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Can Value-Based Models Control Claim Costs?

Can providers in value-based reimbursement agreements with health insurance plans increase their Healthcare Effectiveness Data and Information Set (HEDIS) scores?  A new study provides interesting insights into the effectiveness of these agreements for health and casualty insurance environments.

A new Humana study reports value-based reimbursement models in 2016 resulted in 6 percent fewer hospital inpatient admissions, and 7 percent fewer emergency department visits than patients who received care with providers not in these agreements. 

Other improvements include:

  • Prevention - +13% Colorectal cancer screenings, +8% Breast cancer screenings
  • Outcomes - Chronic condition management, Controlling blood pressure +7% better, Diabetes care/controlling blood sugar +7% better, Medication adherence +2% better
  • Quality Measures - 26% higher overall HEDIS scores for physicians, 11 points higher for engagement and physician satisfaction
  • Cost - Total health care costs were 15% lower vs. original fee-for-service Medicare, Total health care costs were 4% lower vs. Humana standard Medicare Advantage (MA) programs

As primary care physicians (PCPs) grow their value-based care practice and expand their population health capabilities, it’s important to understand the distribution of payments to physicians and health care providers for delivering care. According to the American Academy of Family Physicians (AAFP), PCPs receive 6% of the total distribution of health care payments nationally.  Humana reported their distribution of overall payments to health care providers was higher for value-based PCPs in 2016. PCPs in value-based agreements with Humana received 16.2% of the total payments Humana distributed to health care providers in 2016.  PCPs in non-value-based agreements with Humana received 6.9% of the total payments Humana distributed. 

To read the new report packed with insights for medical providers, risk and claim managers, please click here >>

Blackburn Robert

By Robert J. Blackburn, Managing Principal, Blackburn Group, Inc., contact him at This email address is being protected from spambots. You need JavaScript enabled to view it..

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