Experts: Providers leaving money on the table by ignoring value-based programs

LAS VEGAS - Providers may be pleasantly surprised by new payment models when they learn how much they would have been paid had they participated, according to Rene Cabral-Daniels, CEO of the Community Care Network of Virginia.

"Payments incentive provider behavior," Cabral-Daniels said during a continuing symposium on the business of healthcare during HIMSS16. "There's money left on the table from (using) fee-for-service. 'Here's what your check could have been.'"

Doctors are also leaving money behind by not effectively partnering in value-based models, she said.

Cabral-Daniels is the former general counsel attorney responsible for outpatient payment system oversight at the Centers of Medicare and Medicaid Services.

She now oversees Virginia's only health center controlled network. The Family Health ACO is composed of federally qualified health centers that largely serve the underserved population.

A study has shown that people with the greatest healthcare needs receive the least amount of care, she said. The health centers are more likely to treat patients with chronic illnesses compared to other providers, costing the economy $1 trillion annually.

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The payer mix is only 14 percent private insurance; Medicare 8 percent; Medicaid, 40 percent; and the uninsured, 36 percent.

Payment system reform has at its core, she said: a solid IT infrastructure; integrated care delivery across facilities; measured outcomes and costs; bundled payments for care coordination, expanded services across the geography; and organization of integrated practice units.

Cabral-Daniel's talk focusing on accountable care organizations was part of a series. Earlier Rod Piechowski, senior director, Health Information Systems HIMSS North America shared reports from UnitedHealth Group that showed payments tied to value have tripled over three years to $36 billion in 2015; that number is expected to rise to $65 billion by the end of 2018, he said.

Anthem value-based spending will rise from $38 billion in 2014 to $65 billion in 2018, he said. Currently, about 30 percent of Anthem's total health providers-- approximately 40,000--are involved in value-based payment contracts.

Aetna has approximately $20 billion -- about 30.6 percent of its total spending -- tied to value-based contracts, with a goal to achieve 75 percent by the end of the decade.

Humana in 2014 paid $76.8 million to physicians participating in the Accountable Care Continuum Program, in addition to their normal reimbursements. This is a 28 percent increase from the $60 million paid to physicians in 2013.

Blue Cross Blue Shield Distinction Total Care estimated savings were over $840 million over traditional payment models on an annual basis. Payments represent approximately 20 percent of BCBS's medical claims.