Gregg Masters 00:08
This episode of PopHealth Week on HealthcareNOW Radio is brought to you by Health Innovation Media. Welcome, everyone. I’m Gregg Masters Managing Director of Health Innovation Media and the producer co-host of PopHealth Week. Connect with us by www.popupstudios.productions or follow and direct message me on Twitter via @Greggmastersmph and that’s Greg with two G’s. Joining me in the virtual studio is co-founder and principal Cohost of PopHealth Week Fred Goldstein president of Accountable Health LLC PopHealth Week engages top industry talent spanning health systems health plans, physician enterprises, joint ventures, employer purchasing coalitions or alliances, and the regulatory community in population health best practices and strategies. On today’s episode, our guest is Oraida Roman, the Vice President for value-based strategies at Humana perhaps the best in class Medicare Advantage operator in the United States, she leads the organizational advancement of innovative payment models that enable Humana to support providers as population health managers in value-based care relationships, Humana’s value-based strategies, organization develops, supports and deploys the best programs, practices, and capabilities that assist you man as provider partners and internal customers to successfully achieve enterprise-wide value-based goals. And with that introduction, Fred, over to you.
Fred Goldstein 01:44
Thanks so much, Gregg. And Oraida, welcome to PopHealth Week.
Oraida Roman 01:47
Thank you for having me.
Fred Goldstein 01:49
It’s really a pleasure to get you on. I’m very interested in what we’ll be discussing today. fantastic to watch companies move into this space rather rapidly. So why don’t we start, give the audience a little sense of your background?
Oraida Roman 01:59
Absolutely. I am currently the Vice President of National value-based strategies for Humana. Prior to that role, I worked for four years with provider groups that were trying to work in Value-based strategies. And additionally, I had 18 years of experience with Humana in different roles, trying to bring value-based care throughout the country in that role. So I have been doing this work for a long time. And it’s great to see where we are today.
Fred Goldstein 02:37
Yeah, I know, we’re gonna get into some of that as we talk through this. So one of the things I’ve noticed over the years, I’ve worked some with Humana here locally, not in a formal relationship, but with their Bold Goal program and helping that get launched, they’re doing that around the country. And obviously, value-based care is a critical component of where we’re trying to get to in health care. Where is Humana from a broader sense, in looking at value-based care? And what are they looking at?
Oraida Roman 02:59
Yep, so I’ll start with our high-level numbers, which shows that 68 with slightly over 68% of our Medicare Advantage members are aligned to a value-based primary care provider. And you might say, Well, what does 68% mean? And that means that there are 3 million Humana MA members that are aligned with a value-based care provider and you know, why is that figure important to us? And it’s because we see that as our members are seen by value-based care providers, several really good things happen. We see that there preventative measures go up, we see that members that are aligned with a value-based care provider receive more preventative screenings, more things like A1c or diabetes screenings, they have higher patient safety scores. That in turn leads to things like lower inpatient admission, so our our patients. Our members that are aligned with a value-based provider have 7% lower admissions and members that are aligned to a non-value-based provider 12%, lower emergency room visits and significant savings and in overall medical costs as a result for that. The second is what do these relationships mean for our providers because it takes work for providers to get these results for their patients our member. So we look at how two providers feel In these models working with us, and what we see is our value-based providers have 10%, higher physician engagement scores than providers that don’t have these models. They also receive more of the health care dollar. So one of the things that, you know, those of us that have spent a lot of time in healthcare know, is that primary care physicians tend to be underpaid, and they don’t have the resources to provide the kind of care that they would want to providers in these models are earning with our Humana models about 2.6 times the amount of reimbursement that non-value based providers are. So what we see and why we’re so committed to it is it’s good for our member. And it is also good for for our providers. So it’s definitely a a win win.
Fred Goldstein 05:54
And when you say value-based care for these primary care physicians, what are you talking about maybe what’s the range of that?
Oraida Roman 06:01
Yep. So we have a full continuum of models available for our providers, we you know, the continuum starts with simple models, where providers receive a quality payment for doing things like seeing their patients, administering screenings. So we realize that tracking patients and making sure that they’re being seen regularly making sure that they’re getting all of the preventative care that they should get that takes effort from providers. So some of our models start very simply, with just providing additional funding for our providers to do those things. And then we move into model where we can pay up a monthly capitation or care coordination fee, where it becomes a package of things that providers start doing. And they’re getting regular income to do that. Eventually, move we move into models where we’re sharing the financial results of the work that they’re doing. So we’re sharing surpluses, or, you know, in some providers, when they move into what’s called full value, they take financial responsibility for both surpluses and deficits, for the members that are attributed to them. And they do that because they, you know, usually assume that as they take care of them more comprehensively, they will see financial benefit from that.
Fred Goldstein 07:35
So in the case of those on that far end of the spectrum, doing what global capitation or something like that, is that I know that Humana has their own own primary care networks, and then they obviously have independent people, in that network? Are you seeing the majority of that within your system? Or is that also done outside as well,
Oraida Roman 07:55
it is both inside our system and outside of our system. So I shared earlier that about 68% of our members are aligned with a value-based care provider, and that two-thirds of the population using rough math, a third of them are in surplus, only or lower models of value-based care. And then a third of them are half of that 68% are aligned with full value providers. So we have you know, both national groups and local groups that participate in those models. And where you are. In Florida, it’s almost every provider participates in that model.
Fred Goldstein 08:43
Yeah, I know some of the providers in it as well, it’s been fascinating to watch that and their growth and experience with it, and success with it as well, as you’ve talked about. And so are you seeing differences between the two groups, as you look at that.
Oraida Roman 08:58
So starting with the differences between our more advanced value-based providers and our in our less advanced providers, we do see that as providers move along the value base continue their ability to impact our members health and outcomes increases. You know, and a lot of times that comes from they are able to invest in systems and workflows within their practices, where they’re able to really engage with their patients and help them stay well. help them stay home, help them stay out of the hospital. So we see that as providers have more experience. They can their results continue to improve. And then you know, a slightly different way to look at that question is do we see differences, you know, between our internal providers, ie CenterWell, and providers that we just contract with and what we end we find things that are, you know, providers that are at the most experience level in CenterWell, is one of those groups, but those providers tend to perform, you know that in within a range within that group. But our most advanced providers, whether they are ours, or they are externally you know external providers, they tend to have great performance.
Fred Goldstein 10:24
And obviously, moving to these higher levels of risk require a fair amount of sophistication, technology, reporting and analytics, what sorts of services do you assist them with?
Oraida Roman 10:35
So we have a population health platform, it’s called Population Insights, Compass, and it provides basically all the information that we have for the patients that are attributed to a provider group. So it has everything from what screenings and preventative measures, are they missing, that, you know, the provider can can schedule or prescribe for a patient, it has all of the financial information, everything about every claim that has been paid for their member a provider has access to through that platform, we find that for some of our very experienced providers, they might have developed their own platform. And they don’t want to go to another platform to access data. And what we have for for those providers is the ability to feed them raw data as well into their system. So success in value-based care is highly contingent upon a provider having data about their members. And this is one of the things that that Humana has historically felt very strongly about. And we’ve been providing data to our providers for actually more years than I care to mention, at this point. And I will like just take 5 30 seconds to mention, when I first joined Humana, we used to deliver this information monthly, the dot matrix printed reports that we would deliver to providers on a on a monthly basis. So now being able to say that we have a data platform where they can just log in and run their own reports how they want to see them, it’s incredible to see the advancement we’ve made, even when it sometimes still feels a little overwhelming.
Fred Goldstein 12:38
It’s really fantastic to hear about that. And, you know, really is interesting. So a question on this sort of more into the care management piece of this thing. You know, often health plans have their own care managers in there, and they’re trying to do a diabetes program or something else. Are you seeing that more delivered through these provider groups? Are you doing it a little bit of both? How does that work?
Gregg Masters 13:00
And if you’re just tuning in, you’re listening to Pop Health Week on HealthcareNOW Radio, our guest is Oraida Roman, the Vice President for value-based strategies at Humana.
Oraida Roman 13:11
I would say the short answer is a little bit of both. And some of it is really around meeting providers where they’re at. And we always like to think about it that we like to complement what our providers are doing not compete with what they’re doing. So if they have care managers, and they’re following up with patients, when patients get out of the hospital, we don’t want the physician’s office to call and Humana to call the next day that tends to add confusion for patients and they’re saying Why are you both calling me so we do a lot of coordination with our providers to try to understand what are they doing? How do we complement them? So what you’ll find is some geographies. And I’ll mention Florida again, because Florida is so advanced, providers do a significant amount of that work, other parts of the country where value-based is not as predominant. And providers haven’t yet build the infrastructure to support that we will do more of that work. So that we’re still helping them succeed with their patients. But so it takes a lot of coordination and figuring out what is the right mix. But it’s something we think about a lot like how, again, how do we complement but not compete?
Fred Goldstein 14:39
And as you mentioned, it’s for those more sophisticated, let’s say the Florida model, what’s going on here more where they do it themselves. Does Humana ultimately see that service kind of moving in better functioning ultimately, within these groups? And as they move into more and more risk-based contracts? Do you anticipate that more and more of them will pick up that piece of the service.
Oraida Roman 15:02
We are definitely finding that across the country, as providers get more experienced, they have more resources to dedicate to these patients, we are seeing that they are doing more of that work. And we see a lot of success patients, you know, listen to their doctor, sometimes, you know, as patients, we don’t want to pick up the phone, when our health plan calls. But if our physician’s office calls, we will pick up that that call. So it is a model that is significantly growing across the country.
Fred Goldstein 15:36
Absolutely. That whole idea of having somebody who’s paid within the practice or associated with the clinics or the health care system calling you makes it a little bit easier. Do you I know also, that Humana has gotten involved in value-based care models with specialists? Can you talk to them about that as well?
Oraida Roman 15:52
Absolutely. And this has been very exciting for us because as we saw the success we had in primary care, we looked at what were the right specialist programs, what could we launch in the specialty space. And starting in 2016, we launched our bundles programs. And, you know, that’s something that different payers, including CMS has tried bundled programs, we again started in 2016. That year, we had 17 providers, sorry, seven providers that participated with us in two states, on a pilot for total joint replacement. Our bundles are retrospective episode-based models. So what that means is if you think about the total joint replacement, we work with our and it we work with our providers, so we don’t work with the hospitals or other providers, we’re working with the surgical group that is going to perform the total joint replacement in this case, and we there is a physician that becomes responsible for that bundle. And we compare in a given year, their average costs for doing that procedure to a historical window of cost and what then where they’re able to achieve savings in providing outcomes, we share those savings with them. And we also look at clinical outcomes. So for all of our value-based models we don’t just focus on is there improved financial performance, but we look at work clinical outcomes, also maintained and or improved within the model. So you can think about it as the the clinical outcomes are kind of a quality gates to receiving the financial incentivee, for the program. As I said, we started with a total joint replacement program. And we’ve actually now grown it to we have four different programs. Our total joint replacement program is still the largest one, but we also have a maternity bundle, a spinal fusion bundle and a CABG bundle. So the program now has 1600 providers from the seven that we started with across 27 states. So we’ve seen significant growth in those models.
Fred Goldstein 18:43
And obviously, when you put the quality measures in, you’re now looking at a value-based type program, where you’re looking at both the cost and the outcome. So that’s great to hear. Question on this. And it’s kind of a technical one, I guess, as you’re thinking through two issues I’m thinking about here. The first one is there’s this whole concern of setting something based on a historical and then providers pulling the cost down, and then their baseline changes and the case keeps going down until there’s nothing left. Have you sort of figured out a way to solve that problem yet? Or has Humana worked on that?
Oraida Roman 19:14
Yeah, so we do have and we are seeing some of our our oldest participants in the programs have, you know, initially saw year over year improvement and we have created within our models and as we think of new models, we’re very conscious of right not having that race to the bottom. So some of our older programs do have ways that we continue to pay for continued good performance, even if there isn’t incremental improvement and we monitor that at at the provider level and then again, make payments for continued performance without expecting additional incremental improvement, if additional incremental improvement is gained, then the you know, the payment would also reflect that. And, you know, I can share some and we have seen, you know, significant in improvements. So, for example, our total joint replacement program, we’re seeing a 30% reduction in readmissions for for patients that get a surgery from one of these providers versus our our providers that don’t participate in the programs, we’re seeing spinal fusion, that readmission rate goes down by 39% for providers that participate in the program. So we’re seeing, you know, same as our primary care models, we’re seeing really great results, and the ability to share in those savings with our providers. So in 2020, as an example, 83% of our program participants earned a shared savings. And that payment, on average was about a 29% increase from their traditional fee-for-service model. So we’re seeing same thing we saw in primary care that if we put the right incentives in place, there is benefit for our members because they’re receiving the higher quality care. But there’s also a reward for our providers as they partner with us to do this work. And I know that that was a lot more than you asked, but I’m like, this is something I’m so passionate about that I start talking and I can’t stop.
Fred Goldstein 21:46
No. This is great. And that’s it, you know, the more details, the better. A quick question along those lines, too, is you have this bundled or capitated primary care physician, let’s say they’re globally capitated and then you’ve dropped in a bundled payment for specialty care. And I’m sure you’ve run into that, are you seeing does the the primary care doctor get full credit for the work you’ve done on the bundle side, too.
Oraida Roman 22:12
So we have and you just hit on one of the things that makes things really complicated now, right that 68% of members that are tied to value-based providers when we layer in other models on top of it, it is definitely you know, a complication. And we’re very intentional about the programs that we lay on top of the primary care model. So they do have to provide value on their own. And it needs to be for something that the PCP was working on. And you know, so that’s why why don’t we have 30 bundles, it’s we’ve been intentional, and having bundles that are discrete episodes of care that it is that specialty provider that can really control it. And what happens is, you know, if you want to think about it this way, without the bundled payment, the claims that would be getting charged to that price of PCP provider would be higher, because the specialists haven’t engaged in savings. So now when we create a bundled payment program, the claims that get paid for the actual service go down, and those get charged to the PCP, so they’re paying less than claim, they get charge for the shared savings that the specialist provider gets. So instead of getting a claim that gets attributed to them, but net net, they’re still lower back. And that is why with these models, it is a shared savings model. Because we never want these programs, we don’t want our PCPs to say we don’t see value in these programs, we don’t want to participate. So we’re very thoughtful about the programs that we designed that layer on top of the primary care programs.
Fred Goldstein 24:14
Fascinating. And as you think about this, we’ve got about two, two and a half minutes left on those. Have you had any experiences as everybody’s trying these different ideas, someone who’s like Humana’s gotten a fair amount of experience in it for quite a period of time. Are you have you seen any things that you could talk about that don’t work or maybe have been less successful?
Oraida Roman 24:35
So where we where we see less success, and we still have all of our our bundled programs, and we still have all of our primary care models. Typically when we find that we don’t have success, is it and I’ll start with the primary care side is where we matched the wrong contract to a provider and that is why we have a, you know, a full continuum. And we spend a lot of time getting to know our providers and taking a contract that works for where they are operationally. So you go in and too soon, for example, put a provider on full risk, and they don’t have the resources to manage it, that can lead to failure. So we’ve learned not to do that. But providers where they can be successful, move down the continuum together. So for us, that’s usually the greatest mismatch is a provider might not be ready for the model that they’re in. And then it’s usually not how do we step away from the relationship in totality? But like, how do we back up from where they are, get them successful, and then help them grow their their value based penetration and performance?
Fred Goldstein 26:01
And quickly for those providers who want to get more involved in this type of work? What would you recommend they do?
Oraida Roman 26:08
So in all of our markets, we have provider contracting and provider engagement teams, most providers know who to call locally. And that is one of the greatest assets that we have at Humana is those local teams. So you have people like me sitting at corporate that helped design, new programs, but we have local teams that markets can engage with. And they’re the ones that really helped them find the right relationship between Humana and their practices. So call your your local teams.
Fred Goldstein 26:45
Oh, great. Oraida I’d like to thank you for joining us on PopHealth Week. It’s been a pleasure. I’d love to get you back and get deeper into some of this.
Oraida Roman 26:50
Sounds good. Thank you.
Fred Goldstein 26:53
And back to you, Greg.
Gregg Masters 26:54
And thank you, Fred. That is the last word on today’s broadcast. I want to thank Oraida Roman, the Vice President for value based strategies at Humana for her time and insights today, do follow Humana’s value based care initiatives on Twitter by @Humana and on the web by@www.humana.com. And finally, if you’re enjoying our work at PopHealth Week, please like the show on the podcast platform of your choice. Share with your colleagues and do consider subscribing to keep up with new episodes as they’re posted. For PopHealth Week. My co-host Fred Goldstein. This is Gregg masters saying stay safe everyone. Bye now.