Featured Health Business Daily Story, Dec. 29, 2016

2017 Outlook: Blues Plans Will Continue to Invest In Value-Based Payment Models

Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS, a hard-hitting independent monthly newsletter on new products, market share, management strategies, profitability, strategic alliances and executive compensation of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.) Sign up for a $72 two-month trial subscription today.

By Jill Brown, Executive Editor
January 2017Volume 16Issue 1

Blue Cross and Blue Shield plans will continue to invest in value-based care programs in 2017, as results start to show the initiatives’ potential to slow cost increases and improve quality. That’s despite vows from President-elect Donald Trump and the newly elected Republican Congress to repeal and replace the Affordable Care Act, which helped spur these initiatives.

“Expanding our value-based care platform and population health efforts will be our primary focus in 2017,” Horizon Blue Cross Blue Shield of New Jersey Chairman, President and CEO Bob Marino tells The AIS Report. “Horizon BCBSNJ made substantial investments over the past six years building successful, sustainable value-based care and payment models. As a result, in 2015 more than 60% of our medical spend went to doctors and hospitals that participate in one of our value-base, patient-centered programs.”

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Horizon has several episode-of-care efforts, including its most recently launched program for Crohn’s disease (see story, p. 5). Other episodes focus on joint replacement, colonoscopy and pregnancy. In all, more than 1 million of its members are in patient-centered programs, for which Horizon paid $58.9 million in 2015 care coordination and shared-savings payments to physicians and hospitals (The AIS Report 10/16, p. 12).

Independence Blue Cross President and CEO Daniel Hilferty predicts that value-based care programs should continue to grow, despite all the uncertainty with the recent elections. “If you look at one thing that really should transition nicely from the Obama administration to the Trump administration, it’s a commitment to paying for value,” he tells The AIS Report.

In addition, Independence’s value-based care initiatives — like those at many insurers — are driven by local partnerships rather than federal programs.

These Blues plans are not alone in developing value-based care programs.

Indeed, Anthem Inc. said its Anthem Blue Cross unit’s accountable care organization (ACO) program saved $70.4 million for 450,000 PPO members over a recent 12-month period. The insurer had 17 provider partners in its Enhanced Personal Health Care program. It calculated the savings by comparing each ACO’s cost trend during a 12-month measurement period to the same group’s cost trend for the prior 12 months.

One of Anthem’s partners, Hill Physicians Medical Group, said it had a “specialized multi-disciplinary clinical team solely dedicated to the PPO population, including nurses, social workers, pharmacists and project managers assisting with data analysis to find the most at risk patients for outreach and build reports for physician education and engagement.”

Another partner, Cedars-Sinai Medical Network, said it provided “emergency department physicians with a 24/7 Care Management hotline that allows them to safely discharge patients home knowing that a care manager will immediately follow up. Care managers help arrange prompt doctors appointments, ensure that appropriate medications are taken and attend to other medical needs of patients at home, reducing unnecessary admissions.”

Blue Cross Blue Shield of Michigan also made significant investments in patient-centered medical homes (PCMHs). The insurer started with more than 1,500 PCMHs featuring 4,500 physicians, and paired them with specialists and hospitals to develop “Organized Systems of Care” (OSCs). In fact, the Michigan Blues plan is wrapping insurance products around the OSC networks (see box, below).

The insurer says its OSC system has decreased hospitalizations and emergency visits and has saved about $427 million since it was launched six years ago. The model is based on teams led by primary care physicians and staffed by nurses, pharmacists, care coordinators, nutrition counselors and other caregivers. Services include 24-hour access to the care team, specialist care coordination and disease management services for patients with chronic conditions like diabetes or asthma.

Late last year, the Michigan Blues plan began offering Michigan employers the option of making PCMHs available to out-of-state employees. Blue Distinction Total Care links patient-focused care models across the country, with almost 450 patient-focused care programs in 37 states that use more than 59,000 primary care physicians and nearly 59,000 specialty clinicians (The AIS Report 10/16, p. 12).

On the Medicare side, several Blues plans are participating in CMS’s Medicare Advantage Value-Based Insurance Design model, which allows MA plans to offer reduced cost-sharing for certain “high-value” services, providers or programs in seven clinical categories. Those categories are diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure, patients with past stroke, hypertension, coronary artery disease and mood disorders.

For 2017, the nine participating insurers are Blue Cross Blue Shield of Massachusetts, Fallon Community Health Plan, Tufts Associated Health Plan, Geisinger Health Plan, Aetna Inc., Independence Blue Cross, Highmark Inc., UPMC Health Plan and Indiana University Health Plan.

Blues Work With CMS on Value

Several Blues plans also are participating in CMS’s Comprehensive Primary Care Plus (CPC+) initiative, a five-year program created to push the Medicare primary care model away from traditional fee-for-service (FFS) and toward a value-based system (The AIS Report 11/16, p. 3). Here’s a look at the states where Blues plans were provisionally selected to partner with CMS (along with other payer participants in those states):

  • Arkansas: Arkansas BlueCross BlueShield, Arkansas Health & Wellness Solutions, Arkansas Medicaid, Arkansas Superior Select, HealthSCOPE Benefits, QualChoice Health Plan Services, Inc.

  • Colorado: Anthem, Colorado Choice Health Plans, Colorado Medicaid, Rocky Mountain Health Plans, UnitedHealthcare

  • Hawaii: Hawaii Medical Service Association

  • Kansas and Missouri: BlueCross BlueShield of Kansas City

  • Michigan: BlueCross BlueShield of Michigan, Priority Health

  • Montana: BlueCross BlueShield of Montana, Montana Medicaid, PacificSource Health Plans

  • New Jersey: Amerigroup New Jersey, Inc., Delaware Valley ACO, Horizon Blue Cross Blue Shield of New Jersey, UnitedHealthcare

  • New York Hudson Valley Region: Capital District Physicians’ Health Plan, Empire BlueCross BlueShield, MVP Health Plan, Inc.

  • Ohio and Northern Kentucky: Aetna, Anthem, Aultman Health Foundation, Buckeye Health Plan, CareSource, Gateway Health Plan of Ohio, Inc., Medical Mutual of Ohio, Molina Healthcare of Ohio, Inc., Ohio Medicaid, Paramount Health Care, SummaCare, Inc., The Health Plan, UnitedHealthcare

  • Oklahoma: Advantage Medicare Plan, BlueCross BlueShield of Oklahoma, CommunityCare HMO, Inc., Oklahoma Medicaid, UnitedHealthcare

  • Pennsylvania’s Greater Philadelphia region: Aetna, Independence BlueCross/Keystone Health Plan East, Delaware Valley ACO

  • Rhode Island: BlueCross BlueShield of Rhode Island, Rhode Island Medicaid, Tufts Health Plan, UnitedHealthcare


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