Payers make value-based models a priority, but regulatory and ROI uncertainty get in the way

stethoscope, coins and calculator
Payers are also starting to favor models like capitated contracts, which encourage providers to take on more significant financial risk. (Getty/mckare)

While value-based payment programs are a top strategic priority for payers, that doesn’t mean they’ve been easy to implement and sustain.

Such is the conclusion of the Health Care Transformation Task Force (HCTTF) in a new article published by NEJM Catalyst. Among the top five commercial payers—Cigna, Humana, Aetna, UnitedHealth and Anthem—HCTTF counted 184 publicly announced value-based payer-provider contracts between 2015 and 2017. 

Payers continue to invest so heavily in value-based pay models, the article said, because evidence has shown they produce cost savings and have a positive impact on patients. 

Free Daily Newsletter

Like this story? Subscribe to FierceHealthcare!

The healthcare sector remains in flux as policy, regulation, technology and trends shape the market. FierceHealthcare subscribers rely on our suite of newsletters as their must-read source for the latest news, analysis and data impacting their world. Sign up today to get healthcare news and updates delivered to your inbox and read on the go.

For example, in the first year of Anthem’s Enhanced Personal Health Care program, it cut emergency room costs by 3.5% and realized a gross savings of $9.51 per attributed member per month. And Cigna’s Collaborative Care program generated total medical cost savings of approximately $145 million in 2015.

RELATED: Humana—Providers achieve better cost, quality results under Medicare Advantage value-based arrangements

Payers are also starting to favor models such as accountable care organizations and capitated contracts, which encourage providers to take on more significant financial risk, the HCTTF noted. 

But much like providers, payers face significant challenges in the transition to value-based payment models. 

One of the biggest barriers is the unpredictability of insurance market regulation. That can leave payers with less organizational capacity to focus on alternative payment models, as many are “are scrambling to shore up their risk pools and decide whether and how to offer their products in various markets,” the article says. 

Another major issue is the uncertain return on investment, as it’s often difficult to calculate with the variability of patients, providers and markets. To account for that, payers must give programs enough time to adjust to unexpected hurdles, but also switch to new models quickly if needed, the article advised.

Some experts have worried that the Trump administration’s recent decision to nix mandatory bundled payment models will slow down the movement from fee-for-service to value-based payments, but others aren’t so sure. As HCTTF Executive Director Jeff Micklos noted at a briefing on Wednesday, it might be wiser to keep such programs, but make them voluntary.

Suggested Articles

Even the highest performing physicians and practices will see a “piddly” payment adjustment under the Merit-based Incentive Payment System (MIPS).

Blue Cross and Blue Shield of North Carolina and Cambia Health Solutions have jointly decided to end their talks to enter a "strategic affiliation."

The Trump administration's new rules to overhaul the Stark Law have some areas that could create major regulatory headaches.