Value-based care payment models

Humana recognizes that each physician's need is different, that every practice is unique. We listen to physicians and other healthcare professionals, and we understand there are many factors that can affect their readiness to transition to a value-based care model. Awareness of these differences drove the design of our value-based continuum.

Value-based care payment models

Our value-based care continuum is tailored for primary care physicians (PCPs) who are focused on increasing their population health management capabilities. As a PCP increases these capabilities, he or she gains additional opportunities to advance along the continuum.

Humana's primary care value based continuum infographic
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Humana's primary care value based continuum

Star recognition

Annual bonus for meeting quality metrics

Model practice

Quarterly bonus for meeting quality and outcomes metrics + potential for shared savings

Medical home

Quarterly bonus for meetings quality and outcomes metrics + potential for shared savings + monthly care coordination payment

Full value

Full responsibility for quality and outcomes and cost

Star Recognition

The Humana Star Recognition program is an integral part of Humana's value-based continuum. As the first level of our pay-for-value programs, the Star Recognition program focuses on achievements for specific quality measures. The 2020 Star Recognition program provides incentives to PCPs who meet six out of eight quality metrics. Practices that meet these metrics receive an annual bonus payment. Participating Humana PCPs who are in good standing automatically receive an invitation to participate in our Star Recognition program (unless they are already contracted for Humana's Model Practice, Medical Home or Shared Savings programs). Physicians contracted in a full-value arrangement at the end of the reporting period are not eligible for Star Recognition.

Star Recognition

The Humana Star Recognition program is an integral part of Humana's value-based continuum. As the first level of our pay-for-value programs, the Star Recognition program focuses on achievements for specific quality measures. The 2020 Star Recognition program provides incentives to PCPs who meet six out of eight quality metrics. Practices that meet these metrics receive an annual bonus payment. Participating Humana PCPs who are in good standing automatically receive an invitation to participate in our Star Recognition program (unless they are already contracted for Humana's Model Practice, Medical Home or Shared Savings programs). Physicians contracted in a full-value arrangement at the end of the reporting period are not eligible for Star Recognition.

Model Practice

The second level on the continuum is our Model Practice program. Physicians earn incentives for each quality metric they meet. Additionally, groups can earn incentives for meeting specific clinical initiative targets. Recognition is paid out quarterly for achievements in the Model Practice program. Physician practices receive additional bonuses for improvement in the percentage of Annual Wellness Visits (AWVs) and Initial Preventive Physical Exams (IPPE) performed in the first six months of the year. Participating PCPs with 250 or more Humana-covered patients are eligible to participate in Humana’s Model Practice program. This is a Humana-contracted program.

Model Practice

The second level on the continuum is our Model Practice program. Physicians earn incentives for each quality metric they meet. Additionally, groups can earn incentives for meeting specific clinical initiative targets. Recognition is paid out quarterly for achievements in the Model Practice program. Physician practices receive additional bonuses for improvement in the percentage of Annual Wellness Visits (AWVs) and Initial Preventive Physical Exams (IPPE) performed in the first six months of the year. Participating PCPs with 250 or more Humana-covered patients are eligible to participate in Humana’s Model Practice program. This is a Humana-contracted program.

Medical Home

The next level of Humana’s value-based care continuum is the Medical Home program, which is offered to practices that are recognized as patient-centered medical-homes (PCMH) or are in the process of gaining recognition. These practices have taken certain steps to ensure they fulfill the role of population health managers. For example, PCMH program participants have implemented electronic medical records and likely use electronic prescribing systems. Additionally, they have made other infrastructure changes, including using a care coordinator in the practice.

Medical Home program participants have to meet the same quality measures as those in the Model Practice program. However, the Medical Home program offers a per-member-per-month (PMPM) payment for providing necessary care coordination services to achieve quality metrics and maintain PCMH certification. To remain eligible for the care coordination fee, practices must meet or exceed the reward measures on a quarterly basis. Participating PCPs with 250 or more Humana-covered patients who are medical-home-certified or are in the process of becoming certified may be eligible to participate in Humana’s Medical Home program. This is a program for Humana-contracted physicians.

Medical Home

The next level of Humana’s value-based care continuum is the Medical Home program, which is offered to practices that are recognized as patient-centered medical-homes (PCMH) or are in the process of gaining recognition. These practices have taken certain steps to ensure they fulfill the role of population health managers. For example, PCMH program participants have implemented electronic medical records and likely use electronic prescribing systems. Additionally, they have made other infrastructure changes, including using a care coordinator in the practice.

Medical Home program participants have to meet the same quality measures as those in the Model Practice program. However, the Medical Home program offers a per-member-per-month (PMPM) payment for providing necessary care coordination services to achieve quality metrics and maintain PCMH certification. To remain eligible for the care coordination fee, practices must meet or exceed the reward measures on a quarterly basis. Participating PCPs with 250 or more Humana-covered patients who are medical-home-certified or are in the process of becoming certified may be eligible to participate in Humana’s Medical Home program. This is a program for Humana-contracted physicians.

Full Value

Humana’s full value model offers shared savings opportunities, with physicians taking full accountability and managing a patient’s total cost of care with a set capitation.

Additional opportunities include a global arrangement in which the physician is 100% accountable for the surplus or deficit related to a patient’s total cost of care. Global arrangement offers potentially higher compensation for taking on increased accountability.

The full value model and global arrangement opportunity require a broad set of capabilities (technology and infrastructure). The full value model is the most advanced model within our value-based continuum.

Full Value

Humana’s full value model offers shared savings opportunities, with physicians taking full accountability and managing a patient’s total cost of care with a set capitation.

Additional opportunities include a global arrangement in which the physician is 100% accountable for the surplus or deficit related to a patient’s total cost of care. Global arrangement offers potentially higher compensation for taking on increased accountability.

The full value model and global arrangement opportunity require a broad set of capabilities (technology and infrastructure). The full value model is the most advanced model within our value-based continuum.

Episode-based models

Humana developed its first episode-based models for total joint replacement (TJR) in Ohio's and Tennessee's TJR programs. After expanding in 2017, the program was made available nationwide in 2018.

Also in 2018, Humana added a maternity model; in 2019, we launched a spinal fusion model; and in 2020 we implemented a model for coronary artery bypass graft.

Both of these models are available nationally as well.

Visit our episode-based models page to learn more about the program and the states and episodic conditions into which we are expanding.

Humana’s episode-based models