Beneath two-tailed threat fashions, high quality of care will increase in comparison with FFS Medicare

Data exploration is beginning to yield better insights into how much better value-based payment models are for quality of care.

When comparing two-tailed risk models in Medicare Advantage (MA) versus fee-based Medicare programs, the former performed better on all eight quality metrics. At least, that’s according to a new study published in JAMA this month.

The metrics examined included the likelihood of inpatient admission; inpatient admission through the Emergency Department (ED); ED visits; avoidable ED visits; 30-day recovery; admission for stroke or myocardial infarction; and hospitalization for chronic obstructive pulmonary disease or asthma exacerbation.

The study was led by authors affiliated with Optum of UnitedHealth Group (NYSE:UNH) and Harvard TH Chan School of Public Health. The largest differences between these eight metrics were hospitalizations for chronic obstructive pulmonary disease or asthma exacerbation, likelihood of hospitalization, and avoidable ED rates, representing 44%, 18%, and 14% differences between the two models, respectively.

It was based on a data set of 316,312 people. In particular, it referred to physicians engaged in two-tailed risk models. But it’s also relevant to home care as more providers try to embark on risk-based models.

For example, home care provider Care Advantage Inc. — which made two acquisitions in December — is preparing to participate in these models. While it has worked with payers on some upside risk, it is attempting to build a suite of services that suggest it is also dealing with downside risk.

“It’s important to the overall flow of the patient and how we can care for that patient across that continuum,” Care Advantage CEO Tim Hanold recently told Home Health Care News. “It’s also important because we have a number of pay-for-performance agreements that are underway and some new ones that are coming on board.”

Another example of a provider full steam ahead to move into fully risk-based models is Minnesota-based Lifespark.

“We have secured a full global upside-downside risk contract,” Lifespark CEO Joel Theisen told HHCN earlier this year. “That really allowed us to deliver this model and not be penny wise and pound stupid but really smart for these people. I think it’s the only model in my head. I think everyone should be at risk because I think everyone should be responsible for the health of these individuals that we serve. Not to their own gains, not to their own business case or part or fragment of experience, but to truly global risks.”

It’s possible that physician contracts with Medicare Advantage plans inherently work differently than home care contracts with plans.

However, most provider executives agree that home health care and home care are quality drivers that, in theory, should help with risk-sharing and defined-benefit agreements with health insurers.

“The improvements seen in this study can be partially or fully attributed to the Medicare Advantage model,” the study authors write. “The Medicare Advantage risk adjustment system appears to achieve its intended goal by adjusting per-capita rates for the healthcare burden of the individual beneficiary and the total population served, thereby providing revenue for the development of infrastructure that supports quality and efficiency improvements for patients enrolled in Medicare Advantage models with two-way risk.”

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