Primary care value-based care continuum

Non-value-based

Providers in the non-value-based section of the primary care value-based care continuum are at the starting blocks of their journey to strengthening the healthcare system through increased prevention efforts, improved outcomes and an enhanced patient experience. These PCPs are only contracted with Humana on a fee-for-service basis and have a limited opportunity to earn incentives for quality outcomes. PCPs meeting required criteria, including membership thresholds, may be chosen to participate in a PCP quality recognition program (QRP) for a given line of business.

Non-value-based

Providers in the non-value-based section of the primary care value-based care continuum are at the starting blocks of their journey to strengthening the healthcare system through increased prevention efforts, improved outcomes and an enhanced patient experience. These PCPs are only contracted with Humana on a fee-for-service basis and have a limited opportunity to earn incentives for quality outcomes. PCPs meeting required criteria, including membership thresholds, may be chosen to participate in a PCP quality recognition program (QRP) for a given line of business.

Value-based: Upside only

The first true step on the primary care value-based care continuum is partnering with Humana in an upside-only, value-based care arrangement. This arrangement offers increased opportunity via shared savings, quality incentives or both. In this step on the continuum, providers can hone their skills and care pathways while managing chronic and acute conditions in a “risk-free” environment. The opportunity for shared savings allows providers to assume upside-only risk terms for their Humana-paneled patients, enabling them to share in a portion of the savings they produce through careful management of their patients. In an upside-only arrangement, the provider is not at risk for owing a deficit, but typically the shared-savings opportunity is much smaller than in downside-risk arrangements.

Value-based: Upside only

The first true step on the primary care value-based care continuum is partnering with Humana in an upside-only, value-based care arrangement. This arrangement offers increased opportunity via shared savings, quality incentives or both. In this step on the continuum, providers can hone their skills and care pathways while managing chronic and acute conditions in a “risk-free” environment. The opportunity for shared savings allows providers to assume upside-only risk terms for their Humana-paneled patients, enabling them to share in a portion of the savings they produce through careful management of their patients. In an upside-only arrangement, the provider is not at risk for owing a deficit, but typically the shared-savings opportunity is much smaller than in downside-risk arrangements.

Value-based: Downside risk

In the final step on the primary care value-based care continuum, providers assume increasing levels of accountability for their Humana-paneled patients. By participating in a downside-risk value-based arrangement, providers agree to a level of financial risk for their patients but, in return, they have a more robust opportunity for earning. This opportunity can come in the form of a primary care capitation model or through a comprehensive risk arrangement.

Generally, providers who participate in value-based care at this level can give patients enhanced, coordinated primary care services. Since the provider is responsible for managing a portion or all of his or her patients’ claim costs, the provider must continue to focus on proactively managing chronic and acute conditions, improving outcomes and ensuring an enhanced patient experience.

In a primary care capitation model, the provider agrees to capitated risk terms with a prospective capitated rate paid in lieu of fee-for-service rates for a defined set of services. For most models, providers will receive a monthly payment to manage these services for their Humana-paneled patients. They will receive no other payment for services, so will need to closely manage their care to optimize patient outcomes and experience. Comprehensive risk arrangements typically are done at the percent of premium (POP), with the provider assuming risk for costs that exceed the POP. The three types of comprehensive risk are 1) Partial, where a provider is less than 100% at risk for Parts A and B costs; 2) Full, where a provider is 100% at risk for Part B costs and less than 100% at risk for Part A costs; and 3) Global, where a provider is 100% at risk for both Parts A and B.

Providers who do not exceed 50% partial risk are eligible to participate in a PCP quality recognition program (QRP), such as model practice or medical home, which gives them the opportunity to earn quality incentives for performance within certain quality, clinical and strategic measures.

Value-based: Downside risk

In the final step on the primary care value-based care continuum, providers assume increasing levels of accountability for their Humana-paneled patients. By participating in a downside-risk value-based arrangement, providers agree to a level of financial risk for their patients but, in return, they have a more robust opportunity for earning. This opportunity can come in the form of a primary care capitation model or through a comprehensive risk arrangement.

Generally, providers who participate in value-based care at this level can give patients enhanced, coordinated primary care services. Since the provider is responsible for managing a portion or all of his or her patients’ claim costs, the provider must continue to focus on proactively managing chronic and acute conditions, improving outcomes and ensuring an enhanced patient experience.

In a primary care capitation model, the provider agrees to capitated risk terms with a prospective capitated rate paid in lieu of fee-for-service rates for a defined set of services. For most models, providers will receive a monthly payment to manage these services for their Humana-paneled patients. They will receive no other payment for services, so will need to closely manage their care to optimize patient outcomes and experience. Comprehensive risk arrangements typically are done at the percent of premium (POP), with the provider assuming risk for costs that exceed the POP. The three types of comprehensive risk are 1) Partial, where a provider is less than 100% at risk for Parts A and B costs; 2) Full, where a provider is 100% at risk for Part B costs and less than 100% at risk for Part A costs; and 3) Global, where a provider is 100% at risk for both Parts A and B.

Providers who do not exceed 50% partial risk are eligible to participate in a PCP quality recognition program (QRP), such as model practice or medical home, which gives them the opportunity to earn quality incentives for performance within certain quality, clinical and strategic measures.