Value-based Care

Idaho is the first state to complete its Medicaid eligibility redeterminations process, the state’s Medicaid agency announced on Sept. 8. The state “processed 153,196 renewals, and 31,900 were determined eligible, and 121,296 were ineligible,” according to a post from the state’s Dept. of Health and Welfare (DEW). DEW added that the resumption of redeterminations is “a large and important undertaking that DEW has taken very seriously.” To handle redeterminations, “we committed more than 300 eligibility staff to the effort and an additional 42 staff from our call center.” The news is somewhat surprising, as Idaho paused redeterminations earlier this year due to what KFF termed “technical difficulties.” CMS has warned state Medicaid agencies not to disenroll Medicaid members too quickly.

Since the 21st Century Cures Act loosened enrollment rules in 2021, enabling more patients with a previous diagnosis of end-stage renal disease (ESRD) to enroll in Medicare Advantage, MA insurers have been striking innovative partnerships with kidney care management companies to better manage care and control costs for kidney disease patients. Most recently, Humana Inc. — one of the leading MA insurers serving ESRD enrollees — unveiled a new value-based care pact with Interwell Health that will cater to most Humana MA HMO and PPO members in 13 states living with chronic kidney disease (CKD), as well as members across the country living with ESRD.

According to Brandon Spicer, director of kidney care at Humana, the insurer offers a variety of programs for members living with CKD and ESRD, and its program care managers “work closely with providers to give patients individual support and guidance while educating them about their disease, supporting their physician’s care plan and assisting with coordination of care.”

Vermont’s all-payer accountable care organization (ACO), OneCare Vermont (OCV), has reduced Medicare costs but has had minimal impact on the state's Medicaid and commercial segments, a new report commissioned by CMS says. However, the state’s largest carrier — nonprofit commercial insurer Blue Cross and Blue Shield of Vermont (BCBSVT) — withdrew from the program at the end of the 2022 plan year and does not currently plan to return.

The report, prepared by NORC at the University of Chicago on behalf of the CMS Center for Medicare and Medicaid Innovation (CMMI), focused most of its cost and quality improvement analysis on Medicare. The report did not make any quantitative assessments of OneCare Vermont’s impact on the commercial market. NORC found that the ACO reduced gross spending for Medicare enrollees by $686.40 per member per year, or 6.2% per year, during the first four years of implementation, resulting in a $124.9 million net reduction of Medicare spending during those years, a drop of 5.7%. However, quality improvement and utilization assessments were more difficult to make due to the COVID-19 pandemic, which distorted utilization patterns during 2020 and 2021.

Manhattan Supreme Court Justice Lyle Frank issued an order “permanently” banning New York City from pushing some 250,000 retirees and their dependents into a private Medicare Advantage plan managed by CVS Health Corp.’s Aetna. Led by Mayor Eric Adams (D), the city has spent the last couple of years trying to implement a group MA plan for its retired workers, who continue to protest the switch for a variety of reasons, namely that the plan goes against a longstanding promise to provide them with free and comprehensive health care coverage in retirement. Frank previously ruled that the proposal violated city law by charging retirees $191 per month to maintain their fee-for-service Medicare coverage. In July, Frank granted the petitioners’ request for a preliminary injunction, which temporarily barred the city from executing its plan. In a decision issued Aug. 11, Frank ordered that the city be “permanently enjoined from requiring any City retirees and their dependents from being removed from their current health insurance plan(s), and from being required to either enroll in an Aetna Medicare Advantage Plan or seek their own health coverage.” On Aug. 14, the NYC Office of Labor Relations posted a new update to its retiree health benefits webpage stating that there is “no Opt-Out or Waiver deadline in effect due to an injunction issued by the court” and all current health plans remain in effect. Meanwhile, Aetna appreciates the agreement between the plaintiff’s counsel and the city “to not conduct any additional hearings, briefings or discovery in order for Judge Frank to immediately issue his decision,” according to Rick Frommeyer, senior vice president with Aetna Group Retiree Solutions. “This approach speeds the appellate review of this matter. We look forward to the City’s appeal.”

Two health care sector heavyweights— AHIP, the insurance trade group, and the American Medical Association (AMA), a physician group — are teaming up on an effort to boost value-based care by increasing data sharing. A health care industry insider says that the tentative partnership between two longtime adversaries is just the latest indication that, due to plan sponsor pressure on carriers and providers, value-based care could become the industry standard in independent physician practices and primary care.

AHIP, AMA and an additional partner, the National Association of Accountable Care Organizations (NAACOS), on July 25 rolled out a “playbook” for providers and insurers seeking to adopt value-based reimbursement or become partners in an accountable care organization (ACO). The document, which the three groups say is just the first of several such releases, focuses on how providers and plans can effectively share both individual medical and population data.

Executives from a health plan and hospital say that payer-provider alignment and value-based payment have existential stakes — if independent, regional-scale payers and providers can’t find a way to work together through joint ventures and new payment models, they say, national firms’ acquisitions of small payers and providers will accelerate.

That’s according to Greg Sweat, M.D., a senior vice president and chief health officer at Blue Cross and Blue Shield of Kansas City (Blue KC), and Stephen L. Reintjes, Sr., M.D., president and CEO of North Kanas City Hospital, who spoke during a June 13 session of the 2023 AHIP Conference in Portland, Oregon.

After two months of shopping around its Medicare Advantage business, Bright Health Group, Inc. on June 30 unveiled plans to sell its remaining insurance assets to Molina Healthcare, Inc. in a deal worth approximately $600 million. The transaction will allow the “insurtech” to focus on its consumer care delivery business, which serves fee-for-service Medicare, Medicaid and Affordable Care Act marketplace customers, while enabling Molina to continue its strategic growth in the niche low-income MA space.

Bright in late April disclosed plans to divest its California MA business, Brand New Day and Central Health Plan, to qualify for an extension of an amended agreement with its creditors. (Bright previously exited the ACA exchange business in all 15 states where it operated.) Upon completion of the sale, which is subject to regulatory approval and other closing conditions, the proceeds will provide a significant boost to Bright’s capital position. The company explained in a June 30 press release that it “intends to use the proceeds to satisfy its obligations to its bank lenders with the remaining proceeds used towards liabilities in its discontinued ACA insurance business.” Additionally, it has extended a waiver and amendment to its credit facility.

Health insurers have competed against each other to buy up home-care providers over the past several years. The most recent transaction involves UnitedHealth Group, which revealed a $3.26 billion bid to buy home care provider Amedisys at the end of May. UnitedHealth acquired LHC, another home care provider, in a 2022 deal worth $6 billion. CVS Health Corp. and Humana Inc. have also closed their own blockbuster home care transactions in recent years.

Monique Reese, Highmark Health's senior vice president for home and community care, has a unique perspective on the flurry of transactions that promise to transform home care. Before coming to Highmark in 2018, she led Sutter Health's home care division between 2015 and 2018, and she oversaw UnityPoint Health's home care division between 2010 and 2015.

Clover Health Investments Corp. said it has reached an agreement to settle seven shareholder-filed lawsuits that accused the Medicare-focused insurer of concealing material information from investors before going public. In April, the company agreed to pay $22 million to settle a similar class-action lawsuit filed by shareholders, which centered on allegations outlined in a report from the activist short-selling firm Hindenburg Research. That report called Clover a “broken business” that “misled investors about critical aspects” of its operations in the run-up to the company’s 2021 debut on the stock market, including failing to disclose an active Dept. of Justice investigation. Clover did not admit wrongdoing as part of either the April settlement or the June agreement, which will resolve the remaining shareholder-led civil cases filed against it in Delaware, New York, and Tennessee courts.

To succeed with value-based behavioral health care contracts, Medicaid managed care plans need to tailor those pacts to the unique needs of a given provider, MCO executives say. And plans may not be able to use risk-based contracts with individual practitioners and other small providers — especially if network adequacy is at stake.

“We really try to think about it in three broad categories: Are we bringing clinical value, operational value or financial value” as a result of a value-based contract? posed Kevin Wheeler, M.D., medical director for practice transformation and value-based contracting strategy at AmeriHealth Caritas, during a June 14 session of the AHIP 2023 conference in Portland, Oregon. “And we’re thinking about this in terms of our relationships with our providers and with our members.”