Providers Push Payers to Offer Value-based Care Incentives

Healthcare providers are placing increasing pressure on commercial payers to design reimbursement structures that reward value-based care models rather than the traditional fee-for-service models. Current models generate revenue based on how many tests are ordered for patients, whereas value-based care allows healthcare providers to apply proven techniques and treatments for patients at a reasonable cost. St. John Health System has entered a partnership with Aetna allowing the healthcare provider to target high-risk and high-cost patients, ultimately lowering the cost of healthcare for these individuals in the long term; the proposal is said to have strong backing from physicians.

Value-based care is the direction providers must go; finding the right payer partners is the way to get there.

Healthcare providers, feeling strong pressure to shift away from fee-for-service and toward value-based care models, are asking commercial payers to step up.

As providers make the organizations shift, they need to partner with payers who are willing to design reimbursement structures that reward lower costs, higher quality, and better outcomes.

And while those sound like three goals payers would want to support, it can often be a challenge to find insurers willing to fund the kinds of innovative clinical models required to achieve them.

A Challenge to Find Partners

Senior leaders at St. John Health System in Tulsa, OK, have been working for years to partner with payers that want to enter into value-based reimbursement arrangements. But getting to this point hasn't been easy, says Ann Paul, president of Oklahoma Health Initiatives, the system's accountable care organization. St. John Health System is part of Ascension Health, the largest not-for-profit health system in the country.

"Our overall strategy as a health system is to move as much of our population as possible into value-based arrangements, and that is also a very important objective for Ascension Health," Paul says.

"In Tulsa, our primary service area has about 1.1 million residents, and we currently have about 100,000 patients who are in some kind of value-based arrangement right now. We have for years been moving down that path. In the last few years it has been difficult to get commercial payers to move with us in that direction."

Initially, the only payer St. John was able to strike a value-based deal with was CommunityCare, the insurance company it owns jointly with Saint Francis Health System.

Then, Medicare started to shift toward value and that opened the door for St. John to participate in two new models, Paul says: Comprehensive Primary Care Plus and the Medicare Shared Savings Program.

St. John formed its ACO in 2013 in order to take part in MSSP, which went into effect on January 1, 2014. "We had been eager to move in that direction and had been looking for opportunities," Paul says.

A New Value-Based Collaboration

With its ACO in place, St. John has been actively looking for additional payer partners with which to enter into value-based arrangements. To that end, the health system recently announced a new collaboration with Aetna in Tulsa County, called Aetna Whole Health St. John OKHI.

Members of the narrow network health plan product will have access to coordinated care at Tulsa-area St. John hospitals and more than 500 primary care physicians and specialist that are part of the system's ACO. The plan will be available to self-insured and fully insured businesses effective July 1, 2016, and to small businesses from October 1, 2016.

The collaboration represents a big step in the right direction for St. John, Paul says.

"Aetna is the first [commercial] payer outside of the one we own jointly to aggressively move in that direction. They have the same goals we have. They understand that healthcare is local, and they have been flexible and collaborative. These are all the things we liked when we started having the discussions with Aetna," she says.

The new association with Aetna also moves St. John towards its goal of caring for all its patients within clinical models that emphasize the same level of care coordination and targeting efforts towards those with multiple and chronic conditions, Paul adds.

"From the health system perspective, we want to treat all of our patients the same way. We don't want to have multiple ways that we have to interact with our patients. Aetna understands that they are working with an organization that is already going down this path towards value," she says.

"I think for us, the goal with the Aetna arrangement is getting into a product that complements what we are already doing with our own health plan. We obviously want to grow as an organization, but what we also want is to really target getting our patients into value-based arrangements so we can manage them more consistently."

More Data Improves Care

The collaboration with Aetna gives St. John more access to claims data to help it zero in on high-risk, high-cost patients, which is critical for lowering cost and improving outcomes, Paul says.

"The way Aetna does it is very similar to Medicare for the Shared Savings Program in that they periodically will share with us claims data for individuals who have enrolled in the Aetna Whole Health products and who are attributed to us," she says.

Related: Clinical Registry Groups Push for Greater Access to Medicare Claims Data

"The data gives us several different triggers we can look for, such as diagnosis, frequency of receiving ER care, [and] identifying patients with chronic conditions that should be seeing their primary care provider, but aren't."

The claims data is enhanced significantly by data St. Johns receives through its participation in a health information exchange with other area provider organizations. By having more real-time and retrospective data, Paul says, the health system is able to make big strides in its population health efforts.

"The problem with claims data is that it is after the fact… Our participation with the HIE gives us information on the front end, and on the back end, we are getting that valuable claims data."

With the HIE data, St. John knows that if a patient visits a different ER facility or is admitted to another hospital. It can then have a care manager make contact "to ensure they are getting the prescriptions they need, that they know how to take them, that they follow up with their primary care physician, and if they have any social needs, that we can follow up with them on that," Paul says.





Physician Support is Strong

As with any change, physician buy-in is important for the long-term success of the new collaboration. Aetna allowed St. John to pick the metrics by which physicians will be measured on quality and outcomes, which has helped to alleviate some anxiety and encourage support from the beginning, Paul says.

Because of Aetna's flexibility, she says, the health system was able to select targets that were already being measured, and, therefore, did not place any more stress on physicians who already face a "nightmare" when it comes to all the various metrics different payers use for calculating reimbursements.

Related: Biggest Hurdle in Shift to Value? Physician Engagement

"Physicians are excited about the Aetna arrangement… The fact that Aetna allowed us to select the measures to work with gained buy in. As we talked to all our physicians that have contracts through the ACO about the program. They view it is the direction we need to be going in, and Medicare is going in this direction as well," she says.

"Medicare has pushed up the timeline of moving physicians toward value-based arrangements and being measured on process and on quality outcomes. I think everyone really understands that this is the direction we have to go, so it is really a matter of finding the right partners to help take us there."