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 Themes
- Houston, we’re ready for takeoff—of new primary care models.
Humana’s subsidiary Partners in Primary Care is opening five senior-focused clinics in the city, expanding on its partnership with the University of Houston to train future health care providers in population health. The Partners in Primary Care centers will be used as learning labs to host University of Houston pharmacy and social work students in rotations. Future rotations will also include physician and nursing students. Partners in Primary Care will provide input for the development of curricula about integrated models of care for the new University of Houston College of Medicine’s class of physicians.
CVS Health, which opened three pilot HealthHUB primary care locations in Houston in February, announced that it plans to expand the model to 50 stores this year and 1,500 stores by the end of 2021. CVS' 100 MinuteClinic sites currently focus on low-acuity services such as immunizations and treating colds, yet the company determined that half of the patients who visit MinuteClinics do not have primary care providers. The HealthHUB model will be geared more to everyday health care needs, with a focus on chronic disease management, offering services such as blood draws and sleep apnea assessments.
Earlier this spring, HCSC's venture capital arm and Sanitas USA announced they will open 10 primary care clinics for Blue Cross Blue Shield members in Dallas and Houston. Major goals of the clinics will be providing primary care, referring to reasonably priced specialists and offering services like telemedicine and health education.
- Why Houston? It's one of the fastest growing U.S. cities by population and has attractive MA rates, making it an appealing market for insurers.
- New entrants continue to expand MA plans via partnerships with providers.
- Bright Health will enter five new states in 2020—Illinois, Georgia, Florida, South Carolina and Nebraska—bringing its total footprint to 11 states. Bright Health typically partners with an anchor health system for its narrow-network products.
- Alignment Healthcare and Sutter Health are partnering to launch a new MA plan in Northern California. If CMS approves the application, Alignment and Sutter would begin offering new Medicare Advantage plans in the approved counties in October 2019 and members could seek "in-network" care with Sutter-affiliated and aligned physicians and facilities on January 1, 2020.
- Troy Medicare is launching a pharmacy-focused MA plan in North Carolina, focused on incentivizing independent pharmacists to deliver care and perform care management services. The plan offers independent pharmacists $30 to $50 per-member, per-month payments for care management services. Troy is developing a data infrastructure that will allow the sharing of pharmacy and medical claims data to help improve care coordination between a member’s provider and pharmacist.
- Cerner announced a new "near-site" network offering for employers called Anuva Health. Compared to an on-site employer clinic model, the near-site model looks to share the investment and benefits of a clinic or pharmacy model between multiple employers in a region. These near-site health centers will offer primary care, urgent care, pharmacy services, telehealth and a range of health education and coordination services to employees of member employers. The first health center of the near-site network to open, in Malvern, Pa., will benefit Cerner associates with availability for other local employers to add the benefit for their employees.
- Amazon launches Amazon Comprehend Medical, a natural language processing service that extracts medical information from unstructured text. The service aims to gather information on medical conditions, medications and other health data from doctors' notes, clinical trial reports and patient health records using machine learning models. Amazon Comprehend Medical will be accessible through an application programming interface.
Payers and Providers
- UnitedHealthcare introduced a new bundled payment program for maternity care and has launched it with two provider groups, Lifeline Medical Associates in New Jersey and Privia Medical Group in Texas. UnitedHealthcare plans to expand the bundles program to 20 provider groups by the end of 2019. The bundles program builds on a previous maternity program that helped reduce the rate of non-medically indicated cesarean deliveries, hospital admissions and NICU length of stay.
- Atrius Health announced $39 million in operating surplus, representing a positive turnaround since 2017 amid a shift towards value-based care models. The largest nonprofit independent medical group in New England, Atrius Health derives 75% of its from full-risk contracts. Massachusetts Health Policy Commission reported that Atrius achieved the lowest medical expense in eastern Massachusetts, the lowest use of unnecessary tests and the best rates of avoidable ED visits in the state.
- West Virginia University Health System and The Health Plan, a managed care organization operating in West Virginia, have announced they are merging into a fully integrated health care delivery system. The Health Plan will become a subsidiary of the WVU Health System but will continue as a community-based, not-for-profit corporation. WVU Health System is the state's largest health system and largest private employer, with nine hospitals.
Social Determinants of Health
- New rules that allow insurers to include more supplemental benefits in their Medicare Advantage plans is opening the door to ride-sharing companies like Lyft to have more of their services in benefits for next year. Health plan bids to participate in Medicare Advantage for 2020 were due on Monday, June 3. "We expect to be working with the majority of the largest MA plans by 2020," said Lyft's vice president of health care Megan Callahan, who was hired last year to lead the company’s growing health care businesses.
- Kaiser Permanente is launching Thrive Local, a social health network for members, in partnership with Unite Us. The network connects users to health care and social service resources to improve access to housing, food, safety and utilities. It will be available to both Kaiser members and people in communities Kaiser serves within the next three years. Kaiser notes that up to 29% of members with medical challenges deal with food insecurity, and 23% deal with housing stability, both of which Thrive Local seeks to address.
- Solera Health announced $42 million in funding, led by HCSC Ventures, bringing total funding to $72 million. Solera Health serves as an integrated benefit network—connecting patients to various health management programs in a single, central marketplace as part of employer or private payer insurance products. Solera currently has 60 million lives under contract and recently entered into a partnership with the Blue Cross Blue Shield Institute to launch a nationwide program tackling social determinants of health within communities.
Telehealth and Home Health
- University of Pittsburgh Medical Center (UPMC) launched a new telemedicine company, Infectious Disease Connect, focused on offering infectious disease specialist expertise to smaller hospitals. The company serves 10 UPMC and five non-UPMC hospitals in Pennsylvania today, and it will focus expansion on hospitals with fewer than 300 beds. UPMC offers telemedicine-based infectious disease services to some patients today, and it notes that it enables fewer relocations to tertiary care facilities, reduces infections and decreases unnecessary use of antibiotics. This program also aims to alleviate the impact of a nationwide shortage of infectious disease specialists.
- Heal, which previously focused on in-person home visits, is launching a new telehealth service for patients to support follow-up visits. The company touts its service not as competing with other telehealth providers but as a convenient way to extend the reach of physicians who have already made home visits. Heal has raised $71 million in funding to date.
- Vital Decisions, a company helping individuals facing serious illness to ensure that the care they receive in the last years of life aligns with their values and preferences, recently expanded its telehealth product offering to include video capabilities. Health plan members who are eligible for Vital Decisions' Advanced Care Alignment benefit can now choose to have video-based sessions from any device with their Vital Decisions clinical specialist. The Advanced Care Alignment program is offered to individuals and their families to enable them to engage in a collaborative decision-making process surrounding their care.
- Talkspace, a tele-behavioral health company, secured $50 million in Series D funding, bringing its total raised to $107 million. Talkspace's model connects users with a network of over 5,000 licensed therapists through a web and mobile platform. Users have "dedicated therapists" to whom they can send unlimited messages using a monthly subscription service.
- Medically Home, a company that brings hospital-level care into the home, has raised $10 million in Series B funding. Founded in 2017, Medically Home sends clinicians, technology, equipment, medication and supplies directly to acutely ill patients' bedsides. To date, Medically Home has raised $24 million. The most recent funding round will allow the company to further scale its efforts. Medically Home currently serves patients in parts of Massachusetts, New Jersey and Indiana.
Government & Regulatory Pulse
- The House and Senate released draft legislation on surprise balance billing, and both bills put the onus on insurers to negotiate appropriate rates for out-of-network providers. Balance billing most often occurs in emergency departments or during elective surgery, when a patient goes to an in-network facility but is treated by an out-of-network clinician, typically an anesthesiologist or radiologist. The two bills primarily differ on the mechanism for resolving disputes, but they will likely be reconciled into a single bill for passage. This legislation follows a call to action on surprise balance billing by the Trump administration, which released guidelines for legislators.
- Evolent expanded its partnership with Passport Health Plan, a Louisville, Ky.-based managed care organizations serving more than 300,000 Medicaid beneficiaries. In the deal, Evolent contributed capital for a 70% ownership stake in the plan and assumed greater management responsibility for day-to-day plan operations.
- Care management was responsible for more than 50% of the shared savings earned by Evolent partners’ accountable care organizations, an internal analysis found. Read our insight brief to learn what is driving this financial impact.
- In late May Evolent submitted input to the Centers for Medicare and Medicaid Innovation (CMMI) on its new Direct Contracting payment models. We encourage CMMI to continue the evolution toward full-risk, total-cost-of-care models while providing stability and predictability for those organizations that make the leap.
- For background on Direct Contracting, read our fact sheet.
- Evolent and other organizations called on CMS to make permanent the Next Generation Accountable Care Organization model. The National Association for Accountable Care Organizations, America’s Physician Groups, Premier and the Next Generation ACO Coalition say that the success of the Next Gen model warrants codifying it as a full-risk option in CMS’ Pathways for Success ACO program.
- Evolent’s new series, The Heart of Care, continues to showcase the dedication of our care management experts to their patients. One recent story highlights a Care Advisor's creative solution to help a refugee navigate her health care challenges, while another reveals the behind-the-scenes work to make sure that crucial medical device was not denied to a vulnerable boy.
Evolent in the News
- Introduced in late April, CMS' Direct Contracting payment model encourages primary care providers to take on two-sided risk. Evolent's Chris Dawe, Senior Vice President for Medicare Partnerships, and Ashley Ridlon, Vice President for Health Policy, spoke with Medical Economics about the factors that could have a significant impact on the program's success.
- Evolent has created a Social Needs Index that helps physicians and care managers identify patients whose health outcomes may be harmed by nonmedical factors, such as social isolation, lack of transportation or poor access to healthy foods. Vice President for Research and Development Shantanu Phatakwala explains how the index works in Healthcare Tech Outlook.
- For the fourth straight year, Evolent was listed among the Top 150 Places to Work in Healthcare by Becker's Hospital Review. The publication highlighted Evolent's efforts in employee recognition, wellness, workforce diversity and inclusion, and philanthropy.
Survey Says/Studies Show
- Physician groups derived a larger share of revenue from payment models requiring them to take on risk in 2018 than in previous years, according to a survey by the American Medical Group Association. Fifty-six percent of respondents' federal program revenue came from value-based payment models in 2018, as compared to 45% in 2015. Most federal risk-based payments are under Medicare Advantage agreements, followed by ACO and Medicaid managed care. Risk-based payments grew more slowly in the commercial market, increasing from 22% to 28% of revenue over the same period. The survey covered 75 multispecialty medical groups, integrated delivery systems and independent physician associations.
- The Comprehensive Primary Care Plus (CPC+) program did not affect total Medicare spending, and the value-based reimbursement program for primary care practices had little impact on service use and care quality, according to the program’s first annual evaluation report. After accounting for enhanced CPC+ payments to practices, Medicare spending on beneficiaries treated by providers in CPC+ practices was actually 2% to 3% greater than program expenditures on beneficiaries treated at similar practices not in CPC+.
- Beneficiaries who opt into Medicare Advantage plans have significantly lower annual health care expenditures than those who remain in traditional Medicare, even before joining Medicare Advantage plans, according to an analysis by the Kaiser Family Foundation. The study suggests beneficiaries opting into MA products exhibit systematically different health expenditures even after adjusting for factors like health risk and demographics. This observation is consistent across beneficiaries with specific health conditions, with the average annual expenditures significantly lower across beneficiaries with diabetes, asthma and breast or prostate cancer.
- Medicaid ACOs are relatively rare and slow growing, but those that exist are relatively mature, with significant membership and often Medicare and commercial contracts as well, reports Leavitt Partners. Of about 1,000 ACOs nationally, only 76 were Medicaid ACOs in 2018, covering 3.7 million lives. Growth for these Medicaid ACOs has lagged commercial and Medicare ACOs. However, each Medicaid ACO was relatively large compared to commercial or Medicare ACOs—averaging 44,000 lives for Medicaid ACOs versus 18,000 lives for Medicare ACOs and 24,000 for commercial ACOs.
- Key factors predicting whether ACOs stay in the Medicare Shared Savings Program are whether they (1) achieve bonus payments, (2) are assigned a high benchmark target, and (3) have substantial care coordination services, according to a study by Duke-Margolis Center for Health Policy and Leavitt Partners. The most important factor predicting retention in the program was achieving bonus payments, even for those with just one year of participation.