Are Commercial Payers Experiencing Success With ACO Partnerships?

As accountable care organizations (ACOs) look beyond Medicare for accountable care contracts, they are increasingly engaging with commercial payers. At the National Association of ACOs (NAACOS) Fall 2018 conference, held October 3-5 in Washington, DC, Julian Harris, MD, MBA, president, CareAllies, was joined by Scott Hewitt, vice president, payment strategy and innovation, UnitedHealthcare; and Danielle Lloyd, senior vice president, private market innovations and quality initiatives, America’s Health Insurance Plans (AHIP), to discuss how they are working with ACOs to create new opportunities in the commercial market.

Moderator Katherine Schneider, president and CEO, Delaware Valley ACO, kicked off the panel by saying that while NAACOS continues to evaluate significant changes within the ACO world, such as changes to the Medicare Shared Savings Program (MSSP), which are forcing ACOs to shoulder financial risks sooner, “Our focus today is to shift from MSSP and its offshoots and speak about our relationship with private payers.”

At CareAllies, a Cigna company, the strategy is to support care providers as they take care of their patients who may participate in different plans, either traditional Medicare, Medicare Advantage, or MSSP. “We support them through risk-based plans,” Harris said.

“At AHIP, which is a trade association of health insurance providers, we share best policies among our members,” said Lloyd. “We also have some partnerships like with the Blue Cross Blue Shield Association to run a survey and core quality measure collaborative with CMS.”

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UnitedHealthcare has focused on value-based contracting for over 20 years, according to Hewitt. Speaking with The American Journal of Managed Care^®, Lee Newcomer, MD, MHA, then senior vice president of oncology and genetics, explained that the 2 main types of contracts were bundled payments, where every service that a patient is provided during a predefined period is included under a single payment to the care provider, and episode-based payments, which are based on gain sharing.

Hewitt said at the NAACOS meeting that over 20 million lives are covered under commercial Medicare and Medicaid, and a majority are being tied to population health programs.

Emphasizing their role as facilitators of the value-based program, Harris said that providers may be at varying positions in the value-based journey. “Whether it’s fee-for-service, commercial value-based arrangements, or Medicare ACO: each needs different capabilities. This is where we come in, so the doctors can focus on patient care. That’s the approach we take,” he said.

“A joint operating concept works best so we bring each of our expertise to the table,” Lloyd said. She highlighted the need for not just data exchange between providers and payers—a lot of which is interoperability-related—but also the need for transparency. “Knowing how things are working on both sides is key for best practices.”

When queried on their biggest challenges, keeping track of quality metrics topped the list.

“Our quality collaborative with CMS [launched in 2016] brings all stakeholders together to improve quality care delivery,” Lloyd said, and has yielded 8 core sets of quality measures. “The payers at the table account for 80% of covered lives, and in 2017, these were implemented in 40% of the contracts,” she added, with hopes for better results in 2018.

UnitedHealthcare also tried to carve out a list of measures based on those that are used in the population, Hewitt said. Stressing the congestion in the field, he said that CMS alone is using 1000 different quality measures across their programs. “We narrowed this down to 4 sets of 16 measures, and they are all validated by a third party, such as by the National Quality Forum or the National Committee for Quality Assurance.”

Hewitt also indicated that larger employers usually give them pushback and are not on board in terms of valuing quality metrics.

“I am cautiously optimistic about this, as I bring the journey into context,” said Harris. “So, we can have a narrow set of quality metrics but with caveats that recognize each subgroup and attributing the right metrics to each of them, such as Medicare versus Medicaid. I also think we have to get to a place where we can step back and say, ‘what problems are payers trying to solve and what are they concerned about?’”

He added that employers are currently worried about the affordability crisis in the commercial market, and stakeholders have a collective responsibility to help individuals; employers; and state, government, and commercial payers to stay viable.

When asked to share their thoughts on the proposed new MSSP rule by CMS, Lloyd said that AHIP is sending a draft letter to its members for feedback. “I’ll point out that we have shared our grievances with CMS via a multi-stakeholder letter,” she said, adding that they have expressed concerns with the risk pace. “We like the clarity of moving to risk, but our organization suggested 3-4 years as a reasonable pace for downside risk, but we also think that the level of sharing from 50% to 25% is not tenable.”