A recent value-based care study by Louisville, Ky.-based insurer Humana found that patients treated by physicians in Humana Medicare Advantage (MA) value-based agreements had more preventative care screenings and better health outcomes compared to patients in Humana MA fee-for-service agreements.
The Humana report details results in the areas of prevention and outcomes, quality measures, and cost for Humana MA members affiliated with physician practices in value-based agreements with Humana. This is the fifth year Humana has published a value-based report and the insurer reports ongoing progress in improving health outcomes and lowering costs.
As of Sept. 30, 2018, Humana’s total Medicare Advantage membership is more than 3.5 million members, which includes members affiliated with providers in value-based and standard Medicare Advantage settings. According to the report, Humana reached its 2017 goal of having 66 percent of its 2.9 million individual MA members affiliated with primary care physicians in value-based agreements.
For the annual study, Humana compared quality metrics and prevention measures for calendar year 2017 for approximately 1.74 million MA members who were affiliated with providers in value-based reimbursement model agreements to approximately 130,000 members who were affiliated with providers under standard MA settings, which doesn’t offer added incentives to providers who meet quality or cost targets.
Humana also compared medical cost and utilization for calendar year 2017 for approximately 1.5 million MA members who were affiliated with providers in value-based reimbursement models to approximately 146,000 members who were affiliated with providers under standard MA settings as well as to original fee-for-service Medicare.
The study found that patients affiliated with physicians in Humana MA value-based agreements had more favorable outcomes in all Healthcare Effectiveness Data and Information Set (HEDIS) Star measures. HEDIS is a measurement tool developed by the National Committee for Quality Assurance (NCQA) to assess health plans’ performance on various dimensions of care and service.
Humana MA members affiliated with physicians in value-based agreements experienced 7 percent fewer emergency room visits and 5 percent fewer hospital admissions per thousand compared with standard MA settings in 2017, and the number of preventive screenings was 11 percent higher for colorectal cancer and 10 percent higher for breast cancer.
Patients with diabetes who are affiliated with value-based physicians had more condition-specific screenings and better adherence to medications, demonstrating tighter control of blood glucose and blood pressure levels. The report indicates similar results for patients with hypertension—better medication adherence rates and better management of their blood pressure.
What’s more, the study found that medical costs for patients who are affiliated with physicians in Humana MA value-based agreements were 15.6 percent lower than original Medicare FFS. In addition, more physician practices in Humana MA value-based arrangements received a shared savings surplus in 2017 compared to 2016, up to 70 percent from 60 percent the prior year, according to the latest report.
“We believe value-based care is essential to achieving improved population health. Thus, we continue to work closely with physician practices to support them in the transition to value-based care—with actionable data, care coordination, clinical programs, predictive models and innovative solutions,” Stanley Crittenden, M.D., a physician and lead medical director, national medical review, at Humana, wrote in the report.
According to the report, citing statistics from MedPAC and the Henry J. Kaiser Family Foundation, about 10,000 people join Medicare daily, and the Medicare population is expected to increase from 56 million in 2015 to 81.5 million in 2030. Eighty-three percent of Humana’s 3.3 million Humana MA members, as of December 31, 2017, are living with at least two chronic diseases. Humana is using a holistic approach, leveraging value-based reimbursement models, to address this challenge, according to company officials.
Speaking with Healthcare Informatics earlier this month, Roy Beveridge, M.D., Humana’s Chief Medical Officer, notes that the important takeaway from the value-based care report is the consistent progress of physician practices in value-based care arrangements to improve quality and reduce health care costs.
Roy Beveridge, M.D.
“Based on the report, there’s continued improvement in breast cancer screening, in cervical cancer screenings, and there’s improvement in hospitalizations and ER visits. We’re five years out, and we’re continuing to improve on those metrics that everyone agrees are really important,” he says, noting in particular the 7 percent fewer ER visits among Humana MA members in value-based arrangements. “If you continue to have a decrease in ER visits, that’s an indication that the patient is more engaged with her primary care physician or her specialist so that when she is sick, she is reaching out to her primary care doctor. I look at those quality metrics and I’m very excited by that progress; that change didn’t happen over a year or so, but it continues to accelerate.”
Practicing value-based care works to address the nation’s chronic disease epidemic by giving physicians the support and data they need to focus more on prevention and reduce acute care episodes, Beveridge says. “This model allows physicians to focus time and energy on those patients who need the most support to stay well at home, and out of the hospital. Physicians are clearly seeing the benefit of improved patient outcomes and more shared savings.”
Continuing challenges in the shift to value-based care
While the report points to ongoing progress in the shift to value-based care and successful outcomes for those practices in value-based care arrangements, there continue to be significant barriers for healthcare provider organizations attempting to make that shift. For physicians, moving into value-based care often requires an increase in population health management capabilities and access to accurate, actionable data.
“They need technology; they need data from places like Humana and other big payers; they need to be given time so they can transition; they need the educational tools,” Beveridge says of physician practices transitioning to value-based care models.
Currently, many healthcare organizations find themselves straddling two different reimbursement models, fee-for-service payment models and value-based payment models, or what’s offered referred to as “having a foot in two canoes,” and that continues to be a significant challenge for physicians, he says. “It’s this in-between time, the transition time, where physicians are struggling, and they continue to struggle as they are moving from traditional fee-for-service to outcomes-based reimbursement,” he notes.
In the past five years that Humana has been measuring and reporting progress, one of the biggest lessons learned has been the pace of change, Beveridge says. “I think we, and the government and the industry, underestimated the time that it takes for there to be cultural change in the movement from fee-for-service to value. I naively thought, five or six years ago, that this would be a faster process,” he says, adding, “We are moving collectively in that direction, and at a good clip, but I thought that it would go faster.”
Data and analytics play an integral role in the transition to value-based care payment models and are foundational to success under these models, Beveridge says, and to this end, Humana supports physicians with actionable data to give them a deeper understanding of their patients. However, there also are cultural and operational shifts that are required to succeed under value-based care, he says.
“We have physicians coming in who say, ‘I want to move to value very quickly because I understand it.’ We will tell them it’s really a three- to five-year process. You want to make sure that your data systems can do this. You need to make sure that, from a cultural standpoint, your physicians and nurses understand this. There is a lot of effort in being successful in value-based care. People who underestimate the complexity often don’t do so well. We try to be the shock absorber, and remind people, this is harder than they may think and that you need data systems, you need analytics, and you need the right mindset,” he says.
He continues, “Someone once explained it to me like this—in the fee-for-service world, in the morning huddle, you sit and talk about the patients that are coming in to the office in the next eight hours. In the value world, you sit down with data and you say, ‘Who hasn’t come in to the office in the last eight weeks or in the past year? What do we need to do to engage those patients so that we can help the people who are not coming in to the office that day?’ It’s a cultural change that has to occur. It’s not about taking care of the patient in front of you, it’s about taking care of the patients who are not in front of you.”
He adds, “Until everyone’s trained and thinking that way and you’ve got the data to know who’s not there and why there are not there, it’s hard to be successful.”
Beveridge also contends that primary care physicians are vital to delivering more integrated care to patients, and, moving forward, healthcare organizations that want to be successful under value-based care payment arrangements need to place primary care physicians at the center, he says.
The American Academy of Family Physicians (AAFP) reports that primary care physicians receive 6 percent of the total distribution of health care payments nationally. According to the Humana report, primary care physician practices in value-based arrangements with Humana received 16.8 percent of every dollar spent on member care in 2017. Non-value-based primary care physician practices contracted with Humana received 6.9 percent of total payments Humana distributed in 2017.
“If you believe in the value model, then primary care is king, it’s the most important part. You have to pay for that. And what you see with the data is that we believe that the PCP is the lead and that she needs to be compensated appropriately, because historically, primary care physicians have been underpaid, undervalued and under respected,” Beveridge says.
Humana’s experience with value-based payment arrangements has indicated that, with the evolution of value-based care, primary care physicians are relying on a team-based approach to stay connected to their patients in their everyday lives. To support this, Humana is increasingly focused on augmenting the reach of primary care providers with in-home care services for recently discharged patients.
Beveridge notes that Humana is accelerating its investments in an integrated care delivery strategy, which encompasses supporting physician practices and care providers and leveraging technologies and clinical analytics to enhance the company’s holistic health approach.