The Center for Medicare & Medicaid Innovation (CMMI) is now in its second year of implementation of the Medicare Advantage Value-Based Insurance Design (MA-VBID) model test, a pilot project measuring the potential for value-based insurance design (VBID) in the Medicare Advantage program. In the model test, participating Medicare Advantage Organizations (MAOs), which ordinarily offer Medicare Advantage and Part D benefits to each of their plan enrollees at the same level of uniform coverage and cost sharing, can offer extra coverage or reduced cost sharing to enrollees with CMMI-specified chronic conditions.
 
Manatt Health Strategies analyzed which MAOs are participating in the VBID model test in 2018 and what value-based approaches are being used in their individual plans (also known as plan benefit packages (PBPs)) for which disease conditions. Our findings for CY 2018 show that MAOs generally preserved their approaches from 2017, and continue to focus on diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and hypertension (HPN). Additionally, participating MAOs are mostly reducing cost sharing for medical benefits as their key VBID approach, occasionally in combination with extra coverage of services or reduced cost sharing for Part D drugs. These data give insight into how other MAOs may approach VBID in 2019, when CMS makes the flexibility available to MAOs nationwide.

Presentation slides from 3/21/18 webinar.

eHealth Initiative interviewed senior executives at leading healthcare organizations to determine how policies, consumerism, and patient engagement strategies influence provider decisions. In this webinar, we will hear how the decision to acquire and use technology ultimately affects the revenue cycle.

This webinar will dive into:

• Value-based care trends and the impact on technology
• The role of patient engagement in technology decisions
• Adoption of technology
• Pre-Service innovations

Panelists:

Jeff Chester
Senior Vice President and Chief Revenue Officer for Availity

Taya Mohesier
Director of Health Policy & Product Development, H3C

Charlotte Hale
System Director Admission Services and Central Access, Cox Health

eHealth Initiative conducted a series of interviews to gain insight from an industry perspective on the impact of healthcare reimbursement policies on technology. In October and November 2017, twelve executives, primarily from provider organizations and health information networks (HINs), were interviewed for this research project. Executives answered questions that aimed to establish how policies, consumerism, and patient engagement strategies influence provider decisions around the acquisition and usage of technology, while also affecting revenue.

The conversation in the Value & Reimbursement Roundtable began by looking at value-based care through the lens of accelerators and barriers. Pre-authorizations are perceived as a barrier to care because many physicians find that the process slows downs their clinical workflow, is costly, and burdensome. Participants also thought the term ‘pre-authorization’ was inherently flawed, stating that the name of the process should more accurately reflect its purpose. Pre-authorizations represent an evidence-based review of coverage determination.

The group stated that insurance companies were often a barrier to care and believed the coverage determination process could be automated. Through collaboration with payers and technology companies, roundtable participants envisioned a virtually painless coverage determination process and began planning to implement a digital pilot program that would create a seamless relationship between payers and providers.

This coverage determination system could instantly accept or deny claims and report back to providers the reasons for denial, such as a health plan not offering a procedure or medical device, inconsistencies in a patient’s medical records, or unacceptable test results. The goal is to reduce the burden on the clinical workflow and provide a new type of communication between physicians and patients. With instantaneous insurance coverage information, patients and physicians would be able to craft a better care plan, at the point of care. The group decided three criteria were needed to accelerate the development of a universal value-based care system:

Evidence-based criteria applied in a clinical workflow
A set of “must-haves” that determine the appropriate treatment (procedures, medical devices, services, medications, etc.) for a patient

Harmonization of payer outcome measures
An outcome measure (such as mortality, readmission rates, and patient experience) that is standardized, represents a change in health status of an individual, and recorded after a provider visit

Harmonization for registry submissions
A standardized registry for the various types of value-based care criteria

PILOT: VALUE & REIMBURSEMENT

The digital pilot program took its first step when UnitedHealthcare physicians Dr. Sam Ho, Executive Vice President and Chief Medical Officer, and Dr. Anthony Nguyen, Senior Vice President of Population Health, sent the criteria associated with UnitedHealthcare’s coverage of wheelchairs, sleep apnea studies, and radiology related to lower back pain to Jon Zimmerman, Vice President & General Manager at GE Healthcare.

GE Healthcare will now focus on the creation of technology that can be used to automatically accept or deny claims from payers using evidence-based criteria. From a technological standpoint, Zimmerman believes the process can be created and automated within a few weeks. The key to its success and adoption will be the selection of the appropriate pilot facility. The hospital chosen cannot be too big or small to demonstrate that an automated coverage determination process is feasible in all facilities. Before the pilot occurs, GE will produce a webinar on how to incorporate this new standard into the Electronic Health Record (EHR).

POLICY PLAN: VALUE & REIMBURSEMENT

The Value & Reimbursement Roundtable policy plan calls for eHealth Initiative’s Policy Steering Committee to support the American Hospital Association’s (AHA) letter to increase broadband nationwide, especially in rural areas. AHA supports the increase in data caps and will advocate for this step in the letter. eHealth Initiative also commented on the Trusted Exchange Framework and Common Agreement (TEFCA) and sent a letter on February 20 to make comments on the voluntary data registry.

The most important piece of the value and reimbursement policy plan in 2018 is to educate lawmakers on digital healthcare topics and the issues the private sector is dealing with around value-based care and reimbursements. eHealth Initiative is planning to share the American College of Radiology’s (ACR) Appropriateness Criteria, which uses evidence-based guidelines to assist physicians and other care professionals in making the best imaging and treatment decisions. The plan is to share how technology, the coverage determination pilot, and tools such as the Appropriateness Criteria enhance value-based care.

Presentation slides and recording from 11/22/17 joint webinar from CAQH CORE and eHI.

Emerging value-based payment (VBP) models are critically important in meeting future needs for improved quality and cost of healthcare. This national movement away from fee-for-service (FFS) to VBP is a massive undertaking and the transition can be made more difficult when payment reform efforts occur as add-ons to traditional FFS contracts. One of the operational challenges inherent in the transition to VBP is appropriate use of clinical and administrative data. Guest speaker, Dr. Steven Waldren, is the Director of the AAFP's Alliance for eHealth Innovation. Dr. Waldren will discuss the existing challenges and operational capabilities needed to ensure accurate and reliable data to effectively reward value over volume in healthcare delivery. 

Presentation slides and recording from 11/15/17 webinar.

Harnessing data-driven insights to drive greater effectiveness and care quality is one of the highest priorities of healthcare organizations today. The implementation of an effective data strategy represents one of the cornerstones of better care, as well as greater operational efficiency.

Listen as experts discuss how a strategically developed approach that efficiently extracts, aggregates and processes clinical information from unstructured and structured formats utilizing advanced technologies, such as Natural Language Processing (NLP) and Machine Learning (ML), provides patient-specific insights to support data-driven clinical encounters.

Speakers: 

-Eric Sullivan, Senior Vice President Innovation & Data Strategies, Inovalon
-Dave Cassel, Vice President for Carequality, The Sequoia Project
-Kenyon Crowley, Deputy Director, Center for Health Information and Decision Systems, Robert H. Smith School of Business, University of Maryland

UnitedHealthcare gathered both data and experiences extracted from their work with 110,000 physicians and 1,100 hospitals now
participating in some form of VBC program, including:
• Key findings and successes with their providers who are shifting to VBC.
• Important takeaways and best practices that emerged from their two ACO summits held in 2016 with more than 40 top-performing ACOs.
• Patient and physician stories illustrating the personal impact of VBC.
• Items they believe will be most critical over the coming years for more widespread adoption of VBC models and ACOs.

FHIR is a new standard that defines a web API and related specifications for health data exchange.

National health payer Anthem is collaborating with primary care providers and operating their Enhanced Personal Health Care program. This report outlines the key benefits experienced through this program, including a 3% cost savings for members treated by providers who participated.

We are now in the era of electronic health records (EHR), MACRA and a plethora of digital clinical data, which means we can take advantage of what happens today, sometimes in real-time.