Value-Based Care News Digest - April 2019

April 5, 2019

Every month, Evolent Health rounds up some of the latest value-based care news from the previous month spanning policy, research, innovations, payers and providers. 


Top Trending Topics

  1. Payers continue to merge. The latest to pair were Centene/WellCare and Cambia Health Solutions/Blue Cross and Blue Shield of North Carolina.
    • Centene acquired WellCare to create a $97 billion insurer by revenue that will have about 22 million members across all 50 states.
      • If approved, the acquisition will solidify Centene’s dominance in Medicaid and the individual market, where it is the largest player. WellCare brings a strong Medicare Advantage (MA) presence, an area where Centene "has been eager to expand its offerings."
      • The plans have significant overlap in several states, a fact that may require divestments before regulators will approve the deal.
      • This news comes on the heels of the Justice Department asking a federal appeals court to invalidate the entire Affordable Care Act. If successful, the lawsuit would largely dismantle the individual market and reverse Medicaid expansion in three dozen states.
    • Cambia Health Solutions and Blue Cross and Blue Shield of North Carolina announced a "strategic affiliation" to form a $16 billion bicoastal insurer with shared management and technology.
      • This merger builds on the payers’ existing partnership, Echo Health Ventures, which the two insurers launched in 2016 and have used to jointly invest in health technology ventures.
      • The companies will enter into a long-term management services agreement, in which they have agreed to share management, administrative, operational and other corporate services under the Cambia Health Solutions name.
  1. The lines between payer and provider continue to blur as payers expand their footprints in care delivery.
    • Humana is expanding its senior-focused primary care clinic model to new markets, including Charleston, Houston and Memphis. Humana currently has 223 owned, joint venture, or alliance clinic relationships, which serve 8% of its Medicare Advantage enrollees.
    • Geisinger Health System and Highmark Health are committing $100 million to a joint venture to expand primary, specialty and inpatient care in north central Pennsylvania. The facilities will focus on members of both Geisinger’s and Highmark’s health plans.
  2. Payers and providers have also invested to mitigate shortages in critical positions.
    • HCA acquired its third nursing school with the acquisition of the parent company that owns Galen College of Nursing, a private nursing school with five campuses. HCA has owned nursing education since 2003. The company employs 94,000 registered nurses, making it one of the country's largest nursing employers.
    • Kaiser Permanente and Humana are both supporting medical schools with a heavy focus on value-based care, primary care and community engagement. Geisinger also has its own medical school focused on community health.

Industry News

General News

  1. Amazon, Berkshire Hathaway and J.P. Morgan Chase’s health care venture now has a name (Haven), a website and a new VP of Clinical Strategy, Sandhya Rao. Haven CEO Atul Gawande released a statement noting that, "we’ll start small" and expand. Rao previously served as senior medical director for Partners Population Health. Active job postings focus on Data Science, Analytics, Strategy and Research.
  2. Lab samples via drone? WakeMed is working with UPS, the FAA and the North Carolina Department of Transportation to test it. One major goal of the pilot project is to reduce turnaround times for lab results, which are typically sent via courier car and can face traffic delays.
  3. Crossover Health, which provides medical services to large employers (including Apple and Facebook), has acquired Sherpaa, an asynchronous telehealth company. With the addition of Sherpaa’s technology, Crossover Health will be able to offer a tiered system that provides in-person care to employees at a central site and comparable virtual care to remote employees.

Social Determinants of Health

  1. Lyft is partnering with Oak Street Health to offer transportation for its Medicare population in Indianapolis, in an expansion of a pilot program. The effort aims to reduce missed physician visits and is complementary to Oak Street Health’s van service for members. Oak Street says it is attracted to Lyft given the per-ride cost as opposed to owning additional vehicles, and it has received positive feedback from members about the program.
  2. New York not-for-profit health insurer HealthFirst is partnering with NowPow to implement a web-based tool to connect its 1.4 million members with social services and community-based resources. The investment is an expansion of a pilot program within HealthFirst’s care management program. NowPow grew out of a Center for Medicare and Medicaid Innovation (CMMI)-funded initiative at the University of Chicago.
  3. Unite Us, a care coordination and outcomes tracking platform for health care and social workers, completed a $35 million Series B investment round. Unite Us works to develop networks of clinical and social services providers with the goal of improving patient access to food, housing and transportation; coordinating care with providers; and tracking outcomes. Unite Us focuses on Medicaid and Medicaid beneficiaries, including homeless and justice-involved populations and those with behavioral health or substance abuse challenges.
  4. Signify Health, an in-home and complex care management service provider, acquired TAVHealth to serve as a platform for collaborating with risk-bearing and community-based organizations to address social determinants of health. Signify manages 4,000 physicians and nurse practitioners touching more than one million MA patients.

Home Health

  1. Intermountain Healthcare is launching its Intermountain at Home program to offer in-home checkups with primary care physicians. The program will also connect patients with remote monitoring, telemedicine and virtual online care visits. Intermountain’s chief nursing officer for community-based care expects that at-home care can reduce complications, rehospitalizations and ED visits and decrease the total cost of care by 30%.
  2. UPS is preparing to test a service later this year to dispatch nurses to administer vaccines to adults in their homes. UPS did not disclose which vaccines it will use in the project, but Merck & Co is reportedly in talks with UPS to be its partner for the initiative. UPS will rely on its clinical logistics unit, Marken, to manage the insulated package logistics.
  3. Northwell Health, New York state’s largest health system, announced that its Medicare pilot program for home-based primary care generated $2.4 million in savings, or 21% lower than the benchmark in performance year 2015. The program focused on patients with two or more chronic conditions and a hospital or rehabilitation facility visit in the last year. To decrease costs, Northwell Health relied on in-home physician and nurse visits and had paramedics consult with remote physicians during emergency responses to determine whether an inpatient stay was necessary.
  1. Bayada Home Health Care and AmeriHealth Caritas entered into a value-based contracting agreement. The program will extend across all Bayada’s specialties, including the company’s home health, hospice, personal care, adult nursing and pediatric practices, and it will include AmeriHealth Caritas managed care health plans in Delaware, Pennsylvania and any potential future markets served by both organizations. The program will provide financial incentives for Bayada to meet targets related to potentially preventable hospital admissions, readmissions and ED visits, quality of care and more.


  1. UnitedHealthcare’s OptumRx will require all new employer clients to pass through all pharmacy rebates directly to members’ out-of-pocket expenses. Customers are increasingly exposed to the list price of pharmaceuticals, and public focus has grown on drug pricing. In existing voluntary adoptions of these programs, UnitedHealthcare consumers have seen lower average prices and have been more likely to fill prescriptions. Still, UnitedHealthcare said the requirement will likely result in some premium increases for employers.
  2. CareMore Health, an integrated care delivery system that specializes in treating high-needs patients, has partnered with SpotRx to provide 13,000 patients with access to their prescription medications through an interactive self-serve kiosk. Located in the CareMore Care Center in Tuscon, Ariz., the SpotRx kiosk dispenses medications with a valid prescription. Patients can also access over-the-counter drugs through the kiosk and opt to have their medications delivered to their homes at no additional cost.

Government and Regulatory Pulse


  1. The U.S. Department of Justice took a broader stance against the Affordable Care Act, calling on the 5th U.S. Circuit Court of Appeals to affirm a district court ruling invalidating the entire law. At the heart of the matter is whether the entire Affordable Care Act can stand without the individual mandate penalty, which Congress effectively eliminated in the 2017 tax law.
  2. Congressional Democrats in the U.S. House of Representatives introduced a bill that aims to make the exchange plans more affordable by expanding tax credits; increasing funding for ACA outreach and education, reinsurance and state-based exchange administration; and reversing Trump administration rules they believe could weaken the marketplace.
  3. A federal judge rejected the Trump administration's attempts to expand access to association health plan (AHP) rules. U.S. District Judge John Bates said the administration's final rule allowing associations and employers to band together to create AHPs goes beyond its authority under the Employee Retirement Income Security Act. The administration will likely appeal the judge’s decision.


  1. The administration is exploring overhauling Medicare payment to move the bulk of dialysis treatments from clinics to the home, HHS Secretary Alex Azar indicated during a speech at a kidney disease conference. This could build on CMMI’s End Stage Renal Disease (ESRD) Seamless Care Organizations, a payment demonstration launched by CMMI in 2015. The administration’s plans could take the shape of a mandatory model that realigns payment incentives toward home hemodialysis, peritoneal dialysis and transplantation over in-center dialysis. Just 12% of Americans with ESRD start dialysis treatment at home, well behind some other countries—in Hong Kong it’s 80%, Azar said.
  2. CMS released an improved Part D Opioid Mapping Tool, which now includes more Medicaid and rural data. The updated tool offers greater granularity for state, county and ZIP code-level opioid prescribing rates. First launched in 2015, the tool originally provided a snapshot of Medicare Part D prescribing rates from 2013. Last year it was expanded to include opioid prescribing rates for 2016, as well as the change in opioid prescribing rates from 2013 to 2016. This latest version now includes new features that offer an expanded view of prescribing rates over time and across regions, allowing measurement of trends and comparisons.
  3. Pennsylvania Rural Health Model announced its initial five hospitals and five payer partners to participate in a new alternative payment model from CMMI that uses all-payer global budgets. The goal of the model is to promote rural hospital financial health and allow for investments in population health efforts. Barnes-Kasson Hospital, Endless Mountains Health System, Geisinger Jersey Shore Hospital, University of Pittsburgh Medical Center (UPMC) Kane Hospital and Wayne Memorial Hospital will participate as providers. Gateway, Geisinger, Highmark and UPMC Health Plan will participate as the private payers; the state’s Medicaid program will also participate as a payer.

Evolent Partners in the News

Evolent in the News

  • Even as opponents, including the Trump administration, seek to dismantle the entire Affordable Care Act, they have embraced aspects of the law to advance value-based payment models, Evolent Vice President of Health Policy Ashley Ridlon told Health Leaders Media, Fierce Healthcare and The Business Journals. Accustomed to legal uncertainty surrounding the fate of the entire ACA, the industry is pushing forward with value-based care, she explains.
  • Writing for Managed Healthcare Executive, Evolent Population Health Manager Amy Kennedy explains how an Affordable Care Organization (ACO) engaged more than 250 physicians across parts of three states to reduce inappropriate utilization.

Survey Says/Studies Show

  1. In its fourth annual survey report, Numerof & Associates and the Dean of the Jefferson College of Public Health developed conclusions about "The State of Population Health" based on an online survey of 500+ C-suite health care executives and select open-ended interviews:
  • There was no reported change in the percentage of revenue at risk over the 2017 survey. Most executives reported that 10% or less of revenue came through risk-based contracts. This measure not only remained flat relative to prior surveys, but also fell significantly short of the projections respondents previously made regarding how much revenue would be at risk in 2018.
  • Still, executives agree population health is the future. Consistent with past surveys, almost all respondents (94%) rated it critically (40%), very (42%) or moderately (12%) important. Nearly all respondents (99%) project their organization will have some revenue in models with upside gain and/or downside risk in two years.
  1. Profiled in Harvard Business Review, Walmart has embraced a travel-based "Centers of Excellence" program that sends covered employees to a short list of health systems for procedures such as surgeries, cancer evaluations and organ transplants. Employees experienced similar per-event costs, but they also had consistently lower readmission rates, decreased post-surgical skilled nursing facility usage and shorter hospital stays and delays in returning to work for joint replacement and spine surgeries. Health Designs Plus, Walmart’s third-party administrator, has played a major role in developing Walmart’s travel surgery and ACO approach.
  2. Retail prescription drug coverage is steadily growing as a portion of commercial health plan premiums, according to a study by researchers with The Pew Charitable Trusts. Between 2012 and 2016, the premiums increased from 12.8% to 16.5%. Meanwhile, patient out-of-pocket spending was stable, due to factors including increased insurance coverage and assistance from manufacturers.
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