Health Plans Lead the Way in Value-Based Strategies

| URAC Staff

With nearly two-thirds of Americans under the age of 65 covered by private insurance, no innovation in health care delivery can succeed without the support of health plans and employers. That’s why it’s not enough for the Centers for Medicare & Medicaid Services (CMS) to get behind the value-based reimbursement model; private payers need to get on board as well. 

“To effect change in health care, you can’t do anything without employers and commercial insurers,” said Aaron Turner-Phifer, URAC’s director of government relations. “To have an actual long-term, coherent, seamless health care strategy, you need commercial insurers, private insurers and private employers working hand-in-hand with the things government is trying to do.”

Health plans have been largely supportive of the shift toward value-based reimbursement and its potential to reduce health care costs. Health plans have partnered with CMS in the Core Quality Measures Collaborative—tasked with defining value-based care—and are throwing their support behind the State Innovation Models Initiative, which provide funding for states to test new approaches in health care delivery. 

“Employers and insurers have been, in many respects, leading the way on some of these things,” said Turner-Phifer. 

As one successful example, he points to Blue Cross Blue Shield of Michigan’s Patient-Centered Medical Home program, which cites savings of about $427 million over six years. The program encompasses more than 1,600 practices and 4,500 physicians across the state, serving nearly 2 million patients. Among participating providers, BCBSM found such results as a 15 percent lower rate of adult ER visits and a 21.4 percent lower rate in adult ambulatory care sensitive inpatient stays. Among the elements of the program are patient registries to monitor care, 24-hour patient access to a clinical decision-maker and assistance in creating individualized health goals.

Elsewhere, many accountable care organizations are working in partnership with health plans, and more payers are establishing relationships with provider organizations for accountable care contracting. Turner-Phifer also sees an increasing number of health plans interested in working with pharmaceutical manufacturers to create outcomes-based contracts for drugs, and he notes more plans are partnering with Medicare and state Medicaid agencies to work on value-based reimbursement models. 

Health plans face a winding road ahead to achieve the promise of value-based reimbursement. Take bundled payments, for example: “It can get pretty messy to un-bundle a payment among disparate, non-affiliated parties who all had a vital role to play in the patient outcome,” he said. “Assigning value to someone’s contribution in an episode of care and paying for that—or paying one entity and having it disperse payment to other entities—is something that’s relatively new.”

Big changes may be happening behind the scenes, but Turner-Phifer said it’s still unclear how the shift toward value-based reimbursement will impact the patient experience. Patients may not be aware their providers are sharing electronic health records, but they could begin to experience more calls from their providers, care coordinators or pharmacists to check on their health. “They could not notice anything, they could notice some positives, or they could perceive it as an annoyance and yet another hurdle in the health care system,” he said.

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