Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Value-Based Care News

Humana Serves 63% of Members through Value-Based Care Payment

Health payers are finding the rapid pace to transition to value-based care payment models difficult.

By Vera Gruessner

The future for the health insurance industry likely revolves around value-based care payment, which has grown in use steadily over the last several years. Recent healthcare reforms have centered around tracking the quality of care, reducing spending, and improving patient health outcomes. Value-based care payment models tend to revolve around meeting these three goals.

Value-Based Care Reimbursement

Michael Funk, Vice President, Thought Leadership, for the Provider Development Center of Excellence at Humana, told recently how much Humana has invested in value-based care payment models and their plans for continued investment next year.

“Our goal here at Humana is to continue to support those physicians and other providers to be successful in value-based relationships while, at the same time, growing new relationships with providers in value-based care,” Funk explained.

As a national payer, Humana has pursued value-based care payment more than most and boasts about 63 percent of their membership as being served within a value-based care environment.

“As many as 1.8 million Humana Medicare Advantage members are in value-based care,” Funk said. “49,600 providers in our network are somewhere along the path toward value, which represents over 900 value-based relationships in 43 states and the island of Puerto Rico. As an organization, we feel we’re moving rapidly into the value-based space.”

READ MORE: Humana Expands Orthopedic Bundled Payment Program to NC, VA

Funk also described some of the major challenges that Humana and other commercial payers have faced due to ongoing healthcare reforms and the move away from fee-for-service payment.

“The challenge is that things are moving very, very rapidly,” he continued. “This is not only a payer issue but a provider issue that we hear. When you have as much change as we’ve had in the industry, that adds a lot of stress to the industry. We see it and hear it in terms of providers and the burnout they’re experiencing because of that. And I don’t think that’s any different for the payer side.”

Humana’s rich history and knowledge in the value-based care environment has also set up the payer to be more successful in moving away from fee-for-service and adopting alternative payment models.

“We as a group - including physicians, providers, and payers - we continue to learn from feedback in terms of where we’re going to go in 2017,” added Funk. “That really has been a mutual learning process. Humana has been somewhat in a better position because of our history. We have 30 years with some of our provider relationships in full value arrangements. I think as a result of that and some of the knowledge that’s taken place over that 30 years, put us in a position to be able to move more quickly than others in the space because of the history we have in value-based care.”

Humana is one commercial payer that has followed along with the goals set up by the Centers for Medicare & Medicaid Services (CMS), which hopes to reach 50 percent of their Medicare claims to be in the form of value-based care by 2018.

READ MORE: Humana Expands Medicare Orthopedic Bundled Payment Programs

“This is a movement that has been going on at Humana for quite some time,” he continued. “What we’ve seen in the value-based space, especially when compared to traditional Medicare, value-based care is producing outcomes in Humana membership 19 percent higher HEDIS and star scores. It brings healthier outcomes demonstrated by things like 6 percent fewer ER visits and improved screening rates.”

“Lastly, our most recent announcement is that we’re paying $93 million in addition to fee-for-service payments to some 4,500 provider groups for quality outcomes.  A lot is going on in Humana in the value-based space,” Funk noted.

Recent results from Humana also indicate that the health insurance company was able to reduce cost by 20 percent among providers who operated a value-based care payment model. As Michael Funk stated, Humana’s value-based care platforms have shown 19 percent higher HEDIS scores when compared to fee-for-service Medicare Advantage health plans. Some areas to see improvement include colorectal screening, osteoporosis management, and breast cancer diagnostics.

“We’ve been fairly transparent in that the work that we’re doing has been very primary care centric, but we also recognize the need to expand beyond that,” Funk added. “We have been doing other models. We are moving into the bundled payment space. We have developed a couple of oncology programs that we’re working with some provider groups on. We’ll continue to evolve those programs from the learning that takes place.”

Humana has also held forums to learn about provider struggles and capabilities in the value-based care space, said Michael Funk. Providers have shared the lessons they learned in population health management throughout 2016 and where to go from here.

“We just came back from a collaboration. We refer to it as our Value-based Care Executive Forum where we invited a number of providers across the country to a session where Humana takes the role of facilitator,” said Funk. “The value of the collaboration is bringing together these disparate organizations from across the country that are at varying points along the value-based care journey. It really becomes a sharing and learning opportunity amongst peer groups.”

The forum has shown Humana that more advancement needs to take place in terms of population health management, said Funk.

“Even with the success in terms of where we are at with value-based care and the outcomes we’ve seen from our value-based work, by no means can we plant a flag and say ‘we figured it all out,’” he continued. “We are very early in this journey of population health management. We have seen some early successes, but by no means can we say that we figured it all out and there’s no more work to be done. There is a ton of work that still  needs to be done.”

“There is clearly a need to further expand on our population health technology platform. For example, we have a tool called CareBook, which is our clinical and financial management system,” said Funk. “It brings providers information on Humana membership to help them close gaps in care and identify their chronic patient population. It’s proved to be a successful tool, but we continue to build upon it.”

Additionally, Humana is working to integrate behavioral healthcare into population health management protocols as well as create a more community-wide effort in improving health outcomes. This includes bringing grocery stores and local community centers together to boost overall health.

“Further integration of behavioral health into the overall population health management journey is another area where we’ll continue to improve,” he added. “It’s not just about payers, physicians, and providers. One of the things we need to keep in mind is, as we move to population health, it becomes more of a community-wide effort. What we have found is it does take a village in order to be successful in this. The more engagement we can have from a community-wide perspective such as associations, local governments, and grocery stores all coming together, the more likely we can improve the overall health of that community.”

Funk concluded by describing the importance for commercial payers to build trust with their provider network and create the support providers need to succeed when operating value-based care payment models.

Dig Deeper:
How to Overcome the Challenges of Bundled Payment Models

How Payers Should Prepare for Value-Based Reimbursement



Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...