Blue Cross MN, CareFirst and Humana discuss value-based care and payer-provider collaboration
Health Plans

Hear from payer leaders on the frontlines of value-based care

June 16, 2021
Blue Cross MN, CareFirst and Humana discuss payer-provider collaboration.
Chief Product and Client Officer


ICYMI, Geneia recently published a white paper, How Health Plans Are Using a Phased Approach to Value-Based Care: Four examples of health plans building provider engagement. In the paper, we discussed the idea that the COVID-19 pandemic has incented more physicians to choose value-based and risk-based contracts with health plans. As examples, we cited:

Fast forward to May when I had the privilege of moderating a webinar with leaders from those plans:

  • Karen Amezcua, Senior Director, Provider Partnerships, Blue Cross Blue Shield of Minnesota (Blue Cross MN)
  • Oraida Roman, MHA, Vice President of Value Based Strategies, Humana
  • Brian Wheeler, Vice President, Provider Collaboration and Network Transformation, CareFirst BlueCross BlueShield (CareFirst)

World Congress Phased Approach to VBC webinar speakers

These industry experts discussed how the pandemic has impacted their value-based care programs as well as their plan’s philosophies, results and lessons learned.

Webinar Highlights

Karen Amezcua of Blue Cross MN shared her plan’s three-pronged approach to achieve its goal of reducing the cost trend by 10 percent in five years:

  1. Partner with the large integrated care systems that drive 65 percent of the plan’s overall spend to “evolve the value arrangements from upside only to real deeper risk arrangements that require both the plan and the provider to be jointly accountable for the cost of care.”
  2. Support and protect independent providers to help them survive and be successful.
  3. Leverage traditional health plan sustainability tactics like utilization management and site of care initiatives and provide nominal fee-for-service increases to provider organizations that are unwilling to make meaningful movement towards value.

She also detailed how the plan is supporting independent primary care practices – 53 clinics and 550 practitioners – with a “care workflow tool designed to prompt and reward primary care providers and frontline staff for delivering high-quality care.”

Just as importantly, BC Minnesota has “looked in the mirror to ask what do we need to do differently to support providers in this journey” and affirmed “provider enablement is not just about establishing the contracts. It’s about making sure the provider is successful on that journey.”

Brian Wheeler of CareFirst stressed the importance of collaboration in payer – provider relationships. He shared the plan’s philosophy to expanding their value-based care program to include episodes of care models for specialists and accountable care organizations. “Be more inclusive and bring more folks to the table to solve the problems of escalating healthcare costs. Acknowledge that healthcare is inherently local.”

Brian also highlighted the plan’s practice transformation consulting.

“We do a lot of work to empower providers through a team of consultants to help them understand the data and how they can perform better. We help our partners interpret the data, understand what their opportunities are and then help them implement best practices to change patterns to get the maximum value of those opportunities.”

Like Blue Cross MN, CareFirst too has focused on changing the nature of payer – provider relationships,

“We're redefining what progress and success look like and we're making progress together. It’s time to move from sitting on opposite sides to sitting on the same side of the table and looking at the problems together and figuring out how to solve them.

Oraida Roman of Humana talked about her plan’s philosophy that is the result of 30 years of experience in risk-based and value-based care contracts, “Through the provision of value-based care, we believe that we're able to provide higher quality care and achieve improved health outcomes for our members, as well as create deeper engagement with our providers.”

She also discussed Humana’s history, “In 2010, we really focused on this journey and substantially invested in expanding our primary care based models for our Medicare Advantage members. And then in 2016, we started expanding into specialty and other types of models.”

Humana’s value-based care results include:

  • 67 percent of individual Medicare Advantage members are aligned with a value-based PCP.
  • These members have 26 percent higher HEDIS® scores.
  • Significant reductions in ER visits and hospitalizations have led to a 19 percent reduction in medical costs as compared to original Medicare.
  • The satisfaction level of value-based PCPs is 15 points higher than non-valued based providers, and value-based providers are paid more. “We recognize that our providers do a lot of additional work to get those results for our members, and it is important that we financially reward them for that work so that they can make the investments they need to do to get those results.”

Oraida also shared how Humana has used a phased approach to value-based specialty care. “We’ve grown from one specialty bundle, which was total joint replacement in 2016, to four by the end of 2020. We now have 138 agreements that represent a little over 1,300 physicians in 26 states.”

I wholeheartedly encourage you to view the webinar and hear directly from these value-based care leaders. Click here.

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