Driving specialist physician participation in value-based care

Alternate payment methods (APMs) have the potential to improve health care quality and reduce cost by realigning payment incentives and care delivery. While it is typical for States and payers to focus on primary care models that implement shared savings and risk, much of health care spending is driven by specialist providers. 

The Health Care Payment Learning and Action Network (HCPLAN) is a group of public and private health care leaders dedicated to accelerating alternative payment model adoption. Since 2015, the organization has hosted summits, shared information, built consensus and measured APM adoption. 

The organization forms the basis of the annual APM Measurement Effort used to set value-based payment goals. The chart below highlights goals for payments tied to quality and value in each market segment through the adoption of two-sided risk alternative payment models. 

CMS began developing programs devoted to episodic bundled payment models in 1996.

While this is not a new concept, the design, implementation and data have evolved over time, based on learnings. The timeline reflects a shift toward value-based care, aiming to enhance care coordination, improve patient outcomes and control costs.

Today, data warehouses, data lakes and other advancements in States’ technical solutions:

• Make it easier to define a clinical pathway for targeted populations 
• Set an incentive model using bundled payment APMs
• Put clean, recent, actionable data into the hands of clinicians 
• Allow clinicians to define personalized clinical care pathways to drive change 

States interested in driving savings through APMs can leverage lessons learned from current models implemented by CMS. In addition, State Medicaid agencies are creating their own episode definitions tailored to the populations in a given State. 

Need

Two MCOs operating in a State-mandated episodes of care program needed an end-to-end platform and value-based SME support to meet State-mandated guidelines.

Solution

Optum implemented and provided ongoing operational support for 53 episodes across 2 of the 3 managed care organizations operating in the State. This comprehensive solution was specifically designed to ensure compliance with State requirements and help achieve measurable outcomes, including:

• Lower cost
• Defined clinical pathways
• Quality metric performance
• Improved patient experience
• Provider engagment
• Operational efficiency

Results

One State realized $56.5 million in annual medical expense savings with maintained or improved quality, as published in an independent analysis.

Need

A health plan with 7 million Medicaid members needed help implementing and operating a VBP program to support financial and clinical objectives.

Solution

The plan implemented a comprehensive cloud-based platform featuring a model that enabled nationwide market analysis to determine which episodes should be targeted for implementation. This solution applied Prometheus definitions with potentially avoidable cost categories to define savings and was combined with custom episode support to meet specific State-mandated requirements.

Results

1. Contracted providers achieved 3.5% annual savings of $97 million, based on matched cohort comparison of contracted and non-contracted groups.
2. All 24 contracted States, as well as the contracted providers across 18 States, are being served with ongoing opportunity analysis.