In a session sponsored by Humana at Becker’s 28th Annual Meeting: The Business & Operation of ASCs, Brad Wright, director of value-based programs for Humana, gave an overview of value-based payment opportunities for specialists, including bundled payment programs.
Four key takeaways were:
- Specialist providers need a better understanding of value-based reimbursement and what it means for their practices. Throughout healthcare, payment design has increasingly been moving from fee-for-service payment to some form of value-based or risk-based payment. But many specialists still aren’t sure what this means in practice and, in particular, how it works for their specialty.
Meanwhile, payers continue making inroads with value-based reimbursement in primary care; Mr. Wright said that 69 percent of Humana’s Medicare members are now seen by primary care providers in a value-based arrangement.
- The value-based model isn’t strictly one-size-fits-all — it’s a continuum. Mr. Wright described a continuum with entirely fee-for-service on one end, with no risk to the provider and also no financial opportunity related to value or quality.
In the middle of the continuum is value-based care, with upside-only contracts. That means no risk but there is increasing financial opportunity based on quality metrics achieved.
At the other end of the continuum are value-based agreements with both increasing upside opportunity and downside risk. “It’s increasing risk and increasing opportunity,” Mr. Wright said. “A specialist [in a value-based model] has the opportunity to earn considerably more than they do under a fee-for-service arrangement. However, in some reimbursement models, there is downside risk where they could also lose money.” Because contracts are heavily dependent on data, the value-based arrangements with both increasing upside and downside risk are best for large care groups where there is plenty of data.
- One innovation of value-based care is bundled payments. One example of an upside-only specialist value-based program is bundled payments. Humana’s bundled payment program is a retrospective, episode-based model where participants can share in savings. Savings are achieved when the average risk-adjusted episode cost in a performance period are lower than the average episode cost in the baseline period. As an example, the episode window for the Total Joint Replacement program is 135 days broken into 45-days prior to the procedure and 90-days post.
- Humana already has nearly 188 bundle agreements covering 1,700 providers in 29 states. The program is getting results. Contracted participants in the bundled payment program are outperforming non-participants across specialties in terms of quality improvements, Mr. Wright said. Those outcomes include a 15 percent drop in 30-day readmissions, a 5 percent decrease in deep vein thrombosis and pulmonary embolisms and a 19 percent decline in wound infections. Humana’s reporting package makes it easy for providers to view reports that shed light on overall quality and cost performance.
While value-based care is still something providers are wrestling with, there are increasing opportunities to learn about and engage with these payment programs, even in the specialty realm.
