BCBSM signs big ‘risky’ contract with 6 groups of doctors

Doctors are increasingly placing their earnings on patient outcomes.

Six physician groups have entered into full-risk reimbursement agreements with Blue Cross Blue Shield of Michigan to care for patients under the Medicare Advantage PPO and Blue Care Network Medicare Advantage plans, America’s largest health insurer. state said Wednesday.

A full-risk agreement places financial responsibility on the physician’s organization in exchange for potentially greater reimbursement for high-quality care. When doctors meet their outcome and cost-per-patient goals, they get paid more in BCBSM. But if those goals are not met and the patient’s outcome worsens, the medical team will be responsible for any additional costs, tests, and treatments.

Medicare Advantage is a federal program that allows private insurance companies to sell plans tied to Medicare, the federally paid insurance program for people 65 years of age and older. Typically, Medicare Advantage plans include not only inpatient and outpatient coverage, like traditional Medicare, but also prescription coverage and other package benefits.

The six physician groups are: Ann Arbor-based HVPA of Village MD; Rochester-based MedNetOne Health Solutions; The Oakland Physicians Network Service is based in Sylvan Lake; United Physicians is based at Bingham Farms; PC The Great Lakes Doctors Organization is based in Midland; and Answer Health is based on Grand Rapids.

When the new plans roll out on January 1, about 30 percent of BCBSM’s total Medicare Advantage members will be seen by a contract physician at full risk, the Detroit-based insurer said. know in a press release.

“These latest agreements are powerful and demonstrate our collective leadership in advancing value-based payment models that improve quality and safety, avoid redundancies, and contribute to the improve the patient experience,” said Daniel Loepp, president and CEO of BCBSM, in a press release. “Physician organizations are willing to enter into these agreements because they know it will allow us to achieve our common goal of better, more affordable healthcare.”

Blue Cross kicked off a plan called the “Affordability Blueprint” in 2019 with seven organizations in a partial risk-sharing reimbursement plan for Medicare Advantage patients. That total has grown to 22 and includes about 50 percent of all commercial and Medicare Advantage members in the state of BCBSM.

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The insurer says the use of these risk-sharing programs has reduced healthcare costs by $70 million, along with improving quality metrics in breast and colorectal cancer screening. , childhood immunizations and diabetes control. It’s unclear who received those cost savings.

Medicare Advantage plans are one of the fastest-growing segments of private health insurance — the privatization of public health benefits is highly profitable for insurers.

According to research by the Kaiser Family Foundation, more than 40 percent of Medicare beneficiaries were enrolled in a private Medicare Advantage plan in 2020. In 2019, about 38 percent of Medicare recipients in Michigan were enrolled. Medicare Advantage plan.

Reimbursements have continued to evolve from the traditional fee-for-service model, especially in insurance company-sponsored Medicare Advantage plans.

In 2020, 29.3 percent of all Medicare Advantage payments went to a group of doctors in some sort of risk-sharing policy with an insurer, up from 28.6 percent a year earlier, according to data from the Healthcare Payments Learning and Action Network Alternative Payment Model. It is expected that these risk-based contracts will surpass traditional fee-for-service models in the coming years.

According to the report, progress has been much slower in the commercial insurance market, with only 10.8% of contract-related payments based on risk in 2020.

“We owe it to our members and customers to think and do things differently; to address the key drivers of healthcare costs and to collaborate on solutions to drive more successful outcomes and Health insurance costs are more affordable,” said Todd Van Tol, executive vice president of healthcare value at BCBSM.

This story first appeared in our sister publication, Crain’s Detroit Business.


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