A slate of payer policy changes are needed to expand the use of value-based care (VBC) and whole person care. The policy changes address alternative payment models, the use of higher value sites of service, pharmacy services, and ways to eliminate wasteful administrative spending. In particular, Medicare coverage of newer home-based services, remote monitoring, and hospital-at-home should be expanded. Medicare Advantage policy should protect in-home care models. Medicaid home- and community-based services (HCBS) should leverage managed care capabilities.
The recommendations are intended for government entities and other payers. They were presented in a white paper issued by UnitedHealth Group (UHG). In addition to the focus on VBC, the report makes recommendations about improving overall access to care and improving the consumer experience of care.
Payment Policy Changes To Support VBC
The Medicare physician payment model should be updated to fund physician infrastructure needs related to participating in two-side risk models and to improve payment stability. The medical loss ratio should be amended to include spending on social services and interoperable health technology needed to provide whole-person care.
- Medicare fee-for-service (FFS) should be gradually transitioned to full-risk payment. Provider organizations should provide care coordination and value-added benefits to FFS beneficiaries
- Medicare Advantage payments should reflect a medical trend that accounts for rising healthcare costs and increases in utilization. Medicare Advantage plans should be required to provide coordinated and managed supplemental benefits and ensure rural access for beneficiaries by stabilizing revenue for rural provider organizations.
Technology Concerns Related To VBC
Mandatory minimum cybersecurity standards should be developed collaboratively by the government and private sector. Regulatory policy on artificial intelligence (AI) should allow health care entities to deploy AI tools intended to improve the consumer and provider organization experience of care, reduce costs, and facilitate earlier treatment of medical conditions.
Legal Restrictions On VBC Arrangements
Where practices are transitioning or engaged in VBC arrangements, states should not impose laws limiting the corporate practice of medicine. Further, current policy barriers should be lifted to support shifting care to lower cost settings. For example to permit referrals to higher quality and lower cost providers.
Pharmacy VBC Concerns
Government prescription drug price reporting metrics are a structural barrier that inhibit the adoption of value-based pricing. Market exclusivity for branded drugs (due to patent laws and current FDA approvals) reduce competition for generics and biosimilars. To control costs, these structural and market barriers should be reformed. Federal policy should protect and enable the use of the fill-suite of pharmacy benefit management tools to strengthen competition and lower the cost of medications. Medicare policy for Part D should allow plans greater flexibility to promote affordable coverage, and pharmacists should be permitted to bill for some Medicare Part B services.
Administrative Spending Concerns
Payers and government programs should improve data sharing to more promptly identify fraud and abusive billing. Some plan administration requirements for network adequacy and prior authorization should be standardized across programs. Creating a national provider directory could increase plan efficiency. Federal and state compliance and enforcement efforts should clarify the goals and objectives to eliminate duplicative audits.
Expanding Access To Care
Improving consumer access to care requires strategies to cover the uninsured and simplify how people enroll and renew health insurance. It also requires coverage innovations to meet emerging consumer needs. A key recommendation is expanding access to Medicaid in the 10 states that have not yet adopted this policy, and expanding presumptive eligibility. Funding policy should ensure adequate Medicaid funding, permanently enhanced subsidies for the Exchange plans and CHIP, and protect current tax policy for employer-sponsored insurance. Coverage innovations could eliminate current plan structure and coverage requirements to create options that leverage VBC arrangements to reduce premiums and deductibles. Additionally, restrictions on telehealth should be eliminated, and professionals delivering services via telehealth should count toward network adequacy standards.
Improving The Experience Of Care
The health care experience could be transformed by focusing on equity and reducing disparities for vulnerable populations. The health care workforce should be expanded and diversified. Consumers should have access to actionable information about how to stay healthy and manage chronic conditions. The physician experience should be improved to allow more focus on direct consumer care.
The recommendations were presented in “A Path Forward to a Modern, High-Performing Health System” by Margaret-Mary Wilson, M.D., MBA, MRCP, chief medical officer for UnitedHealth Group and Wyatt Decker, M.D., MBA, chief physician, Value-Based Care and Innovation for UnitedHealth Group. The recommendations are focused on accelerating value-based care, improving consumer access to care, reducing disparities, and transforming the consumer health care experience.
For more information, contact: Will Shanley, Communications Director, UnitedHealth Group, Email: will.shanley@uhc.com; Website: https://www.uhc.com/