For years we’ve known that Healthcare spending in the United States is on an unsustainable trajectory. In 2015 as part of the Affordable Care Act, HHS created the Health Care Payment Learning & Action Network (HCP-LAN). This is public-private partnership whose goal is to accelerate this transition from Fee-for-Service (FFS) to Alternative Payment Models (APMs), models which reward quality care, lower costs and improved health. HCP-LAN pursues this goal by disseminating knowledge and best practices for designing and implementing APMs.
In April, HCP-LAN published their “Roadmap for Driving High Performance in Alternative Payment Models”. The Roadmap is the product of research and interviews with 13 provider organizations and 9 payers who collectively participate in 10 successful population-based and episode-based payment APMs at national and regional levels across the country. The Roadmap provides real-world proven guidance, examples and promising practices from these APMs to organizations who are thinking about or are currently building their own APMs.
The Roadmap covers 3 major categories, APM Design, Payer-Provider Collaboration and Person-Centered Care. Many promising practices are called out in the report. Here are 5 major practices that the report calls out for Payers:
1. Plan Design/APM Investments
The Roadmap reports that many successful APM initiatives now offer financial support to providers to help cover investments required to build a population health and risk management capability. This support can take the form of per-member per-month (PMPM) fees, lump-sum start-up payments, enhanced FFS rates, or even grant money. While this is a significant investment for payers, its often a critical factor in helping less-sophisticated provider organizations make the transition to a new risk-based world, or it provides a necessary care-management fee to incent providers to make the changes necessary to address new operational demands that the APMs make of them. Payers are encouraged to work with the providers to determine what kind of investment will best support and incent the provider organization to transition to a new model.
2. Data Sharing and Analytics
In population health or episode-based APMs, data is critical to managing the care and costs of patients. Most payers are more sophisticated and experienced than provider organizations in this form of data analytics because of their years of experience processing and mining large datasets, capturing and reporting on clinical and operational informatics. Many providers are early in their own data analytics and clinical informatics learning curves. In the report, payers and providers are encouraged to better share data with each other. While providers are eager to get claims data from payers, payers can help them learn how to how to process and interpret this data. Payers are encouraged to work with providers to better understand how data can be made ‘actionable’. For example, if the payer wants the data to inform the provider and provide a case for action, then they need to better understand from the providers’ perspective, how they should structure, format or present the data which will makes it easiest for the providers to understand, disseminate and take the desired action.
3. Measure Alignment
Payers can already calculate many quality measures or identify clinical gaps from the patient claim and clinical data. These measures a critical to the payers’ success. For example, HEDIS quality scores and CAHPS patient quality scores directly feed into the CMS Stars rankings for MA plans, and in increasingly-competitive MA markets, these rankings can make a big enrollment difference. The report recommends that in the interest of reducing provider burden and confusion associated with conflicting or misaligned measures, and in the interest of aligning on common goals, Payers within APMs should use and align on existing core sets which have are most meaningful to providers’ and payers’ patients, and which are common across other important federal or private initiatives.
4. Cost Benchmarking
One of the fundamental tenets of APMs is to manage costs. The report points out that Payers are now introducing regional cost benchmarks to supplement more traditional historical-based costs when establishing thresholds that the APMs must target. This helps provider organizations who are successfully reducing their patient costs on a regular basis from the disincentive of having their historical benchmark continuously reset to newer lower values making them increasingly harder to beat on an on-going basis. Moreover, the report recommends that APMs pay special attention to the costs of new novel therapies. Relying on a historical benchmark should not penalize providers who want to order more novel newer but more expensive treatments if these treatments weren’t available in earlier benchmark years.
5. Collaboration and Partnership Mentality
A key message in the report for both payers and providers, is the need to approach APMs in a true collaborative and partnership mentality. APM success requires traditional barriers across organizations to come down, and win-wins to be identified which most importantly also benefit the patient while managing costs. Both sides of the payer-provider relationship will need strong leadership to overcome potential legacy and institutional biases, and enter the APM with a goal of openness, sharing and teamwork which ultimately helps patients and the overall system.
Check out the Roadmap and Success Factors for yourself:
Roadmap: https://hcp-lan.org/apm-roadmap/
Success Factors: http://hcp-lan.org/workproducts/APM-Success-Factors-Report.pdf
