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We’re used to a health care system that takes care of people after they’re already sick. Value-based care (VBC) moves beyond sick care and takes a proactive, comprehensive, data-driven approach to keeping people healthy.
VBC is a health care delivery model that:
Pays providers based on the health outcomes of their patients and the quality of services they provide
Focuses on preventive services and chronic disease management to improve members’ quality of life
The goal of VBC is to:
Enhance the member’s health care experience
Improve the health of individuals and populations
Reduce the costs of health care
Increase provider satisfaction
Significant financial incentives allow you to reinvest in your practice
Increased data sharing between payor and provider helps identify risk and improve care coordination
Pay is based on quality care and improving patient outcomes
Best practices and infrastructure create foundation for long-term success
Members are at the center of the health care experience
Care is proactive, focused on preventive care, managing chronic conditions and keeping member healthy
Providers are more well-informed and accountable for high-quality outcomes
Treatment is customized at the member level
Our program at a glance
20 distinct provider groups
38% of membership and 36% of total Medicaid spend by VBC
Nearly 3,000 providers across all regions of the state
Minimum quality and engagement thresholds for each payment model to ensure needed care is delivered
Provider Analytics Reporting Suite (PARS) uses actionable data to make sure patients receive the care they need.
Financial and quality targets based on provider-specific population create a fair baseline for meaningful quality improvement and cost reduction.
Cross-functional work groups including medical management, quality, pharmacy and network collaborate to establish best practices.
VBC payment continuum
The total-value program is the pinnacle of earning opportunities we offer. Providers taking part in total-value-based agreements can earn a greater part of surplus payments than those in partial-value-based agreements, while also being accountable for members’ costs.
Each year, providers in total-value-based agreements are paid part of the surplus or pay us part of the deficit related to their assigned members’ cost of care.
As with partial-value-based agreements, total-value-based agreements incentivize preventive, low-cost outreach and care to prevent high-cost, high-risk ED visits and inpatient admissions. Providers in total-value-based agreements have access to advanced resources, data sharing and reporting.
To further encourage preventive care, we give providers the option to take part in partial-value shared savings agreements. Providers who achieve a medical benefits ratio* (also known as medical loss ratio) goal we set are paid part of the surplus related to their assigned members’ cost of care. These agreements incentivize providers to actively engage members in preventive, low-cost outreach and care to prevent high-cost emergency department (ED) visits and inpatient admissions.
Providers who take part in a partial-value-based agreement will have more supports and resources, including robust and regular bi-directional data sharing with us. We expect these providers to progress to total-value-based agreements after one to two years.
To promote diligent and proactive engagement of members, we offer primary care physicians (PCPs) the opportunity to earn incentives by committing to rigorous care coordination in partnership with our care management team.
Primary care providers who take part can receive a monthly capitation amount for each assigned member (PMPM) with an active provider-patient relationship. Providers taking part are required to have regularly scheduled meetings with our care management team to:
Review selected member cases and progress
Ensure active management of all members
Providers must meet program expectations to remain eligible for the PMPM fee.
HEDIS® is the Healthcare Effectiveness Data and Information Set — standardized performance measures developed by the National Committee for Quality Assurance (NCQA) for the managed care industry. Providers can use HEDIS data to ensure appropriate care for members by identifying and eliminating gaps in care.
We offer all providers the opportunity to take part in our HEDIS P4P program. The program pays providers annual bonuses based on the measures they complete. Each measure has a specific incentive amount paid after a target score is achieved. P4P enhances quality of care by incentivizing providers to focus on preventive and screening services.
*Medical Benefit Ratio (MBR) is calculated as the sum of assigned members’ medical expenses divided by the sum of assigned members’ premium revenue.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).