In 2021, a payment model between the State of Connecticut Health Plan and several medical providers in the state was approved by the Centers for Medicare & Medicaid Services (CMS) as an Advanced Alternative Payment Model (AAPM). Now the network of providers participating has grown with the addition of 1,700-provider Southern New England Healthcare Organization (SoNE Health), a clinically integrated network of community physicians and the physicians and hospital partners of Trinity Health of New England.
When it was announced last year, the State of Connecticut Health Plan said it was the first commercial plan in the nation to earn this designation for its episode-of-care payment model. As a result, certain doctors, hospitals and provider groups that have contracted with the state will be eligible for greater reimbursement from Medicare. The state also said that the designation will bolster recent efforts to shift the dynamics of how the state purchases health care.
The CMS designation became effective Jan. 1, 2022. The more than 220,000 employees and retirees under the state health plan have access to the value-based agreements under a program called the “Episodes of Care program.” The program, which is administered by Signify Health, includes a “Network of Distinction” for healthcare providers. SoNE Health has joined the state health plan’s Network of Distinction.
To be included in the Network of Distinction, providers agree to cover an entire procedure or course of treatment — from evaluation to recovery — at a fixed bundled cost. Participating providers must also meet strict patient quality criteria including low rates of infections, complications, and readmissions.
“As a clinically integrated network focused on population health, SoNE HEALTH is a leader in value-based care. We strive to continually optimize the health outcomes of our patient populations while maintaining affordability,” said Lisa Trumble, president and CEO at SoNE Health, in a statement. “From our earliest days, we have been dedicated to a collaborative approach to healthcare, working together with our network providers, health plans and employers to provide the best patient care for patients at an affordable cost. This partnership with the State of Connecticut Health plan represents yet another step on the path from volume to value.”
The State of Connecticut’s employee and retiree health plans, as well as the Connecticut Partnership Plan, launched the Episodes of Care program in October 2020. The initiative encourages doctors, hospitals and provider groups to deliver high-quality, coordinated care at competitive prices for the entire course of treatment — from evaluation through recovery — for a condition or illness.
With the AAPM designation, certain providers in the Episodes of Care program will earn credit toward Medicare’s Quality Payment Program (QPP), rewarding providers that accept financial and clinical responsibility for reducing costs and improving quality of care. Since its inception last year, 1,400 physicians have committed to the state’s quality and cost standards through their participation. Additional provider groups are still eligible to join.
The state said that the Episodes of Care program significantly reduces variations in costs by setting fixed, episode-of-care, prices for over 40 common health episodes that may be delivered by multiple providers across multiple sites. Healthcare services that are eligible to be included in these program episodes could span as much as 60 percent of the average health plan’s spend, and include episodes such as knee replacement, colonoscopy, cataract surgery, care related to pregnancy, and more. Also featured is a comprehensive spine episode aimed at helping members avoid unnecessary surgery.
Signify Health’s role includes identifying, contracting with and supporting participating providers with services, technology, and analytics, as well as securing fixed, episodes-of-care pricing with high-value network providers.
