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Making Total Cost of Care Contracting Work

By Philip Betbeze  
   December 03, 2015

Steve Hamman

One program he says would otherwise be impossible is a diabetes prevention program benefit for members.

"In the senior population, progression is preventable for more than half of patients, yet we don't have diabetes prevention in practice in most of the country, with a few exceptions," Jain says. Yet such programs are a bedrock of making a model like CareMore's work.

"We've got dietitians at the care centers and we stream at-risk patients into a program. We started talking about it in March, and in June, we launched. That's the beauty of capitation—the total cost of care view of it."

Growing importance
CareMore is only one example where total cost of care contracting is making quick headway. Steve Hamman, as senior vice president of enterprise network solutions at Health Care Service Corporation, the licenser of Blue Cross programs in five states, is charged with coordinating and implementing the operational aspects and ongoing operations of total cost of care agreements in some of its markets.

He calls total cost of care contracting "absolutely a core component of what we do."

Such contracting has a long history in one of HCSC's markets in Illinois, with about 100,000 members and 75 different risk-bearing entities that agree to accept professional and outpatient diagnostic risk in the form of capitation. Hamman and his team are charged with tailoring such programs for the variety of market types served by the five health plans under HCSC's banner in Illinois, Oklahoma, Montana, New Mexico, and Texas.

He says total cost of care contracting is gaining traction because of three primary components in its Blue Advantage program in Illinois: demonstrably higher quality compared with HCSC's broad PPO, often even with the same providers; member satisfaction that is at least as good as the PPO product; and costs that are lower by 26% per member, per month.

Philip Betbeze is the senior leadership editor at HealthLeaders.

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