UPMC joins new Medicare Advantage value-based insurance design model, hopes for returns

In theory, Medicare Advantage value-based insurance design should work, according to one insurer that is about to test the new Centers for Medicare and Medicaid Services model.

"Theoretically, this sounded like a really good idea," said Helene Weinraub, vice president of Medicare for the UPMC Health Plan. Her comment Monday got some appreciative laughter from a standing-room only crowd at an America's Health Insurance Plans Medicare conference in Washington, D.C.

UPMC is among nine Medicare Advantage plans taking advantage, or some would say, going out on a limb, to see if CMS's five-year VBID model works to reduce costs and improve quality of care for  patients with certain chronic conditions.

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The model begins in seven states starting Jan. 1, 2017.

The University of Pittsburgh Medical Center and others chosen are doing this without additional funds from CMS; UPMC is implementing the model for 8,000 to 9,000 of its members without adding staff, according to Weinraub.

The combined provider and plan health system giant has one major advantage over smaller systems: a $1.6 billion investment in an information technology infrastructure.

"We had to decide what diseases to choose," Weinraub said.

Using the data, UPMC looked at which chronic diseases had the highest medical and drug costs. They settled on a combination of chronic diseases: congestive heart failure with diabetes and CHF with chronic obstructive pulmonary disease, (COPD). Some patients have all three conditions, Weinraub said.

[Also: AHIP urges more flexibility in new value-based Medicare Advantage model]

Also, UPMC looked at ease of implementation.

"The population needed to be large enough to be relevant and yet small enough to manage and minimize potential loss," she said.

The goal is to assist these members to self-manage their condition. UPMC is giving incentives through $25 quarterly payments, starting with completion of a "Spark Your Health" questionnaire that addresses both medical and behavioral health.

Members get an individualized care plan, see their primary care providers and pay regular copays.

UPMC processes the claims and gets feedback from all affected departments, from case managers to the pharmacy.

Member services will act as a key front-line communication resource to answer members' questions, such as the status of the care plans and their next payment.

UPMC will measure enrollment and participation, and from all of the feedback, will determine the value of the MA model after it's been in place about a year.

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"Ultimately we're looking at our outcome measures," Weinraub said, "(the ability) to reduce readmissions, reduce ED, address star measures and increase member satisfaction."

Plans going into model had to show potential savings and at least be cost neutral, said Adam Finkelstein, health insurance specialist VBID Lead, Seamless Care Models Group, for the Centers for Medicare and Medicaid Innovation.

The model will soon be expanded to more states and conditions.

"Beginning 2018 we will reopen the application window," Finkelstein said.

Twitter: @SusanJMorse