Top 3 Trends Affecting the Health Insurance Market in 2016

December 06, 2016 - Looking back at 2016, there were a number of different trends that continued to impact the health insurance market. The Triple Aim of Healthcare continues to be a major part of the ongoing reforms and trends throughout the insurance industry with payers more focused than in the past to improve the quality of care and patient satisfaction while cutting wasteful spending. Below we outline the top three trends that impacted the health insurance market in 2016.

The rise of accountable care organizations

Throughout 2016, commercial payers have expanded their work in accountable care organizations. In particular, major payers have emphasized the need to advance population health management when operating accountable care organizations.

Michael Funk, Vice President, Thought Leadership, for the Provider Development Center of Excellence at Humana, spoke with HealthPayerIntelligence.com last month about how Humana has been learning about the struggles in population health management providers face when implementing value-based care models.

“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,’” Funk said. “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.”

“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.”

Population health management is an important factor for the success of accountable care organizations. Primary care doctors must incorporate effective referral systems that ensures strong care coordination between specialists, hospitals, radiologists, and primary physician practices.

WellHealth Quality Care, an accountable care network, uses a referral management platform to better manage the care coordination of more than 17,000 members.

“Population health management programs deliver good care to the patients and they make sure our high-risk patients are getting into the specialized programs that they need to, but pay-for-performance models allow for more improvement beyond the traditional fee-for-service PPO,” Steve Keltie, President of Network Development and Marketing at WellHealth Quality Care, said this past March.

“The more population health management we do and the more pay-for-performance accountable care programs we do, we fulfill this accountable care model. What’s the future look like? The future is accountable care.”

Bundled payment models become more common

Another major part of achieving the Triple Aim of Healthcare revolves around episode-based reimbursement called bundled payment models, which had a measurable impact on the health insurance market this past year. The national payer Humana announced this past summer its aim to expand bundled payment models among its Medicare Advantage members.

Humana partnered with four orthopedic specialty facilities to expand its bundled payment programs. The bundled payment contracts will be used to account for the costs of hip and knee replacement surgery across these facilities.

“It is important to make sure that you’re partnering with providers when doing a bundled payment arrangement,” said Chip Howard, Vice President of Payment Innovation at Humana. “It is not going to be successful unless both the payers and providers are successful. From a contract perspective, I would suggest  looking at a glide path to what I would term provider full-accountability.”

When making a financial contract in the bundled payment space, the full responsibilities of providers and payers will need to be spelled out, said Howard.

“In other words, this would mean the provider sharing in the ups and downs of the financial results,” Howard continued. “I think you should take a measured approach to that and not go immediately to a full-value accountability type of arrangement with a provider. Also, making sure that the responsibility of the payer and the provider are clearly outlined in the bundled payment contract so that there aren’t any hiccups down the road that are unanticipated.”

Payers strive to boost HEDIS scores

The push toward value-based care reimbursement has led private payers and providers to invest more time and resources in improving their scores on HEDIS quality measures. More than 90 percent of payers report HEDIS scores showing how well their providers perform on a variety of different quality metrics.

Mount Sinai Health Partners partnered with Humana this past July to allow the payer’s Medicare Advantage members healthcare access to Mount Sinai hospitals and other facilities. The partnership revolves around value-based care payment and keep providers accountable for meeting HEDIS quality measures.

HEDIS quality measures often revolve around preventive screenings as well as diabetes management. Humana has a goal of having 75 percent of their Medicare Advantage members served through a value-based care payment platform in 2017.

WellCare of New York is a public payer that has expanded value-based care contracts to an additional six providers this past summer. These payment reforms will also be focused on improving patient outcomes by boosting providers’ HEDIS scores.

Blue Cross Blue Shield of Rhode Island is another payer that worked on improving HEDIS quality scores among their provider network.

“When  I walked in the door two years ago, there was no infrastructure in place here at Blue Cross Blue Shield Rhode Island to support HEDIS or even the broader Stars program,” Nancy Mamo, AVP/Managing Director of Population Health Analytics at Blue Cross Blue Shield of Rhode Island, told HealthPayerIntelligence.com.

“First, I wanted to create a very substantial pay-for-performance program where our providers are our partners in closing gaps in care,” Mamo explained. “It’s all about closing gaps in care for HEDIS. So we put in place a very robust pay-for-performance program in the millions of dollars that we rolled out to our providers.”

Dig Deeper:

Key Steps for Payer Success in Accountable Care Organizations

How to Overcome the Challenges of Bundled Payment Models