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
- Value-based primary care models are in expansion mode, as companies add new payer partners, raise capital and expand to new locations.
- Most of these companies are using partnerships with major payers to expand to new states and regions.
- Cityblock and Iora Health announced in March that they will expand their clinics into North Carolina with Blue Cross and Blue Shield of North Carolina as their anchor payer partner.
- Sanitas USA will open 10 integrated primary care centers in Texas in partnership with Health Care Service Corporation (HCSC), in a potential precursor to a rollout across HCSC’s five states. The medical centers will accept Blue Cross and Blue Shield card holders, self-pay patients and seniors with traditional Medicare coverage.
- Oak Street has contracted with Aetna to allow any of the payer’s Medicare Advantage (MA) members to seek care at its Indiana and southeast Michigan locations. Oak Street is also adding two new outpatient centers in Flint, Mich., which will be in-network with Health Alliance Plan. Oak Street’s model focuses on offering comprehensive primary care services and dedicated care teams to coordinate patient health needs.
- VillageMD is partnering with Walgreens to open five clinics adjacent to Walgreens stores in Houston—an apparent response to CVS’ recent launch of HealthHUB locations in Houston.
- Most of these companies are using partnerships with major payers to expand to new states and regions.
- The Centers for Medicare and Medicaid Services (CMS) is making moves in value-based care, announcing new primary care provider-centric programs and increasing flexibility in MA benefits.
- CMS anticipates enrolling 25% of Medicare fee-for-service beneficiaries into one of its two new risk models that make up its new Primary Cares Initiative:
- Primary Care First is primarily targeted at smaller practices with less experience in value-based payment models. It offers coordination of care payments and other financial support, with performance-based payments and some financial risk. A version of this model will be targeted at the seriously ill population and will provide extra support for patients who need hospice or palliative care services and effective care coordination.
- Direct Contracting is for practices with at least 5,000 Medicare beneficiaries and offers a 50% savings/losses risk-sharing option, a 100% savings/losses risk-sharing option and a total care capitation model, which would provide capitated, risk-adjusted monthly payments for all participants and preferred providers.
- CMS is offering benefit flexibility to MA plans, allowing non-medical in-home care as a supplemental benefit for MA plans in 2019. For 2020, CMS also announced that MA plans can cover any benefit that is "likely to improve or maintain the health of beneficiaries with chronic conditions."
- CMS anticipates enrolling 25% of Medicare fee-for-service beneficiaries into one of its two new risk models that make up its new Primary Cares Initiative:
- "The doctor will see you on your iPhone now": Payers expand telehealth capabilities.
- Humana partners with Doctor on Demand to launch a new telehealth-centric plan design that will offer virtual primary care visits for urgent care, preventive care and behavioral health services. Members can get referrals to specialists in Humana's network for in-person visits, as needed. A Humana spokesman said the plan's average monthly premiums would be nearly half those of the company's most popular purchased plan
- Cambia Health Solutions partners with Pager to connect members through video, voice and text to nurses, physicians and other care team members to support clinical decision making.
- Health systems continue to merge: Atrium becomes a 50-hospital system in North Carolina, and systems in New York and Connecticut combine.
- Atrium Health, Wake Forest Baptist Health and Wake Forest University will merge to create a 50-hospital system based in North Carolina. The combined entity is launching a new medical school to train physicians in population health management strategies at a campus in Winston-Salem.
- Western Connecticut Health Network and Health Quest (New York) merged to become Nuvance Health, with a combined $2.4 billion in revenue. To get regulators to sign off on the deal, the systems will have certain restrictions including a cost growth cap and required community involvement.
Industry News
General
- Amazon launched a HIPAA-compliant Alexa platform, and several partner organizations are working on Alexa "apps" to provide an in-home communication channel. Boston Children’s Hospital, for example, wants to enable parents and caregivers to update providers on postsurgical progress and set up postoperative appointments. Cigna created a voice program to allow clients’ employees to manage health improvement goals and earn incentives. In addition, Atrium Health’s project will enable customers to search for nearby urgent care centers.
Payers and Providers
- Humana launched a new oncology payment model for MA and commercial members. The program, called the Oncology Model of Care, will offer additional payment to participating cancer practices for improved performance on certain metrics over a one-year period. There are 16 practices participating in the model, which started in January. "The experience for cancer care is fragmented," said Dr. Bryan Loy, corporate medical director of Humana's oncology, laboratory and personalized medicine strategies group. "Humana wants to improve the patient experience and health outcomes for members. We are looking to make sure the care is coordinated."
- UnitedHealthcare will offer a Care Bundles Program to providers in more than 30 states for their patients enrolled in UnitedHealthcare MA plans for certain procedures. Those procedures include hip and knee replacements, spinal fusions and coronary bypasses. UnitedHealthcare will provide partner care providers with care management solutions and support services, patient engagement tools, analytics, consulting and payment administration services. This program is in addition to providers’ ability to participate with UnitedHealthcare in the Bundled Payments for Care Improvement Advanced program.
- A group of nephrologists and primary care physicians has created a new medical group, PRINE Health, in Delaware, to take on risk contracts from insurers to manage chronic kidney disease patients. The group cares for 40,000 patients with chronic kidney disease and 1,000 with end-stage renal disease—patients spending $500 million on health care costs in aggregate. The group’s CEO, Dr. Simon Prince, previously built Beacon Health Partners, an accountable care organization that was sold to Catholic Health Services.
- University Hospitals in Cleveland is launching an Emergency Medical Services (EMS) Accountable Care Network to align with regional EMS providers and deliver improved patient care, decreased costs and increased value. A core goal of the model is to use the in-home presence of EMS staff to play a role in preventive care, using a shared set of protocols and ongoing measurement.
- Blue Cross and Blue Shield of North Carolina and Duke University have formed Experience Health, a joint venture health plan focused on seniors. Duke Health had previously participated in Blue Premier, a value-based care model between BCBS of NC and four other health systems to jointly share risk around health outcomes, cost and customer service. The plan will focus on team-based care, data and analytic tools for chronically ill patients and coordination around treatment goals, billing and appointments.
Social Determinants of Health (SDOH)
- Giant Food, AmeriHealth Caritas and Washington, DC-based nonprofits are partnering to launch Produce Rx. Under the program, select members of AmeriHealth Caritas DC’s managed Medicaid plan can obtain a prescription for fruit and vegetables from a medical professional for a diet-related chronic illness and fill the script in Giant’s supermarket pharmacy. Giant customers can fill the Produce Rx prescriptions during their shopping trips at the store, and each week a Giant pharmacist will give them a $20 coupon for buying fresh fruit and vegetables from the store's produce department. The effort will begin with 500 AmeriHealth patients, with the goal of further expansion.
- UnitedHealthcare and the American Medical Association are supporting the creation of 23 new ICD-10 codes related to SDOH. Currently, systems do not have a consistent way to capture SDOH needs of patients and incorporate them into a health plan. United Healthcare has been tracking and capturing SDOH information internally, but the insurer wants to create a universal classification system.
- Anthem has seen successful enrollment growth as it launches a new social determinants of health benefits package for seniors in its MA plans. The coverage includes meals, transportation, adult day care and in-home personal care. Anthem has seen significant growth in its MA business, boosting enrollment by 14%, or 1.1 million in the first quarter of 2019.
Government & Regulatory PULSE
CMS
- CMS will readjust national hospital payments away from urban towards rural hospitals, while injecting an additional $4.7 billion in total hospital payments for fiscal year 2020. The changes will favor rural hospitals by raising the payments for hospitals with a wage index below the 25th percentile and lowering payments for hospitals above the 75th percentile wage index, with a net additional cost to Medicare of $4.7 billion. The rule is intended to address rural hospital closures; 102 rural hospitals have shut their doors in the last eight years.
- CMS Administrator Seema Verma wrote a letter to state Medicaid directors exhorting states to join one of several dual-eligible Medicaid models supported by CMS. Verma wrote that some of the administrative burdens of operating a Medicare-Medicaid Plan have been rolled back, making it a more attractive option for states to pursue. Fewer than 10% of dually eligible individuals are enrolled in an integrated model today. The three models in which CMS is soliciting interest are: 1) the Medicare-Medicaid Plan option, where states, health plans and CMS sign a three-way contract to provide an integrated, single point-of-interaction to dually eligible members; 2) the managed fee-for-service payment approach, currently in operation in Washington State; and 3) an invitation for states to develop their own integrated model to serve dually eligible members under a custom waiver program.
States
- The U.S. Department of Health and Human Services (HHS) announced it will give more than $350 million to university or health systems in four states—Kentucky, Massachusetts, New York and Ohio—to reduce opioid deaths by 40% over the next three years. This effort is part of a long-term National Institutes of Health initiative to combat addiction that could serve as a blueprint for other states on how to coordinate efforts to prevent and treat addiction across schools, the criminal justice system and other parts of the community.
Evolent News
- In a blog post, Vice President of Health Policy Ashley Ridlon recently weighed in on the promise of CMS’ highly anticipated Direct Contracting model as the next step in the evolution from volume to value, as well as the challenges the model may face.
- Evolent recently launched a new series, The Heart of Care, to show how our care management teams are helping to change the health of the nation, one patient at a time. Read an introduction to the series by CEO Frank Williams and the first success story, highlighting the importance of taking a whole-person approach to complex health problems.
Survey Says/Studies Show
- An Integrated Healthcare Association report in California found that clinical quality was higher and total cost of care slightly lower for patients seen by providers receiving fully-capitated risk delegation. The 2017 study found a 3.5% difference in total cost of care and 10% higher clinical risk scores for patients seeing fully capitated providers. In addition, patients cared for by risk-sharing providers paid about $400 per year less out of pocket than patients with fee-for-service providers.
- CMS’ Comprehensive Primary Care Plus program did not affect total Medicare spending, with participating practices generating between 2% and 3% higher spending than those not in the program. About 2,900 primary care practices and 63 payers participated in the program, which is one of the largest CMS has administered. However, beneficiaries did see lower emergency room visits and greater improvements in quality performance.
- A medically tailored meal delivery program for medically and socially complex adults was associated with reduced likelihood of both inpatient admissions and skilled nursing facility admissions. Reporting their findings in JAMA Internal Medicine, researchers determined that net monthly costs for patients in the cohort would have been about $750 less per month had they all received the meals. California is currently running a medically tailored meal demonstration project, with results expected next year.
- The effectiveness of workplace wellness on the cost of care remains unproven, but large employers continue to invest. In a randomized trial across 33,000 employees at a U.S. retail company, worksites with the wellness program reported higher engagement in regular exercise and weight management but experienced no significant differences in self-reported health, health care spending and utilization, clinical markers of health, or absenteeism and job performance. Still, 33% of large, self-funded health employers expect to invest in financial incentives for wellness programs and are spending three times more per employee than 10 years ago.