AHIP 2024

Providers are key to the success
of value-based specialty programs

Successful value-based specialty programs begin with partnering with providers, agreed panelists at a session at the annual AHIP meeting.

CMS defines value-based care as an integrated and patient-centered approach to managing a patient’s healthcare. Specialty care is focused on managing conditions with high treatment costs, including cancer, cardiovascular disease and kidney disease, and conditions that can be treated with high-priced gene therapies. Patients with these conditions receive care from multiple providers. Coordinating this complex care and measuring its value is the basis of value-based care programs.

But different stakeholders define value differently, Jeremy Wigginton, M.D., chief medical officer at Capital Blue Cross in Harrisburg, Pennsylvania, said during the session: “Patients see value as access and satisfaction. Providers see it as sustained revenue. You have to make sure you are able to address those [differences] before you begin.”

It’s important to address operational complexity to better align providers, who may be participating in multiple programs with different pathways and different metrics. “Doctors say, ‘When we see patients, we don’t know what their insurance carriers are, and we don’t know what value-based program is used.’ We have to create programs that create results.”

Wigginton said plans must have provider buy-in before implementing any value-based program. “If you create a program that is customized with 10 custom measurements, you won’t get provider support. That’s what we want,” he said.

Engagement with providers must start before the development of any program. “This engagement shows physicians [who] have a stake in the program [and that] you’re not trying to just cut their revenue,” Wigginton said.

Employers, Wigginton said, want to know whether these programs stabilize costs. “We keep using the three-letter dirty word, ROI [return on investment]. We have to create narratives around return on investment; that is the expectation. But when we talk about value-based specialty care, ROI is not the way to look. We really need to be starting to think about this as patient-reported outcomes.”

Wigginton advocates for an approach to support high-cost specialty care that is focused on upfront policy management, creating partnerships with other organizations and providing education across the continuum, not just for patients.

Value-based specialty care helps to fill in the gaps in the care journey for patients, Bobby Green, M.D., co-founder, president and chief medical officer at Thyme Care, said during the session. Thyme Care is a company in Nashville that provides technology for care navigation in the oncology space.

Green sees patient navigation as accessing information from patients' electronic health records and harnessing that information to provide them the care they need.

“Cancer is this big, hairy problem with lots of expenses. Traditionally, there was some reluctance to address that, but costs keep going up. The newer drugs added complexity to the model,” Green said.

CMS has led in this area, introducing in 2014 its Oncology Care Model. CMS recently announced an update to its Enhancing Oncology Model, a voluntary payment model for providers that aims to improve care coordination
and quality.

A second cohort of providers will begin in July 2025. CMS has made a few changes for 2025, including updating provider payments for patients who are dually eligible for Medicare and Medicaid and requiring providers to pay back CMS when costs exceed a certain benchmark.

Getting public health out of its silo

Despite a broad mandate to keep people healthy and respond to shared health threats, public health has something of a poor relationship with the rest of the $4.5-trillion-a-year U.S. healthcare system, its providers and payers.

Mandy K. Cohen, M.D., M.P.H., director of the Centers for Disease Control and Prevention (CDC), wants to change that relationship and hopes to persuade health insurers that it is in their interest to do so.

“If public health is strong and it is doing the work it is meant to do, your job gets easier,” Cohen said at the opening keynote session of AHIP meeting.

A keynote session on modernizing U.S. public health. (from left ): moderator Bechara Choucair, M.D.; Mandy Cohen, M.D., M.P.H.;Dave Chokshi, M.D.; Michelle Williams, Sc.D.;and Dan Hanfling, M.D.

Cohen, who was appointed head of the CDC in June 2023, spoke about the health data modernization efforts, interoperability and strategies for gathering information in real time. She said one reason she could speak confidently about the relatively low public health risk from the bird flu outbreak affecting poultry, dairy cows and a small number of dairy workers, is that the CDC now receives “syndromic data” from 90% of the country’s emergency rooms.

Cohen, reprising some of the points she made with two CDC colleagues in an opinion piece titled “Integrating Public Health and Health Care — Protecting Health as a Team Sport,” published in April 2024 in The New England Journal of Medicine, said CDC funding has been organized around responses to particular diseases, such as COVID-19 and, before that, HIV. She said the agency is shifting to organization and funding that build up data, laboratory and workforce capabilities so the agency is “disease agnostic” and can help lead the response to any emerging health threat.

“What I hope to see us do is fund these core infrastructures to allow us to respond no matter the health threat, so we can pivot our data systems, our lab capacity, our manufacturing capability, our supply chain, no matter the health threat [that] comes to us,” she said.

Cohen referenced data modernization, including the Trusted Exchange Framework and Common Agreement and Fast Healthcare Interoperability Resources standards, several times in her pitch for public health to have a closer working relationship with the rest of U.S. healthcare. She noted that as a practical matter, “folks don’t walk into a public health department when they are sick. They walk into the emergency rooms with their insurance card” and said improving electronic case reports of diseases such as measles to public health databases should be a goal. She also mentioned lobbying and public advocacy efforts; one of AHIP’s main functions is lobbying to protect the health insurance industry’s interests. She told the audience that when they go to Washington, D.C., and to Capitol Hill, “I hope advocating for public health aligns with your agenda.”

Cohen made her first keynote remarks in a one-on-one interview with Bechara Choucair, M.D., executive vice president and chief health officer at Kaiser Permanente. That session segued into a panel discussion with Dave Chokshi, M.D., who was the New York City health commissioner from 2020 to 2022 and is now a professor at the City College of New York; Michelle Williams, Sc.D., a professor of epidemiology at the Harvard T.H. Chan School of Public Health and former dean of the school; and Dan Hanfling, M.D., director of private sector strategic partnerships in the White House Office of Pandemic Preparedness and Response. There were differences in emphasis and perspective among the panelists but no real disagreement.

Chokshi is the chair of the Common Health Coalition, whose founding members include AHIP and four other prominent and powerful U.S. healthcare organizations: the Alliance of Community Health Plans, the American Hospital Association, the American Medical Association and Kaiser Permanente. Chokshi said a so-called bright spot of the COVID-19 pandemic is that the “walls between public health and healthcare came tumbling down,” and the coalition’s purpose is to map out collaborations and relationships that will keep them from getting rebuilt.

“Let’s put in place the ways for these relationships to blossom during peacetime, at least relatively speaking, so we are much better equipped for the next health crisis,” Chokshi said.

Williams, noting the massive disruption caused by COVID-19, called for a “mindset shift” about public health: “We have to stop thinking of public health as just a cost and think about public health as a strategic pillar of investment for all of us.” Williams also called for more public-private partnerships and investment in data collection and analysis to break the feast-or-famine funding cycle
for public health.

Hanfling spoke about the 400 local healthcare coalitions across the country organized after 9/11, and the anthrax attacks that prompted the coordination of hospitals, emergency medical service agencies and other organizations to respond to emergencies. He said the coalitions, which the HHS Services supports with $200 million to $250 million annually, would be a good place for payer organizations to “plug into” to be involved in broader health issues.

How might U.S. healthcare be reimagined? That depends on your point of view

The keynote session on the second day of the AHIP annual meeting was called “Reimagining American Health Care: A Bold Vision for the Future.” But it might have been called the Rashomon of healthcare as the three panelists had very different perspectives and portrayals of the state of U.S. healthcare, its shortcomings and how they should be addressed.

Sachin Jain, M.D., MBA, CEO of the Senior Care Action Network (SCAN) Group and SCAN Health Plan, a Medicare Advantage plan in Southern California, painted a bright picture about SCAN but a broadly critical and quite dark one of U.S. healthcare overall, the way it treats physicians and the self-congratulatory denial of problems at AHIP meetings.

“Every single one these conferences is just full of happy talk about how amazing things are and how great things are and how we’re promoting access and promoting quality,” Jain told the AHIP audience. “Then, we’re all privately talking about how freaking hard it is for us to get care for our loved ones and for ourselves. So, I think we have to stop having two separate conversations and start having one conversation, which is like, ‘Hey, we’re in a bad place with American healthcare right now. Lots of things are messed up.’ ”

Andrea Walsh, J.D., president and CEO of HealthPartners, an integrated, nonprofit healthcare system and insurer in the Twin Cities in Minnesota, wasn’t Pollyannaish; “Navigation is a mess — people are on a medical merry-go-round” that Walsh said has led to disjointed care. Walsh also spoke about the public’s distrust of science having a demoralizing effect on people who enter the medical profession and the “brutal reality” that neither Medicare nor Medicaid in many markets cover the cost of actual care. But she trumpeted the success of a hybrid model of virtual and in-person healthcare that HealthPartners launched this year, and she compared it to the way Target, the Minnesota-based retailer, integrates online and in-store shopping.

Walsh also said COVID-19 vaccination efforts had led to changes in how HealthPartners works with the increasingly ethnically diverse population in the Twin Cities. “We’re trying to change the lens and do more with community — codesign with community — as opposed to doing things to community,” she said. She gave as an example a program called Open Faces that works with leaders in their Somali community.

A keynote session onat AHIP on reimagining healthcare (from left): moderator Bruce Japsen, Dan Mendelson, M.P.P.; Sachin Jain, M.D., MBA;
and Andrea Walsh, J.D.

Dan Mendelson, M.P.P., CEO of Morgan Health, a business unit at JPMorgan Chase that funds healthcare models for employer-sponsored healthcare, wasn’t as scathing as Jain but had critical observations about the current state of U.S. healthcare and health plans in particular.

“We’re here at AHIP, and I’ll say this very, very plainly that employers in the United States are not getting what they need for most health plans,” said Mendelson, citing double-digit cost increases and an erosion of quality.

AHIP speakers tend to talk up the accomplishments of their organizations, and Mendelson was no exception. He spoke enthusiastically about Morgan Health establishing an on-site primary care facility in Columbus, Ohio, where JP Morgan has 40,000 employees. Mendelson said that care navigation is “layered on top” of the clinic services to steer employees to low-cost, high-quality providers. Mendelson said he disagreed with the belief that broad networks of providers are better for employees and “curated networks of high quality providers” are preferable.

Jain and Mendelson had different takes on value-based care. Jain expressed frustration that value-based care was an available but unpicked choice. “We’re almost 15 years post-ACA [Affordable Care Act] and we’re 25 years-plus into Medicare Advantage. The ability to do value-based care has existed for a long time. There’s just a lot of organizations that have chosen not to do that.”

Mendelson countered that in contrast with Medicare and Medicaid, only about 10% of the payments in the employer-sponsored sector of the health insurance market are
value-based and “it’s because of the products being offered to employers” by insurers. When value-based models are offered by insurers to employers, Mendelson said, “when you dig into the details of any of those models, you see stuff that you don’t like,” such as provider networks that are not optimized for cost or quality, hidden fees and “denial rates that are so high that they just don’t make a lot of sense.”

Walsh, Jain and Mendelson also had differing views and emotional valence on workforce and physician issues. Walsh expressed concern about the number of older physicians and nurses.

“When you look at the age of the workforce, whether it’s doctors or nurses, as we look ahead, there aren’t going to be enough caregivers for the increasing and aging demographics in the community. So, we’re going to have to innovate and change the way we do provide care,” she said.

Jain painted with a broader brush and a darker palette: “I think the people who used to be super valued for their work now feel more and more like their work is commoditized, devalued and
underappreciated.”

He added, “I think the work we need to do, collectively, as an industry, with a lot of clarity is to stop having yoga classes, stop doing wellness hours and meditation retreats and doctors’ days with lots of tchotchkes that we give to lots of people [and], instead, actually go to work on fixing the workplace and make them places where people actually feel truly empowered and feel like they want to do their jobs with a kind of passion that they came to the profession with in the first place.”

Mendelson spoke “leveraging” a range of different kind of providers to provide care.

“That’s going to be more efficient; [it] is probably going to be a more fun environment for the doctors, and it’s going to [result in] better care for
the patient,” he said.