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  • Writer's pictureMuhammad Sair Khan

New Healthcare Initiatives May Impact Provider Revenue




Payor Initiatives


Over the last few weeks, we talked about the shift in U.S. healthcare policy, what to expect from the value-based healthcare initiative and how you can prepare your medical practice/facility to comply with the changes.


This article looks at the specific programs that Aetna, Anthem, Cigna and UnitedHealthcare are initiating and what kinds of implications they may have on provider revenue.


Aetna, Anthem, Cigna and United Healthcare have each developed individualized programs to support the value-based healthcare agenda. Although the structure of each payor program is slightly different, the fundamental principles center around responsible and results-oriented patient care that pays providers for the outcome they receive with their patients instead of the volume of patients that they see.


Examples of Value-Based Care Include:

  • Increasing access to preventative care

  • Coordination between providers, hospitals, and payors to reduce healthcare costs

  • More efficient use of medical technology

  • Rewarding physicians who achieve the best health outcomes

Aetna


Aetna’s approach to value-based care involves partnering with large healthcare organizations who already operate under value-based care principles. In the past two years, Aetna has partnered with five different healthcare organizations in varying states who provide fully integrated care between primary care physicians, behavioral health specialists, pharmacists, case managers, nutritionists, social workers, urgent cares, hospitals and more. The data has already shown an improvement in patient outcomes and a decrease in healthcare spending.

Anthem

Anthem is taking a slightly different approach to outcome-based care. Rather than partnering with large organizations who already operate under value-based principles, Anthem’s model encourages individual providers to use data and analytics to monitor the quality of patient outcomes effectively. They developed a program called Blue Precision to highlight physicians who consistently provide quality care. Third-party payor audits using NCQA and BTE standards is one method that Anthem uses to determine which providers meet their criteria.



Although the current Blue Precision program is only operating within 12 healthcare specialties, these types of programs provide insight to the future of U.S. healthcare and should be considered by medical practices preparing for the future.

Cigna


Cigna also runs a quality improvement program called the Cigna Collaborative Care Initiative. It’s primary goal is to make sure that patients can easily navigate between different providers to receive the care they need. Cigna employs registered nurses to ensure that sick members follow through with screenings and lab work, schedule appointments with specialists, and have access to the appropriate information to manage their health.

UnitedHealthcare


UnitedHealth Group is already paying 60% of reimbursement fees to physicians and facilities who participate in the value-based model. They have an aggressive plan to increase that number by 2020. Optum (owned by UnitedHealth) is buying doctor practices, urgent care facilities and surgical centers to form ACO’s. The larger these networks become, the easier it will be to for medical professionals to share data, streamline and improve the quality of care the patient receives, and ultimately cut healthcare costs.

Are You Prepared?


Although the approach to value-based care varies between the four major insurance providers, the emphasis is undoubtedly, quality healthcare. These initiatives signify the new standards that healthcare professionals will have to meet to receive insurance reimbursement.


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