa Bay area, including Tampa General Hospital, Florida Hospital, Bayfront Health and Hospital Corporation of America. "Normally, they are competitors for us," Beermann said. "They were willing to give us the opportunity to see how we can perform with them, and we’re happy to offer a fairly expansive network with BayCare’s name on it because of it. We came together to see what we could do with this." So why would a hospital get into the insurance game? To take a more direct role in which doctors patients see and how often. "Tampa Bay isn’t the healthiest community, we’re below the national average. This is a way for us to take ownership of that and try to change it," Beermann said. "But we’re also moving to a wellness platform. It’s not our job to just take care of the folks when they’re sick anymore. We’re responsible for keeping the patient healthy, so they don’t have to come back to the hospital." He also noted that 40 to 50 percent of hospital admissions are Medicare patients, hence the focus on Medicare Advantage plans. For Florida Hospital and Orlando Health, the two biggest hospital systems in Central Florida, offering insurance to Disney employees was a way of cutting out the "middle man," said Schoch, the Florida Hospital vice president. "The relationship is built around lowering the cost of care, which is decreasing unnecessary hospital admissions and readmissions," he said. "It’s been a nice relationship right from the get-go." Schoch called this type of arrangement the "new frontier of health care," as most in the industry are working to lower costs by changing the customary delivery model. Disney employees have access to a network of physicians and hospitals from both chains, depending on the plan they select. Florida Hospital has dabbled in this area before, offering specific bundles of preventative care to employers that can be added on to traditional insurance plans, such as diabetes coverage. The goal, Schoch said, is to continue to learn from the partnership with Disney and eventually offer the service to other companies. Contact Justine Griffin at [email protected] or (727) 893-8467. Follow @SunBizGriffin.