The
transition to value-based care has stalled, but the unique structure of
Medicare Advantage can help payers advance to lower costs and better outcomes.
January 10,
2020 - As America strives for positive changes to the healthcare
system, it may find the greatest advancements for value-based care in Medicare
Advantage plans.
Over 90 percent of
healthcare payers in a small Health Care Payment Learning and Action Network
survey said they expected alternative payment models to increase. However, most
were unwilling to divorce from fee-for-service entirely. Instead, they expected
to move into value-based reimbursement models that were still rooted in
fee-for-service structures.
Furthermore, over
half of the payments made in 2017 in the commercial sector were value-based
reimbursements, according to the Catalyst
for Payment Reform Scorecard. But 90 percent of these payments
were grounded in fee-for-service structures and only around six percent involved
providers taking on downside risk.
Payers have made many
strides forward in recent years toward value-based care, but what will it take
for the industry to fully commit?
By reforming their
Medicare Advantage plans, hesitant payers may achieve the leverage they need to
devote their whole system to value-based care.
Florida Blue, Humana,
and Optima Health have been using Medicare Advantage to progress their
value-based care initiatives. These payers have distinct structures and serve
different populations. Florida Blue is a single-state health plan, while Humana
is the second-largest Medicare
Advantage plan in the nation and Optima Health is owned by the integrated
healthcare delivery system, Sentara.
Despite those
variations—and, in part, because of them—these payers illuminate how Medicare
Advantage’s flexibility, community-orientation, provider resources, and quality
measures make these plans the ideal starting point for value-based care reform.
BENEFIT
FLEXIBILITY
Whereas traditional
Medicare may leave payers burdened or baffled by changing regulations, Medicare
Advantage plans are freed by them. CMS policies regarding Medicare Advantage
plans are getting less and less restrictive with each passing year. For example,
the plan year 2020 updates allowed benefits
such as meal delivery, transportation for non-medical needs, and in-home
services.
It is this
flexibility that has allowed Humana to invest in more personalized benefit
designs that address specific health concerns for the market’s population,
explained Will Shrank, MD, chief medical officer at Humana.
“We can be flexible,
personalize, leverage, and a remarkable data source to be both precise about
the needs of members, and to share that data with providers in a nimble way,”
he said in an interview with HealthPayerIntelligence.com. “So if a
provider is taking risks in partnering with us as compared to doing so directly
with the government, we think there are a lot of advantages.”
“As a result, we're
able to really accelerate the move towards value-based care and the likelihood
that we will be successful in that endeavor,” he stressed.
Such liberty can help
payers innovate value-based care solutions in other areas of their business. It
ultimately helps break down barriers to value-based care, including the lack of
providers’ community orientation.
SOCIAL
DETERMINANTS OF HEALTH AND COMMUNITY RESOURCES
By taking the time to
partner with community organizations, Medicare Advantage plans offer an
invaluable resource to providers who are working around the clock for their
patients and may not have the time to vet and pursue community relationships.
To Sarah Iselin,
executive vice president of government programs and diversified business at
Florida Blue, a primary factor in Medicare Advantage plans’ role in healthcare
is maintaining community for patients. A plan’s power to motivate value-based
care rests largely on its connections with communities.
“Medicare Advantage
programs support providing seniors with access to high-quality affordable
health benefits,” she recently said in an interview. “And Medicare Advantage
plans, in part because of additional flexibility that CMS has given us, are
uniquely able to support keeping people in their homes and communities, playing
a material role in making healthcare simpler at a time when people are at the
most vulnerable moments in their lives.”
These community
relationships are often best used to address social determinants of health,
which have a larger impact on member outcomes than purely clinical care,
according to commonly cited statistics.
CMS expanded Medicare
Advantage policies for this year to cover more benefits that address social
determinants of health. Covered benefits such as daycare services, therapeutic
massages, and caregiver support give payers the opportunity to connect
beneficiaries with local resources and companionship.
The leaders at
Florida Blue, Humana, and Optima Health were positive about the changes and the
potential to further value-based care through their community relationships
allowed with these new flexibilities.
“We are a single-state health insurance
company, which means we have a really deep understanding of our local
community, of the residents in our local community, and of what they need,”
Iselin said. “And so that flexibility that we've gotten from CMS is really
allowing us to design Medicare Advantage plans that are responsive to all of
those needs and to do it with a really deep understanding and with really deep
partnerships with the local healthcare delivery system.”
For example, Florida
Blue’s Medicare Advantage plan is in the process of piloting a transportation
service that will get seniors out of their homes and into social situations,
connecting them with family, friends, and communities. The payer is also using
the extended benefits to cover house cleaning, meal preparation, and other
benefits that are not directly medical but that can act as preventive care for
behavioral and mental conditions.
Shrank also noted
that Humana will be using new flexibilities to build on
its community relationships and social determinants of health focus to pursue
grocery benefits and home improvements for patients at risk for falls. It is
these benefits that set Medicare Advantage apart from traditional Medicare, he
said.
Like Humana, Optima
Health is also using these benefits to address behavioral or mental healthcare
needs. The company’s Medicare Advantage plans will provide hearing aid benefits
and bolster community resources in 2020, said Patti Darnley, senior vice
president of government programs at Optima Health. And when a member is
avoiding a doctor’s visit because they are struggling to pay their bills, the
Medicare Advantage plan may be able to leverage its community resources to
help, she added.
“We are really trying
to use resources in the community as well as trying to incentivize or reward
members for behaviors that actually help them and, ultimately, help the
healthcare system,” she explained to HealthPayerIntelligence.com.
Each of these
benefits that are now covered under Medicare Advantage move the industry
step-by-step in a value-based care direction.
“There's a whole
array of services that we can and do provide for our members that create an
environment that supports wellness, and that will promote successful
value-based care,” Shrank summarized.
In turn, this helps
to reinforce payer-provider communication, another key component to value-based
care. For example, in order to determine what kind of social determinants of
health benefits to target, Optima Health’s Medicare Advantage plan turns to its
providers.
“We really get some
feedback from our providers about where they are seeing issues,” Darnley
explained.
PROVIDER
RESOURCES
While provider
feedback is essential to creating plans that work for specific member
populations, payers also need to be talking back to their providers to truly
implement value-based care.
In some situations,
the payer has all of the pieces in place to pursue value-based care, such as
claims data, member engagement, and community resources. However, its provider
partners may not have the bandwidth to serve at a similar capacity, which could
impede value-based care efforts.
Medicare Advantage
plans excel at enabling payers to connect providers with the resources they
need to engage in value-based care agreements, industry experts agreed.
For example, Humana
invests in giving providers access to the technologies that they do not have
the resources to acquire. The large payer also engages with patients outside of
the provider’s office through follow-up phone calls or home visits to ensure
members receive the necessary care.
“Because of our scale
and our presence in communities, we can offer a different set of solutions that
wrap around clinical care in ways that are hard for providers to produce on
their own, or certainly hard for the government to produce,” Shrank said. “By
pulling all of those services together in an integrated way, we can wrap around
the very diverse and complex needs of the populations that our partnering
providers need.”
For Optima Health,
that partnership with providers takes on a unique quality. Optima Health is
owned by Sentara, a non-profit, integrated delivery system with 300 sites of
care, including 12 hospitals.
The proximity to
providers allows Optima Health to pivot more quickly so that its resources are
genuinely fulfilling providers’ needs. This is best demonstrated in the payer’s
ability to pilot new programs in one of their provider settings before heavily
investing in expanding it across their entire health system.
While
interoperability often blocks payers from supporting providers in a value-based
care environment, Medicare Advantage plans like Optima Health can overcome that
barrier.
To Darnley, Optima
Health’s integrated structure allows the Medicare Advantage plan to take a more
holistic approach to care. With the vertically consolidated system, the process
of accessing patient data and assessing their care needs can be much more
streamlined.
The structure also
gives the payer more control over member spending because they can more
accurately target their funding. Using member surveys and regular meetings with
their providers, Optima Health’s resources are less siloed. The payer can
support not just the interests of the provider, or the plan, or the patient but
all of them at once.
By providing better
resources for provider partners, payers have noticed a shift in the
historically adversarial relationship between payers and providers. Rather than
the transaction-based conversations of the past, discussions between payers and
providers now focus on how Medicare Advantage plans can help their providers,
in search of a value-based partnership.
“It's based on a
recognition that there is a lot of waste in our healthcare system,” Shrank
explained. “Through better partnership, better care coordination, better health
outcomes, and less unnecessary utilization of services, there is an opportunity
to meaningfully improve the patient experience, the patient’s health, and also
the provider or the payer experience, and our financial performance.”
When providers take
on more financial risk, as they may in Humana’s Spinal Fusion Episode-Based
Model announced earlier
this year which involves upside risk, the payer tends to back off and become
less of an administrative presence, Shrank noted. That is when the relationship
transforms into more of a partnership.
To ensure that the
relationship is working for the patients as well, however, Medicare Advantage
plans benefit from setting their own quality measures.
QUALITY
MEASURES
The ultimate goal of
value-based care is to provide the highest quality of care at the lowest
possible cost. To that end, CMS has laid out its Medicare Advantage star rating
system that is the same for all health plans. But many
health plans that strive to achieve truly value-based care also have internal
quality measures that they pursue.
At Humana, these
internal measures are centered on health outcomes. Patient experience and
provider experience also play into the company’s quality measures.
“We measure the
provider's experience working with us, and we think of that as a real
priority,” Shrank said. “If the providers in our network see us as a real
partner, and if they see us as an asset in managing the health of the patients
they serve, rather than as more of an administrative barrier, we know that
we're doing our job right.”
Maintaining positive
results in these metrics can influence Humana employees’ bonuses and give the
payer a sense of whether it is appropriately supporting its members.
Optima Health also
puts a lot of emphasis on the provider’s role in quality measurement. Darnley
underscored that the payer’s Medicare Advantage plan empowers providers with
data in order to pursue quality measures.
“We provide providers
with information as part of that value-based care contract. It shows where we
have gaps in care and what patients we need them to outreach to, working
collaboratively with those physicians by giving them the information that they
want and then helping them make sure that they are addressing the patient's
needs,” Darnley elaborated.
Iselin highlighted
Florida Blue’s use of net promoter scores and the importance of measuring
member satisfaction, in addition to measuring patient outcomes. Both Blue Cross
Blue Shield, Florida Blue’s parent company, and Humana have achieved strong
net promoter score performance in the past.
“It's not just about
cost,” Iselin expounded. “It is just as much about ensuring that they're
getting high quality, truly patient-centered care. Balancing both of those
considerations is really critical and important for consumers and for our
success as a health plan.”
Medicare Advantage
plans are a springboard for taking value-based care into all areas of payer
business. All three plans expressed enthusiasm about the direction that
value-based care in Medicare Advantage is heading.
“I expect to see
nothing but growth in Medicare Advantage as we move forward as consumers are
making choices,” Iselin summarized. “We're excited to be a part of it.”
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