Value-Based Care News Digest - March 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. New medical schools aim to increase the supply of primary care physicians by waiving tuition and focusing their training in population health.
   • Students in the first five classes between 2020 and 2024 at Kaiser Permanente School of Medicine will have their tuition and fees waived. The school’s website notes that "students will have clinical experiences in settings that excel in patient-centered care and population health."
   • NYU is opening a new medical school on Long Island that will offer a three-year program with full-tuition scholarships and focus on training primary care physicians. Final approval for the new medical school is pending and is expected this spring. The school will accept 24 students in its first class in the summer of 2019
   • Last fall, Humana announced it would fund a new medical school at the University of Houston in Texas focused on training physicians in population health. The first 30 students will attend tuition free.
2. Living room = exam room? CMS and payers seek to shift usage from emergency departments to alternate, less costly sites of care.
   • Expected to launch next year, the Emergency Triage, Treat and Transport Model would reimburse ambulance providers for onsite and telemedicine-enabled assessments; transport to alternative care sites such as an urgent care center or primary care clinic; or treatment in place in response to a 911 call. The five-year voluntary Medicare payment model will require ambulance providers and local governments responsible for 911 dispatch to cooperate on triage and care delivery, and it will provide funds to assist in integrating services. Currently, Medicare regulations only allow payment for emergency ground ambulance services when individuals are transported to hospitals, critical access hospitals, skilled nursing facilities and dialysis centers.
   • Medicare-Medicaid plan Mercy Care has teamed up with Philips and DispatchHealth to allow eligible members to receive in-home urgent care from DispatchHealth at the touch of a button, using a Philips device many elderly patients already wear for medical alerts and fall detection.
   • The need for these efforts is reinforced by a recent study that found that about one-third of ED visits for six common chronic conditions were likely preventable and could have been treated in a less expensive outpatient setting. Patients with these six conditions represented 60 percent of the 24 million ED visits in 2017.
3. "Your CVS Health doctor will see you now" at one of three HealthHub locations the company opened in Houston this month.
   • With the new store format, more than 20 percent of each CVS store is dedicated to health services, including clinic space with exam rooms that offer an expanded lineup of services such as blood draws and chronic disease management.
   • Customers are greeted by a "care concierge" who can provide advice on insurance or health and wellness devices and guide them to services. The redesigned stores have a clinic space with exam rooms like those in primary care offices, and the clinics are staffed by advanced practice providers. The HealthHUBs also include "wellness rooms" for group events and nutrition classes.
   • With the acquisition of Aetna, the new store format is part of CVS CEO Larry Merlo's goal for the combined company to "have a community focus, engaging consumers with the care they need when and where they need it."
4. Regional Blues continue the push to value by partnering with providers to launch alternative payment models.
   • Blue Cross and Blue Shield of Vermont (BCBSVT) is continuing to partner with OneCare Vermont to share in financial savings and risk of up to 6 percent of the total cost of care for individual and small employer members attributed to the program. OneCare Vermont covers approximately 24,000 BCBSVT members with primary care physicians in the OneCare network. 
   • Atrius Health and Blue Cross Blue Shield of Massachusetts are launching an alternative payment model in which Atrius Health receives a global budget to care for more than 130,000 Blue Cross patients with commercial PPO, HMO and Medicare plans. This is the first Blue Cross provider contract and first Atrius Health payer contract to have full risk, including cost and quality accountability, for PPO members.
   • Anthem Blue Cross and Blue Shield in Ohio is partnering with the Cleveland Clinic Cardiac Concierge Program to provide Kroger employees and their families access to complex heart surgery, using bundled payments. Under the program, a single payment will cover a patient's treatment. Kroger also will pay all travel expenses to Cleveland Clinic for eligible plan members and a companion.

Industry Spotlight

Each month, we highlight new or novel steps being taken toward value-based care.

General Updates

1. PatientPing, a care coordination platform that connects providers and health plans, and Humana are partnering to support Humana Medicare Advantage members in North Carolina. Humana will use PatientPing's provider enablement platform to monitor acute and post-acute events in real time. 
2. Cityblock, which uses technology to address the medical, social and behavioral health needs of low-income people, plans to begin serving people in the greater Waterbury, Conn., area this spring. The startup is working to manage EmblemHealth members in Crown Heights, its first neighborhood hub. Cityblock has received $23.2 million in financing from investors including Sidewalk Labs—Alphabet's urban innovation arm—and Thrive Capital. Former CMS administrator Andy Slavitt is on the company's board.
3. Aetna has partnered with Apple to roll out the new personalized health app Attain. Attain will provide Aetna members using an Apple Watch personalized health goals and recommendations and the ability to track their daily activity levels. It will offer incentives for actions to improve health and well-being. Attain initially will be available on a first-come, first-served basis to between 250,000 and 300,000 Aetna commercial members who sign up for it.
4. Health Care Service Corp. (HCSC) and the Blue Cross Blue Shield Institute launched a food delivery service in "food deserts" that lack access to affordable and fresh foods. The foodQ delivery service aims to improve health outcomes, especially for people with diet-related chronic conditions, by reducing hospital admissions and ED visits. During a six-month pilot, foodQ will deliver in 25 Chicago ZIP codes and 15 Dallas ZIP codes where HCSC has health plans. The service is available to anyone, regardless of insurance status or plan. By subscribing to the service for $10 a month, customers can get free delivery and a buy-one-get-one option for each meal.
5. Cigna exceeded its value-based care goal of having 50 percent of Medicare and commercial provider payments in alternative payment arrangements in the company’s top 40 markets by the end of 2018. Cigna established the goal in 2015 to accelerate the transition to alternative payment models. Cigna's efforts resulted in medical cost savings of more than $600 million from 2013 to 2017. Additionally, 85 percent of Cigna Medicare Advantage customers obtain care through value-based arrangements.
6. Medtronic, one of the world's largest medical device companies, developed a five-year partnership with the Medical University of South Carolina (MUSC) focused on value-based care. This is MUSC's second partnership with a medical device company; it struck a deal to collaborate with German company Siemens in August 2018. Not much has been released about the specifics of the partnership, but MUSC leaders shared they will initially test four areas of care: joint replacement, tracheotomies, vascular disease and respiratory monitoring. The stated objective is to combine "Medtronic therapy and technology expertise and MUSC's clinical and academic expertise to create a more connected and coordinated care model."

Evolent News

1. Evolent will help to support thousands of Medicaid beneficiaries in Arkansas with complex behavioral health needs and intellectual and developmental disabilities through a partnership with Beacon Health Options and five other provider organizations in the Empower PASSE. Evolent will provide a wide range of ongoing support, including health plan member and provider services; claims processing; provider data management; member and provider portals; analytics; utilization management; and provider data services and technology.
2. Evolent has also partnered with River City Medical Group (RCMG), an independent physician association in California, to form a managed services organization (MSO). Initially, the new MSO will focus on providing services, including claims management, utilization management and care management capabilities, to the approximately 300,000 California Medicaid (Medi-Cal) managed care members delegated to RCMG by its health plan partners.

Government and Regulatory Pulse

CMS

1. By 2027, the U.S. will be spending $6 trillion a year on health care, according to CMS projections. Annual spending growth is expected to average 5.5 percent, up from 4.4 percent in 2018 and 3.9 percent in 2019. As Baby Boomers flock to Medicare, annual increases in Medicare spending will outpace the national average, at 7.1 percent, while Medicaid spending will grow at a more modest 6 percent.
2. Five percent of the U.S, population accounted for half of all health care spending in the U.S. in 2016, the Agency for Healthcare Research and Quality reported. Of this group’s spending, Medicare and private insurance each paid for roughly 36 percent. The bottom 50 percent of persons ranked by health care expenditures accounted for just 3 percent of the nation's health care spending.

States

1. A report released by the California Future Health Workforce Commission outlined a $3 billion plan to avoid a physician shortage in the state. Among other steps, lawmakers will need to grant nurse practitioners the ability to practice at the top of their licenses, increase opportunities to study medicine, and expand doctor training programs, the report said. The report comes at a time when the governor wants to significantly expand access to health care for lower-income and immigrant communities.
2. Several state regulators say they do not have the authority and capacity to properly regulate the marketing of short-term insurance plans, according to a study by the Georgetown Center on Health Insurance Reforms. The study explored how states are overseeing marketing of short-term plans after an HHS regulation expanded their duration from three months to 12 months. While some states issued warnings and advisories to educate consumers on the risks of the plans versus ACA-acquired coverage, the study found the capacity to widely disseminate information is lacking.
3. Twenty-four companies have notified Oregon officials that they want to get into the state's Medicaid coordinated care organizations (CCOs). New bidders include Kaiser Permanente and Providence Health & Services. Established insurers in the state, such as Moda, are looking to grow their share of the state's $5 billion in Medicaid CCO money. Complete applications are due to state officials in April, and contracts will be awarded in July. Oregon first launched the CCOs in 2012.

Survey Says/Studies Show

1. Two-thirds of patients said cost strongly influences their overall satisfaction with their hospital or physician. However, nearly 60 percent of health systems do not discuss costs with patients, according to a survey from VisitPay, a patient financial engagement platform. Most patients (67 percent) did not obtain cost estimates before receiving medical treatment. The majority (56 percent) of patient visits are unplanned and not budgeted, according to the survey.
2. Growing the ranks of primary care physicians can increase life expectancy, but the concentration of PCPs has declined in the U.S., Stanford Medicine researchers found. Driven in large part by severe losses of physicians in rural areas, the average number of physicians per 100,000 people decreased from 46.6 in 2005 to 41.1 in 2015. For every 10 additional PCPs per 100,000 people in a community, the researchers found a 51.5-day increase in life expectancy, as well as declines in mortality rates from cancer, heart disease, respiratory disorders and other common causes. Increased concentrations of specialists were associated with a less pronounced increased life expectancy—19.2 days for every 10 specialists.
3. Medicare and Medicaid are doing a better job of containing costs than private insurers, Urban Institute researchers concluded. While overall spending in the federal programs is growing more quickly, per-enrollee spending between 2006 and 2017 grew 2.4 percent a year in Medicare and 1.6 percent in Medicaid, compared to 4.4 percent for private health insurance enrollees. The researchers point out that private payers pay higher hospital and physician rates while the public programs have more leverage over rates.   
4. Over an 18-month period, hospitals acquired 8,000 more medical practices, and 14,000 more physicians left independent practice to become hospital employees, according to a new analysis by the Physicians Advocacy Institute (PAI) and Avalere Health. Forty-four percent of physicians were employed by hospitals or health systems as of January 2018, compared to about 25 percent in 2012. Over the same time period, the number of hospital-owned physician practices increased from 35,700 to more than 80,000.
5. Although higher prices post-hospital mergers are the consequences most often discussed, such consolidation can also result in worse health care, a New York Times article argues. Studies show that rates of mortality and of major health setbacks grow when competition falls. This runs counter to claims by some in the industry in favor of mergers. By harnessing economies of scale and scope, they've argued, larger organizations can offer better care at lower costs. Martin Gaynor, a Carnegie Mellon University economist who is an author of several reviews exploring the consequences of hospital consolidation, said that "evidence from three decades of hospital mergers does not support the claim that consolidation improves quality."

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