Value-Based Contracting

Value-Based Contracting

Value-based care, done well by high performing providers, can advance the quality of care and reduce costs for you and your patients. There are several methods to increase quality. Some key elements include:

• Physician practices and health plans working together to coordinate patient care.
• Bi-directional data sharing to gain greater insight into patient experiences.
• Physician reimbursement based on the quality of care they provide, not the quantity.

Healthy Blue is encouraging optimal care for patients with a focus on value over volume. We do this by working with:

• Local doctors
• Case managers
• Health coaches
• Nurses
• Hospitals

This focus transforms healthcare delivery. The key is ensuring members receive the right care, at the right time, in the right setting while making healthcare more affordable for everyone.

Here are a few examples of innovative patient-focused care programs delivering measurable results:

Common Value-Based Care Program Methodologies

Quality Care Gap Closure

This approach offers payment for specific care gaps to meet quality target directives. Defined HEDIS measures have assigned point values that total up to 100. A provider’s performance (i.e. points) drives the amount of incentive payout earned as an annual lump sum bonus payment.

Quality Compliance Rate

This approach uses a system of pay for performance principles including:

• Quality
• Access
• Utilization measures

The goal is to encourage efficient, preventative and cost-effective health care practice. It's accomplished by redesigning the payment model from volume-based to value-based payment. This involves aligning financial incentives and offering tools for patient-centered quality care outcomes.

Negotiated Risk/Shared Savings

Larger group practices can benefit from a cost of care method that rewards providers for closely managing the costs associated with quality of care to Medicaid members.

Shared savings encourages efficient, preventative, and cost-effective health care practices. HEDIS quality metrics serve to determine shared savings eligibility. Depending on the arrangement, the provider can take on either all upside, or a mix of upside and downside risk.

Program objectives include:

• Improvement of targeted clinical quality results
• Promotion of quality
• Safe and effective patient care across the delivery system
• Improving provider operational efficiency
• Improving medical cost management

The objectives are supported with payout incentives for improving quality care and tools to reduce medically unnecessary costs.

Specialty Value Based

This non-PCP driven approach offers incentives to eligible specialty providers who meet target goals. The key objectives are to:

• Improve clinical quality outcomes
• Improve member outcomes
• Improve focus on preventative and primary care
• Improve efficient and appropriate utilization of benefits

This encourages providers to deliver quality and efficient care while focusing on the healthcare needs of our members.

Delegated Risk

This model decreases medical and administrative spending, increases quality, and improves satisfaction.

This method:

• Globally capitates providers
• Delegates administrative functions to the provider
• Incentivizes providers to manage costs within a pre-determined budget allowed to them with a cap payment

Delegated activities typically include:

• Care management
• Claims
• Utilization management

This approach may focus on only professional claims. Alternately, professional and institutional claims can be split, or professional and institutional claims can be full risk.