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How Payers Can Effectively Scale Value-Based Care Networks

Payers need to collaborate with providers and leverage data analytics to scale a value-based care network, improve beneficiary outcomes, and reduce care costs.

Scaling value-based care networks requires provider collaboration and data analytics.

Source: Thinkstock

By Thomas Beaton

- Value-based care networks are a promising opportunity for payers that want to manage costs and improve outcomes of beneficiaries.  But effectively scaling collaborative, risk-based reimbursement networks for millions of beneficiaries requires a great deal of strategy and insight.

The BlueCross Blue Shield Association (BCBSA) has successfully scaled its value-based care initiatives through the Blue Distinction Total Care Network: a group of accountable care organizations (ACOs), patient-centered medical homes, and similar programs that operate in local BCBS payer markets.

In 2018, Total Care Network participants lowered costs by 35 percent, reduced beneficiary hospitalizations by 15 percent, and outperformed other providers in 22 out of 23 nationally-recognized quality measures.

Kari Hedges, Senior Vice President of Commercial Markets & Enterprise Data Solutions at BCBSA, says that the Total Care Program may drive future developments that improve the value-based care environment.

“We see our value-based programs across the country as a great way to improve costs and outcomes in addition to other things related to community health and the promotion of population health,” Hedges said.

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Hedges explained that the Total Care Network was initially formed in 2015 to determine which clinical factors had the strongest correlations with care quality and healthcare costs.

“Our goal in developing Total Care was to bring forward higher quality more coordinated care by partnering with hospitals and doctors all across the country to focus on prevention, wellness, and disease management,” Hedges said. “BCBSA has sought to achieve this by understanding and addressing the quality of care and the cost of care.”

Kari Hedges, Senior Vice President, Commercial Markets & Enterprise Data Solutions at BCBSA Source: Xtelligent Media

In order to produce the most impactful results, BCBSA focused on trimming inefficiencies and closing care gaps around chronic diseases like diabetes and cardiovascular conditions.

Hedges said that BCBSA saw the chronic disease outcomes of members, and related preventive care services, as the primary quality indicator. Ultimately, she found that addressing both preventive care and chronic disease management was necessary to ensure success of value-based care programs.

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“We aim to make sure that beneficiaries are getting services such as routine physicals, well-child visits, immunizations, and other types of care that we know can help prevent further complications and diseases down the line,” Hedges said.

Provider engagement was another concern for BCBSA.

Regional BCBS organizations needed to drive engagement with local providers and recruit more physicians into value-based programs, Hedges stated. Local payer groups are critical because they can leverage relationships within their communities and understand the unique needs of their regional provider partners.

“The way the healthcare market operates in Michigan might work differently in California and look different in Mississippi,” Hedges said.  “Understanding provider needs at the local level and how the provider community is organized helped us elevate value-based programs to a national level.”

Data sharing between BCBSA and local payer groups also helped to support efforts in scaling up the Total Care program.

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BCBSA currently conducts analytics on value-based care operations across BCBSA divisions and shares its insights to local health plans. The analytics are used as a tool to educate health plans about possible gaps or opportunities for improvements in healthcare performance.

“At a national level, we share that information with BlueCross BlueShield plans so they can identify best practices or lessons learned to promote the advancement of these programs in their individual marketplaces,” Hedges said.

“Measuring and sharing results is key. Local plans have to do so in partnership with the provider organization and then look at the possible incentives that can help both organizations move towards quality-based reimbursement.”

A combination of national guidance from BCBSA and local provider engagement allowed Total Care to grow into a network that serves 19 million beneficiaries.

“Having those aligned incentives and aligned goals was very helpful increasing the ACOs and patient-centered medical homes within our national market,” Hedges said.

When local health plans melded performance data and provider buy-in, they were able to launch a variety of reimbursement models. The models ranged from incentive-based payments and bundled payments to shared risk agreements related to preventive care and chronic disease outcomes.

“The local plans end up establishing reimbursement for care management services, an incentive for meeting targets, or goals associated with outcome improvements and process improvements,” Hedges explained. “In some cases, the providers have taken on some of the risks and are owning some of the accountability directly for ensuring the types of outcomes.”

Hedges attributed the Total Care program’s 35 percent reduction in cost to the adoption of alternative reimbursement models.

Currently, the Total Care program is a PPO plan platform that operates in 43 states, and BCBSA is planning to further expand its value-based care programs. Hedges said she is optimistic about the potential growth her organization’s value-based portfolio.

“We are encouraged by our results here to continue to promote and grow these types of programs across the country,” Hedges concluded.

“BCBSA is working towards the advancement of these programs, maturing these programs, and having more patients get access to value-based care that is focused on outcomes and improving patient care.”


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