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.
That report compared quality metrics and prevention measures for calendar year 2016 for approximately 1.65 million Medicare Advantage members who were affiliated with providers in value-based reimbursement model agreements to 191,000 members who were affiliated with providers under standard Medicare Advantage settings. Humana also compared costs for approximately 1.4 million Medicare Advantage members in VBC model agreements to original fee-for-service Medicare, and also compared outcomes for those 1.4 million to 216,000 members who were affiliated with providers under standard Medicare Advantage settings.
The study found that providers in value-based reimbursement model agreements had 26 percent higher Healthcare Effectiveness Data and Information Set (HEDIS) scores compared to providers in standard Medicare Advantage settings. Humana Medicare Advantage members affiliated with providers in VBC model agreements experienced 6 percent fewer hospital inpatient admissions and 7 percent fewer emergency department visits, and the number of preventive screenings was 8 percent higher for breast cancer and 13 percent higher for colorectal cancer. What’s more, medical costs for Medicare Advantage members affiliated with providers in VBC models were 15 percent lower versus those affiliated with physicians under original FFS Medicare.
Healthcare Informatics Associate Editor Heather Landi recently sat down with Roy Beveridge, M.D., Humana’s chief medical officer, during a recent visit to New York City to discuss the report findings. Beveridge joined Humana in 2013, and is board-certified in medical oncology and internal medicine. He previously was chief medical officer of McKesson Specialty Health, a subsidiary of McKesson Corp. Below are excerpts from that interview.
Humana recently released its inaugural value-based care report. What are a few of the key takeaways from that study?
Basically, what it shows is that value-based care really is an improvement in terms of quality; no matter how you measure it, there’s quality improvement. The thing that’s hard for people to understand, and I practiced medicine for 22 years and I had trouble understanding it, is if you improve quality, the mindset has always been, you must be increasing cost. In medicine, much of the lack of quality comes from over testing, hospital readmissions, or things such as people not getting their breast cancer screenings or colonoscopies. The important takeaway is that quality increases, and what we also found in the report is that there is a 15 percent reduction in cost.
Another important thing is to consider the distribution of health care payments. According to the AAFP (American Academy of Family Physicians), their data has shown that primary care physicians receive 6 percent of the total distribution of health care payments nationally. At Humana, we believe that the family practitioner is the quarterback of the system, so then we ask the question of what percentage of that dollar goes to the family practitioner. Human’s distribution of overall payments to health care providers was higher for value-based PCPs in 2016—PCPs in value-based agreements with Humana received 16.2 percent of the total payments Humana distributed to health care providers in 2016, while PCPs in non-value-based agreements with Humana received 6.9 percent of the total payments Humana distributed. So, we’ve gone from 6 percent to 16 percent; we actually have put the family practitioner in the driver’s seat as they have now become the quarterback. If you believe in value-based medicine, you have to have a quarterback and you have to pay them more.
How would you describe the evolution of value-based care and payment models?
It’s interesting, if we look back at history, the government and everybody tried to do this in the 1990s. People will say, “People tried it in the 1990s, and it didn’t work.” The reason it didn’t work is that the government and payers basically said to providers, I’ll pay you $5 to take care of every single patient. Then you got into these food fights where people said, “This is a complicated patient and I don’t want to take care of them.” Then you had all this shifting of patients back and forth. In this new world, no one can shift. In Medicare Advantage, if somebody signs up, they are yours. The most important thing now is that the government now pays in a risk-adjusted manner, and that’s the key. So, now there is an incentive to take care of that sick patient, and the incentive is to make them healthier, because if we make the patient healthier, then we’re spending less money on hospitalization and drugs. This value-based model aligns exactly with having the patient get healthier, we get paid more, the doctor sees patients to keep them healthy, it aligns everyone. The other thing is that it results is less hospitalization. That’s what this report shows—it shows that if you align incentives correctly then the patient’s health improves, the dollars flow appropriately, the primary care doctors get paid more; I don’t see how anybody loses in this game.
What do physicians need in order to make this transition to value-based care and payment models, and to be successful under these models?
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.
I think the biggest challenge for physicians is when they try to do both [value-based payment models and fee-for-service payment models] at the same time. With a value-based reimbursement model, you, as a physician, are spending more time with the patients. Let’s think about it this way; let’s take a doctor who has 200 patients who are in value and 3,800 patients who are in fee-for-service. If that doctor is spending 40 minutes with his patients in value-based care models and he tries to do that with all his patients, those 3,800 patients will make him go bankrupt, because you can’t spend 40 minutes with every patient because you’re only getting paid a fee-for-service amount. That’s what you keep hearing from the doctors: it’s hard and we can’t do both at the same time. And the answer is, you have to get to a threshold of value so that you can do it for everyone. It’s hard to do both at the same time.
What role does technology and data and analytics play in your population health strategy?
We support the physicians with actionable data to give them a deeper understanding of their patients. We are trying to help address gaps in care by notifying physicians when screenings are due, or if patients appear to not be taking medicine as prescribed. 'This patient hasn’t had a mammogram in 15 months. This member hasn’t had a colonoscopy in six years. This member with diabetes hasn’t had an eye exam and, by the way, we looked at the patient’s labs, and the patient is going to go into kidney failure in three years if you don’t do something.' This is the analytics that we have running all the time, on every single one of their patients.
As an example, one of the largest practices in the U.S. is in central Ohio and we actually embedded people in their practice to train them to do a lot of this value stuff. It’s as much as we’ll embed people to embedding our technology so the practices can see the data flow to connecting them to our analytics, so they can see what’s happening with each of their patients. We’re feeding the physicians a tremendous amount of information, so they can figure out how to care for their patients.
Addressing social determinants of health plays a vital role in any population health strategy. How can payers, physicians and community organizations work together to address SDoH?
The biggest learning with social determinants of health is that physical health is related to so many other things. We know now that if a patient has diabetes and that patient also has a behavioral health issue their cost to the system is 4 to 5 times greater. If you look at diabetes, food insecurity is a huge issue. If you are diabetic and you don’t have access to good, healthy food, I can guarantee that you are going to end up in the hospital frequently due to diabetic problems and your control of your diabetes is going to be terrible. So, understanding this is the first thing, and the second thing is that you have to work to address it.
We’re working with Feeding America and a lot of non-profits and hospital systems to address the issue of how do we identify people who are food insecure and bring food to those people. [Editor’s note: Humana developed a Bold Goal of improving health 20 percent by 2020 and addressing food insecurity is a key focus, as outlined in this recent report.]
One of the largest determinants of someone being readmitted to the hospital after a hospitalization is they don’t have food in the fridge. Food insecurity causes a huge amount of cost to the system. So, if you don’t take care of that, how are you going to control your costs? From a societal standpoint, it’s the right thing to do, and from a business standpoint, social determinants must be addressed. The more we can make it a business priority, then you got everyone doing it, so it’s no longer a social work issue or a non-profit issue. If you’re in a value-based world, then you need to try to build it into the structure, where, if you have patients with diabetes, then you have to think about their food status.
