Resetting Payer-Provider Arrangements for COVID-19 and the Evolving Improvement Journey

The path to healthcare transformation rests in the improvement journey—the incremental steps that move the industry towards higher-quality care and lower cost. A health system’s comprehensive improvement journey includes payer-provider arrangements that motivate improvement efforts.

COVID-19 renewed the importance of payer-provider arrangements, as the pandemic resulted in lower volumes for providers. Strained hospital resources were common as high-acuity COVID-19 patients occupied ICU beds. Changing the structure of the payment programs was not a top priority for providers or payers during the pandemic’s emergency phases.

Progressing in the improvement journey requires the industry to reset the performance standards of these payer-provider models to the post COVID-19 environment. For example, moving forward, the industry must consider the impact of remote care, how to reimburse telehealth services, and the need for consistent payments to providers.

Healthcare Payers and Providers: A Financial Arrangement Review

No matter how committed an organization is to provide the best care, a system often struggles to take the steps necessary to kick off change without some financial stimulus. As the industry recovers from COVID-19, providers are re-evaluating the financial arrangements that motivate them to improve their processes while benefiting payers and patients.

随着医疗保健支付者和提供商的安排不断演变，支付者行业越来越倾向于为提供商带来下行风险。下面将讨论最流行的模型。

Pay for Performance

The most basic arrangement for healthcare payers and providers is pay for performance (P4P). A straightforward incentive system, P4P rewards improvement based on established metrics (and sometimes penalizes if the provider fails to hit the metric). For example, if a certain percentage of patients in a population receives preventive screening during the year, the provider will receive the incentive payment. This kind of arrangement is a basic starting point that drives some improvement.

The majority of fee-for-service (FFS) payment systems link quality metrics to payment. For Medicare payments, hospitals participate in three programs:

• TheHospital Value-Based Purchasing (VBP) Programrewards and penalizes hospitals for experience, quality, safety, and efficiency.
• TheHospital Readmission Reduction Program(HRRP) compares readmission rates for specific high-volume conditions and reduces payments based on high readmission rates.
• TheHospital-Acquired Condition Program(HACRP) hits hospitals with reductions for high rates on conditions such as central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI).

CMS has extended the above types of programs to physicians and post-acute care. This emphasis on quality metrics increases awareness of the measures and forces organizations to focus on improvement.

Bundled Payments

In a bundled payment arrangement, a payer gives a single payment for all provider services constituting an episode of care, regardless of how many providers that episode involved. Before bundled payments, the provider would bill each service separately, but under a bundle arrangement, hospitals, post-acute providers, and physicians receive one payment for the episode. This arrangement holds providers accountable as a group for their performance and motivates them to work together to eliminate duplication and waste.

The CMS bundled payment program is calledBundled Payments for Care Improvement Advanced(BPCI Advanced). CMS defines in advance what constitutes an episode of care and which providers’ services that episode includes. CMS updated its voluntary BPCI-Advanced program in 2018, and the program will operate until 2023. CMS has given indications this program may become mandatory after 2023.

Providers participating in BPCI Advanced chose to enroll in 1 or more of the32 clinical episodes，包括充血性心力衰竭、尿路感染、败血症和各种骨科手术。截至2019年3月，该项目有334名参与者，代表了全国715家医院和580家医生集团诊所。大多数参与者选择参与少于5个捆绑。如果成本超过了目标价格，并且组织没有保持质量标准，那么该计划就会带来好处和坏处。

Health Affairsdid a preliminary review of the CMS bundle program for lower extremity joint replacement (LEJR) and reported the program maintained quality and reduce cost. The study found variability among non-LEJR episodes and urged continued research as the BPCI program adds more data and participants.

Bundled payment arrangements are becoming more common for commercial payers and employers, including the following examples:

• An employer coalition, includingWalmart and Lowe’s, negotiated with four centers to perform hip and knee implant procedures. Employees who have their procedures done at participating centers will receive complete coverage, including travel costs.
• Humanaexpanded itsEpisode-Based Models2019年，除了产科、肿瘤科和关节束，还有脊柱融合术。
• UnitedHealthcareannounced itsCare Bundles Programin 2019. In specific geographic regions, the payer offered incentives for providers who exceed standards on price and quality. UnitedHealthcare partners with providers on services and support, such as care management, to help patients navigate the continuum of care from pre-hospital to post-acute care.
• Horizon Blue Crossuses theEpisodes of Caremodel to engage specialty care physicians. The upside-only program goals include achieving the best long-term outcomes, reducing the total cost of care, and creating a positive experience for patients.

捆绑支付对组织来说是一种很好的方式，可以让他们轻松地达成共享储蓄协议。由于捆绑支付只针对一种类型的护理，如骨科，该组织不会承担太多风险。然而，计划的管理可能需要大量的资源才能成功。质量指标，如减少并发症和降低再入院率，是这些项目的重要组成部分。提供者必须控制利用率并在多种设置中提供高质量的护理，才能成功地进行捆绑服务。

ACOs

Establishing an accountable care arrangement with a payer means entering into a total cost-of-care system that rewards or penalizes based on a patient population’s total cost. This arrangement measures and defines quality metrics.

As of the third quarter of 2019, there were1,588 public and private ACOsin the United States covering 44 million lives. TheMedicare Shared Savings Programstarted in 2012 with114 participantsand peaked in 2018 with 561. For 2021, the MSSP has477 participants，其中有41%的人受益，有1070万受益人受益。

2021年没有新的MSSP参与者，因为CMS在大流行期间不允许新的应用。In 2018, CMS introducedPathways to Success, which limited the time an ACO could take to assume down-side risk and changed formulas for sharing the savings. These requirements caused some ACOs to withdraw from the program.

商业支付者继续与供应商合作，为会员提供类似于aco的安排。这些安排涵盖了护理的总成本和质量指标，项目往往在较长时间内有广泛的成本衡量标准，例如在五年内将护理总成本降低10%。In December 2020,Intermountain Health Care and UnitedHealthcareannounced an ACO that aims to improve care coordination and health indicators for a Medicare Advantage population.

CMS于2019年底推出了下一代ACO模型。The ACO-like model calledGlobal and Professional Direct Contracting (GPDC)accepted applications for a 2022 start date but announced there would be no new applications accepted in 2021. This downside risk model offered flexible cash flow, more predictable cost targets and few quality metrics.

Some organizations may want to ease into the ACO world incrementally by starting with bundled payments. The ACO down-side risk evaluation should involve a detailed review of the participant’s market and organization. The organization needs to develop specific analytical and clinical strategies that will guarantee success in an ACO arrangement. One way to gain knowledge is participation in pilot programs to learn the processes and evaluate risk-tolerance and ability to manage a population.

The Evolving Improvement Journey: Resetting Performance Standards for Healthcare Payers and Providers

Several common threads run through the three types of payer-provider arrangements above. In each, payers and providers must figure out how to work together to improve processes. They must agree on a set of quality, efficiency, and/or patient satisfaction metrics by which they’ll measure performance. Then, organizations must adopt a system for implementing, measuring, and sustaining cost-structure improvement, enabling organizations to profit from a more significant portion of their shared savings payments.

尽管CMS在2020年因COVID-19暂停了付费供应商项目，但这很可能是暂时的。组织应该继续与支付方和支持项目合作，以提高质量，降低成本，继续改进之旅。

Additional Reading

你想了解更多关于这个话题吗?Here are some articles we suggest:

1. Today’s Top Five Healthcare Payer Financial Opportunities
2. Six Strategies to Navigate COVID-19 Financial Recovery for Health Systems
3. Healthcare Analytics for Payers: How to Thrive Through Shifting Financial Risk
4. ACOs: Four Ways Technology Contributes to Success
5. Six Challenges to Becoming a Data-Driven Payer Organization

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