Humana Joins Traditional Medicare Value-Based Contracting Model

Humana has announced that it will be participating in a CMS traditional Medicare value-based contracting model and will offer coordinated care for traditional Medicare beneficiaries.

“We’re honored that Humana Care Solutions is one of only 53 organizations selected to participate in this innovative value-based model, which strives to accelerate the shift away from fee-for-service across the nation while providing greater financial consistency for providers,” said Oraida Roman, vice president of value-based strategies at Humana.

“This is important and exciting work, to collaborate with clinicians and expand the availability of value-based care beyond Humana’s membership, and in a way that supports physician organizations during uncertain times.”

As of June 30, 2020, Humana served almost 8.4 million Medicare beneficiaries, 4.5 million of whom were in Medicare Advantage plans.

The payer will develop value-based contracts with providers in order to facilitate care coordination for beneficiaries as part of the Global and Professional Direct Contracting Model (“Direct Contracting Model”).

This is not the same model as the Geographic Direct Contracting Model, which is still under review.

“The DCM was established by the Innovation Center at the Centers for Medicare & Medicaid Services (CMS) to encourage physician organizations, and other types of health organizations, to voluntarily transition from fee-for-service to value-based care and test whether the model will improve quality and reduce costs in Original Medicare while reducing organizational administrative burden,” the press release summarized.

The model launched on April 1, 2021. As of May 4, 2021, Humana had already partnered with 420 primary care providers as of May 4, 2021 who will enter into value-based contracts with Humana Care Solutions—the direct contracting entity.

The Humana direct contracting model will operate in Florida, Texas, and Washington, according to the CMS Center for Medicare and Medicaid Innovation (CMMI) notice. However, the entire model will serve 38 states, the District of Columbia, and Puerto Rico.

Payers were able to choose between the global risk-sharing option and the professional risk-sharing option.

According to the CMMI website, the global risk-sharing model is the highest risk-sharing arrangement and uses either primary care capitation or total care capitation for payment. This model requires 100 percent risk sharing. The professional model is the lower risk-sharing arrangement at 50 percent risk-sharing and leverages primary care capitated payment.

Most of the participants (39 direct contracting entities) selected the global-risk sharing option, the notice shared.

The participating payers’ contracts are broken down into multiple categories, according to the CMMI website.

These categories include standard direct contracting entities (which already have experience serving traditional Medicare beneficiaries), new entrants (entities that have not served traditional Medicare beneficiaries in the past), and high needs population direct contracting entities (entities serving beneficiaries with complex care requirements).

With over three decades’ worth of experience providing value-based care services, Humana will be participating as a standard direct contracting entity.

“Humana Care Solutions will take on quality and cost accountability for the care of aligned Original Medicare beneficiaries,” the press release explained.

“Furthermore, Humana Care Solutions will support providers with clinical and analytical capabilities to improve care coordination and drive a more holistic approach to patient care that goes beyond traditional clinical treatment.”

The payer has been engaged in multiple value-based contracting models in the past few months. In 2020, Humana announced that it would be participating in the CMS Primary Care First model. In February 2021, the payer launched a Medicare Advantage value-based care model to promote hospice care coordination.

CMMI has been enhancing the Direct Contracting Global and Professional model in recent years, improving benchmarks and risk adjustment methodologies.