"We don't want to wait for symptoms. We can be proactive, before a full exacerbation of a chronic disease," says one ACO executive.
Editor's note: This article is part of HealthLeaders' Mind the Gapseries, a three-part exploration of how healthcare is bringing information, patients, care, and payment closer together. Read the other articles on automated prior authorizations and real-time drug benefits checks.
Yet another benefit of the pandemic's telehealth expansion is more hospital-at-home (HAH) and remote patient monitoring (RPM) programs. Integra Community Care Network, the accountable care organization (ACO) for Care New England Health System, is launching both in partnership with tech company Biofourmis. And with the Centers for Medicare & Medicaid Services (CMS) expanding HAH waiver eligibility and reimbursement parity beyond the COVID personal health emergency, look for more payviders and health systems to deliver at-home solutions.
Two programs for at-home care
The Integra HAH waiver program, per the Biofourmis press release, will " 'admit' patients to their homes instead of a medical facility for inpatient-level care." Data from wearable sensors connects with the company's FDA-cleared Biovitals Analytics Engine to monitor the status of Medicare patients, who will also be connected via tablets, video, and in-person home visits as needed.
"This enables us to be just so much more connected to patients and better able to help people feel comfortable 24/7," says Ana Tuya Fulton, MD, MBA, chief medical officer at Integra and executive chief of Geriatrics & Palliative Care at Care New England.
Integra's second program for remote monitoring applies to its entire ACO population—Medicare, Medicare Advantage, Medicaid, and commercial—with a focus on patients with congestive heart failure, COPD, asthma, and other chronic conditions.
"Integra ACO has remote monitoring for multiple populations," says Fulton "with a focus on improving outcomes, decreasing costs, and improving patient/member satisfaction." From the Biofourmis release, Fulton added: “From a clinical and cost standpoint, safely keeping patients out of the hospital is certainly one of our goals as a risk-bearing ACO …"
A little help from CMS
The HAH program from Integra/Care New England and a growing list of hospitals was made possible by CMS' Acute Hospital Care at Home waiver. Announced in November 2020, the program is part of the agency's broader Hospital Without Walls initiative. While the program is strictly for Medicare beneficiaries, Fulton notes that some states may be working toward a similar solution for people enrolled in Medicaid. In December 2021, CMS issued a revised Fact Sheet to help state and local governments develop "alternate care sites with information on how to seek payments through CMS programs."
Integra's foundations
Fulton cites Integra ACO's foundations as a strong one for their current work. "We've been learning the care pathway with our patients," she says. "We started as an early ACO in community-based, complex care management with interdisciplinary teams taking care of the highest need, typically older patients. Noting that "we wanted to build a continuum to give options," Integra expanded from nurse practitioner and nurse care manager home visits to a
Community Care Medicine program in 2018 that added rapid-response acute care to the home. In 2021, Fulton says that Integra added to their remote-monitoring capacity with one goal: "We don't want to wait for symptoms. We can be proactive, before a full exacerbation of a chronic disease."
The role of patient identification
As to the other ways that an ACO can grow itself operationally? "Correct patient identification is everything," says Fulton, adding: "No one has it nailed down 100% and everyone is looking for the secret recipe. Utilization and cost data to stratify risk is not enough."
Fulton continues: "We spend a good chunk of our time digesting data from claims-based payer reports, including Medicare. Who are our patients, what are their conditions, what claims do they have?" She adds: "We look at their clinical needs, our medical programing, community resources, social determinants of health. We spend a great deal of time in an ACO analyzing data, honing programs—and it changes every year. I spend so much time living in the patient EHR."
While Fulton is living the patient's EHR, she is helping to create a situation where more patients can do their living at home. Integra's HAH and RPM programs seek to transfer elements of care from a hospital setting to one where convenience and familiarity may help speed healing.
"This is a much-needed conversation, at the point of care," says plan executive Martin Burruano.
Editor's note: This Q&A is part of HealthLeaders' Mind the Gap series, a three-part exploration of how healthcare is bringing information, patients, care, and payment closer together. Gaps abound in healthcare: in data, coverage, and equity. There are equally fundamental spaces between information and patients, patients and care, and care and reimbursement. The degrees of separation between these elements are often excessive and unnecessary. Payers and their partners are helping to close these gaps—and ensuring the value in healthcare's value chain is linked throughout. Read the other articles on automated prior authorizations and hospital-at-home care.
Independent Health is one of many health plans gearing up to offer real-time prescription benefits checks for patients at point of care, following a January 2021 final rule from the Centers for Medicare & Medicaid Services (CMS) requiring Part D plans to provide this information to enrollees.
HealthLeaders spoke with Martin Burruano, vice president of pharmacy services at Western New York's Independent Health, about how smaller, regional plans are implementing real-time benefits checks.
HealthLeaders: What does Independent Health's tool include?
Martin Burruano: The myBenefitCheck solution from DrFirst will include up-to-date, patient-specific drug coverage information for nearly 400,000 members, including required prior authorizations and out-of-pocket costs for prescribed medications and therapeutically appropriate alternatives.
HealthLeaders: How long has Independent Health been working on this, and what impact did the CMS requirement have?
Burruano: While implementing a real-time prescription benefits check is CMS-driven, Independent Health had been looking at cost transparency as a part of our business plans for a long time, as well as improving member and provider experience.
It's hard for prescribers. They deal with multiple plans, PBMs, and dozens of formularies, drug coverage criteria, and polices. And clarity around member cost share is especially important given the growing number of high-deductible plans. This is a much-needed conversation, at the point of care that includes lower-cost alternatives, prior authorization, quantity limits.
It was one of those welcome requirements. What currently happens is that a claim rejects from the PBM at the pharmacy and slows things down. Efficiency in the system, up front, is better administratively and for the member and provider. CMS recognized the need, including for interoperability of platforms. It's a win-win for providers, members, and the health plan.
HealthLeaders: What are the unique implementation challenges and opportunities for regional plans?
Burruano: Really, all plans are kind of in the same place. It may even be easier for regional plans because we have strong relationships and mutual trust with our providers already. This is giving them another tool in their toolbox, which makes adoption easier.
HealthLeaders: How are you rolling this out to your physicians?
Educating providers on the benefits of what this means for their total cost of care and greater member satisfaction is huge. Most of our PCPs are in value-based models, so total cost of care really matters. Specialists are included also and there is just less administrative burden for everyone.
HealthLeaders: What is the scale of your rollout?
Burruano: This will be one big bang for all lines of business at once. There's no real advantage to pilot in this situation, even leading up to a CMS requirement. Physicians don’t practice by lines of business and at point of care, they may not even know who the patient's specific payer is.
HealthLeaders: What role did your PBM play?
Burruano: We own and operate our own PBM, Pharmacy Benefit Dimensions, and they were part of the implementation process from day one. It makes designing for flexibility much easier.
About its final rule, which is effective January 1, 2023, CMS stated: "With this tool, enrollees will be better able to know what they will need to pay before they are standing at the pharmacy counter." Independent Health is one of many plans working toward full implementation by that date to improve member and provider experience.
"…[A]lthough the proverbial devil is in the details, a reasonable path exists toward greater direct contracting between purchasers and ACOs," states The American Journal of Accountable Care.
In its December 2021 issue, The American Journal of Accountable Care(AJAC) highlights how multiple factors—including the "pandemic … a reduction in sales and tax bases, along with a continued increase in health care costs, has driven active exploration of alternative approaches" to traditional purchasing mechanisms. This exploration transcends traditional health plan relationships to direct contracting between employers and accountable care organizations (ACO). For these to succeed, ACOs must understand key purchaser objectives and priorities.
Why is this happening? The AJAC authors highlight that purchasers are beginning to see traditional health plan approaches—using claims data to create case and disease management programs to target patients with the most complex conditions, highest utilization, and highest costs—as limited. While these components are important, the rising importance of social determinants of health (SDOH) linked with both alternative data is driving employers and other groups toward "high-performance solutions" that are more innovative and disruptive.
Direct contracting options and implementation findings
These high-performance solutions include direct contracting with centers of excellence (COE), outcomes-driven narrow networks, and ACOs. In its 2020 Health Care Delivery Survey, Willis Towers Watson reported that over the next three years, 73% of employers intend to adopt these strategies. The company’s 2022 survey showed that more are planning or considering the following alternatives:
An additional 23% are looking to COEs
An additional 30% may partner with narrow networks
Some 37% more may contract with vendors to improve employee well-being
These are in addition to the 48%, 21%, and 45% of employers (respectively) that already deploy these solutions.
What ACOs must consider
Where direct contracting is considered, the AJAC article notes that organizations like ACOs must consider the following:
Scope: Noting that "few ACOs truly excel at offering multiple high-value service lines," they may want to focus on more limited contracting for what they do best. The journal articles cite recent examples of the Connecticut and New Jersey State Employees’ Health Plans shifting to bundled payments for surgery, hospitalization, and other "high-performance solutions not offered by the current plan administrator."
Organization: The authors contrast the advantages of health-system-based and provider-based ACOs: the former for "core services … including [the] case and care management, as well as claims administration" traditionally offered by health plans, and the latter for better "inherent alignment between business goals and purchaser objectives."
Infrastructure: For direct contracting to succeed, ACOs must also "have dedicated personnel" for the infrastructure roles that plans generally provide: sales/marketing, claims, analytics, and consumer support.
Value: Because all alternative payment methods are rooted in increased value, ACOs must demonstrate they can do better than their counterparts. The authors again cite the importance of data analytics to fulfill this promise.
Early focus and priorities
Even desired alternatives must often start smaller to create opportunities to demonstrate difference and success. The AJAC identifies seven purchaser questions that ACOs must be prepared to answer:
Can the ACO prove it has delivered better results?
Are the ACO and purchaser truly a good fit?
Are the ACO’s current clients satisfied?
Like any innovative venture, does the ACO know how to scale?
Can the ACO sustain results over time?
Does the ACO make implementation and deployment easy?
Can the ACO offer outcome guarantees?
The AJAC authors acknowledge that answers and success stories are still emerging. But the note that "although the proverbial devil is in the details, a reasonable path exists toward greater direct contracting between purchasers and ACOs."
"We know nothing in healthcare will be successful if we do not have a way to pay for it—and if [it] does not serve everyone in a community." — Alliance of Community Health Plans
Community health plans are often the unsung heroes in their markets, demonstrating close relationships with local providers and a deep knowledge of community needs. Covid-19 has made these bonds even more important, and inspired innovations that meet immediate pandemic needs while driving longer-term solutions. Local payers are taking these same actions, summarized by the Alliance of Community Health Plans in its 2021 Report on Affordability and a recent blog on federal policy recommendations for 2022.
Here are the top seven achievements and recommendations from ACHP and its members, which represent approximately 25 community health plans offering diverse lines of business across the U.S.
1. Expanding telehealth.
Service areas have included mental health; physical, occupational, and speech therapy; and even medication management, including dialysis. Telehealth aligned naturally with these and other services, with the Centers for Medicare & Medicaid Services (CMS) aiding and extending reimbursement beyond the public health emergency (PHE). Along with many stakeholders, the ACHP is calling for CMS to continue broadening telehealth’s potential.
2. Creating remote admission and monitoring infrastructures.
The pandemic and telehealth technology have advanced hospital-at-home and remote monitoring. In addition to large payers, 75% of community plans have created or expanded these programs with the ACHP reporting "significant savings for both consumers and the health system, plus improved consumer satisfaction."
3. Designing virtual-first health plans.
Three "provider-aligned" ACHP plans—Harvard Pilgrim Health Care, Kaiser Permanente, and Priority Health—introduced virtual-first offerings in 2021, mirroring national payers such as UnitedHealth Group, Cigna, and Aetna. ACHP plan premiums were up to 20% lower. Harvard Pilgrim and Priority partnered with Doctor on Demand while Kaiser was able to build on a strong, existing telehealth foundation.
4. Calling for a better Medicare Advantage.
Among the ACHP’s policy recommendations is a strengthening of Medicare Advantage (MA) for the growing mass of older Americans aging and whose expectations differ. Specific suggestions include better ways to measure quality—a concern shared by the MA oversight agency, MedPAC—and to document patient status, particularly for data gathered from remote encounters.
5. Maintaining access.
There is a reason why states like Nevada are creating public options: between Medicaid and the marketplace, gaps in affordable coverage remain. There are still 12 states that have not expanded their Medicaid programs and an additional five did so in 2020 or later. There is also no guarantee that the federal government will make COVID-19-era subsidies permanent. The ACHP also notes a Medicaid redetermination process that remains complex for people whose eligibility shifts due to personal income changes.
6. Making health equity commitments permanent.
Here, the AHCP’s recommendations range from sustained funding and initiatives to standardized health data collection, two approaches for understanding just how uneven the playing field is and how to level it.
7. Controlling prescription drug costs.
While Build Back Better as a comprehensive package has likely fizzled, components with increasingly-hard-to-come-by bipartisan support could find new life as individual measures. This includes drug cost control measures ranging from federal negotiating power to faster generic approvals.
These achievements and recommendations reflect the ACHP’s broader 10-year Roadmap to Reform, which emphasizes collaboration, value, and community health.
"This is a re-imagined PA process, one where expedited approval becomes the standard," says one Humana executive.
Editor's note: This article is part of HealthLeaders' Mind the Gap series, a three-part exploration of how healthcare is bringing information, patients, care, and payment closer together. Read the other articles on real-time benefits checks and hospital-at-home care.
Humana is expanding its real-time prior authorization (PA) platform to its providers in all 50 states. The planned rollout comes less than one year after the company launched a 12-state pilot, which generated enough ROI for Humana to begin a nationwide implementation. One plan executive reports that the platform's instant service approvals are generating immediate, short- and long-term improvements.
The early results
The platform—which was designed and implemented in partnership with Cohere Health—is focused on PAs for musculoskeletal (MSK) services. "In just nine months, the results … have exceeded our expectations," said William Shrank, MD, MSHS, chief medical officer at Humana. Those results include:
Platform processes 95% of MSK PAs
Median PA approval time of 0 minutes
89% of service requests can be scheduled immediately
The platform expansion will apply to all Humana Medicare and commercial members and bring real-time MSK PA to more than 65,000 contracted providers. The company hopes to build on what it sees as both the obvious and broader value of PA automation: better treatment decisions, faster service, and significant savings, with the added benefits of increasing patient safety and reducing utilization waste.
The secret sauce
Humana's PA platform is an example of a technology approach that solves multiple problems through multiple components. The approval process is linked to best-practice treatment suggestions at the point of authorization—"clinical nudges" that help doctors make smarter and more cost-effective choices.
The result, according to Cohere and affirmed by Humana, is a platform that "automates both provider and payer steps in the process, while also coupling AI and machine learning with evidence-based clinical policy to support better care decisions."
Embedded within Cohere's platform are MSK clinical pathways defined by the American Academy of Orthopaedic Surgeons (AAOS), are publicly available, and that signal pop-up recommendations at point-of-service authorization. Physicians who request 24 physical therapy visits, for example, but accept the platform AAOS recommendation of just 12 to start will receive an automatic PA.
This replaces the historical process where the request would likely be denied, activating a lengthier, manual review. Cohere reports, for example, that this "successfully influences providers to switch from an inpatient to an outpatient setting, when warranted by the evidence, in 65% of cases."
"This is a re-imagined PA process," says Lisa Stephens, MBA, PMP and SVP of operations at Humana. "One where expedited approval becomes the standard, especially if clinically proven care pathways are chosen."
Improving payer-provider relationships
In the state of the union between payers and providers, PA and other utilization management (UM) controls are a growing sore spot. In a May 2021 Medical Group Management Association (MGMA) Stat poll, 81% of MGMA members indicated that payer PA requirements had increased since 2020, with some adding full-time staff to focus on PA management.
"PA is a significant pain point. It's a high administrative burden on both ends for payers and physicians," acknowledges Stephens.
The American Medical Association (AMA), in collaboration with patients, providers, and medical associations, has defined more than 20 principles for PA and UM reform tied to clinical validity, continuity of care, transparency and fairness, access and administrative efficiency, and alternatives and exemptions.
Humana's PA platform touches on several of these principles, including AMA Principle #1: "Any utilization management program applied to a service, device or drug should be
based on accurate and up-to-date clinical criteria and never cost alone. The referenced clinical information should be readily available to the prescribing/ordering provider and the public."
Humana physician response has been positive.
"We are hearing from physicians and their staffs that this is a better experience," adds Stephens. "Providers can give real-time feedback via the PA interface." The result? Cohere reports that 72% of providers are "very satisfied" with the platform.
Just the beginning
Humana is exploring how to refine its current operational model as it partners with Cohere to add other conditions to the platform, including those that present a similar profile to MSK.
"MSK traditionally has a very disparate service approach. Diagnostic and treatment options could include x-ray, MRI, physical therapy, surgery, pain medication. MSK is a great example of a complex care situation." Such situations are ripe for the physician partnership, automated platform, and clinical pathways that approach what Humana is expanding.
Humana's Stephens also calls the PA platform "just one proof point of what we're doing to simplify, improve and automate … we are trying to be a leader in the industry." In addition to the MSK PA expansion, other company approaches and objectives include:
Integrating PA into the physician EHR
Improving clinician peer-to-peer review
Partnering with national organizations
Stephens notes that these efforts exceed traditional targets.
Humana's PA platform is an example of how healthcare's stakeholders are better minding the gaps of time, access, care delivery, and reimbursement. The ideal outcome is that the highest-touch, most important aspects of care delivery occur where they belong: between provider and patient.
"With more insurers in almost every state exchange, there is less risk of getting hit with adverse selection like they did the first time. The volatility of the mid-2010s has gone away," says one industry analyst.
Before December 15, the first cut-off date for open enrollment, the Centers for Medicare & Medicaid Services (CMS) reported that close to 4.6 million people had signed up for marketplace coverage through either HealthCare.gov or a State exchange. This includes nearly 1 million new enrollees. These numbers are from CMS' National Marketplace Open Enrollment report. The agency has been providing weekly snapshots throughout open enrollment, with subsidies from the American Rescue Plan and increased plan participation continuing to boost numbers.
As open enrollment draws to a close, Bill Melville—principal analyst of Market Access Insights with Clarivate—identifies five key reasons for 2022 success compared to the early days of the exchanges:
1. The big players continue to come back
"Markets are essentially stable," says Melville "which is why the for-profit nationals have returned to the business." This includes UnitedHealth Group and Aetna, which can offer low-cost care options through its growing integration with CVS Health.
2. More options are available
In addition to 32 new insurers, Melville notes, "Centene has stepped into many places and boosted exchanges. Anthem widened its scope, and regional plans like Medica and CareSource stretched into new markets." Some states are seeing more options than ever before. "In 2022, Georgia has four new carriers, bringing the state to 11; this is more than any time since the exchanges began. That is a big turnaround."
3. New insurers are expanding
Startup health plans continue to earn their stripes and expand their business lines. "New for-profit companies like Oscar and Bright Health are continuing to expand, but their narrow, high-performing network models were built for exchange customers," notes Melville.
4. It's not the 2010s
"The risk is much lower for participation now, as payers have learned how to price for exchanges," adds Melville. "With more insurers in almost every state exchange, there is less risk of getting hit with adverse selection like they did the first time. The volatility of the mid-2010s has gone away. A few years ago, we were talking about the risk of 'bare counties'–counties with zero exchange options." Today, that's simply not the case.
5. Putting the affordable into the Affordable Care Act
CMS reports that $10 monthly premiums are available to 80% of enrollees. Says Melville, "For 2022 and 2023, consumers will pay no more than 8.5% of their income on premiums. It was previously 10% and was lowered through the coronavirus relief package passed in early 2021. But it addresses a longstanding issue—premiums were not affordable for people who earned too much for subsidies."
This is all great news as open enrollment extends through January 15 for coverage that starts February 1. CMS notes that HealthCare.gov will continue to offer help from more than 1,500 trained Navigators, thanks to a $10.2 million funding boost for the 2022 season.
"This is a whole new ballgame," notes one academic consultant—an observation about marketplace exchanges that also applies to every aspect of healthcare next year.
Pandemic year three is at hand and will continue to affect everything from cost-sharing and telehealth to data disruption and tech innovation. Expect multiple disruptions aimed at improving patient experience and outcomes, including, social determinants of health (SDOH); exchange and Medicare Advantage (MA) plan growth; and advanced digitization. Payers will continue to grapple with the forces of consolidation and value-based care (VBC) as COVID concern runs tandem with delivery system progress.
Finally, the full story of patient health
The pandemic laid bare healthcare's disparities. Healthcare, especially payers, have the data to do something about it. To a degree that they always have, but alternative data integrated from multiple sources and activated by artificial intelligence will be even bigger game changers.
Big payers will continue to cozy-up the exchanges
Federal subsidies, a special enrollment period, and change of administration have breathed new life into the ACA marketplace. As of August 2021, the Kaiser Family Foundation (KFF) reported that a record 12.2 million people were enrolled in exchange plans. And while KFF was cautious as to current Open Enrollment projections, others are more optimistic. "This is a whole new ballgame," says consultant and adjunct professor Katie Keith of Georgetown University Law School.
In addition to 32 new insurers, larger payers have reestablished themselves. Bill Melville, principal analyst of Market Access Insights with Clarivate notes: “Exchanges have drawn back major insurers who left them, notably Aetna in eight new markets and UnitedHealth Group in seven. The risk is much lower for participation now, as payers have learned how to price for exchanges."
Expect more Medicare Advantage disruptions
MA plans will continue to see enrollment growth through expansion and collaboration. Cigna has expanded its small-group partnership with insurance startup Oscar while more established players like Blue Cross Blue Shield (BCBS) either expanded or entered new markets (CareFirst's group entry).
Two additional MA disruptions loom with Humana at the crux of both: Star Rating changes with quadruple-weighted customer experience measures as of plan year 2023 and a larger shift to VBC rooted in home health. "Humana has invested heavily in home-based health services for its Medicare Advantage members," says Paula Wade, also a Market Access Insights principal analyst with Clarivate. Her colleague Melville adds: “The company plans to have 50% of its MA lives in value-based home-health models within five years," noting that "Humana’s strength in MA could lead the entire segment into a value-based shift.”
VBC will expand within its limits
That an MA payer's shift into VBC could lead others to follow says a lot about how original Medicare's VBC demonstrations are faring. Quality has improved and costs decreased—or not—depending on the source. All eyes will be CMS' strategy refresh and Global and Professional Direct Contracting (GPDC) Model, which welcomes new entrants January 1, 2022, and "opens capitation for both new and experienced groups" per industry consultant Jennifer Bresnick.
This is against a payer VBC backdrop that will continue to be marked by expansion and constraint in 2022: the former as VBC is applied to novel drug treatments and digital therapeutic services, and the latter as the industry seeks more degrees of separation from its fee-for-service chassis. But this will be just the beginning. Speaking at a Health Plan of the Future webinar, Jake Sattelmair, co-founder and CEO of Wellframe, notes: "Provider payment is no longer the primary vector for influencing risk," with co-presenter Marcia Macphearson, Partner, Oliver Wyman, adding: "Alignment of reimbursement structures is only a first step … If payers stop there, they will not get the results."
Digitization growth through a consumer focus
Macphearson and Sattelmair highlight that the next step for VBC is identical to that for healthcare's digital transformation: putting consumers first. The two are intertwined, as reflected in AI Multiple's definition of digital transformation as "the use of the latest technologies to enhance existing processes and offer new and improved services and products to customers. It aims to create value by changing how businesses operate and how they deliver value." In 2022, and over the next decade, payer digitization efforts will accelerate beyond core business with the help of startup supporters and payers' own innovation ventures.
Payers will continue to get a little closer
How will payers achieve this? Consolidation and integration, the disruptive forces that show no signs of stopping. Clarivate's Wade notes: "So many hospital systems have morphed into huge regional Integrated Delivery Networks (IDN), and that has inhibited carriers' ability to dictate contract terms and pricing. It also allows the more advanced IDNs to contract directly for care with local employer groups. Often, the payers' best solution is to design a co-branded regional plan." Reflecting IDN power, payer advocacy group America's Health Insurance Plans even rebranded itself in 2021. The new "just AHIP" reflects a "P" that increasingly stands for "payvider."
As these arrangements grow, Wade adds that "big insurers will continue to develop and integrate their own healthcare delivery assets: from the large-scale buyups by UnitedHealth … to Humana's network of owned clinics and home health operations." Melville adds another example, the increased CVS Health-Aetna integration that is tying more CVS MinuteClinic and HealthHUBs to Aetna plan designs.
Wait and see on BBB
Finally, there is the grab bag known as the Build Back Better bill (BBB): its items have been picked through and who knows what the leftover goodies are worth? The BBB is already a shell of its former self but does—if it passes—retain in-home care funding and coverage subsidies for the Medicaid program, drug-price negotiation levers, and hearing benefits for original Medicare but not the lower age-in threshold that would have expanded care. Still, any major healthcare reform proposal is a step forward. It remains to be seen whether that step will happen in 2022.
The plan describes its approach as a glimpse into what the future of U.S. healthcare could look like.
Can a health plan be calibrated to achieve value-based results? Healthfirst and its latest patient outcomes across eight clinical areas suggest yes—and by making the community-based, health-equity infrastructure that has historically been missing from value-based care (VBC) models central to its response. The health plan's most recent gains in maternal health, senior care, and other areas are documented in new case studies. They are rooted in Healthfirst's ADVANCE health equity model which—combined with complex resource management, provider integration, and clinical leadership—has helped Healthfirst activate public health and equity as a care strategy, not a crisis response.
1. Results spanning conditions and populations
Healthfirst's new case studies feature better outcomes in five areas:
Asthma – Fewer ER admissions for those with asthma, with AIRnyc
Hypertension – A 30% improvement in six-month blood pressure control among South Asian Americans, with Project IMPACT, Community Heath Worker, and Million Hearts
Senior care – Reduced hospital readmissions and higher likelihood of two or more PCP visits, with JASA care transitions program
Maternal health – Higher rates of postpartum visit and outpatient gynecological care (11% and 7% respectively), with Mount Sinai
HIV – Better overall health for those living with HIV/AIDS, with WholeYou
Healthfirst—a nonprofit integrated delivery network co-founded in 1993 with 15 hospitals—is delivering these results across its 1.7 million members in the New York City, Long Island, and surrounding areas enrolled in the company's Medicaid, Medicare Advantage, and individual and small group plans.
"These areas are compelling because public health and Healthfirst administrative and claims data showed clear issues," says Tom Wang, manager of research and evaluation, partnerships for medical outcomes with Healthfirst.
To this he adds one important callout: "Programs involving health equity are not targeted for quick wins." Wang noted the roughly three-year period to ensure careful program study, contracting, implementation, and evaluation.
In the results above, notice the word "with." The power of "with" is central to Healthfirst's approach: find care models that are working, the community organizations that created them, then use plan and provider data to personalize them across both plan populations and individual neighborhoods.
In this way, Healthfirst's approach spans hyperlocal, state-level, and national models and partners.
"For senior care, we were advised to talk to JASA (Jewish Association Serving the Aging)," says Rashi Kumar, Healthfirst director of research and policy, partnerships for medical outcomes. "They already had a care transitions program and we implemented it using Healthfirst members and data. Another example is WholeYou, a Public Health Solutions program that Kumar reports was already evidence based.
These and other examples illustrate an unsung aspect of VBC: smart, complex resource orchestration.
3. Public health and equity as care strategy, not crisis response.
Using proven, partnership-based models suggests another aspect of resource management: an all-hands-on-deck approach to meeting the mission differently.
"The industry focused for a long time on reducing costs amongst so-called 'high utilizers of care', which is a stigmatizing term," says Kumar. "The focus on high cost, and reducing high cost, was the prevailing concept for a long time, and I believe it is adversarial to the true concept of population health."
To combat this, Healthfirst has embedded its health equity model, ADVANCE, throughout its operations. ADVANCE, as defined on the Healthfirst website, is named for its components and based on the belief that healthcare should be: Available, Data-Informed, Value-Driven, Accessible, Nurturing, Community-Based, and Evidence-Based.
Healthfirst is using its results and the ADVANCE model to call other stakeholders to action.
"Disparities will not be eliminated unless everyone is at the table," says Errol Pierre, Healthfirst SVP, state programs. "It's a team sport. And we are a health plan that does not take an adversarial role."
4. Analytics and clinical leadership.
Leadership is part of that team sport. Says Kumar: "We have proximity to public health leaders and researchers and the ability to look at Healthfirst data in concert with these experts. This includes clinical leaders at Healthfirst's member hospital, like Mount Sinai, and its own VP and executive medical director for partnerships and medical outcomes."
Healthfirst's analytics and clinical leadership is rooted in an alternate view of measuring equity.
"There is a big focus right now on being able to measure disparities by stratifying metrics, for example, cancer screening rates by race and ethnicities," says Kumar. "Some researchers are beginning to question whether this is solution-oriented enough … and are interested in measuring patient trust and developing an equity index. This is the next frontier: developing new methods to understand and even quantify equity."
5. From safety nets to safety networks.
Value-based has many meanings, depending on who you talk to. It is a contracting model, a care model, and a finance and reimbursement model. When VBC achieves its highest aims, it drives integration in a way that brings non-traditional, community providers to the table. The Healthfirst team says it believes that its approach is truly different, that it is a mission-, equity- and value-based glimpse into what the future of U.S. healthcare could look like.
Editor's note: This story was updated on December 27, 2021.
Here are the six best reimbursement stories from 2021 HealthLeaders' coverage and beyond.
COVID-19 continued to impact healthcare reimbursement as the pandemic entered its second year. Yet, what's different is that longer-term strategies and new business opportunities are emerging beyond crisis response. The Centers for Medicare & Medicaid Services (CMS) aided these plans by extending telehealth reimbursement. Conversely, the results of its value-based care programs remain mixed with the agency announcing a revamped road map. Otherwise, the tie that continues to bind reimbursement is healthcare's increasingly complex value chain and how new services, therapies, and players will impact the delivery system. Here are the six best reimbursement stories from 2021 HealthLeaders' coverage and beyond.
CMS extends telehealth reimbursements for physician services, mental health
Virtual medicine isn't going anywhere. In fact, it's expanding thanks to 2021 final regulations from CMS. Recognizing that you can't unscramble the egg that COVID cracked—i.e., primary care and mental health virtual visits that kept access alive during quarantine—the agency continued physician reimbursement for Medicare telehealth service through 2023. The list of reimbursable telehealth services is here.
With payers now introducing virtual-first health plans and the pandemic still a factor, there has been a national awakening that network inadequacy in rural areas is not the only reason people can't access care. The final rule also makes virtual Medicare mental health services more broadly available in a field that is already suffering a provider shortage, in remote and urban areas alike.
COVID eliminates cost-sharing, payers bring it back
The pandemic impacted healthcare cost in addition to access. Costs like copays and deductibles were waived for care no one could have anticipated, including hospitalizations. But that was 2020. In June 2021, HealthLeaders reported that "[m]any major payers … [had] lifted their cost-sharing waivers for COVID-19 bills based on a preprint University of Medicine study that is now final in the Journal of the American Medical Association (JAMA).
A related Health System Tracker survey from August 2021 found that while Delta was still surging, hospitalization costs were no longer waived by 72% of plans, specifically the two-largest plans in every state and the District of Columbia. Among these payers, only 2% planned to extend waivers through March 2022. While Omicron appears to be a weaker variant, hospitalizations continue—along with the cost burden of care.
Amazon's impact on healthcare reimbursement
Jeff Bezos' attempt to bend the employer cost curve through the Haven co-venture may have failed, but Amazon Care is taking off as HealthLeaders reported in March 2021. Amazon Care aims to strengthen in-home care by linking on-site and virtual services. It includes independent pilots as well as a multi-partner Moving Home Health coalition that is "dedicated to advancing home-based care policies and reimbursement models." The company's home-delivery prescription business is growing as well, including with payers who have spoken on background with HealthLeaders regarding their Amazon contracts.
Value-based care (VBC) charts new waters
Depending on the lens you use, the pandemic either slowed or advanced value-based progress: the first via suspended or fewer VBC contracts (particularly for high-cost, condition-specific therapies), the latter via gains in telehealth usage and reimbursement that will likely remain permanent. Either way, COVID ensured that 2021 was a less-than-great year for data continuity, particularly the compared-to-baseline results needed to measure VBC, as the FFS chassis continued to dominate.
CMS' yes—wait maybe?—on VBC
Year two of COVID marked performance year one for CMS' Global and Professional Direct Contracting (GPDC) program. GPDC, a next-next generation of accountable care organizations (ACO), puts a greater emphasis on capitation and higher risk models and opens the door to new types of participants.
This is according to industry consultant Jennifer Bresnick, who suggests sign-up has been lackluster with program applications now closed. New insurers like Clover Health are on the participant list but it remains to be seen whether GPDC can achieve the notable quality and cost improvements— with June 2021 HealthLeaders coverage suggesting price increases linked to ACO consolidation.
Congressional calls for more, please, on VBC progress as ACO participants dropped was followed by a strategy refresh announcement from CMS' Center for Medicare & Medicaid Innovation (CMMI) that seeks to advance accountable care and other innovations, health equity, access, and system transformation. Look for more news in 2022 as part of the CMMI's new 2030 vision.
Reimbursement and funding pathways for new services
Virtual health is not the only service seeing pandemic growth. Digital therapeutics (DTx), including those that require prescription (PDT), emerged in a big way in 2021 as did strategies to reimburse them. Even as CMS repealed its final rule on Medicare Coverage of Innovative Technology, payers, PBMs, employers, and DTx manufacturers forged ahead. And while there is plenty still to figure out, 2021 saw two big steps: the first state Medicaid program to plan reimbursement for PDT and the continued growth of PBM pipelines to manage DTx claims.
Advancing how to finance and reimburse novel therapies was another 2021 development. Avalere reported that 56% of payers have executed outcomes-based contracts (OBC), a value-based approach applied to extremely high-cost drug treatments—often cell- or gene-based and sometimes one-time curative therapies. Participation grew for some therapies while shrinking in others as health plan assess OBC challenges, including unique timelines for funding, cost-savings, and outcomes.
"Who is going to pay is the $10,000 question. And it's not just health plans," says one Avalere executive.
Avalere Health's fifth annual survey of outcomes-based contracts (OBC) for novel therapies showed varied results in overall participation and across specific therapies. OBCs center on "high-cost novel treatments and other types of products" and "typically include an agreement between health plans and drug or device manufacturers that ties product reimbursement to specific clinical, quality, or utilization outcomes." John Neal, an Avalere managing director notes: "These products come with big price tags. Payers want to make sure the outcomes are what was indicated in clinical trials."
Year-over-year survey results were mixed and include:
56% of payers participate in OBCs.
There was an increase in payers with more than 10 OBCs in place (from 6% to 12%) but a notable decrease among those with 5–10 contracts (from 19% to 9%).
The number of payers with only one OBC or 2–5 was steady.
The September 2021 survey included 51 U.S. health plans and pharmacy benefit managers of diverse size and their approximately 59 million lives.
Interest across therapies
Payers are deploying OBCs across multiple treatment areas. Included in the Avalere results were high-uptake areas like respiratory, endocrine, oncology, and heart. These OBC types were followed by infectious and immune/inflammatory diseases, then orthopedics and mental health. Therapeutic-specific results were mixed as well:
The largest therapeutic area increases were: endocrine (49% to 68%), respiratory (45% to 54%), and cardiovascular (70% to 79%).
Three areas saw the largest declines in the number of OBCs: oncology (62% to 18%) and infectious disease (41% to 31%).
Rare/Orphan diseases represent the smallest number of OBCs, which also dropped sharply from 18% to 5%.
What the results suggest
Of the results overall, Neal says: "While there was continued and steady interest and growth from payers—especially in transformative areas with new therapies and big price tags—declines in the number of contracts was probably due to COVID. This was especially true in oncology and areas where treatment and data measurement was deferred," he notes.
Avalere head of client solutions, marketing, and operations Sarah Butler adds: “The significant increase in payers who have more than 10 OBCs in place is showing us that some payers are successfully executing these agreements. … At the same time, however, the decline in payers that have tried one OBC indicates fewer new entrants in this space.”
OBC payer challenges
Applying alternative payment and financing methods to novel therapies is particularly challenging. "Successful implementation and adjudication of an OBC or other type of value-based contract requires significant investment into infrastructure that can support outcomes tracking and coordination among entities involved."
The survey results highlight that payers are looking not only for cost control but outcomes, especially for novel therapies. Brigit Kyei-Baffour, an associate principal with Avalere, emphasizes: "It's not just how much the payer saves but also patient results like avoiding readmissions, preventing complications, and improved adherence—all of which have important cost offsets."
"Not just payers"
These risks and challenges are acute with OBC payment and financing. "These therapies are a huge upfront investment," says Avalere consultant Zach Zalewski. "Where the rubber meets the road is when a product hits the market and the question is, 'How am I going to front a $2 million price tag.' "
"Who is going to pay is the $10,000 question. And it's not just health plans," says Neal. "This is where value-based contracting comes into play, having some certainty that products will work will help forecast risk."
"Where payers need help," Kyei-Baffour adds, "is increased education around novel therapy added values and benefits. Thinking about a patient's trajectory is part of the value story when there are so many unknowns."
Innovative solutions
OBC design for these areas will need to be as innovative as the products they cover.
These new entrants include cell and gene treatments that range from curative, one-time therapies to those that could span multiple payers if members change plans.
"For patients who travel to other payers, risk pooling can capture longitudinal reinsurance," says Neal. "These kinds of arrangements could massively accelerate but there is a huge operational challenge."
Installments: Payment made over time with amounts and time frames calculated based on patient benefit.
Hybrid: Payment also made over time and with incentive payments linked to defined health outcomes.
Payers will need more pilots to build the systems to support these alternative payment approaches. These will take place if payers see that the long-term value of one-and-done treatments can offset higher initial costs.
A better endgame
Earlier collaboration between pharmaceutical companies and payers could be an answer. Some stakeholders are recognizing the benefit of discussions on data needs, effectiveness, and market potential as early as Phase II of clinical trials, according to Clinical Leader.
The endgame is the potential for a longer, healthier life.
"There is a lot of payer interest on the manufacturer side. We're talking about new, transformative therapies where there are no good alternatives and where you have an opportunity to modify a disease to transform people's lives."
