Value-Based Care News Digest - September 2019

September 11, 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 Themes

1. Rapid growth continues in new primary care practices.

  • ​Cano Health, which operates 36 medical centers and pharmacies for seniors in Florida, was ranked the fastest-growing health care company by Inc. magazine, with three-year revenue growth of 14,000 percent. The company has ambitions to expand nationally; in addition to growing to more than 50 health centers in Florida in the next year, it is in negotiations to expand the business to Texas, according to the company's founder.
  • Iora Health and Humana are adding eleven Iora Primary Care practices to Humana's Medicare Advantage network in Phoenix, Atlanta and Houston.
  • Walmart is opening a new clinic, called Walmart Health, in Georgia that will offer services such as primary care, dental, counseling, labs and audiology. The new clinic is in a separate building next door to a Walmart store to give patients a sense of privacy. Other clinics that the company has opened in Texas, South Carolina and Georgia have been inside retail locations. Walmart recruited a former Humana executive to lead the company's clinic efforts.
  • VillageMD will use $100 million in series B funding to expand its primary care footprint in existing and new markets. The company was founded in 2013 and has grown to serve more than 2,500 physicians across eight markets, while caring for approximately 500,000 lives. It oversees more than $32 billion in total medical spend in value-based contracts

2. Payer new entrants and incumbents launch or expand their Medicare Advantage plans.

  • New entrants
    • Health2047, the American Medical Association’s for-profit health care innovation arm, is launching a Medicare Advantage plan for underserved seniors in Cook County, Ill. The plan, called Zing Health, is the third company to spin out of Health2047 since the commercialization enterprise launched in 2016.
  • Incumbents
    • Alignment Healthcare, a Medicare Advantage insurer founded in 2013, is doubling its number of territories and plans in the 2020 enrollment cycle. Currently serving eight counties with 10 health maintenance organization plan products, the company is expanding its coverage to 16 counties with 22 HMO and PPO products in 2020, pending regulatory approval.
    • Anthem Blue Cross and Blue Shield in Maine and MaineHealth are forming a joint venture to offer Medicare Advantage plans for 2020. Named AMH Health, LLC, the joint venture will bring together the region's leading health system and health insurer.

3. Payers gain additional influence in medical education

  • Dr. J. Mario Molina will be founding dean of the Keck Graduate Institute (KGI) School of Medicine in Southern California. For 20 years, Molina was the CEO of Molina Healthcare, which primarily operates Medicare and Medicaid health plans. Molina's vision for the KGI School of Medicine is to change the approach to health care education He intends the school to focus on "the intersection of multicultural competency, population health research and commercial innovation."
  • Other payers—for example, Humana, Kaiser Permanente—have also recently founded schools of medicine to train physicians on what is important to them strategically: concepts such as population health, the importance of social determinants of health and the need to emphasize value over the volume of services provided.

Industry News

Payers and Providers

Primary Care

  • SSM Health and Paladina Health have created a new joint venture to offer a direct-to-employer primary care offering in the St. Louis, Mo., region. In this new value-based care model, businesses will pay a flat fee for each employee's primary care services. The employee can then access all the primary care they need without co-pays or other additional out-of-pocket costs. The new company plans to open its first clinic in the St. Louis region by the end of this year, and its services will be available to St. Louis-area businesses in early 2020. The new model will also be offered to SSM Health employees and their dependents covered by SSM Health's medical plan. The two organizations will share ownership in the new joint venture, with Paladina Health serving as the operating partner.
  • Baylor Scott and White Health is launching a direct primary care model in several North Texas clinics this year. Members will be charged a monthly fee that covers office visits and lab tests; insurance is still needed for hospitalizations and other services. The new model is managed by Accresa, a health care technology company that works with direct primary care practices to connect patients, employers, employees and providers and provides administrative support. The new model is being offered through Baylor's accountable care organization.

Social Determinants of Health


Government & Regulatory

CMS

  • Two CMS decisions are helping to bring down barriers for Medicare patients to access CAR-T therapy, a promising but costly treatment that involves genetically engineering human immune cells to attack proteins on cancer cells. In a National Coverage Decision, CMS announced that Medicare would cover two CAR-T therapies that are FDA-approved to treat different types of lymphoma and leukemia. Previously, CAR-T coverage determinations differed from one CMS region to another, contributing to inconsistency and confusion. Additionally, CMS will increase its reimbursement to hospitals from 50% of the additional costs associated with administering CAR-T therapy to 65%. While the increase was welcomed, the hospital industry pointed out that hospitals could still be left with six-figure shortfalls, given that the therapy itself costs $375,000 to $475,000, and associated hospitalization costs can add hundreds of thousands to that.

States


Evolent in the News

  • Providers have had "surprisingly tepid responses" to CMS' new Direct Contracting payment models, Evolent Vice President of Health Policy Ashley Ridlon told Health Leaders Media. Nevertheless, as the Aug. 5 deadline neared for organizations to notify CMS of its interest in the program, she expected many would submit nonbinding letters of interest "just in case." CMS has launched Direct Contracting models to encourage primary care practices and others to take increasing financial risk—up to 100%—for a population of patients.

Survey Says/Studies Show

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