In the first part of our series, we talked about the barriers to commercial risk. But, there are also many reasons that it is an opportunity worth pursuing.
The tenor of the conversation around value-based care can make it seem like all industry players are pitted against each other. But in reality, most segments are aligned around the goal of removing cost from the system.
Health plans view themselves as responsible for reining in costs—and they largely are. Patients would like less money coming out of their pocket. Employers would like to spend less on health benefits. Life sciences and medical technology firms are working on better ways to diagnose and treat patients. And providers want to deliver the best care, which takes into account quality and cost.
Even if folks have different expectations, there is common ground.
We’re already seeing partnership around avoidable ED utilization, better pregnancy outcomes, and improved access to care including behavioral health.
For maternal health, there is tremendous variation in the experience, quality, and cost for services. Population-based payment gives providers freedom to invest in, for example, birth doulas to advocate on the mother’s behalf and reduce unnecessary utilization of expensive drugs and services.
Unmet behavioral health need was a challenge before the pandemic and only has grown since. And true value-based payment justifies provider investment in psychosocial supports necessary to avoid acute utilization, like a dedicated behavioral health care manager.
There are already clear incentives for providers, plans, and employers to partner in these areas whether the metric of success is cost of care, quality of care, productivity, and/or absenteeism.
Our team is running an analysis of the top 20 opportunities in the commercial population and already seeing ways providers, plans, and employers can partner.
Many of the top opportunities are about reducing utilization and cost while improving quality today. Some of the emerging areas we are studying including cancer care, genetic and biomarker testing, and home health/hospice.
Of course, with the commercial population, there are also places to boost utilization which will have impact on cost and quality down the road. Unsurprising opportunities in that space include things like immunizations and screenings.
Important to note, we are also digging into the data on things like maternal health and behavioral health – and intersections between top opportunities.
As we continue the analysis, we’ll highlight organizations already moving the ball forward and pinpoint opportunities for those just getting started and those further ahead on the risk curve.
CMMI aims to have all Medicare and most Medicaid beneficiaries in accountable care arrangements by 2030. CMMI also expressed an interest in re-examining and streamlining the overall number of alternative payment models it oversees, as well as including mandatory models.
Many questions remain unanswered about the administration’s approach to risk. But if CMS effectively shifts to value-based payment, we’d anticipate commercial payers will too – just as they’ve done with select bundled payment arrangements, accountable care organizations, and other care coordination strategies.
All to say, we wouldn’t bet on the incumbent model for commercial contracts. FFS is no better for commercial than it is for Medicare and Medicaid.
It might be possible to identify 3-5 core bundles that drive the majority of savings. And, as long as the list of bundles was manageable, it could avoid some of the administrative complexity that undermines writing contracts around specific care events instead of taking a wholistic picture of the population. It could be tougher on providers who push for risk in Medicare and Medicaid and need to line up bundles in commercial, but it could work.
We’ve heard folks talk about everything from continuing on the path of HDHP with better price transparency to HMO-like contracts since the operating environment could be SO different this time around.
VBC is an appealing option - among a few appealing options – in part because moving in that direction aligns across lines of business.
An overnight shift to commercial value-based care isn’t going to happen. But there are clear opportunities worth pursuing.
The question of commercial risk also has larger implications for how the lines of business intersect or diverge. Medicare and Medicaid are headed to risk. Progress is slow, but at this point, probably committed enough to keep going. Commercial is still more of an open question.
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