Humana Expands Bundled Payment Models for Spinal, Joint Surgeries

July 23, 2019 - Humana recently expanded its value-based payment models by signing four more agreements with providers for bundled payment models for spinal fusion surgeries.

The payer also announced the growth of its bundled payment model for Medicare Advantage beneficiaries undergoing total joint replacements at certain provider practices. Eleven more practices are now part of the bundled payment program, bringing the total to 75 medical practices in 21 states.

“We’re delighted to support provider groups as they quarterback a more coordinated approach to care for their patients undergoing spinal fusion surgery,” said vice president of Humana’s value-based strategies organization, Oraida Roman. “Humana is proud to share data and analytics with physicians and clinicians in collaboration toward improving the patient experience and health outcomes in spinal care.”

Through the spinal fusion episode-based model, coordinated care is available to health maintenance organization (HMO) and preferred provider organization (PPO) members. The model is bundled payment and it offers additional payment to physicians and clinicians for improved health outcomes and costs.

Three indicators measure the health outcomes: readmissions, cervical complications, and lumbar complications. Humana also looks at the risk-adjusted episodic cost-of-care.

With these new providers, the payer started its second group of spinal fusion episode-based model participants.

Similar to the spinal fusion episode-based model, the total joint replacement model is for HMO and PPO Medicare Advantage members and it offers additional payment to physicians for positive outcomes.

The two bundled payment programs are part of Humana’s value-based payment efforts.

Over half of Humana’s four million Medicare Advantage members are engaged in value-based payment models, with another 115,000 commercial members also being cared for by 58,000 physicians across the US and Puerto Rico through over 1,000 value-based relationships, according to the payer’s press release.

The two bundled payment programs are just two of the four value-based payment initiatives run by Huamana.

The spinal fusion episode-based model started in Indiana, Ohio, and Virginia earlier this year. It currently encompasses a total of nine groups in seven states where members can receive coordinated care for spinal fusion surgeries.

The Total Joint Replacement model launched in 2016 in Ohio and Tennessee, and quickly expanded to Indiana and Kentucky in April 2017, North Carolina and Virginia in May 2017, and seven other states in April 2018. The model includes 75 medical practices in 21 states.

The maternity episode-based model started in  April 2018 and the oncology model began a year later in April 2019.

Around the same time as Humana’s spinal fusion and oncology models launched, UnitedHealthcare also expanded its own bundled payment program, presenting the opportunity to providers in over 30 states. The program aims to improve care quality while reducing costs by using UnitedHealthcare’s data and technology experience. The program offers solutions for patient identification, risk stratification, and site of care optimization and utilizes technologies such as apps, messaging, and analytics. These services will be available to Medicare Advantage members in 2020 with spinal, orthopedic, and cardiac bundled payment options.

Bundled payment programs are also a staple of the federal government’s push for value-based care. Most recently, CMS proposed a bundled payment model for radiation oncology. The models differ from those offered by Humans and UHC because the radiation oncology model not only offers incentive, but also threatens negative action if the provider does not abide by cost and quality standards.

Incorporating financial risk through bundled payment models has been a top priority for CMS. But private payers have been slow to adopt the same practice.

Humana has been open to allowing providers to take on downside risk through its models, but for now the payer is focused on expanding its value-based payment models to more providers.

“For physicians, a value-based care model recognizes their commitment to their patients' health and compensates them for the high-quality, complex care they deliver,” Humana’s website states. “This model of care combines the practice of proactive population medicine with an aligned payment structure—one that reimburses physicians for care that leads to better health and a better experience for their patients.”