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Another long, technical thread to end the day! @BlueCrossNC is on a mission to transform health care. This means sharing how we tackled problems that have stymied efforts at payment reform at scale, including how to fund the inclusion of self-insured segments within #BluePremier.
Fully insured segments are straightforward – as a plan, we can accrue the estimate reserves that we track on an ongoing basis for any given risk arrangement in which we hold the dollars. But self-insured populations are a different story. Many plans have faced this quandary.
Some have just left them out of the included populations entirely. But leaving out these populations dampens the value of the program and shortchanges the members who will benefit from accountability and alignment of providers to improve outcomes, experience, and affordability.
One of our first guiding principles was to include them and to cover as much medical spend under #BluePremier as possible.
Originally, we thought we would convert the shared savings that were earned by a given #ACO into a per member per month (PMPM) payment that would begin on a monthly basis in January 2021, two years after the first performance year in January 2019.
Ex: 2019 performance year, 2020 settlement year, 2021 payment year. We would essentially be passing through the dollars that would be collected from the self-insured accounts.
But we scratched that. Our provider partners hated it. For ACOs it depressed the expected value of participating, all the while they would incur costs of doing the work. Some told us they wouldn’t sign at all.
We then thought we could at least pay the fully insured lines as a lump sum in the summer of 2020. This helped, but we still needed to go bigger—could we pay the whole enchilada as a lump sum?
After many weeks of rethinking and retooling our technical capacity we developed a bifurcated approach: for 2019, we’d estimate self-insured client liabilities at our #BluePremier systems for the clients for them to accrue , but bill these as a lump sum.
Then in 2020, we would begin a prospective PMPM billing cycle that would again be based on self-insured client liabilities. Both would enable lump sum payments to #BluePremier providers.
If we didn’t pull this together, I’m convinced we would have had fewer #BluePremier providers, and we would not be on track to our goal of 50% of members served by providers in value-based agreements in 2020.
It speaks to the incredible @BlueCrossNC team’s ability to demonstrate what is possible – even under pressure. @scottheiser
