New Commercial Insurance Value-Based Care Programs

The benefits of value-based healthcare are becoming clearer with each passing year: patients are achieving better overall health and reporting higher satisfaction, payers are spending fewer dollars for higher quality care, and providers are being rewarded for their role in improving care coordination and reducing utilization costs. It is a true win-win-win scenario, and therefore, it comes as no surprise that more and more private insurers are betting on the value-based care movement.

Which payers have value-based care programs?


*This list is not intended to be exhaustive, as payers are continuously developing new value-based programs and experimenting with different models. Please contact representatives from your network if you are interested in finding out what value-based models are currently available through your insurers.

How does it work?

Each payer will have their own set of programs and models that they are using to implement value-based care. Some of the most common types of value-based programs are:


Performance-Based Programs

In performance-based programs, hospitals and/or physicians are rewarded with bonuses when they improve upon quality of care while maintaining cost-effectiveness. Common metrics used to measure quality of care include: the rate of readmissions, hospital-acquired conditions, and out-of-network provider use.


Bundled and Episode-Based Programs

Bundled and episode-based programs are very similar to CMS’s BPCI models. Episode initiators are provided a prospective target price that takes into account the full episode of care. Initiators are responsible for organizing post-acute care contracts and containing downstream costs. If the episode comes in under the target price, the initiator shares in the additional savings. For episodes that end up costing more than that the allotted episode payment, the initiator is typically responsible for the additional costs.


Accountable Care Organizations (ACOs)

ACOs bring together different care providers, including primary care physicians, specialists, hospitals, and other health care professionals in order to better coordinate patient care. Doing so allows these organizations to operate more efficiently and manage patients’ long-term health, including chronic conditions, more effectively. ACOs are rewarded when they meet or exceed certain benchmarks that are generally set around reducing cost while improving the standard of care.

ACOs tend to be large in scale and are most effective at managing population health across entire communities or regions.


Patient-Centered Medical Homes

Patient-centered medical homes are structured in much the same was as ACOs, except patients in patient-centered medical homes have all aspects of their care organized by their single primary care physicians. The primary care physician is compensated for each patient that is under their care, as well as a share of any savings from reducing downstream costs.

How large are these programs?

As of August 2017, the Health Care Transformation Task Force (HCTTF) has tallied 184 publicly announced value-based payer-provider contracts among the top five commercial payers, as follows:

In a 2016 survey of 115 health insurers, payers reported that 58% of their business had already shifted from fee-for-service toward value-based reimbursement.


Aetna and UnitedHealth indicate that they have more than 45% of their total annual medical spend in value-based contracts. For UnitedHealth, that equates to $52 billion of a $115 billion annual total. Aetna aims to have 75% of its total business in value models by 2020, a goal that is notably supported by its investments in joint venture partnerships with health systems and its large ACO footprint. Many other payer organizations, including UnitedHealth, have also invested broadly in accountable care arrangements.


Anthem recently announced that 58% of its total medical spend across all lines of business is in value-based contracts, with “over 75% . . . represented by shared savings arrangements, shared risk arrangements, [and] population-based payment models.” The insurer has invested more than $255 million in care coordination payments to providers in its Enhanced Personal Health Care (EPHC) program, which was created to build upon the success of patient-centered and value-based care.


Blue Cross Blue Shield of Michigan tells HCTTF that it has spent a sizeable amount to set up its value-based care programs. Over the last decade, internal resource allocation to these initiatives — including IT, analytics, operations, and human resources — has topped $100 million. Additionally, the organization has paid out more than $1.5 billion through value-based arrangement partnerships with more than 130 hospitals and 20,000 physicians across the state.

What are the benefits of a value-based care approach?

Through its EPHC program, cited earlier, Anthem cut emergency room costs by 3.5% and realized a gross savings of $9.51 per attributed member per month in the program’s first year. Provider participants also saw 7.8% fewer acute inpatient admits per 1,000 patients.


The Blue Cross Blue Shield Association announced the creation of Blue Distinction Total Care (Total Care), made up of 450 patient-focused care programs across 36 independent affiliates, that is expected to generate an estimated $840 million in annual savings over traditional payment models. The Blues’ Patient-Centered Medical Home programs have seen promising savings: In one example, CareFirst BCBS reported $267 million in savings between 2011 and 2013, with a corresponding 6.4% fewer hospital admissions and 8.1% fewer readmissions compared to non–medical home patients.


Cigna’s Collaborative Care program, which fosters collaborative arrangements with large physician groups and applies a pay-for-value structure, generated total medical cost savings of approximately $145 million in 2015. Cigna also reported that its top-performing national physician groups saw, on average, a 30% lower rate in avoidable ER visits compared to local markets.


Humana saw an estimated 20% cost savings for members affiliated with providers in a value-based reimbursement model setting, and reported a 10% increase in medication review for patients with special needs.

How can Claris Reflex help with performance-based and episode-based programs?

Claris Reflex is an effective means for practices and disconnected care teams to coordinate care across several different modalities as patients prepare for and recover from total joint replacements. Using the integrated Claris platform, members of the care team are able to efficiently track, coach and monitor their patients throughout the entire episode of care, while our proprietary CareDot system automatically triages patients based on associated risk levels so that workflow and resources can be redirected to those patients that need it the most.


The flexibility and mobility of the Claris Reflex system allows case managers and other members of the care team to follow patients as they move throughout the continuum of care, providing a safety net that will prevent patients from falling through the cracks as they discharge to and from different clinical settings. Clinicians are also able to receive and respond to actionable, customizable alerts via our mobile caregiver app, online caregiver console, or email, allowing them to react to adverse events in real-time and prevent costly readmissions.


Patients using the Claris Reflex system have reported exceptionally high levels of engagement and satisfaction throughout their preparation and recovery from joint replacement. Claris Reflex serves as an invaluable tool to ensure patients stay engaged, satisfied, and on-track throughout their clinical episode.

How can Claris Reflex help ACOs and Patient-Centered Medical Homes?

Claris Continuum combines social patient engagement with remote monitoring to provide a complete and continuous care management experience for clients at home. By allowing patients to better self-manage their chronic diseases at home with confidence, Claris Continuum delivers better patients at lower cost. In addition to self-management, patients are able to stay connected with their entire care team across various organizations and specialties via a single application. Providing such access ensures that patients receive the care they need when they need it, preventing costly and unnecessary readmissions or ER visits.


Claris Continuum is easily deployed to patients using our pre-configured care profiles which automatically guide patients through tasks for managing their chronic conditions (e.g. COPD, CHF, diabetes, etc) using Bluetooth connected monitoring. Profiles and care programs are easily tailored to respond to certain adverse events, so that care protocols adapt and evolve alongside the patient.

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