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“One Foot in the Boat, One Foot on the Dock”: Providers and Payers Forge a New Social Contract into Value-Based Healthcare

September 26, 2017
by Mark Hagland
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This summer, with so much public and media attention focused on congressional conflict over whether to repeal and replace all or parts of the insurance-related components of the Affordable Care Act (ACA), the unobservant might be forgiven for not realizing that the landscape on the ground within the healthcare industry had already shifted irrevocably. For all the conflict over the ACA’s insurance provisions, few mainstream media outlets noted the unanimity on both sides of the aisle in the U.S. Congress over retaining the aspects of the law that are commonly referred to as its “internal health system reform” elements.

What’s more, within the executive branch of the federal government, at the highest levels of the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS), there is policy unanimity on the desire for internal health system reform to proceed ahead. Secretary of Health and Human Services Tom Price, M.D., a former practicing orthopedist and former Republican congressman from Georgia, and CMS Administrator Seema Verma, have both reaffirmed in broad terms their support for accountable care organization (ACO) development, voluntary bundled-payment programs (though not mandatory ones), and the value-based purchasing program for hospitals sponsored by the Medicare program, under the ACA. They have also left in place the Centers for Medicare and Medicaid Innovation (CMMI), a division within CMS that has been acting as a facilitator of payment reform experimentation.

Meanwhile, things are, if anything, moving even faster on the private health insurance side. While Medicare’s various ACO programs continue to expand gradually, many private health insurers are moving very quickly to try to encourage forward physician groups, hospitals, and health systems to enter into risk-bearing contracts with them. And while only a small minority of patient care organizations have yet entered into contracts that involve any downside risk, the day when significant numbers do so is coming faster than many might have predicted.

At base, all of this is being driven by financial and demographic factors that loom large over all of U.S. healthcare. Back in February, the Medicare program’s actuaries once again reaffirmed projections that they had made in 2016 that envision an explosion of U.S. healthcare system costs. In February, the Medicare actuaries predicted that total annual U.S. healthcare system spending would go from $3.358 trillion in 2016 to $5.548 trillion in 2025, with the percentage of the gross domestic product (GDP) spent on healthcare rising to 19.9 percent by 2025. That projection of an astonishing 60-percent increase in total national healthcare spending within the next nine years is itself the product of projections around the aging of the U.S. population and the accelerating explosion in chronic illness among Americans.

So where does this leave payers and providers? Scrambling to build new contracts, new ways of caring for patients/plan members, and new information technology platforms and other foundations, to facilitate the new healthcare.

Don Crane

“The bus is moving down the road, and at some rate of speed,” says Don Crane, president and CEO ofthe Los Angeles-based CAPG, which describes itself on its website as “the leading association in the country representing physician organizations practicing capitated, coordinated care,” with “close to 300 multispecialty medical groups and independent practice associations (IPAs) across 44 states, the District of Columbia, and Puerto Rico.” “It naturally got its start with the ACA, with its provisions related to ACOs and PCMHs,” Crane says, referring to patient-centered medical homes, “but also got a huge boost with the implementation of the MACRA [Medicare Access and CHIP Reauthorization Act of 2015] law, which is not being challenged. And that tailwind continues to be strong. Likewise, the private market is demanding greater value—employer coalitions, health plans, are all demanding it. And performance measurement and quality measurement programs are moving forward as never before. And there’s a more sophisticated approach now at looking at the total cost of care. So the train is not being slowed. And the reason it’s going to continue to gain momentum, is that it’s the best strategy.”

A New Social Contract

At base, something is happening now that really is unprecedented: health insurers and providers are coming together and genuinely collaborating. In the “managed care 1.0” of the 1990s and 2000s, the “social contract” around managed care involved a fundamentally adversarial relationship between health insurers and providers, with health plans trying to hold down costs by restricting and attempting to control utilization on the part of plan members/patients, and often denying claims or delaying payment. For their part, providers—particularly physicians, but also in some contexts, hospitals—constantly played a game of “utilization chicken,” finding ways to get around health plan restrictions. Instead, now, real collaboration is possible, as health plans and providers literally share financial risk for outcomes, and move forward under the banner of population health management and care management.

How are health plan leaders expressing their interest in that new kind of relationship with providers? In many ways, including through reassuring providers of their intentions. For Mai Pham, M.D., who joined the Indianapolis-based Anthem Inc. earlier this year, working to improve the plan-provider relationship is at the core of her job. Even her title reflects it: vice president, provider alignment solutions. “I think it’s completely understandable that providers would have that reflexive response” of being wary of the new approach from health plans, says the Washington, D.C.-based Pham. “But as payers—we’ve always recognized that we need to build on that understanding. And providers are not a homogeneous group. They’re very different in terms of their attitudes, in terms of the markets they work in, and in terms of their skill to do this kind of work. So step one for us is recognizing that there’s diversity among providers, and that we have to meet them where they are. And it’s simply unrealistic to expect a small rural medical practice to go from 0 to 90. On the other hand, it’s also not realistic to expect a more sophisticated medical group that’s been in this for a long time, to take only baby steps. So we as payers can take a variety of steps to move out of that—including in how we engage providers.”

Mai Pham, M.D.

There are a few main areas, Dr. Pham says, in which she and her colleagues at Anthem are working with particular vigor to move forward in terms of how they work with patient care organizations. First, she says, she and her colleagues actively solicit “input earlier in the process” of contracting with providers, “to set up processes for iterating with them.” Second, they are looking to “find creative ways to alleviate some of that administrative burden” that providers face. “And frankly,” she continues, “if you’re in a good relationship with us, we’re not as worried to have to subject you to things like utilization management [UM]. Are we there yet? No, but we’re on the way. And a major thing, and quite closely related to your target audience’s interest, is that we increasingly recognize that providers need very pragmatic day-to-day help with data and analytics, and the way we communicate with members. So we’re increasingly investing in tools. We’re offering providers tools to make things work better for them. We’re trying to offer that direct support.” With regard to the ability to focus less on UM, Pham cites CAPG as the type of organization that is already working collaboratively with Anthem to move forward on shared goals.

A colleague of hers who works on the opposite coast and who has been interacting significantly with providers for some time is Antonio Linares, M.D. The Sacramento-based Linares, whose title is regional vice president and medical director, Anthem national accounts, says, “I was on a panel a year ago talking about the progress to date in value-based payment initiatives. And at that time, you may recall, people were debating whether the glass was half-full or half-empty in terms of whether we were progressing in the right direction or stalling. In that context, I think that we’re continuing to generate greater momentum with regard to payment for value versus payment for volume. And in that value category, when I did that presentation, we looked at four dimensions of value.”

Looking at those four dimensions, Dr. Linares says, “One is, are patients getting timely access to care? And we say, by contract, providers must provide after-hours and weekend access. That has been well-received, and with new technologies, providers are moving ahead with telemedicine and other areas.” The next dimension, he says, is “the provider agreement in their contract to accept data and to use hot-spotter-type reports to improve care.” Were physicians aware that 10 of their patients were seen in EDs in the past month? “Practices are continuously surprised when you come to them with reports saying, here are patients who have not had primary care visits in the past few months but accessed ERs, for example.” In the context of ACO contracts, Anthem alerts physicians to patients’ ED use, accessing of out-of-network labs or outpatient facilities, or high-cost imaging facilities, he notes. The third and fourth dimensions are around quality and around rapid access to appointments. Importantly, he notes, the quality metrics on which physicians and patient care organizations will be measured, are mutually agreed on in advance.

Cindy Lee

That entire arena, around the metrics for measurement of quality, efficiency, cost-effectiveness, and patient/plan member responsiveness, remains an area of tension, says Cindy Lee, a director at The Chartis Group who leads the Chicago-based consulting firm’s value-based care practice. “When we talk to providers,” Lee says, “one of the things that they cite as a frustration is the number of measures they’re required to report across the different programs and agencies. And with MACRA and MIPS [the Merit-based Incentive Payment System that is part of the MACRA law], there’s a heightened awareness these days,” she says. “And the data are often diffused across organizations, so it takes quite a bit of effort and time to report data, even though the requirements might be similar. And the ways in which organizations will manage care across the continuum can become a frustration. An example is that when a patient ends up in an ED, which can be a leading indicator of a potential admission, it can take a lot of time to get that data back, for use. So for the actual clinician, that can be challenging, because the data lives in so many different places. When we get to the national care management model level, providers will say, this isn’t any different from what I’ve done before to optimize care management and manage costs, but the reporting requirements and expectations are becoming elevated now,” Lee says.

Physician and Hospital Leaders Put the Pedal to the Metal

Despite the manifold challenges involved, innovative physician groups, hospitals, and health systems are indeed moving forward now, some of them quite rapidly, into the new healthcare.

What does the fundamental strategy have to be, for provider leaders, in all this? “First, you never lose focus on the clinical model. What’s right for the patient?” emphasizes Jeffrey LeBenger, M.D., chairman and CEO of the Berkeley Heights-based Summit Medical Group, a multispecialty physician group practice that covers a broad swath of northeastern New Jersey. With nearly 800 physicians and other providers in seven counties in northern-central New Jersey, and with excellent performance results—“We’ve done very, very well in our population health process, meaning that we beat the market in PMPM [per member per month] costs in the state by almost 8 percent in the past year,” Dr. LeBenger notes—the key to success for himself and his colleagues at Summit Medical Group has been focusing efforts on managing the care of the sickest 5 to 10 percent of patients attributed to them through their ACOs, both federal and private. “Everybody says it’s population health, population health,” he says. “To be honest, I think that’s a bit wrong. You have to look at your model of healthcare.” And all of that will be driven by data analytics and continuous clinical performance improvement.

To be sure, the challenges facing the leaders of patient care organizations as they move forward into value-based healthcare through risk-based contracting are far broader and more intense than many who haven’t really started on the journey even realize, say industry leaders. One industry leader who holds that view is Barbara Spivak, M.D., president and CEO of the Mt. Auburn, Mass.-based Mount Auburn Cambridge Independent Practice Association, or MACIPA. Dr. Spivak, who has been CEO of MACIPA since September 1997, helped lead the organization into the federal Pioneer ACO Program, which MACIPA participated in for three years; MACIPA is now in Track 3 of the Medicare Shared Savings Program (MSSP) for ACOs. And though her organization continues to make progress in terms of quality, utilization and care management, within the federal programs, she says, speaking of the payment landscape in Massachusetts, “We’re in a system here” in the Bay state “that doesn’t really value healthcare, in the sense that doctors are still being paid fee-for-service for everything they do, and the value-based part of this is coming at the system level.”

Barbara Spivak, M.D.

What that means, Spivak says, is that, “As a result, we live in a very odd world where the doctors are being paid fee-for-service basis, but in the end, are responsible for total cost. There isn’t a sense in these programs, public or private, that in order to really manage care, physicians, hospitals, and home care organizations need to bind together around infrastructure—care managers, disease managers, social workers, health coaches, data managers, pharmacists. There are a lot of things you need in order to manage care, that cost money.” As a result, she says bluntly, success in value-based healthcare will come as clinicians focus on “helping the patients better maneuver through the system and get better care. In the end, that will help us save money, because the most expensive things in healthcare now are not doctor visits, but hospital stays, post-acute stays, and pharmacy. And I could argue that the more patients see physicians and nurse practitioners, the less they’ll use other services.”

In some cases, pushing forward into value-based healthcare, in some healthcare markets, is requiring providers to push health plans to move forward, rather than the other way around. Terri Steinberg, M.D., chief health information officer and vice president, population health informatics, at the New Castle, Delaware-based Christiana Care Health Services, says that “Christiana Care has really battled with payers to share risk. Why did we do it? There’s a countless number of care management behaviors that can only be supported under a risk-based contract,” she testifies. “We use an embedded care management model, where individuals are assigned to a specific care model, embedded in the EHR. Care management is really driven by both big data and small data. [For] big data—we take file feeds from all different sources (including Lexis Nexis) to generate a pure risk score, and that score drives the activity of the care managers. The social determinants are the most important single factor. So we’ve endeavored to take data from all sources, including socioeconomic, for the purposes of health risk assessment. Once you’ve done that, that’s where the ‘little data’ comes in. Finally, there’s the notion of using care management to drive provider behavior. And we use claims management like everyone else. And we see tremendous range of costs, for example, Provider A versus B on total knee replacement. And we show providers their cost profiles. And if you want an orthopedic surgeon to move from Implant A to Implant B, it’s not the hospital that will change that surgeon’s behavior, but the referring primary care physician, who says to that surgeon, you’re impacting my bottom line.”

Success Over Time in Orlando

Still for all of those challenges, successes are being scored by some hospital-based health systems. One organization that has done quite well in all this is the Orlando-based Orlando Health, which encompasses eight hospitals in central Florida, and 900 employed and 2,800 affiliated physicians, and a health system staff of over 18,000. There, Jerry Senne, vice president of value-based care and population health, and Brandon Burket, director of value-based and accountable care, feel proud of what they’ve been able to accomplish in their health system’s participation in the MSSP program; Orlando Health joined the MSSP program on January 1, 2013, and, Burket notes, “We’ve been able to generate shared savings every single year. We’ve also generated some of the highest quality scores” in the program, he notes. In the first year of the MSSP program, he notes, any organization that reported data earned a 100 percent score, including Orlando Health. And already by the second year, “We were at around 92 percent, which put us in the top decile in the country” in terms of savings, with scores rising slightly higher each year since then. Meanwhile, Orlando Health continues to expand the number of patients involved in some form of ACO, with private ACO contracts with four private health insurers—United Healthcare, AvMed, Cigna, and Blue Cross Blue Shield of Florida. Altogether, nearly 110,000 Orlando Health patients are enrolled in some form of ACO, with about 16,000 of those in the Medicare Shared Savings Program.

Jeffrey LeBenger, M.D.

As for the health system’s experience of value-based healthcare, Senne says that “There’s no doubt that the ACOs have been very, very helpful in terms of creating an environment in which physicians and hospitals can work together to begin to manage care. The arrangements start out as upside-only, gainshare arrangements,” Senne says, but participation in downside risk-sharing is coming soon. “A couple of key things have been catalytic to” ACO participation, from his perspective, Senne continues. “One was the federal government’s and payers’ willingness to cooperate and share based on quality and performance. Prior to that, it was full risk or nothing. Second, it allowed physicians to remain independent but still participate in those programs. Third, it created an arrangement to allow for attribution of patients; and for the first time, it allowed members to be attributed without active enrollment. So ACO development has been successful, but not sufficient for the future. And it will be important for healthcare systems and ACOs to move upstream on the risk curve, to be able to participate more in risk and perform against a fixed annual budget, which is basically the risk formula.”

One Foot in the Boat, One on the Dock—For the Foreseeable Future

As everyone interviewed for this article agrees, the next several years will be challenging for patient care organizations, as, inevitably, they move further into risk-based contracting, while still maintaining a significant share of modified fee-for-service payment going forward. This reality relates to what many have been referring to as the “one foot in the boat, one foot on the dock” phenomenon.

There really is no way around that challenging reality, given how challenging moving into value-based healthcare actually is for providers, says CAPG’s Crane. “That’s how things are right now, and it’s hard. So you have to build two systems”—process systems and information systems—to move forward successfully in the next several years. “Doing that is costly and difficult, and I sympathize with it. Think about the Boy Scout model for a moment—you need to be prepared for what’s coming next, or you’re going to miss the boat or the bus or the train,” he says.

In the end, Crane says, the reality is that, “In the fee-for-service world, a whole lot of the purchasing is done by the individual patients—the patients are directing where they get their care, often in open networks. As we transition to population health, and maybe even population-based payment, populations move around in blocs—Boeing employees or seniors in San Jose, for example—and all of a sudden, your whole patient moves via bloc-based contracts. And if you’re on the inside of that, you’re not losing two patients, you’re suddenly losing all of your patients from one group. And so if you don’t want to miss the train, you need to be prepared.”

What are the implications of all this for healthcare IT leaders? They are many, especially around IT infrastructure, interoperability, and analytics capabilities. In any case, say all those interviewed for this article, the transition into value-based healthcare will continue to be a step-by-step one, and challenging for the foreseeable future. It’s time to gear up for the journey, they say—and to expect bumps along the way. 

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Heritage Medical Systems’ Voyage to Value—and How Physicians are Leading the Way

October 11, 2018
by Rajiv Leventhal, Managing Editor
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“If you have no risk at all, how hard you work at something is different than if you have some risk,” says one healthcare leader

As the accountable care train continues to speed up, innovative healthcare leaders are realizing that physicians—the ones who are working side-by-side with patients on a regular basis—will be key to making the transition to value successful. In California, Heritage Medical Systems, which also has providers operating in New York and Arizona, has been at the forefront of the accountable care revolution, and its senior executives point to its physicians as the ones who are leading the change.

Mark Wagar, president of Heritage Physicians Organization, which operates under the broader Heritage Medical Systems umbrella, recently spoke with Healthcare Informatics about his organization’s value-based care journey, its accountable care organization (ACO) progress, and how physician culture can be changed as providers take on more risk for their patients. Below are excerpts of that interview.

Where do things stand regarding Heritage’s value-based care evolution?

Heritage Physicians Organization is part of Heritage Medical Systems, which has lots of medical organizations in several states. I believe we have about 3,700 primary care physicians and 12,000 specialists that are involved in our ACO endeavors. This has been driven off the original and largest piece of our business in California. And it was a policy decision early on, from our founder, Dr. Richard Merkin, to get into [the Center for Medicare & Medicaid Services’] Pioneer ACO model, even though it was not our core business.

We have been involved in value-based care, the full-risk version, for decades, but we wanted to demonstrate that if you can surround private fee-for-service physicians with the kind of capabilities and infrastructure that we give our traditional business, an ACO has potential. So we did that and are continuing to move forward with that program. But we also believe this: the country would benefit if this all moved faster.

Heritage has evolved from the Pioneer ACO model, to the MSSP (Medicare Shared Savings Program), now to the Next Generation ACO model. Can you talk about the biggest lessons learned so far?

Generally, it’s a step in the right direction. The ability to get more of the funding earlier enables provider organizations to have the funding, change the system, and change what we do. You don’t have to drive off billable events only. We finally have this exploding recognition suddenly that social determinants and behavioral health are important. But that has been apparent to any physician organization for decades, particularly for us as we have been involved in value-based care and risk arrangements since the 1970s.

It became obvious that depending on the patients and the circumstance—what happens in their home and community, what surrounds them, and what their other issues are—may be more important than the physical interaction with their providers. You have to know that in order to manage their health. Once you move away from the mindset of, “I just need to be excellent when you fall in the door, sick or injured,” and move toward, “I will try to help you not fall in the door sick or injured,” or at least have it take longer for it to happen, or maybe you won’t be as bad when you do fall in the door, that’s when the light bulb goes on. We are happy that it’s becoming a broad part of the equation.

Mark Wagar

What are some of the most important IT and data elements to being successful in this transition?

I think as much real-time data and access as you can get is extremely important—so what care a patient is getting, and where, and what is happening in his or her life. If you work from the traditional basis, we pay claims in partnership with our health plan partners, and we pay the claims on the vast majority of our business. And when we do that, our physicians, nurses, pharmacists, social workers, and everyone else involved in the patient’s care, don’t have to wait every three to six months for a review of the data. We see the data today—this hour.

If someone shows up with a conflicting set of prescriptions, or an event that the primary care physician didn’t know about, you want to find out about that right away, and find out what’s happening and what’s wrong. Looking back at trends is important in terms of a future planning perspective, but in terms of what is happening with the patient right now, especially those who are at risk, you want to have that information right now—today, tonight, this hour—and do something about it.

Dr. Merkin’s next question after he talks with physicians about a patient is, “So you know this information, and what are we doing about that right now?” It’s much different than the traditional fee-for-service system where the data just isn’t available to the provider at the level until much later.

What are your thoughts on the recent policy developments on the ACO front these days? Are the government’s proposals to push providers into risk more aggressive than some would like?

Yes, it’s more aggressive than some would like. But this is not about what all of us would like; it’s about how you get to where things are optimal and most effective faster. If you fully embrace both the access to the resources, and the risk, and you are able to spend the money on the resources—in terms of changing the system, changing the way you do business, and not accepting the status quo—you can make a significant difference.

The one-sided risk models are a very important way for providers who may be uncertain to get started, but we are talking about managing a human being-based system of care. If you have no risk at all, how hard you work at something is different than if you have some risk. Providers always want more dollars to do something with, but you don’t get dollars if you aren’t in a position to do something materially different, and essentially guarantee that at least some of it will happen.

We still have a fee-for-service-based system and much of the value-based payments that health plans have moved to is a positive thing that has stimulated some change, but it’s paying you a year or a year-and-a-half later—maybe a little differently if you happen to administer a result as a bonus—but you are still getting that underlying fee-for-service payment. If you are in a one-sided model, it masks and slows down how quickly you get to what could be done if you had more of the resources.  

How have you and your colleagues been able to change the physician culture, in terms of moving physicians to a new understanding of what’s going on in healthcare?

In Heritage’s markets where the models are most mature, it’s a combination of physician groups where the doctors are employed, as well as significant numbers of independent practices and smaller offices in the community, and we can blend those. But the physicians individually are not at personal material downside risk. There is an organizational structure that manages the money that comes in when we are fully at risk, but regardless of whether they are employed or an independent practice, they are all tied to a payment at the individual physician level.

That’s one of the things that is missed in the whole conversation over providers being put more at risk—an individual practice office with a few thousand patients is not in a position, actuarily, to accept all that risk. You have to be partnered with some kind of system.

In our instance, in our most mature markets, it’s a blend of employed physicians and independent practices, but in some markets all we have are independent practices. So we can do this if we surround them with the infrastructure if you aggregate enough members from the plans that give you an actuarily valid risk base, and then you have the money up front, so you can help them with information and give them information faster. Then, they can do good things for their patients faster.

What advice can you give to others who are just starting out on this journey?

I [wouldn’t] sit and stew about how difficult it is to be in your position and be surrounded by all these regulations and requirements that can become tough to manage. You can talk about that all day, but it’s ultimately the people’s money and they are asking for better quality, better service and access, and more moderated costs. The only people that can ultimately change things on all those fronts, for the better, are provider organizations—predominately those led by physicians.

But we cannot afford to take decades to make the next set of changes, unless we want government intervention that breeds mediocrity as a result. Physicians and providers should lead this change, and moving this faster will bring the best things for their patients in the long run. Demand more of the dollar in your control immediately, and in order to do that you have to have the structure around you and the willingness to accept responsibility for that dollar. We are trying to show people out there that you can partner with others, and it’s possible to get net better across these factors if you enable the physicians to manage more of the dollar from a clinical perspective, to the patient’s benefit.

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Are Disruptive Forces in U.S. Healthcare Accelerating Now? Notes on the Now-Approved CVS-Aetna Deal

October 10, 2018
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The DoJ’s approval of the CVS-Aetna merger signals a new phase in the healthcare business world—and it’s time for patient care executives to rethink the meaning of competition

As Associate Editor Heather Landi noted in her news report Oct. 10, on Wednesday, the Department of Justice (DoJ) approved a proposed $69 billion merger between CVS Health and health insurer Aetna, after Aetna entered into an agreement with the Department to divest its Medicare Part D prescription drug plan business.

“The deal,” Landi wrote, “is the latest in a wave of combinations among healthcare companies, including many pharmacy benefit manager (PBM) and insurer integrations. Last month, the Justice Department approved Cigna’s $67 billion takeover of Express Scripts. CVS Health announced in early December 2017 its intention to acquire Aetna in a $69 billion-dollar merger, marking the largest ever in the health insurance industry. Woonsocket, R.I.-based CVS operates the nation’s largest retail pharmacy chain, owns a large pharmacy benefit manager called Caremark, and is the nation’s second-largest provider of individual prescription drug plans, with approximately 4.8 million members. CVS earned revenues of approximately $185 billion in 2017. Aetna, headquartered in Hartford, Connecticut, is the nation’s third-largest health-insurance company and fourth-largest individual prescription drug plan insurer, with over two million prescription drug plan members. Aetna earned revenues of approximately $60 billion in 2017.”

As Reed Abelson wrote in a report in Wednesday’s New York Times, “The approval marks the close of an era, during which powerful pharmacy benefit managers brokered drug prices among pharmaceutical companies, insurers and employers. But a combined CVS-Aetna may be even more formidable. As the last major free-standing pharmacy manager, CVS Health had revenues of about $185 billion last year, and provided prescription plans to roughly 94 million customers. Aetna, one of the nation’s largest insurers with about $60 billion in revenue last year, covers 22 million people in its health plans.”

And, while executives from the two mega-companies assert that this merger will allow them to better coordinate care for consumers, while also better controlling costs, some consumer advocates believe that the opposite could actually take place—that consumers could lose both choice and reasonable medication costs. “This type of consolidation in a market already dominated by a few, powerful players presents the very real possibility of reduced competition that harms consumer choice and quality,” George Slover, senior policy counsel for Consumers Union, an advocacy group, said in a statement. “The combination of CVS and Aetna creates an enormous market force that we haven’t seen before.” The consumer organization, the Times report noted, had opposed the Aetna-CVS merger, arguing that people enrolled in Aetna health plans could be forced to seek care at CVS retail clinics, and that those who were not insured by Aetna could pay higher prices for drugs than those who were.

Meanwhile, what fascinates me in all this is the potentially accumulative impact of all the various disruptive business combinations that have been emerging in U.S. healthcare—not just CVS/Aetna, but also the Amazon/Berkshire Hathaway/JP Morgan Chase collaboration on healthcare costs and other challenges; Wal-Mart’s interest in potentially acquiring Humana; and the forays into consumer-facing healthcare IT on the part of Google and Microsoft.

All of these business deals, collaborations, and potential connections involve either “interspecies” combinations, or forays into new areas on the part of companies from outside those core business areas. And that should concern traditionalist-thinking leaders in patient care organizations, especially senior executives in tradition-bound hospitals and health systems, who have historically thought about competition as being direct hospital organization to hospital organization competition. With all sorts of non-traditional business combinations emerging, that kind of thinking ends up being not just limiting, but potentially debilitating.

The reality is that every part of the policy, business and operational landscape on which hospital-based organizations is now in motion—at the same time. Physicians are coalescing into ever-larger multispecialty physician groups, some of them affiliated with hospital-based integrated health systems, but many of them totally independent. Health plans are acquiring physician practices, and are, in many markets direct competitors with hospitals in the acquisition of those practices. Health plans are also continuing to consolidate among themselves. Employer-purchasers are eliminating the health plan “middleman,” and setting up direct contracting with some of the largest and best-known nationally branded patient care organizations; and on and on.

I wrote last year about attending a fascinating session on employer direct contracting that took place at the World Health Care Congress in Washington, D.C. last spring. Employer-purchaser executives talked with great enthusiasm about such contracts. One executive, representing the nationwide Lowes home improvement retail company, shared his enthusiastic response to contracting directly with the Mayo Clinic, to bring patients from places as faraway as Montana and Mississippi, to Cleveland, for total joint replacement surgeries, at scale.

I quoted Bob Ihrie, who had recently retired as senior vice president, compensation and benefits, at the North Wilkesboro, North Carolina-based Lowe’s Companies, about that contracted relationship. “As Ihrie noted, for an extremely far-flung self-insured employer like Lowe’s, with its 1,800-plus home improvement stores spread across the U.S., doing what the Chicago-based Boeing Corporation, with its massive plants in Washington state, California, Missouri, and South Carolina, and its ability to build bricks-and-mortar corporate medical clinics in those locations, the options for Lowe’s are rather different,” I wrote. “Thus, the desire to create systems to improve their patient outcomes for their covered lives, and improve costs.” Indeed, I wrote that Ihrie told that World Health Care Congress audience, that, “The quality results have been so overwhelming that for Lowe’s for 2017, if you elect not to go to a center of excellence, you need a mandatory second opinion, and if it doesn’t approve, you won’t be covered.” He further noted that “Wal-Mart actually mandates travel to a center of excellence.”

In other words, the old thinking among hospital organization senior executives—to think primarily about market competition as being illustrated by the fact that the hospital down the road is building a new facility—is hopelessly outdated at this point. Indeed, it’s time to consider that market competition may now mean a major nationwide retailer with a strong local presence, compelling its employees and their family members to fly across the country to a patient care organization with national branding and presence, rather than to one’s own facility, or to the facility down the street.

In short, it’s time for hospital executives to think very differently about what market competition and market disruption might mean for their organizations. It’s time to start playing three-dimensional chess.

And I haven’t even discussed the role that consumer-facing technologies, many of them spread through online apps and wearable technologies, will begin to play in all this. That adds yet another cross-hatch factor to this entire discussion.

So it’s time for healthcare executives to rethink the very definition of market competition, and to think in unprecedented ways about market disruption; because this DoJ approval of the CVS-Aetna merger should absolutely be taken as a sign of things yet to come.




Related Insights For: Value-Based Care


At the HIT Summit in Raleigh, a Health Plan Executive Points to the Future of Value-Based Care

October 8, 2018
by Mark Hagland, Editor-in-Chief
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Speaking at the HIT Summit in Raleigh last month, Humana’s Ben Lunsford offered attendees insights into the future of value-based healthcare, and his health plan’s future intentions

Speaking at the Health IT Summit in Raleigh, held September 27 and 28, and sponsored by Healthcare Informatics, Ben Lunsford, vice president, value-based strategies, at the Louisville-based Humana, offered attendees insights into the future of value-based healthcare and the trajectory of value in the current U.S. healthcare system.

Lunsford spoke on the topic “Humana’s Value-Based Strategy,” on Friday Sep. 28 at the Summit, which was held at the Washington Duke Inn & Golf Club, on the campus of Duke University, in Durham. As of 2014, according to the Wikipedia entry on the company, Humana had over 13 million customers in the U.S., and 41,146 employees as of 2018, and net income of $2.448 billion on revenues of $53.767 billion, in 2017.

Lunsford, who is based in Birmingham, Alabama, and has been at Humana for 14 years, focused on the company’s Medicare Advantage (Medicare managed care) business, which encompasses 3.5 million members; in addition, the health plan counts 1.5 million commercial group members and 9 million military members.

As Lunsford shared in his presentation, “Value-based care is different from the current fee-for-service (FFS) model of care, which simply pays for the number of services a patient receives. These services include physician and hospital visits, procedures and tests. While value-based care pays physicians for these services, it also includes more pay for meeting quality measures, coordinating care, preventing repetitive treatments, controlling overall costs and improving health outcomes.”

Lunsford proceeded to share with his audience the Primary care Value-Based Continuum model that Human has been executing, in its contracting with primary care physicians. It consists of four stages of development, with intensifying contracting features from one to the next. In order from least to most advanced, they are: the “Star Rewards” program, model practice program, medical home program, and full-value program.

In the Star Rewards program, primary care physicians have their outcomes evaluated using HEDIS-based quality metrics, with an annual payout benefit calculated in terms of a percentage of claims opportunity. In the model practice program, both HEDIS-based quality metrics, and clinical measures developed by Humana medical managers, are employed, and the rewards to primary care physicians involve a quarterly shared savings opportunity. The medical home model involves primary care physicians working in medical groups that have received some official form of recognition as patient-centered medical homes; those physicians are eligible for a PMP (per member per month) care coordination opportunity, with increased financial incentives. And finally, the full-value program involves monthly PMPM global capitation.

The Star Rewards Program this year has been using very well-known measures, such as breast cancer and colorectal screening rates, nephropathy screening rates and hemoglobin a1c control measures for diabetics, medication adherence rates for hypertensives, etc. PCPs are asked to meet six of nine NCQA (National Committee for Quality Assurance) HEDIS (Healthcare Effectiveness Data and Information Set) measures; practices that achieve that goal receive a 12-percent bonus paid annually.

Meanwhile, incentives accelerate both in terms of amounts of money, and pay schedules, as PCPs move into more advanced programs. Those in the Model Practice Program who meet quality measure standards (which are more extensive and include a readmission rate measure) receive $8 PMPM quarterly. Then, as they advance to the Medical Home Program, PCPs can participate in shared savings with Humana. And of course, for the PCPs ready to advance to the most advanced model, full capitation, those physicians will be participating in a model that is continuous in payment differentials.

Humana is also developing bundled payments in specific areas of specialty care, beginning with total joint replacements.

Speaking of all these models, Lunsford told his audience, “The patient experience of healthcare can seem fragmented. It can be frustrating for the health consumers. Ultimately, care delivery needs to be integrated rather than episodic, and focused on coordinated care and overall population health. This transition from volume to value is critical in enabling the shift to this integrated healthcare model, which… will allow us to have a sustainable healthcare system.”

It is of course no accident that Lunsford put the main focus of his comments on primary care physicians, who, he said, have the most influence on the health outcomes of patients. “Outside of direct care,” which itself is a huge part of all of this, he noted that PCPs “have an amazing amount of influence on the integrated care model; they’re the ones deciding which specialists to send patients to; providing needed prescriptions; educating patients on wellness. They’re our quarterbacks of care.”

That said, he continued, “Meanwhile, likewise, the patient has an amazing amount of influence on their own care. They’re the decision-makers. They’re deciding to engage in wellness and disease management programs; they’re deciding to be with a payer or a provider, based on the care they get. It’s absolutely critical to making the integrated care model succeed. And lastly, as a health plan, we bring an amazing amount of resources to the table, including a considerable amount of data. With that data, our historical picture of a transactional relationship is changing. We’re developing data to help physicians; we provide care referral and insights to physicians; and we can provide health and disease management programs, and care delivery options for where patients want to receive care, which oftentimes, is in the home. So we all bring something to the model.”

Though most of his time was focused on primary care physicians, and secondly, on plan members/patients, Lunsford did share about Humana’s new program, initiated on January 1, focused on hospitals, its Hospital Incentive Program. As described in his presentation, “The Humana Hospital Incentive Program (HIP) provides hospitals with an opportunity to participate in a value-based program that recognizes hospitals’ continuous patient improvement efforts, via earned annual incentive.”

The program provides annual incentives for hospitals based on performance in the areas of patient experience, patient safety, and patient outcomes. Among the specific measures included are a hospital’s HCAPHS (Hospital Consumer Assessment of Healthcare providers and Systems) scores; healthcare-associated infections; care coordination; palliative care; readmission rates, and average lengths of stay. The various measures are individually weighted, collectively totally 100 percent of the eligible incentive.

“We’re not only experiencing a seismic shift in the approach to integrated care, but also in the way we reimburse for it,” Lunsford told his audience, as he explained Humana’s value-based payment program. Meanwhile, he added, “Brand loyalty is another component of value. We make as consumers a choice around value in every purchase we make.”

Indeed, Lunsford said, “Humana’s primary care value-based continuum is truly the cornerstone” of the company’s strategy. And he noted, it is purposely “structured as a continuum: participants can move into the model. From Star rewards, to model practice, to medical home, to full value. As providers progress down that path. Each program builds upon the previous one. Star rewards just starts with quality; that continues forward into the other stages.” What’s more, he said, “This ability to enable and encourage, but not mandate, progression down that path to full value, is something that we find very valuable.”

Meanwhile, after explaining about the measures being used in the health plan’s programs, Lunsford said, “I often hear, why can’t payers get together and focus on the same set of measures? Wouldn’t that be a perfect world? I agree. But we seek guidance and counsel from many providers. And we also look at things like prevalence? Is a particular condition prevalent? We look at the PCP’s ability to impact the measure. And we look at things like our ability to measure. You’ll notice on the right that some of the measures are relatively binary. Did something occur or not? That is one factor. Also, the priority CMS places on us from the point of health plan scoring, influences us, too.”

Further, he said, “Let’s talk a little bit about how we set payment models. There’s a value placed on the achievement of certain measures. And it’s a delicate ballet between behavioral, actuary, and our clinical leaders, to determine what the best amount is that we can set. Second is the competitive element. If we pay you a dollar for something and Blue Cross or Aetna pays you five dollars, who will you focus on?”

Meanwhile, Lunsford noted of the model practice program, whose participating physicians are delivering care to 37 percent of Humana’s Medicare Advantage population, “Each measure has an incremental dollar amount assigned to it.” What’s more, he noted, elements such as ER utilization, readmission rate, and patient experience, that are being measured. Meanwhile, the measures used in the medical home program, the next step up, match those measured in the model practice program.

When it comes to medical specialists who contract with Humana under Medicare Advantage, they can participate in bundled payments around total joint replacement; and specialists participating in commercial insurance with Humana can participate in a maternity program.

As for the Hospital-Incentive Program that Humana launched in January, Lunsford noted, “We partnered with the Joint Commission on developing this model and a couple of its measures. It centers around the patient experience, patient safety, and patient outcomes, with, as mentioned above, six key measures: HCAHPS score; healthcare-associated infection; care coordination; palliative care; readmission rate; and average length of stay.

“We continually evaluate the care our members are receiving through value-based payment models,” Lunsford told his audience; and Humana executives plan to “aggressively” push value-based payments going forward. Meanwhile, he touted the fact that “Sixty-six percent of our Medicare Advantage members are now in some sort of value-based arrangement.”

Following his presentation, Lunsford spoke with Healthcare Informatics Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

Can you say what percentage of all members are in value-based arrangements?

We don’t publish that number; but we can provide the number of members we have on the commercial side.

Understandably, much of your presentation focused on your arrangements with primary care physicians. Can you speak to your goals around contractual arrangements with hospitals?

The tie for us between a member or patient, the one responsible for care in value-based models, is the primary care physicians. To be sure, that PCP can be employed by or affiliated with a hospital or integrated health system, and we’ll still interact with that physician in the same way.

Can you speak to changes in the physician culture that are making physicians more amenable to entering into value-based contracting arrangements? Do you see progress accelerating?

Yes, I think so. Just by the sheer fact that we have 66 percent of our Medicare Advantage members in those value-based arrangements, shows that this concept of value-based is not going away; and it’s becoming more solid.

Are physicians more hip to what’s going on than a few years ago, in terms of the trajectory of the overall healthcare system?


Can you speak to physicians’ preparedness to participate in measurement programs?

There is a wide array of capabilities in that space. And as a payer, we have to be able to meet those providers where they are in that capability space. Our Carebook team manages that digital interface.

Can you speak to physicians’ success, to date, in working with you in those measurement arrangements?

An early understanding of where their opportunity is, in terms of quality improvement—understanding where those gaps exist, and the tools that exist to address those gaps, early on as possible, is the most important element.

In what direction do you see your programs heading, over time?

We’d love to see an increase in participation, even at 66 percent now. We want all the groups in those programs to be successful. All three of us—the patient, the provider, and the health plan—all win, when they’re succeeding in these programs. So, growth, success, and I would say, expansion; so as we look at other value-based models, that’s a critical focus for these programs.

Can you say a few words about the hospital-based program?

Yes. This is our first program we have focused on improving quality delivered in the inpatient setting. Incentive arrangements are relatively new, and of course, new to Humana. Our number-one goal there aligns with the goals of our primary care programs, and that is being focused on hospitals succeeding in all the measures we’ve stablished in the program.

Can you say how many hospitals are participating so far?

We’ll release that number soon.

Is there anything you’d like to say to the healthcare IT leaders in our audience?

Recognizing the capabilities and influence that we all have in interacting together to help this model succeed, that’s crucial. The cooperation of everyone to help drive success, is critical.




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