After finalizing an agreement with commercial insurer Cigna, UCHealth has joined the ongoing effort to redefine the terms of reimbursement for health care services.
The arrangement is between Cigna and Colorado Health Medical Group (CHMG), UCHealth’s more than two dozen medical group practices in northern and southern Colorado. The “value-based” contract, which goes into effect April 1, aims to reward UCHealth and CHMG providers for successfully managing Cigna’s members. That means meeting or exceeding agreed-upon clinical quality and patient satisfaction goals as well as keeping costs in line with the market for a targeted population.
To encourage success, Cigna will provide up-front dollars to help CHMG practices pay for a case manager to coordinate patient care, said Kelly Henry, senior director of payer strategies and value-based contracting for UCHealth. In addition, the practices can earn additional reimbursement by keeping costs of care comparable to or lower than the market, meeting quality metrics, and improving patient outcomes, Henry said. Those savings, in turn, could be reallocated to clinical infrastructure that improves the quality and efficiency of care, she added.
The agreement specifies six different “domains of value,” Henry noted:
- Improving the patient experience
- Promoting preventive health measures such as breast and colorectal cancer screenings
- Coordinating care and appropriate utilization, such as giving patients the option of a lower-cost generic drug when one is available
- Managing children’s health with well-care visits and other preventive measures
- Focusing on identifying and helping to manage depression and other behavioral health issues
- Coordinating care for patients with chronic conditions like diabetes
Jean Haynes, chief population health officer for UCHealth, said she expects CHMG and Cigna will establish baseline data in these categories as soon as possible and then review results on a quarterly basis.
“We will look for opportunities and adjust accordingly based on the health needs of the patient population,” Haynes said.
A new kind of wheel
The immediate challenge of the Cigna relationship is to find effective ways to manage the health of a large group of individuals, many of whom may never have seen a CHMG provider before. One strategy: establish relationships with individual patients by reaching out to them proactively, enco. That might include encouraging them to come in for preventive tests and perhaps biometric screenings to identify potential risks, such as high blood pressure, or suggesting ways to maintain their health. The overall goal is to encourage those who are healthy to stay that way, prevent illness in those who are at risk, and manage care for those with chronic conditions.
“We will need to engage with and meet patients where they are, across the entire health care spectrum,” Haynes said.
The value-based contract is part of what Henry called a national “cultural shift” in the way physicians, hospitals, and other providers are paid for delivering health care. The traditional method, fee-for-service (FFS), is volume based, Henry said. Insurers reimburse providers for each service they deliver: office visits, procedures, lab tests, and so on. The result, critics say, is a system that encourages fragmented, episodic care that is expensive and frequently wasteful.
The new model is akin to comparison shopping by consumers who use several criteria to find the best buy. In this case, the consumers are the Centers for Medicare and Medicaid Services (CMS) and commercial payers like Cigna. They are looking to align with providers who can meet what the Institute for Healthcare Improvement (IHI) calls the “triple aim”: delivering high-quality care, controlling costs, and offering a satisfying experience for patients.
The Cigna contract is a “stepping-stone” toward a system that blends performance and outcomes measures with FFS payments, Henry said. The new approach also de-emphasizes two sides haggling over reimbursement rates and instead seeks areas where their interests align.
“Payers are working to partner with providers,” Henry said. “They are still paying for ‘widgets,’ but they are saying that if we want to work together to manage their members and our patients better, they will share the tools and data to help us achieve the triple aim.”
The contract encourages data sharing that will be essential to achieving these goals, Henry said. Cigna has committed to providing information about the cost of care for its patient population and where they go to receive services, from lab tests to emergency department visits to hospitalizations – information that wouldn’t otherwise be available if a member went outside of UCHealth’s integrated system.
In turn, UCHealth will exchange clinical data to help Cigna understand the services their members are receiving. That might drive improvements, such as making sure there are enough same-day appointments for patients who are ill to get in to see their primary care provider, “rather than going to the emergency department down the street,” Henry said.
Change on the fly
Information sharing alone won’t ensure success, said Austin Bailey, MD, a family medicine physician and CHMG’s medical director for primary care services. Physicians and their practices will have to change their traditional approach to delivering care, which he called a hub-and-spoke model.
“When I practiced everything came through me,” Bailey said. “I doled out the tasks.” A system that rewards practices for managing an entire population of patients demands teamwork, with staff playing essential roles, such as making sure that patients adhere to their treatment plans and scheduling them for preventive care.
“We need a team to follow our population and highlight the patients who need our services,” he said.
While most physicians are familiar with payers asking them to meet rudimentary quality measures for diabetes, hypertension, preventive care and so on, the Cigna contract ups the ante, putting real dollars at stake for meeting or missing performance goals, Bailey added
CHMG is also working on developing new methods of care delivery to meet patients’ needs, Bailey said. For example, the FFS world reimburses physicians for face-to-face patient encounters. That means ensuring as many same-day or close to same-day appointments as possible. But telemedicine encounters, either through a web-based portal or even over the phone, could expand access.
“We want to move in that direction,” he said. The state of Colorado has smoothed that path, by providing Medicaid reimbursement for preventive and routine medical care and other selected telemedicine services.
Bailey said he has joined with many other CHMG leaders in meeting with groups and face-to-face with every primary care physician to explain the contract and the changes it will require. While some are more ready to adapt than others, he said, most welcome a shift from the volume-based model that asks physicians to do “less and less for more and more patients,” he said.
“Most of our physicians see this as a refreshing change,” Bailey said. “It’s an opportunity to get off the hamster wheel.”
The Cigna contract is an opportunity for UCHealth and CHMG to prove its value to a payer in caring for thousands of members in northern and southern Colorado, Haynes concluded.
“The reality is that payers are held accountable by their customers, many of whom are large employers, to provide great access to care and ensure great outcomes at the most affordable prices,” she said. “Payers can’t do that without committed provider partners. Our opportunity is to create value for Cigna’s members, who will be our patients. When we demonstrate the value of this partnership, there won’t be a payer in the market that won’t want to include UCHealth in their network.”