As healthcare evolves, reimbursement models continue to shift from volume to value. That means more providers are taking risk and moving into value-based reimbursement models. One such model is the Accountable Care Organization (ACOs) in which the provider has accountability for achieving quality improvements and spending reductions.

ACOs are not the only model. In today’s market, providers often form and/or contract with entities such as Managed Services Organizations (MSOs), Clinically Integrated Networks (CINs), or Independent Physician Associations (IPAs). For providers, the benefit of these organizations is clear: they supply the infrastructure and tools to be successful in meeting quality and cost targets required for their value based contracts. The result is better care for patients (especially the chronically ill), reduced waste and inefficiencies and financial incentives that are structured on quality benchmarks. ACOs, MSOs, CINs, and IPAs all incentivize primary care providers (PCPs) to improve the health of their entire patient population.

There are hundreds of these organizations across Medicare, Medicaid, and Commercial lines of business and many are executing value contracts and already realizing shared savings for primary care.  As they come together, the providers develop increased access to enhanced technology and expanded patient reach.  As these organizations mature, they are also beginning to engage specialists in value initiatives.

Magellan’s view of value is Specialty Care

To support value in specialty care, Magellan has developed a provider solution that is centered on behavioral health and physical health integration. It is designed specifically for provider organizations to successfully manage population health and take on risk under value based reimbursement through clinical, operational, and digital capabilities. Program components support the entire continuum of care and include:

• Screen & Engage: More accurate diagnosis through tools that are embedded into the primary care practice workflow
• High Performance Networks: Increased access to providers with improved quality and efficiency scores who embrace the vision of population health and support value based payment
• Case Management: Collaborative approach with warm hand-offs between the primary care office to Magellan to drive better outcomes
• Collaborative Care Model: Team-based integrated behavioral healthcare driven by Magellan expertise and digital screening capabilities to track patient progress and treat to target
• Authorization Support, Concurrent Review  & Transitions of Care: Discharge planning and case shaping to support patients transitioning from an inpatient facility to their home
• Telehealth: Increased access to care through a network of telehealth providers and text therapy providers
• Other Digital Solutions: Digital Cognitive Behavioral Therapy (D-CBT) for patients that is integrated with Magellan’s Smart Screener

In addition to the core solution set, Magellan has a comprehensive suite of behavioral health, specialty, and pharmacy products that can be customized for provider organizations. Magellan also supports providers in developing accountable care organizations for complex specialty care such as cardiac conditions. This approach supports and incentivizes cardiologists to proactively managing patients to improve quality and reduce costs. Magellan recently entered into its first specialty ACO relationship and will continue to develop and launch these types of relationships.

 

Magellan Health Insights: Hi Gina, thank you for sitting down with us. What can you tell us about the ACCOM Pilot project?

Gina Vehige: ACCOM—Accountable Cardiac Care of Mississippi—is the name of a venture between Cardiology Associates of North Mississippi (CANM) and Magellan Health. In November of 2017, CANM and Magellan came together to explore ways for both organizations to gain experience and succeed in a value-based reimbursement environment.

CANM physicians, nurse practitioners, and staff provide and oversee patient care. Magellan provides the data analysis as well as case management, and systems such as utilization management and clinical decision support, case management, and behavioral health screening tools.

ACCOM’s first value-based reimbursement contract is with Blue Cross and Blue Shield of Mississippi. Blue Cross and Blue Shield of Mississippi provides the claims data for Magellan to analyze and set mutual performance targets for cost and quality with CANM.

MHI: Can you explain what value-based reimbursement means and why it’s important?

GV: Value-based reimbursement is a new way of paying for medical care. With value-based reimbursement, providers are given cost and quality targets and the associated responsibility for achieving those targets in order to be paid their fees and a share of the savings as well as quality incentives.

Under the old fee-for-service model, providers ordered tests, procedures, office visits, and so forth and were then paid per service performed. Essentially, the more services provided, the more fees could be made. As a counter balance, payers managed utilization and quality through top-down utilization management measures and quality improvement incentives. These efforts often resulted in additional work for providers to justify each procedure and obtain authorizations by fax, telephone, or web portal. The effectiveness of the utilization management and quality improvement under fee-for-service was debatable.

MHI: You mentioned analytics – why are analytics so beneficial to these arrangements?

GV: Quite simply, physician practices still exist in a void of actionable information. Historically, practices were limited to the data provided in their billing and scheduling systems. Even electronic medical records (EMR) typically evolved to emphasize the storage of patient demographic and encounter data only. If physicians can ONLY get to their own data, they can’t compare or benchmark their cost and quality performance to their competitors.

Magellan’s expertise in analyzing claims data provides physicians with insight into their practice and provides them with the ability to identify opportunities for improvement. It allows them to ask the critical questions that help them manage a population:

• How many patients who were prescribed a medication actually stayed compliant (consumed and refilled) their medication as often as should be expected?
• How many patients with congestive heart failure are actually on the recommended therapy for that disease?
• How many patients who received an implantable device were tried on optimal medical therapy for a sufficient time before an invasive intervention was implemented?
• What percentage of patients are achieving their blood pressure and cholesterol management goals?
• What percentage of patients are keeping their follow-up appointments?

Those are important questions for physicians to have answers to. By having access to this information, a physician can improve outcomes, reduce costs, and improve patient and provider satisfaction.

MHI: What other expertise does Magellan bring to a group like CANM?

GV: The ability to manage the patient across the continuum of care and time—even while they are home— is key to managing the chronic conditions often associated with heart disease. For patients at risk, regular contact with a case manager to ensure treatment plan and medication compliance, can provide motivation and support to deal with the burden of disease. Beyond our analytical capabilities, Magellan brings population management expertise and systems that help the practice manage the patient through their entire case experience, not just when they are hospitalized or seen in the physicians’ office.

Another key toolset that Magellan provides is clinical decision support and utilization management, through the use of our guidelines and systems. These help the providers ensure that the services provided meet national guidelines wherever appropriate. Whenever guidelines are not met, but the procedure or tests are still felt to be appropriate, physicians will enhance the validity of the medical record by thoroughly documenting why exceptions should be made for an individual case. Magellan provides the staff, training, guidelines, and tools that are the basis for such reviews.  The associated reporting that goes along with this activity can help the practice identify opportunities to be more efficient in the provision of care.

Finally, Magellan brings a great deal of expertise in case management. Our services and tools allow the case managers to engage patients and identify priorities for improving their overall health. Regular outreach with patients help provide crucial support and can identify changes in condition that can be addressed via office visits or medication adjustments before symptoms exacerbate and the patient requires emergency room visits or hospital stays. This additional level of contact with healthcare professionals can also be comforting to patients who are anxious about their disease.

MHI: Why CANM—Why were they a good fit for Magellan?

GV: CANM is a large cardiology practice (13 physicians, five nurse practitioners, one pharmacist) based in Tupelo, Mississippi, and supporting the surrounding 26 counties. They have a history of being at the forefront of technology and high quality cardiac care. In addition, CANM embraced the cardiovascular guidelines presented by Magellan. CANM also took the lead on reviewing the pharmacy claims data compiled by Magellan to develop their own practice formulary, focusing on lower cost generic medications wherever clinically appropriate. CANM also engages in cardiology research, helping to identify the best cost and quality interventions to improve cardiac health.

MHI: What are the challenges facing cardiologists in the current marketplace?

GV: Right now, a typical cardiologist “controls” 90 percent of the cardiac spend, but makes in fees about 10 percent of those dollars. For example, if the physician orders a test to be performed in a hospital setting, he or she may get a fee for examining the patient and interpreting the test, but they do not get money for the use of the facility, equipment or staff to run the test. A similar situation occurs when physicians order a medication.

In the fee-for-service environment, income from procedures is high, but under pressure from the focus on utilization management. Time spent counseling and supporting patients to modify lifestyle risks—while vitally important to overall health and cardiovascular disease risk reduction—is less valued. Furthermore, physician satisfaction is at an all-time low, across all specialties. By rewarding providers for managing high-cost procedures and spending time helping patients during and between office visits do more to manage their life-style risks, physicians achieve greater satisfaction from their work and less burn-out.

MHI: What’s next? Where do you see new challenges in the future and how do we meet them?

GV: I see a continued migration to value-based reimbursement arrangements. Provider groups will come together with other provider groups in an attempt to better manage risk within their populations. These provider groups will be the market of the future, and it will serve us well to prepare to serve that market with the valuable services we have established over years of experience serving health plans. Payers will increasingly leave it up to the providers to find the most efficient and effective ways to deliver the full continuum of care with the right partners. Magellan can utilize and improve our existing tools to serve these new markets to help both health plans and providers succeed.