UnitedHealthcare Community & State is committed to supporting our provider partners as they work to improve the health of our members. Through extensive development of our value-based programs across the nation, we are improving care quality, reducing costs and providing incentives that benefit our provider partners.
Managed care organizations (MCOs) in nearly every state are accredited and regularly reviewed by the National Committee on Quality Assurance (NCQA) and overseen by state legislatures and Departments of Health and Human Services. As a result, UnitedHealthcare Community & State is held accountable for up to 69 quality measures each year. These standards ensure that MCOs provide high-value care to patients and invest in measures to improve health outcomes.
Through extensive development of our value-based programs across the nation, we are improving care quality, reducing costs and providing incentives that benefit our provider partners.
To meet these quality measures and support our provider partners as they care for our members, UnitedHealthcare Community & State has developed robust value-based programs across the nation. This article highlights specific details belonging to our programs in Arizona, Kansas and Louisiana.
Our Arizona Community Plans [Arizona Health Care Cost Containment System: AHCCCS Complete Care (ACC); Developmental Disabilities (DD); Long Term Care (LTC); Dual Special Needs (DSNP)] operate multiple value-based program models, all focused on primary care and behavioral health care. Incentives provided through the program include:
Total cost of care Model
These agreements, which typically span two years and focus on primary care physician (PCP) member assignment, are designed for large, single primary care providers or for Accountable Care Organization (ACO) partners that aggregate multi-primary care provider groups, offering shared savings and/or quality incentives. While these agreements are predominantly upside only, there are limited risk agreements in place.
These agreements support either Long-Term Care membership alone, given the unique benefits and population, or agreements that combine membership from ACC, Developmental Disabilities (DD) and Dual Special Needs Plans (DSNP). The quality or performance measures are Medicaid compliant and guided by state-directed priorities, when applicable to the population. Baseline rates are established, along with agreed upon performance targets, and the number of achieved quality goals establishes the quality per member per month (PMPM) or percentage of shared savings earned in the event that a pool of dollars is generated due to benefit-cost ratio (BCR) reduction.
Historically, we have also offered access to one or more software platforms to support meaningful and actionable data exchange. These agreements are also supported by the UnitedHealthcare ACO team for data sharing, reporting, scorecards, file exchange and monthly and quarterly Joint Operational Committee meetings.
Based on primary care provider assignments, this model includes one-year, long-term care agreements with multiple, often smaller PCP tax identification numbers (TINs). Our Community Plan acts as the “aggregator” agent in this model, through which we offer participating PCP practices shared savings incentives tied to achieving quality measure targets achieved by each practice. The health plan pools the total cost of care across all enrolled groups. In the event we generate a shared savings pool based on the collective performance, incentives are dispersed when quality targets are met. The aggregation model is applicable to ACC, DD and LTC membership.
For providers that are not included in the models listed above, a Community Plan – Primary Care Professional Incentive (CP-PCPi) model and an obstetrics (OB CP-PCPi) model offer incentives through one-year agreements. These models focus on an amount that is paid per open gap closed, with incentives based on claims and Healthcare Effectiveness Data and Information Set (HEDIS) measures. The PCP incentives align with similar quality measures noted in the models above whereas the OB model focuses on standardized pregnancy-related quality measures.
CMS 5-Star Rating
Our plan’s DSNP/Fully-Integrated Special Needs Plans (FIDE) SNP focuses on incentives for a specific population based on CMS 5-Star Ratings reached at the TIN level. These one-year agreements are based on PCP assignment and are a part of the national Medicare Advantage CP PCPi incentive model.
Our incentive programs for Behavioral Health Homes focus specifically on behavioral health performance measures (e.g., Follow-Up After Hospitalization [FUH] in 7 and 30 days of a behavioral health acute inpatient admission). These new attribution models include one-year agreements and are supported by a market Behavioral Health Home Team, which routinely meets with partnering behavioral health provider groups.
The Arizona Community Plan also has various forms of service, quality and performance measures built into the majority of capitated agreements, which allows us to qualify for state-required percent spend under value-based program targets. These include Lab Corp, Dental Benefit Plan, Optum Behavioral Health and Preferred Home Care.
The ACO support team has been a long-standing market differentiator for our program and predated the emergence of VBP. And based on our market knowledge, our team has the advantage of a wider array of value-based program options — and as a result, a high level of provider and patient inclusion. Even with behavioral health models still being relatively new, we have introduced the option to expand care and serve more individuals.
Based on our market knowledge, our team has the advantage of a wider array of value-based program options — and as a result, a high level of inclusion.
To measure success, Healthcare Economics has developed reporting that assesses ACO performance, relative to non-ACOs, which has historically shown consistent performance. We also engage with quality reports and are looking for more ways to access timely and accurate reporting that can drive our value-based programs. We remain focused on advancing these models, minimizing the chance of overlapping incentives and working to measure results despite some inherent challenges in doing so.
Toward the start of developing our Kansas Community Plan (KanCare) value-based program, nearly 50% of our members were served by our top 25 providers, many of which are FQHCs. Since that time, we have looked to strengthen our relationships with all of our providers through collaboration using different methods, including:
Our leadership team directly meets with provider leadership to discuss needs, growth goals, strategic initiatives and new programs and policies for each year. This communication between C-suite leaders helps strengthen relationships, ensures that both parties are aligned on future goals and priorities and often leads to expanded discussions.
When our members schedule and show up for immunizations, wellness appointments and other essential services, we offer member rewards. These incentives help drive traffic to provider offices, increase the likelihood that members will keep their appointment and improve health outcomes by closing care gaps.
We work with providers to identify members who are accessing out of network services that could be better served through more integrated care at that provider facility.
We are actively seeking feedback from key leaders at our high-volume provider organizations. This will help gauge how our value-based programs are being received by provider partners. We are also measuring the success of our value-based programs by monitoring growth at a facility, county and state level.
Our leadership team directly meets with provider leadership to discuss needs, growth goals, strategic initiatives and new programs and policies for each year.
Our Louisiana plan (Healthy Louisiana) works with a broad range of high-volume provider organizations. The success of this program largely rides on gap closure models that promote care access, including:
CP PCPi gap closure model
This model includes specific measures for adult and child-driven visits. Through the CP PCPi program, providers are equipped with 12 measures (6 for adults, 6 for children) that, when completed, give the provider credit for closing the care gap.
For example, if a provider’s goal is to complete 50 child visits, then for child 1 – 49 the provider will receive $25. After 50 child visits are completed, that $25 credit doubles for all additional children, and for the original 50 that were seen. This retroactive credit acts as a stronger incentive for providers to meet their threshold and exceed it.
Implemented at 40 practices state-wide, this OB gap closure model includes financial incentives for administering 17-P, which helps stave off preterm birth.
Medication-assisted treatment (MAT) model
This model targets members managing substance abuse through medical and behavioral treatment. For example, if a member is prescribed a medication to manage their addiction, a 30-day report will determine if the member is picking up and refilling their medication in adherence with their care plan. For members that adhere to and complete their treatment, including attending any prescribed counseling, the provider will receive a reward incentive for closing the care gap.
Further supporting FQHCs during COVID-19
Many FQHCs were heavily impacted by COVID-19. To demonstrate partnership during these challenging times, we created the Transformation Pathways initiative, which offered funding to solve pressing issues specific to each FQHC. And our contribution to help build capacity for these centers did not end once funding was deployed. Following this initiative, many of the nearly 300 FQHCs that participated have reached out to describe how the initial investment has impacted their ability to build capacity for their patients and the community. This has forged new conversations and elevated our provider relationships as we head into the future.
Strengthening provider partnerships moving forward
Value-based programs help drive clinical collaboration and better align incentives around both care cost and quality. They also compliment fee-for-service models, with the intent to slowly move toward risk-based models. This creates opportunity to grow support teams and continue to improve offerings. As we continue to develop our value-based program approach, we will continue to improve program flexibility and enhance supporting data and reports.