Value-based models of commercial payers have achieved some great results and could show ways federal initiatives need to change, say their leaders.


Oct. 19—Prominent not-for-profit health plans urged Medicare this week not to make its upcoming payment models so stringent that they limit provider participation in private payment reforms.

The 36 large not-for-profit health plans of the Blue Cross and Blue Shield Association (BCBSA) warned about unintended impacts from provider participation in the advanced alternative payment models (APMs) promised under the recently released final rules implementing the Medicare Access and CHIP Reauthorization Act (MACRA).

Clinicians who either receive 25 percent of their Medicare covered professional services or see 20 percent of their Medicare patients through an advanced APM in 2017 will earn a 5 percent Medicare payment bonus in 2019. Up to 120,000 clinicians were expected to qualify for payment through the APM track of MACRA in 2017, but Obama administration officials said they hope to rapidly increase the share of physicians in such models.

The Centers for Medicare & Medicaid Services (CMS) said it is considering testing a new Track 1+ accountable care organization (ACO) for 2018. The MACRA final rule also eased the risk criteria for advanced APMs, which would allow a broader range of models, such as those tailored to small practices or specialties, to be designated as APMs under MACRA. New APMs expected to be available by 2018 include a new voluntary bundled payment model and the Advancing Cardiac Care Coordination Through Episode Payment Models program.

Alissa Fox, senior vice president for BCBSA, said at an Oct. 19 Capitol Hill briefing that her members are “very concerned” that the implementation of advanced APMs under MACRA will restrict the ability of providers to also participate in the APMs operated by those private payers. Specifically, commercial payers are concerned that a national model for all providers will inhibit regional and state-specific commercial approaches.

“So we will continue to stress that with CMS,” Fox said.

Results From Private Models

The 36 Blues spend about $145 billion annually on value-based care, comprising more than one-third of their medical claim spending.

“And we are seeing excellent results, in terms of better outcomes and reductions in unnecessary hospitalizations and emergency room visits,” Fox said.

Noteworthy results include the ability of the Highmark Home & Community Services model to cut skilled nursing facility (SNF) utilization by 25 percent, with no impact on readmissions, among Medicare Advantage patients.

“Post-acute care has certainly emerged as one of the leading success stories with regard to our integrated delivery and financing model,” Brian Holzer, MD, president of Highmark Home and Community Services LLC, said at the briefing.

Other large savings accrued by Blue’s value-based care models have included a 9.87 percent reduction in spending on care for Crohn’s disease patients, on whom BCBS of Illinois had been spending an average of $11,000 annually. Those savings came through Project Sonar, one of the first intensive medical homes for specialty medical groups.

Most of those savings came through reduced inpatient care and emergency department utilization stemming, in part, from the creation of an ongoing patient contact system and from providing 24-hour, seven-day access to care for patients with inflammatory bowel disease.

“We spend an awful lot of time in health care trying to force providers into value-based initiatives where they can impact the ultimate cost of care, but we can’t succeed unless we bring the patients into the fold,” Tony Farah, MD, chief medical officer (CMO) of the Allegheny Health Network, said at the briefing.

Such models could provide important lessons for CMS, according to participants.

“It allows us to react in real time to data, and it’s not available through Medicare and CMS, where the data is always so far behind,” Farah said.

OCM Outlook

Meanwhile, providers had a mixed outlook on the federal government’s Oncology Care Model (OCM). CMS launched the OCM in July with nearly 200 physician group practices and 17 payers joining the five-year pilot, which provides financial incentives for practices to improve care coordination and reduce the total cost of chemotherapy treatment episodes.

Leslie Botnick, MD, CMO at Vantage Oncology, said the OCM would target “low-hanging fruit” in the form of savings in the operating room—but not savings throughout a cancer treatment episode beginning with the biopsy.

But Edward Licitra, MD, chairman of the board for Regional Cancer Associates, an OCM participant, hailed the model for providing needed investment funding.

“When you think about the economics of transforming your practice and building infrastructure and creating systems and paying vendors to collect data—we really couldn’t do that,” Licitra said. “OCM provides us with the mechanism to finance all of this.”

Botnick noted that community-based practices are more used to practicing under strict guidelines and cost controls than are hospitals.

“To have this ability is a great step forward,” Botnick said.

Licitra said his practice’s “very small” profit margins require it to more closely follow guidelines on appropriate patient care because the organization has “more skin in the game” compared with hospital systems.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Wednesday, October 19, 2016