AmeriHealth Caritas Extends Value-Based Care to Small, Rural Providers

Company’s Medicaid plans in Louisiana and New Hampshire are offering Small Providers and Rural Communities (SPARC) models, with planned implementations in other markets later this year

Published with permission from Healthcare Innovation

Small and rural providers have often struggled to be included in value-based care models. Medicaid insurer AmeriHealth Caritas is helping to address this need through its Small Providers and Rural Communities (SPARC) suite of value-based contracting models. In a recent interview with Healthcare Innovation, Jim Jones, vice president of healthcare analytics for AmeriHealth Caritas, described the SPARC program.

Pennsylvania-based AmeriHealth Caritas operates in 13 states and the District of Columbia, serving approximately 5 million Medicaid, Medicare, Children’s Health Insurance Program (CHIP), and Health Insurance Marketplace members through its integrated managed care products.

Part of the company’s broader PerformPlus suite of value-based programs, SPARC offers value-based solutions tailored to the needs of small and rural providers. AmeriHealth Caritas Medicaid plans in Louisiana and New Hampshire are currently offering SPARC models, with planned implementations in other markets later this year.

"Historically, value-based care programs have focused on larger hospital systems and large provider groups and I think that's largely because of the sample size and economy of scale," Jones said. The more members and dollars flowing through a system can make it easier to calculate performance metrics that are more statistically stable. “Performance measures with low-volume providers and episodes can create a little bit more volatility, so I think there has been the hesitation historically, but we have a 15-year history of value-based care agreements,” he added.

Jones also said, “Over time, we got our market penetration rates up pretty high. We average around 90 percent of our members included in one of our value-based programs. From that perspective, we noticed that there are some providers that can get left out of value-based agreements, because they're smaller, and they typically wouldn't meet standard panel size requirements. We saw that as an opportunity to address and expand our approach and get a little more creative to pull in those types of provider groups.”

AmeriHealth Caritas has rolled the concept out to include a couple of different ways. It has episode-based solutions as well as other programs where it aggregates performance metrics across several participating providers that are grouping together, Jones said. “We've got a couple of episodes models that we've seen success with around chronic conditions and other associated quality measures where we're seeing early improvement markers in these initial markets, which facilitated our internal discussion and decision to expand these programs into other markets.”

In one of the markets, AmeriHealth Caritas started with all the all the primary care practices that typically do not qualify for inclusion in other programs because of panel size. “We created these customized programs for them,” Jones said, “and then we have relationships in the other markets that I've described, wherein we have local teams that work with rural and community-based or behavioral health alliances, which have been instrumental in our success and getting this off the ground.”

These models are upside only, Jones explained, but in their long-term partnerships, it's AmeriHealth Caritas’ intent to work with providers and as they use the technology solutions and get better at identifying members who need early and frequent intervention, it offers programs across the full continuum of risk. “If they choose to move to partial risk or full risk, we are fully ready and able to support that,” he said.

AmeriHealth Caritas has a Caring Communities virtual ACO that now includes community-based organizations. “We realized that a lot of our members have chronic conditions — hypertension, diabetes — where proper nutrition can make a big difference in their health outcomes,” Jones said. “We got creative with a local food bank in Pennsylvania to create a value-based program wherein they're actively involved in the members’ care and making sure that after medical encounters, they're getting the proper food and nutrition that they require for their condition. We're tracking those outcomes over time, and sharing that as part of the value-based construct.”

AmeriHealth Caritas has designed its value-based programs to make sure that it is properly rewarding all the extra things that providers and partners are doing to properly engage these members and get them the care they need and close their care gaps, Jones said. “We fully support being able to alleviate that administrative burden and create a more stable financial stream for them to support these extra things in value-based care that they otherwise wouldn't have been rewarded for. That makes sense.”

The organization also has a maternity quality enhancement program that has a health equity component to it. “We have a very strong focus on health equity, and improving what we call the social determinants of life,” Jones said. “We actively track members of social determinant needs in our programs, and we also have what we call our Pulse Survey. After a member has an encounter, we send them a text message that that they're able to respond to with emojis and indicate to us how that encounter was with the provider, which we think is very innovative.”

The movement toward including non-traditional providers is something that AmeriHealth Caritas is highly passionate about, he said. “We do include social determinant of life-based incentives in many of our programs. Also, if a provider is interested in moving to a higher risk-type of value-based program, we do have stepping-stone programs that are partial-risk programs that get them there as we work with them over time. That's another thing that I think is pretty unique.”