Payers want primary care providers to assume more risk
Value-based contracts are becoming the norm, moving payers and providers toward inceased risk sharing. Even Congress will take steps to make providers bear more risk, FierceHealthPayer previously reported. In fact, Highmark Blue Cross Blue Shield plans to have 75 percent of members in pay-for-value contracts for 2016, James Fawcett, senior vice president for provider contracting and relations, told the audience at the National Accountable Care Organization Summit in the District of Columbia last month, notes the article.
To shift more risk to providers, insurers use various payment models. For example, Highmark has implemented an end-state renal disease (ESRD) program that includes shared savings contracts with major dialysis providers throughout the insurer's region.
Highmark also is pushing more data to providers and patients, added Fawcett. This, in turn, will hopefully better engage the physicians in shared-risk models.
Other insurers, such as Cigna, use accountable care organizations that start with only shared savings and then move to shared savings to transfer some risk to the providers. Its ACOs also include pharmacy and behavior spending, and later will include patient experience, Richard Salmon, M.D., Cigna's national medical director for performance measure and improvement, said at the summit.
"Successful ACOs are the anchors of tiered and limited network products," Salmon said. "We're pushing to continue to grow market share."
Yet insurs won't save money with shared-risk models targeted at low-cost members, said H. Scott Sarran, M.D., divisional senior vice president and chief medical officer, government programs, at Health Care Service Corporation. Rather, insurers should create programs that support both quality and cost savings.
To engage physicians and other specialists, insurers take different approaches. Cigna, for example, promises specialists referrals in exchange for working in a value-based environment, notes AIS.
- read the AIS Health article
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