What You Should Know: 

– Aledade, the nation’s leading network of independent primary care practices, announced today the acquisition of Michigan-based Medical Advantage. 

– This strategic acquisition further solidifies Aledade’s position as the preeminent Accountable Care Organization (ACO) network and a driving force in value-based care.

Expanding Physician Partnerships in Michigan

The acquisition significantly expands Aledade’s network in Michigan, bringing the number of partnered physicians from 35 to roughly 700. This strengthens Aledade’s ability to deliver high-quality, value-based care to a wider patient population across the state.

Preserving Physician Choice and Value-Based Opportunities

Importantly, Aledade will maintain Medical Advantage’s standing as a physician organization, allowing it to participate in value-based care arrangements with various payers, including the prominent Blue Cross Blue Shield of Michigan. This ensures continued flexibility and choice for both physicians and patients.

“This is the merger of two organizations dedicated to doing what’s good for patients, practices and society,” said Farzad Mostashari, M.D., co-founder and CEO of Aledade. “Working together, we can help more independent primary care practices in Michigan not only to participate, but succeed, in value-based care. This partnership means more Michigan primary care physicians will have support in doing what they do best – keeping Michiganders healthy.”

Employers incur approximately $575 billion each year due to their employees’ poor health, and the number of employees who spend at least $100,000 a year on medical care rose by 50% between 2013 and 2021.^, Much of these costs are driven by fragmented care, improper benefits utilization, and poor health literacy.

Today, members have greater choices regarding where they receive their care. In a single year, they may use an urgent care center, a pharmacy clinic, a retail clinic, a specialist, and a telehealth service. While it is convenient to have so many options, there is no single point of care overseeing the member’s best interest. This can lead to conflicting care plans, duplicate tests, medication interactions, greater costs, and poor outcomes. 

A great way to mitigate this type of fragmented care is to engage members in a way that helps them better understand their unique health needs and how best to utilize their benefits for the best outcomes and lowest costs. Doing so also helps improve a member’s health literacy, or “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.” High health literacy is essential for proper utilization and optimal outcomes. Low health literacy is estimated to cost employers and insurers $4.8 billion annually in excessive administrative costs.

How to promote member engagement

The word “engagement” is not the same as “touches.” Touches might constitute employee emails or meetings that include information about their benefits or how to develop healthy lifestyles. These are valuable, but they don’t constitute true engagement. Active engagement is when members take action to engage with caregivers, seek education about their unique health needs, and know how best to navigate the healthcare system to get the care they need. 

The following five elements are essential to an effective active member engagement program:

• Includes care navigation, case management, disease management, and utilization management
• Provides personal health nurses—registered nurses with diverse clinical experience 
• Actively facilitates member-provider engagement to reduce the risk of fragmented care
• Customized to each member’s goals and unique health needs
• Includes assessments of non-medical factors like SDOH

How an active engagement program benefits employers

There are numerous benefits employers can realize by implementing an active member engagement program. These include the following:

• Can lower medical costs by 5.3% and reduce hospitalizations by 12.5% through enhanced support for better decision-making 
• Reduce overall medical costs through improved benefits utilization
• Lower absenteeism and presenteeism
• Improve member health and productivity
• Enhance member satisfaction with their medical benefits

According to Healthcare Finance, “Proactive efforts by health plans to engage with members – by providing advice on how to control costs or helping to coordinate care – drive significant improvement in overall customer satisfaction.”

How an active engagement program benefits members

Members who are more engaged in their healthcare journey take greater responsibility for making changes needed to improve their health. Additional benefits include the following:

• Customized care and guidance through personal health nurses (PHNs) for reduced fragmentation and optimal outcomes
• Support for chronic conditions with continuous monitoring, medication management, and guidance for their specific health condition(s)
• More timely interventions to prevent minor issues from becoming major health problems
• Sustainable behavioral change through improved accountability and healthier habits
• Prioritization of preventative care for a better quality of life

Success Story

A multi-national manufacturer implemented an active member engagement program to promote better primary care utilization and to provide better benefits navigation using personal health nurses (PHNs). The PHNs provide an individualized approach that helps members better navigate the care continuum to find the right care in the right setting at the right time. The program included the following elements:

• Dedicated one-on-one collaboration and care planning with a registered nurse
• Interventions that coordinate care, medications, and other benefits and resources
• Technology that prioritizes highest-risk members for outreach and engagement
• Integration with health plans, pharmacy benefit managers, third-party administrators, healthcare provider networks, and other benefit solution vendors

Once high-risk members were identified within the manufacturer’s 40,000 regional workforce, the company implemented a multipronged engagement plan that included:

• Deploying community-based PHNs to facilitate conversations and discover opportunities to coordinate care and eliminate barriers to care access
• Multifaceted campaign to promote program awareness, including print, web, and social media
• Virtual health fairs
• Navigating members to the proper level of care, including bidirectional referrals with behavioral health benefits provider

The results were beyond the company’s expectations and included:

• 85% employee engagement
• 95% employee satisfaction
• 3.13:1 return on investment

The bottom line

It is unlikely that healthcare premiums will come down anytime soon. Therefore, employers need to do all they can to help improve their employees’ health. Employing an active member engagement program is an excellent place to begin. 

About Mary Bacaj, Ph.D.

As President of Value-Based Care (VBC) for Conifer Health Solutions, Mary Bacaj is responsible for leading the company’s business unit that delivers population health management and financial risk management services to more than 250 organizations. Conifer VBC is uniquely positioned as a partner to employers and unions, risk-bearing healthcare providers and health plans.

Mary joined Conifer Health in 2014 as Vice President of Strategy to help the company identify and implement solutions that ensure individuals receive the right care at the right time, while healthcare providers are aligned to improve the health of the population. She is a recognized subject matter expert in pay-for-performance programs, hospital and physician alliances, and healthcare reform.

Prior to joining Conifer Health, she was an Engagement Manager at McKinsey & Company, where she worked with senior executives at health systems and health technology companies on strategic challenges, such as population health management, hospital and physician mergers and acquisitions, and risk-based contracting.

What You Should Know:

–              St. Louis-based, privately held Lumeris announced the completion of a $100M equity capital raise.

–              The funding round was led by Deerfield Management, a longstanding lender, and new investor Endeavor Health. Existing investors Kleiner Perkins, Sandbox Industries, BlueCross BlueShield Venture Partners and JDLinx (an investment company owned by John Doerr) participated in the round.

Advancing Value-Based Care: Lumeris’ Decade of Excellence and Future Commitments

For over a decade, Lumeris has been at the forefront of delivering exceptional value-based care outcomes for healthcare providers and their patients. This infusion of new capital underscores the commitment to supporting the rapid expansion of Lumeris’ provider partnerships, which now include some of the nation’s largest health systems and physician groups. Lumeris equips these partners with cutting-edge technology and streamlined care delivery processes, enabling them to achieve remarkable improvements in both healthcare quality and cost-effectiveness.

Through an innovative shared risk model that integrates essential tools, capabilities, and expertise, Lumeris ensures that its provider partners can confidently address both current and future value-based care requirements. Recently acknowledged by the Healthcare Technology Report for its outstanding software, exclusively accessible to Lumeris’ partners, the company also proudly oversees Essence Healthcare, the highest-rated Medicare Advantage plan in the industry, consistently earning a 5-star rating from CMS over the past three years.

Lumeris stands as a pioneer in the transformation of value-based care, leveraging technology-driven capabilities to establish a comprehensive care system that aligns with the expectations of every healthcare provider for their own family. As a trusted partner, Lumeris engages in collaborative ventures with premier health systems and physician practices across the nation, sharing in the risks and operational duties necessary to implement tailored, highly effective value-based care models for diverse populations.

“Our proven track record in enabling health systems and physician groups to manage all value-based populations, including Medicare Advantage, Traditional Medicare, Commercial, and Medicaid, has consistently delivered high-quality outcomes while effectively managing the total cost of care,” said Mike Long, Chairman and CEO of Lumeris. “This recent investment will further enable us to meet the growing demand from our provider partners to adopt value-based models.”

What You Should Know: 

– inVio Health Network and CVS Accountable Care Organization, a division of CVS Health, have announced a collaboration to participate in the new Medicare Accountable Care Organization (ACO) REACH program. This initiative focuses on improving access to high-quality healthcare for traditional Medicare beneficiaries in South Carolina.

– The collaboration builds upon the past achievements of Prisma Health Upstate and Prisma Health Midlands Networks, which merged in 2021 to form inVio Health Network. These entities have a proven track record of success in the Medicare Shared Savings Program (MSSP), another CMS program. Through MSSP, they have demonstrably reduced healthcare costs while maintaining exceptional quality of care for over 60,000 Medicare beneficiaries.

REACH Program: Reducing Barriers and Improving Outcomes

The REACH program from the Center for Medicare & Medicaid Innovation (CMMI) aims to address healthcare disparities. Participating ACOs like the newly formed collaboration between inVio and CVS will work towards:

• Reduced Barriers to Care: The program seeks to eliminate obstacles that prevent patients from receiving necessary medical attention.
• Coordinated Care: A focus on ensuring patients receive well-coordinated care across different healthcare providers.
• High-Quality Patient-Centered Care: Prioritizing patient needs and preferences to deliver exceptional medical care.
• Improved Overall Health and Satisfaction: The ultimate goal is to improve patients’ health, clinical outcomes, and overall satisfaction with their Medicare coverage.

Enhancing High Quality Patient Care

inVio Health Network, a leading physician-led network in the Southeast, brings deep local knowledge and a commitment to high-quality patient care. CVS Accountable Care contributes its extensive experience and resources. Together, they will leverage this combined expertise to:

• Enhance Care Coordination: Advanced analytics will be used to streamline care coordination for patients, ensuring they receive seamless treatment across different providers.
• Value-Based Care and Population Health Management: The collaboration will implement key programs and resources focused on value-based care and population health management. This data-driven approach allows for proactive care and improved health outcomes for the entire patient population.
• Longitudinal Care Management: The focus will be on providing patients with consistent and comprehensive care throughout their healthcare journey.

“We are on a collaborative value-based journey with our physicians and healthcare clinicians to improve the quality and health across South Carolina, regionally, and nationally,” said Dr. Bill Gerard, CEO of inVio Health Network, “This new model allows us to provide enhanced resources and clinical services across our network where we will be collaborating with MinuteClinic locations across South Carolina to be part of our network’s ACO REACH program. We look forward to the incredible opportunities ahead as we transform healthcare together.”

What You Should Know:

– Conduce Health, a healthcare technology company focused on value-based care raises $3M in seed funding led by Connecticut Innovations with participation from AlleyCorp and CityLight.

– With a network of over 150 specialists, Conduce provides a centralized platform for managing specialty care risk, optimizing contracting, and utilizing data science to deliver the right care at the right time.

The Problem: Disconnected Care for Complex Conditions

Value-based care models are changing healthcare, but integrating specialty care remains a challenge. Patients with chronic diseases often require multiple specialists, yet the primary care and specialist ecosystems are fragmented. This can lead to:

• Hyperlocal complexities: Finding the right specialist in a specific geographic area can be difficult.
• Attribution challenges: Assigning responsibility for patient outcomes across multiple providers can be complex.
• Risk tolerance disparity: Primary care providers (PCPs) and specialists may have different risk tolerances, hindering collaboration.

Conduce’s Solution: A Marketplace for Personalized Care

Conduce offers a unique solution with its multi-specialty value-based care marketplace. Here’s how it works:

• Conduce Clinical Profiles™: This innovative system categorizes patients based on multi-dimensional factors, ensuring they are matched with the most suitable specialists.
• Specialty Provider Network: Conduce builds a network of high-quality specialists tailored to meet the specific needs of each patient profile.
• Streamlined Referral Engine: Conduce simplifies the referral process, seamlessly integrating with existing PCP workflows.

Marketplace Availability

Conduce’s marketplace is already active in South Carolina and Georgia, with plans for rapid expansion across the Southeast. They are actively seeking partnerships with:

• Primary Care Organizations
• Specialty Physicians
• Specialty Vendors

The lack of a complete and comprehensive patient record limits the ability of the physician to improve care and puts organizations at financial and regulatory risk. The Centers for Medicare and Medicaid Services (CMS) estimated that for payment year 2018 alone, it will recover $428.4 million (net) and $4.7 billion from 2023 through 2032, including extrapolation effects. The HHS Office of Inspector General (OIG) recently reported that, from October 2014 through December 2016, 153 audit reports were issued containing 193 overpayment recoveries totaling $648 million, largely due to errors in medical documentation.

To address these concerns and other matters, CMS announced significant regulatory changes to the Medicare Advantage (MA) program beginning in 2024. Changes to MA rates, the MA risk adjustment (RA) model, and star ratings are being implemented, with some already fully in effect and other RA model changes being rolled out over three years. Now is a critical moment for Medicare Advantage Organizations (MAOs) and risk-bearing providers to prepare. At the same time, CMS is implementing changes in how its Risk Adjustment Data Validation (RADV) audits are conducted and how their findings lead to overpayment assessments. Errors identified in already completed audits will be extrapolated more aggressively for audits going back to 2018, and then going forward for new audits.

While CMS has stated that its primary focus will be on MAOs most at risk for improper payments, all MA plans will face more stringent scrutiny, enforcement, penalties, and repayment requirements for conditions submitted for reimbursement. At the same time, the OIG will continue its broader set of audits, referring its findings to CMS for financial recovery. Additionally — and appropriately — the linkage of care delivery programs to risk condition capture is important from a policy standpoint, and for the success of Value-Based Care (VBC) programs. 

The Time Value of Data

Many of these documentation errors stem from traditionally burdensome processes and the inherent nature of the retrospective chart review process. Retrospective reviews are an important part of RA programs given patient enrollment timing, lack of prior documentation on claims, and the need for true encounter data. As a result, reviews commonly take place many months after the patient encounters in question, which creates three potential issues.

1. Time and complexity are added to the process, as reviewers must look through months of accumulated patient records to reconcile the data.
2. Less timely accurate reimbursement, with a lag time of 12-18 months, can impact revenue streams for providers and payers to support patient care.
3. There is a potential impact on patient care programs across a cohort, given data coordination between payers and providers.

In the short term, organizations would be wise to begin auditing their historic claims submission data and ensuring their medical records and claims are in sync. Any errors discovered can be proactively addressed through chart audit reviews for potential deletes and adjusted reimbursement.

Going forward, organizations can implement strategies to close these gaps at the point of care to address the issues above and improve care for patient populations.

Avoid Penalties With a Prospective Approach

Taking a prospective approach to risk adjustment can solve billing inaccuracies and provide better patient insights. However, a lack of standardization and efficient solutions has prevented providers from adopting and scaling the process. Many providers are struggling with clunky spreadsheets and cumbersome processes that add to clinical team burnout.

The use of technology for concurrent reviews continues to gain uptake as the most viable solution for ensuring complete diagnosis capture and accurate documentation by reconciling HCC codes and documentation immediately after the patient encounter, before billing and claims submission.

AI-powered concurrent solutions can reduce the time it takes for providers and health plans to identify and resolve discrepancies from months to just hours, providing real-time reconciliation of diagnoses. Because this prospective approach catches inconsistencies upfront, it drastically reduces the time and expense of chart reviews. Given the timely documentation of conditions, payers and providers can coordinate better quality and depth of care for patients. For example, proactive interventions to support successful VBC delivery programs for patients with chronic conditions can be rolled out. Furthermore, these activities can help prevent high-cost-of-care scenarios.

By proactively managing and analyzing costly chronic conditions against those that are risk-adjustable, organizations can avoid misrepresenting patient risk. Payers and provider groups can leverage automation to conduct risk adjustment on a broader patient population and more accurately capture and quantify risk, even storing these data elements in a centralized manner for better long-term collaboration. Certainly, implementing prospective programs takes time, operating discipline, and analytical prowess, but it can yield improved outcomes as well as reduce downside risk from government audits.

There will always be a need and demand for retrospective review as part of a comprehensive, accurate risk adjustment program. That being said, closing care gaps through concurrent reconciliation will reduce the retrospective burden over time. But most importantly, this proactive approach can drastically improve quality of care and patient outcomes, and increase physician time with patients while lowering the overall cost of care.

About Sachin Patel

Sachin Patel is the Chief Executive Officer of Apixio, an AI platform that improves administrative, clinical, and financial outcomes for health plans and providers. Patel brings broad experience across both healthcare and technology, spanning a variety of leadership roles, including operations, finance, and development. 

The momentum of value-based care (VBC) is poised to accelerate. The Centers for Medicare and Medicaid Services (CMS) has outlined an ambitious objective: to transition all traditional Medicare beneficiaries into a VBC arrangement by 2030, a notable increase from the mere 7% recorded in 2021 by Bain Research. As more plans, providers and members enter VBC arrangements, substantial volumes of clinical data will need to be managed effectively to oversee patient risk and care quality. 

The transition to VBC is a complex path. Common obstacles include changing regulations and policies, trouble collecting and reporting patient information, such as care gaps, unpredictable revenue, complex financial risk, lack of resources to implement and manage VBC programs, and interoperability gaps within and outside the organization, according to a Definitive Healthcare survey.  

These barriers exacerbate an increasingly complex system. The industry generates more patient data to be shared with more entities, preferably in time to impact patient care. Yet, the processes are currently manual, inefficient, and error-prone. Data and process fragmentation throughout the U.S. healthcare system contributes to administrative waste and $265 billion in unnecessary costs, according to Drug Topics. 

AI-powered technologies have already demonstrated their worth in advancing VBC. 

AI-enabled technologies are being employed across the industry, helping accelerate the transition to VBC. These technologies, including machine learning (ML), natural language processing (NLP), and optical character recognition (OCR), are in widespread use, while the use of generative AI, such as ChatGPT and Google Bard, is on the rise. Given the vast amounts of data, the complexity of the processes, and the decentralized nature of the U.S. healthcare system, AI brings unique capabilities. First, these technologies enable aggregating and synthesizing structured and unstructured patient claims and clinical data from electronic health record systems (EHRs), national and regional health information exchanges (HIEs), community providers, specialists, labs, prescriptions, etc. 

Beyond aggregating and synthesizing data, AI then makes myriad data worthwhile. AI is unmatched in its abilities to sort and aggregate data, discern patterns, highlight relevant information, automate tasks, and streamline processes. As payers and providers face increasing pressure to enhance quality care outcomes while lowering costs, leveraging data both prospectively and retrospectively is critical – and AI makes that possible at scale. With the correct data in the hands of the right resource at the right time, it becomes possible to profile and manage member risk proactively. With pertinent information, payers and providers can employ evidence-based interventions to manage patient conditions and the health of at-risk populations. Here are three high-value use cases where AI improves payer operations in VBC.  

Redefining risk adjustment programs 

AI-enabled technology can expand and improve risk management by making both retrospective and prospective risk adjustment possible. By aggregating extensive clinical and claims data, AI can synthesize and prioritize suspected diagnoses, including links to clinical source documentation, and deliver that information to providers at the point of care. With this information in hand, providers can make evidence-based decisions to address gaps in care when they are seeing the patient rather than after the fact. Arming providers with a longitudinal patient summary for conducting comprehensive risk assessments improves patient outcomes while lowering the cost of care.  

Driving better quality improvement programs 

For quality improvement, AI analyzes data and summarizes actionable insights to predict disease progression, manages at-risk populations, and suggests appropriate interventions, which reduces costs associated with advanced disease management. AI-enabled technology can deliver personalized treatment plans and medication regimens, leading to better adherence and outcomes while avoiding costly adjustments and hospitalizations. AI can help providers monitor and analyze healthcare quality indicators for continuous improvement, driving quality of care, better patient experiences, and lower costs associated with avoidable errors. 

Improving provider adoption of VBC contracts and processes 

Putting accurate, relevant information in the hands of providers directly within their workflows is vital to building clinician trust and adoption. AI-enabled technology can summarize the insights providers need at the point of care to assess suggested diagnoses and make informed care decisions that mitigate risks by closing gaps in care. Offering accurate, timely information that providers can apply immediately builds clinician confidence in the technology while reducing common provider abrasion points. In addition, AI can automate menial tasks to use resources better. For example, AI-assisted documentation, which can tap enormous content libraries of industry-standard synonyms, acronyms, and abbreviations, helps clinicians document patient encounters quickly and accurately, freeing them to focus on patient care.  

Conclusion  

AI is demonstrating its transformative potential to accelerate VBC. It rapidly extracts valuable insights from various unconnected data sources and presents healthcare providers with a comprehensive view of member risk before and during patient encounters. Equipping providers to assess member risk, increase diagnosis accuracy, and close care gaps takes risk adjustment and quality improvement to a new level. By harnessing AI in these capacities, at-risk healthcare organizations can give providers the tools they need to fully embrace VBC, along with its potential to improve member outcomes, lower costs, and make the U.S. healthcare system better for all.  

About Jay Ackerman 

Jay is an Enterprise Software executive responsible for setting the vision, strategy, and objectives for Reveleer. As a leader, he is also keenly focused on shaping and stewarding the culture at Reveleer to attract a robust collaborative team, while driving an innovation mandate to execute our mission to accelerate value-based care.He is a seasoned software and services executive with over 30 years of experience in various leadership capacities. While at Reveleer, he established the company as a leader in SaaS solutions to enable our customer set to take control of these critical value-based care programs. Before Reveleer, Jay was the Chief Revenue Officer at Guidance Software, a publicly traded software security company. He is equally proud of his contribution to the success of ServiceSource, where he was the Worldwide Head of Sales and Customer Success at ServiceSource and WNS North America. WNS, where he was the President & CEO. Both organizations grew rapidly and joined the public markets.

What You Should Know:

– Thyme Care, a leader in value-based cancer care, has launched Thyme Care Oncology Partners (TCOP), a dedicated platform designed to support oncology practices in the transition to value-based care models.

– Through partnerships with payers and providers, Thyme Care’s TCOP platform fosters collaboration and prioritizes patient-centric care while reducing costs. This innovative approach positions Thyme Care as a leader in shaping the future of value-based cancer care.

Over 400 Oncologists Join Forces for Better Cancer Care

With over 400 oncologists across 25 states already participating, TCOP fosters collaboration and knowledge sharing within a growing network of oncology practices. Thyme Care partners with TCOP practices to design and implement value-based care programs that benefit patients covered by participating health plans and government programs.

Addressing Rising Cancer Care Costs

The increasing cost of cancer care, marked by expensive treatments, delays, and unnecessary hospitalizations, necessitates a new approach. Patient navigation and value-based interventions are critical to reduce these costs. Recent initiatives, such as the CMS’ Enhancing Oncology Model and the move to reimburse patient navigation services in 2024, reflect this shift.

Overcoming Challenges of Patient Navigation Programs

Thyme Care’s comprehensive services empower oncologists to prioritize high-quality, patient-centric care. The platform eliminates administrative and financial burdens often associated with value-based care initiatives. While patient navigation programs hold promise, traditional approaches have proven expensive and burdensome for practices to implement, scale, and accurately measure. Thyme Care addresses this challenge by offering patient-centered care resources directly within participating oncology practices. These resources include:

• 24/7 Virtual Oncology Care Team: Provides wraparound services such as care coordination, symptom management, access to social and economic resources, and the collection of electronic patient-reported outcomes (ePROs).
• Robust Data & Analytics Engine: Enables practices to understand their patient populations, identify opportunities to improve value, and prioritize patient needs. This also includes reporting capabilities for accurate, individual practice-level results.
• Novel Payment Models: Unlocks value-based treatment decisions without compromising practice finances.

Thyme Care: A Seamless Extension of the Oncology Practice

By functioning as an extension of the practice, Thyme Care alleviates administrative burdens, enhances efficiency, and empowers success in value-based care arrangements. The company’s ability to expand partnerships with payers and providers across commercial and Medicare Advantage segments allows for the rapid growth of the TCOP network.

“Traditional healthcare views value-based care as everyone’s job but no one’s responsibility – great in theory, but too daunting for one party to take accountability for. We’re bringing together all of the stakeholders in such a way that it makes sense for everyone to be a part of,” said Bobby Green, MD, co-founder, chief medical officer, and president of Thyme Care. “Too often in the past this has been attempted without collaborating with the people actually taking care of cancer patients, the oncologists. Together with our partners, we’re helping to drive this shift to value-based cancer care.” 

What You Should Know:

– Innovaccer, a healthcare IT company, announced today the acquisition of Pharmacy Quality Solutions (PQS), a leader in Pharmacy-Payer performance technology.

– By leveraging PQS’s strengths, Innovaccer is poised to play a leading role in shaping the future of value-based care and medication management within the healthcare landscape.

Enhancing Value-Based Care

The acquisition positions Innovaccer to play a more significant role in the transformation of healthcare towards value-based care models. Value-based care focuses on rewarding quality outcomes over treatment volume, aiming to improve patient care and reduce costs.

PQS: A Leader in Pharmacy Quality Improvement

PQS plays a vital role in connecting healthcare payers and providers. Their platform facilitates:

• Standardized measurement and reporting on key medication use quality measures
• Value-based reimbursement programs focused on medication adherence, treatment outcomes, and patient safety
• Delivery of quality insights to optimize medication management for various patient populations

Solidifying Market Position and Future Opportunities:

This acquisition solidifies Innovaccer’s leadership in the healthcare IT space. The combined network creates:

• Opportunities for cross-selling into new pharmacy and payer markets
• The industry’s largest clinical connectivity between prescribers and community pharmacies

Innovaccer prioritizes a smooth transition for PQS employees and customers. PQS will maintain its existing structure to ensure business continuity and minimize disruption for its partners.

Expanding Pharmacy Network and Market Reach

PQS boasts an impressive network reach, covering:

• 95% of all community pharmacies
• 10 of the Top 10 Pharmacy chains (including national chains and independents)
• Up to 60 million lives (representing 9 out of 10 Medicare lives)
• Partnerships with 5 of the Top 6 Medicare Advantage health plans

This acquisition broadens Innovaccer’s reach within the pharmacy sector and strengthens its market position.

“We are excited to work with the PQS team to create an ecosystem approach of accelerating Value-Based Care, with data and AI” said Abhinav Shashank, cofounder and CEO, Innovaccer. “The possibilities that this acquisition brings to Innovaccer and our valued stakeholders pave a new area of growth. The acquisition not only expands our capabilities and expertise in improving patient outcomes, establishing clinical data exchange in payers and now by adding the PQS pharmacy solutions, we have created a connected ecosystem of payer, provider and pharmacy.”

What You Should Know:

– Chamber Cardio (Chamber), a groundbreaking healthcare company designed to support cardiologists in the transition to value-based care raises $8M in seed funding led by General Catalyst, with participation from existing investor AlleyCorp and additional support from Company Ventures, American Family Ventures, and City Light.

– By providing technology-enabled support and a deep understanding of value-based care, Chamber empowers cardiologists to deliver high-quality care, improve patient outcomes, and achieve greater practice success.

Addressing Challenges, Transforming Care

Cardiovascular disease is a major health burden, costing the healthcare system over $400 billion annually. Co-founded by healthcare industry leaders George Aloth, Dr. Sameer Sheth, and Dr. Jeffrey De Flavio, Chamber addresses these challenges by providing real-time data insights, evidence-based guidelines, dedicated care teams, and contracting support. This comprehensive approach streamlines workflows and empowers cardiologists to focus on delivering high-quality patient care.

The Future of Cardiac Care

Chamber positions itself as a premier solution for both cardiologists and payers, fostering collaboration to improve patient outcomes. Currently serving patients in the Mid-Atlantic region, Chamber has ambitious plans for nationwide expansion. They are actively seek to grow their network of cardiologists and partner with additional payers.

“Our objective is to provide unparalleled support to cardiologists as they navigate the transition to value-based care, putting them in control of their practice,” said George Aloth, Co-Founder and CEO of Chamber. “By doing so, we aim to provide patients with the highest quality of care, ultimately improving health outcomes for heart disease.”

What You Should Know:

– Humana Inc. (NYSE: HUM) and kidney care provider Strive Health announced today a new multi-state, value-based care agreement for kidney care to more Medicare Advantage members.

– This expanded value-based kidney care partnership extends access to Strive’s innovative kidney care model to Humana Medicare Advantage HMO and PPO plan members living with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) across five states.

Transforming Kidney Care Delivery

The agreement signifies a commitment to value-based care, a healthcare approach that prioritizes patient health outcomes and quality of life. Through this partnership, Humana members in Indiana, Illinois, Kentucky, Michigan, and northwest North Carolina will benefit from:

– Access to Strive’s value-based kidney care program.

– A dedicated interdisciplinary care team that collaborates with a member’s physician to provide whole-person care.

Services including:

– Medication management and care management.

– Dialysis access planning.

– Transplant coordination.

– Social services.

Building on a Strong Foundation

This new agreement expands on an existing relationship between Humana and Strive, which began offering value-based kidney care to Humana members in Indiana and Kentucky in 2020. The success of this initial collaboration paves the way for broader access and improved care for Humana members across the newly included states.

“Humana is committed to providing our members with evidence-based, multi-specialty kidney care,” said Jim Stodola, Humana Vice President of Trend Management. “An estimated 37 million Americans live with chronic kidney disease, and with that number continuing to grow, our priority is to continue to strengthen access to the highest levels of kidney care for our members.”

What You Should Know:

– While the shift towards value-based care (VBC) is underway, a recent Black Book survey reveals that only 37% of medical practices are currently receiving payments from upside-risk arrangements and shared savings, while 12% receive payments from full risk.

– This leaves a significant portion, over 50%, still relying on traditional Fee-For-Service models.

Healthcare Providers Seek Guidance in VBC Transition

The survey also highlights the increasing demand for VBC consulting services. Two-thirds of providers venturing into VBC rely on advisors to navigate the complexities of:

Care delivery challenges: Optimizing workflows and implementing evidence-based practices.

Data analytics: Utilizing data to drive informed decision-making.

Stakeholder collaboration: Fostering partnerships among providers, payers, and patients.

Key Areas of Focus in VBC Consulting

The survey identified eight key areas where VBC consulting firms assist healthcare organizations:

Strategy Development: Creating a roadmap for transitioning to VBC and achieving desired outcomes.

Data Analytics: Implementing solutions to collect, analyze, and utilize data for informed decision-making.

Performance Improvement: Identifying areas for improvement in care delivery and patient outcomes.

Population Health Management: Developing programs to address the specific needs of patient groups.

Provider & Payer Collaboration: Facilitating partnerships and aligning goals between providers and payers.

Technology Integration: Selecting and implementing technology solutions to support VBC initiatives.

Regulatory Compliance: Ensuring adherence to relevant regulations and standards.

Financial Modeling: Projecting the financial implications of the transition to VBC.

Survey Findings and Recommendations

The survey also emphasizes the need for:

– Faster Pace of VBC Adoption: 81% of respondents believe predictable compensation is crucial to accelerate VBC adoption.

– Enhanced Provider Confidence: Building trust and ensuring financial stability for providers transitioning to VBC.

Top VBC Consulting Firms

The survey identified top-performing VBC consulting firms for both physician practices and hospital systems:

– Physician Practices & Ambulatory Organizations: CareAllies, a division of The Cigna Group

– Hospitals & Health Systems: SG2, a Vizient company

What You Should Know:

– Strive Health, the national leader in value-based kidney care, and Medical Mutual, one of the largest Ohio-based health insurance companies, announced a new value-based kidney care partnership.

– The strategic collaboration aims to deliver value-based kidney care to eligible members with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) across all lines of business, including Medicare Advantage, individual, and commercial group health plans.

Addressing a Hidden Health Crisis:

Over 1.3 million adults in Ohio live with CKD, but only 150,000 are aware of their condition. This lack of awareness can lead to delayed diagnosis and treatment, worsening health outcomes. Strive and Medical Mutual aim to increase awareness and early intervention by leveraging their combined resources and reach.

Partnership Impact and Reach

The strategic partnership is expected to support over 10,000 Ohioans living with kidney disease. Strive currently serves over 100,000 patients across 34 states and partners with over 700 nephrology providers. Their NCQA-accredited case management and population health programs and HITRUST-certified technology platform ensure high-quality care delivery.

Transforming Kidney Care Delivery

Strive’s proven value-based care model has demonstrably improved patient outcomes. Their approach, which combines technology-enabled interventions with seamless integration with local providers, has led to a 42% reduction in hospitalizations and a 94% satisfaction rate among patients. This partnership will bring this model to eligible Medical Mutual members, offering them:

– Coordinated care: Strive will work with patients, their local providers, and Medical Mutual to ensure they receive the right care at the right time.

– Proactive management: Strive’s care team will proactively monitor patients’ health and intervene to prevent complications.

– Improved patient experience: Patients will have access to a dedicated care team, educational resources, and support services.

“Providing Medical Mutual members better access to value-based kidney care is an important step in achieving our mission to revolutionize kidney care through comprehensive, patient-centered solutions that improve the quality of life for those affected by CKD,” said Chris Riopelle, Co-Founder and CEO at Strive Health. “Medical Mutual is committed to improving the lives of Ohioans through high-quality healthcare coverage and partnerships like this one, and I look forward to seeing the impact we will have in the coming years in working closely together to improve outcomes for people with kidney disease in Ohio.”

Strive currently serves over 100,000 patients nationwide across 34 states, partnering with over 700 nephrology providers.

In the ongoing transition to value-based care (VBC), provider contracting poses challenges for health plans and providers. In my past role as the VP of Quality at a large health plan, I was part of the team that reviewed provider contracts that included risk around quality. Adding my role to the review process reduced the frustration of the Network and Quality teams because I could identify the reporting requirements that the health plan couldn’t meet and create alignment with measure priorities.

Value-based contracting rapidly evolves, with federal and state regulatory bodies imposing new mandates. The Centers for Medicare and Medicaid Services (CMS) intends to shift traditional Medicare and many Medicaid beneficiaries into VBC arrangements by 2030. The growing emphasis on quality further fuels the demand for VBC contracts as payers push for them and providers recognize their significance in driving volume and revenue.

This acceleration toward VBC results in complex contracts with intricate data management needs to achieve quality outcomes. Here’s how quality considerations and the associated data influence VBC contracts.

Understanding VBC contracting concepts

Most contracts fall along a spectrum, increasing complexity as risk sharing expands. The following are the most common contracting concepts, from minimal to more comprehensive risk sharing:

• Gainsharing: For providers just starting with VBC, they share in the savings and not the risk of loss, giving them an upside-only arrangement.
• Upside/Downside Risk Models: Providers share in both savings and risk. In these contracts, providers receive a per-patient allotment of funds and retain the defined portion of the surplus generated. However, if they spend more than the allotment, they are responsible for a specified portion of the deficit.
• Bundled Payments: The provider receives a fixed payment for all services within a single episode of care or for a specific period, such as joint-replacement surgery. If the provider successfully delivers care and prevents complications or errors, they keep a portion of the savings. However, they are responsible for the deficit if costs exceed the fixed amount.
• Capitation – Professional-Only Risk: The payer establishes risk pools, typically based on a monthly payment per member (PMPM). The amount payers give providers is based on the average expected healthcare utilization and risk profile of the patient pool, among other factors. Providers are only responsible for the professional side risk.
• Capitation – Global Risk: This arrangement is the same as the Professional-Only Risk above, except providers and payers fully share risk in these contracts.

As each party takes on financial risk, the need for VBC expertise and technology to support care and contract management increases. There are several contract considerations to help payers and providers build the proper foundation for VBC success.

Identify the best approach for all parties.

While achieving a perfect contract for all parties may be unlikely, better collaboration is more likely to result in win-win scenarios. Initial negotiations often begin with the health plan’s template, aligned to their goals, but healthcare is diverse. Providers and payers must ensure the right stakeholders are involved to ensure quality metrics are tailored to the provider’s specific patient population, such as children or diabetics. Payers and providers must also align on standards, like NCQA or CMS Core Set, so parties can determine the most appropriate risk-sharing levels, ensure the measures are reportable, and gather necessary data.

Consider how to match measures to members

Plans with multiple lines of business must consider the measures that best reflect the desired outcomes for each population and look for commonality where possible. Another consideration is, when negotiating with a provider practice, payers should consider the specialists. If the practice has an endocrinologist, it benefits all parties to have quality measures related to diabetes in the contract. 

Focus on carrots, not sticks.

The proper contract will encourage compliance through incentives rather than penalties. Payers should tie provider incentives to defined quality measures and promote ease of reporting, such as CPT 2 codes and providing supplemental data to health plans to lower the cost of data acquisition. This approach, emphasized by Jessica Columbus of Apex Health, promotes efficiency for providers, such as using point-of-care alerts to guide actions aligning with contract goals.

One data feed to rule them all 

The ongoing challenge in VBC is building the required infrastructure and technology. Complicating matters is the need for a standardized minimum data set, with health plans having differing specifications for supplemental data files. Even with standardized measures, consolidating data from multiple sources is highly challenging. Efficient use of available data is crucial for health plans to avoid frequent revisits to providers.

Consider the implications for data aggregation. Suppose a provider collaborates with seven plans, each with a distinct gap-in-care list and inconsistent header data. In that case, the payer must invest resources in consolidating this data to manage quality measures effectively.

Nick D’Ambra, former VP of Quality Improvement at AbsoluteCare, shared an essential experience at the RISE HEDIS & Quality Improvement Summit. While working on a state-mandated performance improvement project to streamline clinical practice guidelines, the central question emerged: Could a broader opportunity exist to collaborate with other managed care organizations and create a unified file format meeting all their needs?

Bridging the data management gap 

Collecting and reporting data for Value-Based Care (VBC) is challenging, especially with the increasing volume of data as VBC becomes more common. However, the impact of AI technologies like machine learning, natural language processing, and optical character recognition, including generative AI like ChatGPT and Bing Chat, is significant. These technologies excel at aggregating and synthesizing patient data from various sources.

Unlike spreadsheets, which require manual input and manipulation, health plans can automate AI to operationalize data intake and tasks, identify patterns, highlight relevant information, and streamline processes. For payers and providers managing quality measures in contracts, leveraging data both prospectively and retrospectively is crucial, and AI enables this at scale. 

Winning at VBC

Organizations that effectively leverage AI to precisely identify, monitor, and report quality outcomes will position themselves for success in attaining value-based contracts, thereby enhancing patient health and bolstering financial performance.

About Elissa Toder, MBA

Elissa Toder, MBA, is the Vice President of Quality Improvement Strategy & Solutions at Reveleer. Elissa holds a BS in Health Policy Administration from Penn State University and earned her MBA at Clark University.

What You Should Know:

– Medical Home Network (MHN), a leader in transforming care in the safety net, announced today its partnership with 64 federally qualified health centers (FQHCs) across seven states. These FQHCs will participate in two key CMS value-based care programs: ACO REACH and MSSP (Medicare Shared Savings Program).

– This expansion comes on the heels of an impressive achievement by existing MHN partners: $10.1M in gross savings and a perfect quality score in the 2022 performance year for the NeueHealth Premier ACO.

Expanding Access to Value-Based Care

2024 marks MHN’s first year in the MSSP and its second year in ACO REACH. The participating ACOs will collectively cover nearly 50,000 Medicare lives, significantly expanding access to value-based care for underserved communities.

Empowering FQHCs with Technology and Support

MHN equips FQHCs with the tools and resources needed to succeed in value-based care models. They provide:

• AI-driven analytics: Real-time insights into patient health, enabling proactive care and improved outcomes.
• Care coordination support: Building strong systems for holistic patient management across various providers.
• Technical assistance and guidance: Navigating the complexities of value-based programs.

Advancing CMS’ Vision

This expansion aligns with CMS’ goal of having 100% of Medicare beneficiaries in accountable care relationships by 2030. As FQHCs serve a growing number of Medicare patients and play a vital role in the safety net, their participation in value-based programs is crucial to achieving this vision. This newly formed MSSP ACO includes 17 FQHCs across five states, with Cheryl Lulias serving as CEO. This collaboration signifies MHN’s commitment to expanding its reach and impact.

“Since our founding in 2009, MHN has believed that supporting community health centers is the key to building healthier communities. Enabling their participation in these value-based care models is a natural extension of our mission, and we’re thrilled so many forward-thinking organizations have trusted us and our proven care model to help them on this journey,” said Cheryl Lulias, president and CEO, MHN and CEO, Medical Home Network REACH ACO.