UnitedHealthcare Community Plan of Rhode Island is committed to the highest quality of care for our members. Alternative Payment Models (APM) are one way that we achieve quality and support the delivery of value-based, affordable care.
In this article, we explore how the Community Plan of Rhode Island utilizes a value-based care (VBC) program to advance provider and member experiences and improve health outcomes for the population we serve.
Achieving quality outcomes through Medicaid accountable entities
Our commitment to APM is reflected through our active participation in the Rhode Island Medicaid Accountable Entity (AE) Program. The Rhode Island Medicaid Accountable Entities improve care coordination and delivery by holding providers accountable to the patient population they serve. AEs are responsible for the outcomes, cost and quality of care for Medicaid members who are patients of an AE’s primary care provider — though the program also includes services outside of primary care, most notably behavioral health and social support services. UnitedHealthcare Community Plan of Rhode Island utilizes a value-based contract with the AE to provide a structure where the AE can focus on:
- Quality metrics;
- Population and health system transformation;
- Integrated physical and behavioral health care management;
- Total cost of care; and
- The transition from shared savings to meaningful shared downside risk or full risk.
UnitedHealthcare Community Plan of Rhode Island has more than 70% of our members attributed to AEs.
Additionally, the Medicaid AE program has a Medicaid Infrastructure Incentive Program (MIIP) which provides incentive dollars that AEs and Medicaid Managed Care Organizations (MMCOs) earn through performance tied to specific outcome measures. Collectively, the AE's achieved a nearly 11% reduction in readmission rates from 2018 – 2019.
In 2019, four of our Accountable Entities (AEs) met the max quality score and were eligible for Total Cost of Care shared savings.
UnitedHealthcare Community Plan of Rhode Island has transitioned from pay-for-reporting and has three pay-for-performance measures which meet the evolving AE program requirements and drive improved outcomes:
- Breast cancer screenings: Average rate increased approximately 3% between CY 2018 and 2019;
- Mental illness hospitalization 30-day follow-ups: Average rate increased approximately 2% between CY 2018 and 2019; and
- Eye exams: Established as new quality measure in CY 2019.
Commitment to quality care leads to improved health plan ratings
The National Committee for Quality Assurance has awarded the UnitedHealthcare Community Plan of Rhode Island an accreditation status of Accredited for service and clinical quality that meet the basic requirements of NCQA's rigorous standards for consumer protection and quality improvement.
Based on an assessment of consumer satisfaction, prevention and treatment, NCQA also rated our health plan a 4.5 out of 5 in NCQA’s Medicaid Health Insurance Plan Ratings 2019–2020. Our dual-eligible special needs plan (DSNP) also received a rating of 4.0 out of 5 in NCQA’s Medicare Health Insurance Plan Ratings 2019–2020.*
These ratings are due in large part to the elevated reception of our value-based program and our provider communities' commitment to quality.
Health System Transformation Projects
Accountable Entities are required to design and implement at least three Health System Transformation Program (HSTP) projects to earn incentive funds — the goal being that these initiatives and solutions will be sustainable after the incentive funding ceases.
Each of these projects is created in collaboration with the MMCOs, focusing on care coordination and population health management, which in turn leads to shared savings for the AE creating a sustainable program over time. For example, investments might include developing a new technology feature (e.g., a texting platform for patient engagement), training staff (e.g., standards for annual wellness exam including social determinants of health), new internal structures (e.g., universal screenings for conditions) or establishing community-clinical partnerships (e.g., integrating a behavioral health care manager).
The Medicaid Infrastructure Incentive Program payments are tied to AEs achieving milestones. Outcome measures are a type of milestone. For 2019-2020, all five AEs are on track to receive pay-for-reporting incentives for the following:
- Ambulatory Care: Emergency Department, Inpatient Utilization—General Hospital/Acute Care
- All-Cause Readmissions
- Potentially Avoidable Emergency Department Visits
Strengthening relationships with accountable entities
Our relationships with Medicaid AEs are fundamental to the success of our VBC program and the health outcomes of our members. To maintain strong relationships with these organizations, we meet with each AE’s quality and clinical teams on a monthly basis to identify and help address needs and barriers so that they can achieve higher ratings and meet their goals. Our MCO leadership also meets with AE leaders every quarter in a Joint Operating Committee forum, offering time for collaboration to better align care, review outcomes and share best practices.
We currently share cost and utilization data with all of our AEs. Moving forward, we will also be assisting AEs to utilize data more effectively to meet quality measures, improve health outcomes and support program sustainability. Starting in June 2021, AEs will have the ability to share quality data through a new electronic clinical data exchange, which will equip providers with timelier and more accurate member level information. UnitedHealthcare is also sharing condition level quality, cost and utilization analytics to assist our AEs in making referral decisions.
Our AE relationships are evolving with a commitment to improved population-based quality outcomes for our Medicaid population. As we continue to move toward paying providers based on the quality, rather than the quantity of care they give patients, we can continue to help improve the health of the people we serve across Rhode Island.
*Due to COVID-19, NCQA will not release 2020–2021 Health Plan Ratings for any product line. This rating is based upon 2019-2020 Health Plan Ratings.