VBC May Poorly Affect Health Equity, Amazon Adds Health Offering

January 11, 2024 - Value-based care efforts have aimed for health equity, but one Health Affairs study found evidence that some value-based purchasing efforts may maintain care disparities for Black Medicare beneficiaries.

Additionally, Amazon announced it will add a new capability to its repertoire of healthcare capabilities. On top of its existing virtual care, pharmaceutical, telehealth, in-home, and preventive care offerings, the company's Health Condition Programs will allow patients to access digital health benefits for chronic diseases.

Meanwhile, the OCHIN Epic Electronic Health Record Network has received nine community health organizations into its ranks. The network aims to improve access to care in underserved regions.

Finally, Elevance Health has legally challenged the Department of Health and Human Services on its Medicare Advantage star ratings methodology. The payer expects to lose $500 million in quality bonus payment revenue in 2025.

Kyle Murphy: Hello and welcome to Healthcare Strategies | Headlines.

Kelsey Waddill: Woo-hoo.

Kyle Murphy: In today's episode...

• OCHIN Adds Nine New Community Health Organizations to Network
• Value-Based Care Appears to be Failing Black Medicare Beneficiaries
• Amazon Enables Digital Health Benefits Check for Chronic Conditions
• MA Plan Looks to Take HHS to Court Over Star Ratings

It's good to be back. This is Kyle Murphy, vice president of editorial Xtelligent Healthcare Media, and as always, I am joined by the newly promoted...

Kelsey Waddill: Woo-hoo.

Kyle Murphy: ...managing editor and multimedia manager, Kelsey Waddill. You really earned it. You really did it, huh? You really conquered 2023.

Kelsey Waddill: It only took like seven episodes of Healthcare Strategies | Headlines.

Kyle Murphy: That was the deciding factor. Should we promote her? What has she done? I'm like, "Well, she recorded a few episodes of Headlines." It's not easy to do this podcast.

Kelsey Waddill: It is not. We have to come up with jokes, we have to come up with questions at the beginning about what we like and don't like.

Kyle Murphy: Exactly, and then at some point I have to say something like, "Let's get to the headlines."

Kelsey Waddill: Which...

Kyle Murphy: So, let's do it.

Kelsey Waddill: All right.

Kyle Murphy: Here we go. In the last quarter of 2023, eight ambulatory community healthcare organizations and one rural hospital—eight plus one equals nine—join the OCHIN Epic Electronic Health Record Network. This expansion is part of a broader initiative to enhance care access and streamline clinical workflows—I've never heard that phrase before. The new members are part of OCHIN's growing network that already serves over 5.5 million—with an M—patients across 2,000 healthcare delivery sites nationwide—nationwide (singing).

Kelsey Waddill: (singing) is on your side.

Kyle Murphy: This implementation aims to meet the needs of community-based healthcare providers—we know how important those folks are—and improve care access in underserved populations.

Established in the year 2000—the year 2000 [fake British accent]—through federal grant funding, OCHIN was initially created to link six Oregon community health centers. Wow, it really exceeded that mission, huh?

Kelsey Waddill: Yeah.

Kyle Murphy: The aim was to equip these centers with the most effective health information technology and supportive services, fostering health improvement within their local communities. Its partnership with Epic dates back to 2001 to offer an EHR platform tailored to the unique needs of healthcare providers in community health centers, as well as rural and medically underserved patients.

So Kelsey, community health centers typically lack the resources to invest in some of the more sophisticated health IT systems, despite their critical nature in terms of what they work on. So, how important is it for the health IT community to support these types of organizations and the providers that work there?

Kelsey Waddill: I think it's obviously vital. We're becoming more and more dependent, year over year, on technology in healthcare—in case nobody noticed that—and organizations that don't have access to these technologies, which by the way can be very expensive to implement, are going to fall farther and farther behind. And the consequences are not just for the hospitals—many of which, by the way, in rural areas are shuttering—but also for the patients who really deserve to be able to see their full medical record and to have their doctor be able to access their full medical record. So, I think the growth that this network has experienced over the last two decades really speaks to the demand for this kind of a resource.

Well, speaking of underserved communities, value-based care appears to be failing Black Medicare beneficiaries.

Are value-based purchasing models delivering on their health equity promises for Medicare beneficiaries? One Health Affairs study says not necessarily. Although Medicare's value-based purchasing model was designed to reward providers for keeping patients out of the hospital and penalize poor outcomes, hospitals serving primarily Black communities have been disproportionately negatively affected.

This study in particular focused on the results related to three conditions: acute myocardial infarction, heart failure, and pneumonia. The researchers looked at the 30-day mortality rates for these conditions and compared high proportion Black hospitals to their counterparts both before and after value-based purchasing implementation.

Overall, 30-day mortality rates for these conditions did not worsen between hospitals with majority Black patient populations and non-majority Black patient populations. However, for pneumonia, Black patients saw worse outcomes after value-based purchasing was implemented. High proportion Black hospitals continued to see higher rates of mortality for acute myocardial infarction and pneumonia than their peer hospitals, even after value-based purchasing went into effect.

The authors situated these results within a body of research showing that value-based purchasing models have disproportionately penalized high proportion Black hospitals. Now, CMS has started to account for the unique challenges that these facilities face by introducing a proposed rule that would incorporate a health equity adjustment bonus into the value-based purchasing model and requiring hospitals to collect more health-related social needs data.

Kyle Murphy: I think it's important. I think it's great that they've recognized this issue. I think when it comes to value-based care across the board, there needs to be a lot of strategic work done to ensure that these programs benefit the greatest number of people and where there are shortcomings or weaknesses, that those are shored up. And I think it's probably going to become more pronounced as time moves forward, just as we understand about just the way the healthcare systems disproportionately serve the communities, depending on whether you're urban, rural, rich, or poor. So, to ensure that these disparities don't get larger, CMS needs to fine-tune on a more regular basis, and in the past they would do that. So, I hope this is part of a much broader effort to really be self-critical to ensure that these programs actually have their intended effect, and it's not just "the rich get richer and the poor get poorer."

Kelsey Waddill: Studies like this are important.

Kyle Murphy: A step in the right direction. No program is perfect. Running a federal program is very, very difficult. So, there needs to be fine-tuning and there needs to be a lot of feedback and research. The only way we can improve as a healthcare system is by pooling our resources and our knowledge, so I'm optimistic.

Kelsey Waddill: And not assuming that something that says it's health equity driven is going to automatically result in lower disparities. Sometimes, like you said, it needs tweaking.

Kyle Murphy: Hell yeah.

Well, if there's a company that's definitely winning overall in terms of the healthcare space, it seems to be Amazon.

Amazon has launched the Health Condition Programs, an initiative to connect healthcare consumers with digital health benefits for chronic conditions through their employer or insurance. Partnering with Omada Health, the program targets conditions like pre-diabetes, diabetes, and hypertension. Consumers can check eligibility on Amazon's website and access benefits like health coaching and connected devices. Amazon aims to make healthcare benefits more accessible and is addressing data privacy concerns in accordance with HIPAA regulations.

The partnership with Omada Health is a strategic move to expand Amazon's influence in the healthcare sector, which is by no means small. Amazon continues to expand its offerings. Amazon Health comprises Amazon Pharmacy and Amazon Clinic, a virtual health service that delivers convenient, affordable care for more than 20 common conditions, such as allergies, acne, and hair loss. Amazon Care provides virtual care visits as well as free telehealth consultations, and in-home visits for a fee from nurses for testing and vaccination. And they recently acquired One Medical. It's a virtual and in-office care service that provides preventative care and chronic preventive care management for chronic illnesses, pediatric, and mental health concerns.

Kelsey Waddill: Got all the bases covered.

Kyle Murphy: Got all the bases covered. I hope so; Amazon is a struggling company.

Thinking [about] this holistically, are all these options, are they creating more convenience at the expense of the goal of longitudinal, personalized, coordinated care in your opinion?

Kelsey Waddill: This might seem like a bit of a cop-out, but I think that time is going to have to tell on that because I think--

Kyle Murphy: Boo.

Kelsey Waddill: --we're still exiting out of the pandemic phase when these sorts of things... Reliance on this was necessary, but I think what we're seeing right now is definitely that there are some trade-offs. The New England Journal of Medicine published a survey that said that 70 percent of healthcare leaders globally agree that retail care settings produce lower quality of care than primary care settings, which is obviously a problem. And nearly half of those participants also said that they were concerned about what you just referenced, about tracking patients through the system and coordinating care. But at the same time, two-thirds of the respondents had to acknowledge that patients like retail clinics, that patients have a positive view of these facilities that provide easy, convenient access to care.

So, I think it's going to be hard to wean the public maybe off of retail clinics and providers are just going to have to start finding ways to acquire that information about what's going on in those clinics, probably through partnerships and technology.

Kyle Murphy: I would say that I think these offerings have a place, and I think a lot of that's for non-acute sick care when you just need something quick. But when it comes to managing an individual's full health--that's a primary care thing. You need someone to kind of steer. So, obviously the dust needs to settle on a lot of this stuff, like you said, but my concern is if people are only receiving care through these outlets, that their health experience is not going to be organized. The onus is going to be on the individual to remember all these things. And where does that information live and how do you analyze those trends? You can't, as far as I understand it, because your information is spread across numerous systems, so we call that fragmentation. So, we'll see what happens, but access is better than no access.

Kelsey Waddill: Well, we're going to wrap up with some legal drama. A Medicare Advantage plan looks to take HHS to court over star ratings.

Elevance Health has filed a lawsuit against the Department of Health and Human Services, challenging the methodology used for calculating Medicare Advantage star ratings. The payers' complaint about the changes in the rating system alleges that these modifications led to inaccurately low scores for 2024, violating the Administrative Procedure Act. The lawsuit claims that the new method called the Tukey method--

Kyle Murphy: Not the turkey method, the Tukey method.

Kelsey Waddill: Not the turkey method, which is actually how I read it the first time that I saw that term.

The Tukey method used by CMS to determine ratings does not adhere to, according to Elevance Health, the regulation that limits cut point adjustments to 5 percent each year. This has led to a significant reduction in the number of high-rated plans. Only 42 percent of health plans achieved a four-star rating or higher in 2024 compared to 51 percent in 2023.

But if you know anything about Medicare Advantage star ratings, you'll know that the actual quality rating is not the only thing this major payer is worried about. Star ratings impact Medicare Advantage Plan bonus payments with the goal of rewarding plans that have better quality with higher pay. So, these lower scores affected Elevance Health's eligibility for quality bonus payments. More specifically, in an October earnings call, the payer predicted a $500 million drop in its quality bonus revenue in 2025. Elevance Health's goal is to receive a redetermination of the 2024 star ratings and bonus payments.

Kyle Murphy: Well, I think what ends up happening is that some of these payers are understanding or coming to terms with the reality of being in an incentive-based program. There can't just be winners all the time. Medicare Advantage, Part C, has become the cash cow that has really led to incredible growth for some of the largest payers in the country who do really, really well. And we haven't necessarily seen a massive improvement in outcomes for Medicare beneficiaries who opt into this, which is now more than half of the Medicare population. I just think you're coming to terms with the reality, which is everyone is going to be five stars all the time. If you are perfect all the time, then there's probably an issue with the system. I can't wrap my head around this, but I understand these organizations, because some of them are for-profit; they're worried about their bottom line because they're counting on these bonus payments, but that's the risk of doing business in healthcare.

Kelsey Waddill: Right, it's risk-based payment.

Kyle Murphy: If you're risk averse, then sorry, it's probably not the playground for you. With that, and this 2024 Medicare Advantage plans are going to be audited.

Kelsey Waddill: Yes.

Kyle Murphy: There's going to be some audits about whether their payments are accurate because the documentation does or does not support the health status and the RAF scores and everything like that. So, I think this is going to be a rather scrutinizing year for MA plans, and rightfully so. You do business with the federal government and you are going to face scrutiny, and these organizations shouldn't be surprised. They can try all they want using these legal recourses. I understand that, but I think they just didn't do a great job of reading the fine print.

Kelsey Waddill: We'll see what happens with this one.

Kyle Murphy: We'll see what happens, and that concludes today's episode. Kelsey, good to see you as always.

Kelsey Waddill: Good to see you. 2024! New year!

Kyle Murphy: All right, 2024, here we come. Make sure to subscribe, like us on Apple, Spotify, or wherever you consume your podcasts. Welcome back, everyone. Take care.