Mitigating efforts
Both providers and health plans have undertaken extensive efforts throughout 2020 to prevent a broad decline in patient health, especially among those with chronic health conditions.
Geisinger Health Plan has broadly supported an increase in telehealth visits to counter situations where patients were unable or unwilling to seek in-person care. Telehealth visits by plan enrollees increased sharply from less than 1% of visits before the pandemic. Although they dropped off after the spring, by October such visits remained 10% of all visits, said John Bulger, MD, CMO for the health plan.
Mental health televisits have especially increased. But the telehealth expansion did not head off an ongoing 10% to 20% drop in ED volumes at hospitals covered by the health plan or that there were many fewer stroke and heart attack patients. The overall ED reduction contributed to reducing the total cost of care — since some were likely low acuity — but some of the decrease may have resulted in increased morbidity and mortality, Bulger said.
The health plan and Geisinger Health System have tried to reach out to chronically ill patients and those at risk for chronic disease with campaigns to get them to return to care. Other efforts have included hosting virtual town halls, advertising on social media, holding Facebook Live events, reaching out to business leaders and creating remote sites for patients concerned about COVID-19. Other changes included increasing provider payment rates for telehealth and reducing patient copays for virtual care.
The health plan and health system also continued their long-standing strategy to push care closer to home, such as through its Geisinger at Home program, which sends caregivers to homes of high-risk patients with chronic disease to help with management. Other programs continued during the pandemic to bolster patient health included those providing food for people without access to fresh food or to a vehicle or other easy mode of transportation.
“We have a concern of what it is going to look like on the provider and payer side, but we’re trying to mitigate it the best we can,” Bulger said.
Mount Sinai expanded remote monitoring for heart failure and hypertension and is working to expand remote monitoring for more conditions, like diabetes, Fields said. The health system also changed its care management to add broad-based texting, self-screening tools and telecare management. Online screening tools looking for social and clinical signs of deteriorating health can convert to live chat for care management.
“It’s a little different than the traditional care management models,” Fields said. “We’ve had to reinvent how we do it.”
CommonSpirit Health found that when ambulatory care declined during the pandemic, its care coordination enrollment tripled.
“That’s part of our team-based model; when they can’t come in in person, we are thoughtful about who needs to be reached out to early and pro-actively and maintain that connection to care providers,” said Nick Stine, MD, senior vice president of population health for the health system.
The health system has focused on catching up on annual wellness visits for its senior population and on extending the time for comprehensive health risk assessments. Those now include screening for depression, assessing fall risks, determining functional status at home and providing preventive care services. Health plans only recently started paying for the health system’s virtual annual wellness visits.
In 2019, nationally only 15% to 25% of seniors in local markets got virtual or in-person annual wellness visits. The health system is aiming to increase that by five percentage points in each market in which it operates.
“We haven’t really known what to do with the concern about the disruption in the continuity in prevention services, and this gives a nice rallying effort to make sure that we have our virtual capabilities expanded and optimized, in addition to what we’re able to do in person,” Stine said.
The health system is still trying to clarify which patients truly need in-person visits, but it has found that vulnerable and low-income populations are as likely to use virtual healthcare services it offers as is any other population.
For Humana, which has yet to see its enrollees’ visit volumes return to pre-pandemic levels, efforts to spur more to seek needed care include eliminating cost-sharing for telehealth primary care visits and behavioral health visits, sending PPE to enrollees to boost confidence in returning to healthcare settings and sending home preventive testing kits, such as for colon cancer and diabetes screening.
“We’re seeing a return of many of those visits but not quite to the point that we would have expected in the absence of the pandemic,” said Humana’s Shrank.
Value pay effects?
Many public and private health plans operating value-based payment models offered providers wide latitude in 2020, especially protections from downside financial risk. It remains unclear whether any such financial protection for providers in those models will be offered in 2021.
Like many providers, Mount Sinai performed well in the modified 2020 models in which it participates. That is because financial performance in many value-based-care models is driven by utilization, and 2020 utilization “went down pretty dramatically,” Fields said.
“Most of my colleagues in this space believe that in 2021 things are going to re-emerge and probably re-emerge to a greater degree,” Fields said.
The health system is preparing for a 2021 surge in utilization, but that could be delayed until mid-year, depending on distribution time frames for COVID-19 vaccines, he said.
Among the 400,000 lives for which the health system is at varying levels of financial risk, its 2020 outreach has focused on those at highest risk for deterioration. In addition to the increased complexity of outreach and management due to the pandemic, the size of the population at risk has increased because of worsening social determinants, Fields said.
That pool includes those who have lost employer-sponsored insurance and were on the edge of being at risk of chronic disease, as well as a growing Medicaid population, for whom the health system assumes full financial risk.
“So that now changes our risk pool pretty dramatically,” Fields said.
CommonSpirit Health's 2.6 million lives attributed to value-based payment are roughly divided evenly among Medicaid, Medicare and commercial health plans.
The health system has found capitated models provided some financial cushion during the pandemic, because it was easier to redeploy resources based on patient needs, without requiring billable codes, Stine said. But the health system is not tailoring its outreach to chronically ill patients based on their enrollment in any value-based payment models.
“The premise of those value-based models for us is the more proactive and the more responsive we are to our populations’ needs, that’s the business model and that’s what appeals to us,” Stine said. “It’s such a mission-aligned business model.”
However, the health system sees its Medicaid populations — including capitated arrangements with California Medicaid plans — as experiencing an amplified version of 2020 stresses, including economic struggles, racial inequity stresses, disruptions in schooling and challenges for working parents.
“It only adds to a general concern that we want to be applying efforts to the total population,” Stine said.
Specific model effects
It remains unclear for those tracking value-pay models whether worsening overall patient health will affect financial performance under value-based payment models.
For instance, providers in Medicare accountable care organizations (ACOs) were worried only the sickest would be attributed to them because they were the only ones seeking care early in the pandemic, said Noah Champagne, a consulting actuary for Milliman, which advises ACOs. But ACO providers saw patient volumes in primary care restored quickly through telehealth expansions. By June, most of the ACOs’ primary care provider revenue was restored, although ED care still lagged.
Data lags make it hard to tell if ACO enrollees have gotten sicker from missed care, so ACOs don’t yet know whether their telehealth initiatives have helped or not, Champagne said.
In terms of financial risk, Medicare led commercial health plans in eliminating much of the 2020 downside risk for ACOs. However, it's unknown whether such latitude will be extended into 2021 and if ACO model risk adjustments would be sufficient to cover the increased morbidity of its patient population, Champagne said.
What’s more concerning for hospitals are the financial ramifications of sicker 2021 populations in Medicare bundled payment programs, said Aisha Pittman, MPH, director of quality policy and analysis for Premier. That fear stems from the episodic design of the bundles, where providers are held accountable for outcomes in short and defined episodes of care that do not allow for long-term management.
“So there is definitely a concern that next year it is going to have an impact on the bundled payment programs and that the cases they are treating are going to have higher comorbidities and [be] at greater risk, which often leads to greater cost across all of the bundled payments,” Pittman said.
But overall, providers in value-based payment models feel confident that they were well prepared for the pandemic challenge because they developed enhanced data analytics, care management, telehealth and aligned networks across the continuum, Pittman said.
“Where they had these systems in place, they were better able to respond and therefore feel like they have a better handle on their populations and [have] been able to manage them,” Pittman said.
