How Medical Mutual Helps Our Customers Achieve Value-based Healthcare

The rising costs of healthcare are a concern for you as well as for Medical Mutual. Together we strive to reach a balance between costs and quality known as value-based healthcare. Value-based healthcare focuses on improving the quality of outcomes for your plan participants rather than compensating providers solely on the quantity of services they administer.

As more and more value-based healthcare programs and provisions are put into play, it’s important to understand value-based healthcare as practiced by Medical Mutual including:

  • How value-based contracting with care coordination is defined
  • Care coordination examples
  • How value-based contracting with care coordination is funded
  • Why value-based healthcare is necessary

Read on for more information on how Medical Mutual is implementing value-based healthcare initiatives and contact your Medical Mutual representative for details.

Value-based Contracting with Care Coordination

Value-based contracting is a way for Medical Mutual and our in-network providers to set goals that improve and maintain the high level of care we administer. Through these contracts, providers who meet outlined goals receive performance bonuses. Goals may be around clinical (patients receive preventive screenings), quality outcomes (patients control chronic conditions), utilization (low hospital readmission rates), and satisfaction (reasonable patient wait times).

Care coordination is a vital part of value-based contracting that helps fund services or infrastructure which allow value-based healthcare to take hold and thrive. Care coordination programs are designed to improve health outcomes for your plan participants.

Medical Mutual, along with most health insurance carriers, utilizes value-based contracting with care coordination. It is an industry-wide practice endorsed and used by the Centers for Medicare and Medicaid Services (CMS). It is also a major initiative of the State of Ohio Governor's Office on Health Transformation.

Care Coordination Examples

Care Coordination can take a variety of forms. Medical Mutual works with our in-network providers and you to determine what’s needed and what has the potential for the greatest positive effect. The following outline examples of current care coordination programs in practice.

Hospitalist  Extended Hours  Quality Nurses  Non-medical Staff 
 Hire a hospitalist who sees the practice’s patients who have been admitted to the hospital, reviews care for those patients with any specialists involved and reports on that care to other practice members.  Fund evening or weekend hours for patient appointments. These extended hours allow patients to see their primary care providers when they might otherwise have been forced to seek treatment at an emergency room.  Quality nurses or care navigators are responsible for identifying gaps in patient care such as missing colonoscopies and making outreach to those patients.  Add a dietician or a social worker to a practice who are on-site to counsel patients immediately about healthy eating habits to prevent obesity or community resources for those struggling to pay for prescriptions in addition to utilities.

The Financial Side of Value-based Healthcare

A complete shift to value-based compensation is an evolutionary process, so most of the current models are hybrids. Providers still receive a portion of payments based on the fees for services they administer and they also receive bonuses as outlined in their value-based contracts. You won’t pay more to Medical Mutual; you’ll pay differently.

What we charge your group will be more stable and predictable since value-based payments to providers are fixed. Fee-for-service payments, on the other hand, vary depending on activity making it more difficult for us to anticipate and thus price.

Care coordination programs, such as quality nurses or extended hours, require resources. It’s common for these resources to be funded through a per-member-per-month (PMPM) fee collected by Medical Mutual. Because care coordination is intended to improve the health of your plan participants, it’s important to note Medical Mutual does NOT retain any portion of the care coordination fees we collect.

The Importance of Value-based Healthcare

Value-based healthcare elevates the level of care your plan participants receive.

  • Care is focused not on quantity of services, but on activities that enhance the health of your plan participants.
  • Employing value-based contracts and care coordination reduces your organization’s healthcare expenses.
  • Money saved by offering appropriate care, rather than volumes of care, offset the value-based compensation and care coordination fees you pay.

Medical Mutual recognizes the move to value-based healthcare is a paradigm shift. We are committed to improving the delivery of healthcare for your plan participants. Value-based contracting and the promotion of care coordination activities will play an ever increasing part in achieving that goal.