Boulder Care meets all quality metrics in first Medicaid pay-for-performance contract

Boulder Care, a telehealth provider for substance use disorder, has met all of its performance quality measures in a value-based payment arrangement with a managed Medicaid insurer in Oregon.

The contract was set up last year with Umpqua Health Alliance, tying reimbursement to a set of patient outcomes for UHA members in treatment with Boulder. This marks the provider's first Medicaid contract eligible for performance payment and achieved, executives said.

Working together, the partners developed a value-based payment framework for all 34,000 UHA members intended to increase access to timely, evidence-based addiction treatment while avoiding adverse outcomes. Boulder agreed to put a portion of its reimbursement for medical services at risk until quality performance metrics were achieved. 

Data confirm that Boulder met or exceeded its metrics, the company says, qualifying to receive the full performance-based payment. 

“Risk withhold is intended to incentivize providers to manage overall cost of services delivered to UHA members through efficiency and quality,” UHA Chief Medical Officer Douglas Carr, M.D., said in an announcement shown in advance to Fierce Healthcare. “We were pleased to execute a value-based payment agreement with Boulder for the services they provide our members with substance use disorders and for their achievement of these metrics.”

The measures included National Quality Forum metrics for high-quality substance use disorder care related to initiation and engagement of treatment, timely follow-up support after an emergency department visit and continuity of care for patients in medication treatment for opioid use disorder. 

The contract is part of Boulder’s broader mission to be held accountable by payers to achieve measurable patient outcomes, tying its financial success to the success of payer customers and their members.

The provider serves several thousand patients across nearly 100 payers. With the goal of not turning anyone away from care, Boulder limits the number of markets it is in and only enters states where it knows it can accept every single plan, Boulder founder and CEO Stephanie Strong said. About 80% of Boulder’s patients are on Medicaid.

“These patients are the nation’s most underserved, high-need and costly under status quo,” Strong told Fierce Healthcare.

Due to historically low reimbursement rates, many substance use disorder providers don’t accept Medicaid or are cash-pay only, per Strong, in effect “operating outside the system.” But in managed care arrangements, Medicaid plans are willing to reimburse for value. This makes substance use disorder treatment, particularly among digital-enabled providers, one of the most attractive new areas to execute value-based payment, Strong believes.

Boulder has found commercial payers are quicker to adopt unique payment arrangements. Medicaid takes longer to develop, Strong said, but is a more compelling area for both impact and shared savings. 

“There’s a lot of money for everyone to go around, and everybody wins—patients, providers and payers,” Strong said.

Half of Boulder’s business is value-based care. It has grown the number of patients under value-based care by 10x year over year, according to Strong. If a payer isn’t ready to set up a value-based arrangement, Boulder starts with fee-for-service and looks at claims data together to get them up to value-based care eventually. 

“We’re not making decisions based on insurance type and we’re not bound by those same restrictions as a lot of traditional providers,” Strong said.