Seeing value-based contracts in the payer price transparency data

by 
Anav Sharma
MRFs
May 10, 2024

With good reason, payers and providers alike are curious about commercial value-based care (VBC) contracting activity and what their peers have set up outside standard fee-for-service arrangements. 

Though uptake has been limited in commercial plans, VBC represents a significant opportunity for payers to align incentives and for providers to make extra margin on quality and improvements in clinical outcomes.

With the release of the payer price transparency data, several details on value based contracts are finally public information. Serif Health can help you sort through the massive volumes of data being released by payers to find the relevant needles in the haystack for your analyses. 

In this blog, we will cover three arrangements outside standard fee-for-service and how they show up in the payer published price transparency data:

1. Bundles: an arrangement where the payer reimburses the provider a flat rate for a set of services covering a discrete episode of care (e.g., a joint replacement / knee surgery, oncology); services rendered outside the defined bundle remain standard fee-for-service

2. Capitation: an arrangement where the payer ‘caps’, or capitates, what the provider receives for a patient’s care; typically structured as per-member-per-month (PMPM) fee and works well for a health system that can cover the majority / all of what a patient needs

3. Case rates: an arrangement where the payer reimburses the provider the same rate for each ‘case’, regardless of the complexity / acuity of care; e.g., in urgent care, a case rate could be ~$200 per visit irrespective of what services need to occur  

Bundles

Beginning with bundles, we can use Memorial Sloan Kettering’s contract with Anthem / Empire NY as an example:

The two key fields here are:

(A) Bundled Code List: For this bundle, this list contains ~115 different CPT, HCPCS, and Revenue codes that capture the full episode of care from chemo-therapy infusions to diagnostic radiology to occupational / physical therapy & rehab.

(B) Rate: $50,418 – this indicates what MSK receives for the episode of care defined in the bundled_code list Serif Health enumerates. 

Capitation

Capitated agreements follow a similar structure as bundles. An illustrative example here is Sanitas’ medical centers that are exclusive to BCBS Texas: 

The two key fields are once again:

(A) Bundled Code List: This is the set of ~2K codes / services that circumscribe what is included in the contract. Compared to the bundle contract which encapsulates an episode of care, this set of covered services is much more comprehensive and includes primary care, urgent care, lab and diagnostic imaging services, care coordination, and wellness and disease management programs. 

(B) Rate: $9.64 – this refers to the per-member-per-month (PMPM) fee for all commercial covered lives included in this particular BCBS Texas’ network. To extend this unit rate to capture total revenue, additional research / context is necessary to determine the number of active members on the plan. At Serif, we can loop in our partners and subject matter experts in these arenas.

Case Rates

Unlike bundles / capitation which have a clear CMS-defined schema for payers to follow, case rates appear in the price transparency data in several different ways:

(A) Custom codes: Payers like UHC use custom codes outside the standard CPT / HCPCS, CMS Revenue Codes, MS-DRG library to indicate case rates.

For instance, in the example below, United uses a custom code: “EMR” to disclose Optum urgent care centers receive a flat $285 per visit fee. 

(B) Same rate across many codes: Unlike United which uses custom codes, payers like Aetna indicate case rates by showing the same negotiated_rate across various code-ranges. For example, for E&M visits (CPT codes 99202-99205, 99212-99215), typically you see rates increase as you go from 99202 to 99205 since they are for different time-increments (e.g, 15 min for 99202 vs 60 min for 99205).

However, in this scenario, Aetna shows a flat $120 across the code-range. This shows the provider is under a case rate per-visit regardless of services rendered. 

(C) Unique code: Another way case rates appear in the data is the payer instructs the provider to bill a specific code. Continuing with our urgent care example, this could be code S9083: Global Fees for Urgent Care. For the same Optum Urgent Care case rate we saw in United, we can see how Cigna represents this differently using S9083:

Across all these examples, you can notice another pattern amongst case-rates: they do not have any decimals. This makes sense given standard fee-for-service rates typically result from multiplying an assigned % of CMS. In other words, if a number is round, odds are you have identified a case rate in the data! 

As innovation occurs in managed care contracting to evolve past fee-for-service, price transparency remains a key mechanism to see how market leaders have set up their value-based care contracts. Using the data can help with transitioning to novel contract structures, benchmarking existing contracts to both fee-for-service and value-based arrangements, and creating win-win outcomes for provider / payer negotiations. We are excited to help our customers achieve these goals! If you are interested in learning more, please reach out to sales@serifhealth.com or book time here!