A key component of the health plan is identifying how to share data that providers can use to deliver proactive care that keeps patients healthier, which saves money.
As accountable care organization (ACO) contracts proliferate across the country, health plans are introducing new types of products designed to improve the likelihood that ACOs fulfill their promise to reduce costs, improve patient outcomes, and offer good experiences for patients.
UnitedHealthcare, which has contracts with some 800 regional ACOs around the country, started selling its first national ACO-based product to employers late last year. The NexusACO health plan includes three notable features:
- UnitedHealthcare will extend NexusACO contracts only to the ACOs that are outperforming their competitors in a given market.
- The plan design will incentivize members to use UnitedHealthcare’s “Tier 1” providers, signifying they have met certain quality and cost criteria.
- Members are required to select a primary care physician (PCP), which increases the likelihood that their care will be coordinated.
The product launched Jan. 1 through 18 contracts in 15 markets. More contracts will be signed this year, with a goal of approximately 30 arrangements in place by next January, says Reed Bjergo, the insurer’s vice president for Next-Generation Network-Based Products.
Consumers who live outside those markets can still participate in the NexusACO product, obtaining care from local physicians with the Tier 1 designation.
About one-third of patients insured by UnitedHealthcare receive care from providers in value-based arrangements, and that number is expected to grow. By the end of 2018, the insurer wants to have $65 billion in payments to physicians and hospitals tied to value-based arrangements, up from $52 billion in 2016.
By combining various elements of UnitedHealthcare’s other value-based offerings, the NexusACO plan design should attract employers and their workers to see what higher value healthcare looks like, Bjergo says. The health plan projects an employer can save up to 15 percent by choosing the NexusACO product over a broad access UnitedHealthcare plan.
NexusACO Projected Savings
“We feel like it’s a true accelerant on our path down value-based care,” Bjergo says.
What It Means for Patients
Consumers participating in the NexusACO must choose a primary care physician, and their out-of-pocket costs will be significantly lower if they choose providers in Tier 1 of UnitedHealthcare’s Premium Physician Designation Program. That program—the first in the industry when it started in 2005—uses clinical information from healthcare claims and other sources to evaluate physicians and recognize those who meet criteria and cost efficiency.
UnitedHealthcare evaluates quality by comparing a physician’s individual performance to the insurer’s national rate among other physicians responsible for the same type of patients. To evaluate cost efficiency, it compares a physician’s healthcare costs to the risk- or severity-adjusted costs of peers in the same specialty and geographic market.
Although plan offerings differ from one employer to the next, consumers who choose Tier 1 providers will have co-insurance levels at least 20 to 30 percent lower than if they choose non-Tier 1 providers, Bjergo says.
“We really want to incent consumers to seek their care and have their care delivered by what we consider to be the highest-performing physicians,” he says.
What It Means for Health Systems
Providers participating in NexusACO contracts receive financial incentives—based on their quality and cost performance—that exceed those offered in UnitedHealthcare’s other ACO contracts. “There is significant upside potential for both the hospital system and the participating physicians,” Bjergo says.
Beyond that, the NexusACO differs from the insurer’s regional ACOs in a few ways:
Activation teams. Each ACO that enters into a NexusACO arrangement is assigned an “activation team” to help the system deliver the high-quality, low-cost care needed to succeed in the contract. Each team includes a market medical director, an ACO account manager, and a clinical transformation consultant.
The team’s goal is to figure out how UnitedHealthcare can work most effectively with the hospitals and physicians that make up the ACO. A key component is identifying how to share data in ways that providers can act upon to deliver proactive care that keeps patients healthier, which saves money.
“Is there an emerging trend that we can see in the data? Do we have patients that we should be seeing?” Bjergo says. “We can help identify opportunities that yield the best cases, and in some cases, that means pointing to patients that aren’t even yet being seen.”
In addition, the activation team reports on referral patterns so ACO leaders know whether patients are staying within the network when they receive specialty care.
Referral patterns. One of the first tasks for the activation team is to review whether the specialists in the ACO are top performers according to UnitedHealthcare’s quality and efficiency criteria and recommend adjustments as needed. “If we have a gap in a specialty, how can we fill that in to ensure that our members will be receiving the maximum benefit available?” Bjergo says. “We have to make sure that the network is sufficient.”
Second, the insurer works with the ACO to determine the best way to share information so that PCPs and plan members know which specialists are in Tier 1.
ACO Partner Selection
UnitedHealthcare is positioning NexusACO as an exclusive offering, meaning that it wants to contract with the highest-performing ACOs, in both cost and quality, in a given market. In Denver, it has NexusACO contracts with three health systems, but in most of the other markets in which the health plan is offered, there is only one health system with a NexusACO contract.
Bjergo described NexusACO as a logical extension of the Premium Physician Designation program, which has sought to differentiate providers based on their performance for more than a decade.
“We are very interested in deepening our relationships with those systems that can prove their performance through empirical data,” he says.
Lola Butcher is a freelance writer and editor based in Missouri.
Interviewed for this article:
Reed Bjergo, vice president, UnitedHealthcare, Minnetonka, Minn.
Forum members: What do you think? Please share your thoughts in the comments section below.
- What are some of the most successful ACO strategies? Do you have any examples that you have been involved with?
- In your community, are physicians ready to accept new quality measures that lead to value-based arrangements such as ACOs?