To provide consumers with an affordable alternative to high deductible health plans (HDHPs), Altarum has created an innovative new model for those who use health care the most. The Medical Episode Spending Allowance (MESA) plan, developed with support from the Robert Wood Johnson Foundation, is especially well suited for those with chronic or serious health conditions, and takes value-based insurance design to a whole new level, improving quality of care while lowering costs.
“Employers and consumers are looking for alternatives to increasingly unaffordable health coverage, and finding a solution that works is essential,” said François de Brantes, vice president and director of Altarum’s Center for Payment Innovation. “That’s what our MESA Blueprint is all about. By turning the high deductible health plan on its head, the MESA plan significantly reduces the potential for people with on-going illnesses from foregoing needed care.”
How Does MESA Work?
MESA’s incentives are finely calibrated to encourage consumers to seek out high value care and for providers to deliver it. The plan is based on a reference pricing model, so consumers can choose service providers that offer high quality care at a lower price.
Members pay out-of-pocket only when the cost of care extends above the specified allowance for a given episode of care. Plan members who select network providers that have accepted financial risk—for example through a bundled payment—could potentially avoid out-of-pocket expenses entirely. MESA also arms consumers with tools to research procedures, identify providers in their area, and view providers’ costs and quality ratings, so they can select the best care.
“As Americans are being asked to pay more for their health care, health insurance innovations, such as the Medical Episode Spending Allowance (MESA), that align consumer and provider incentives on quality and cost measures are an essential step forward,” said A. Mark Fendrick, MD, director of the University of Michigan Center for Value-Based insurance Design. “Strategies that reduce the patients’ out of pocket cost burden for clinically indicated services provided by from high performing clinicians are a necessary and important strategies to achieve the Triple Aim.”
“The Kentuckiana Health Collaborative, a coalition of employers, payers, providers, and consumers of health care, supports alignment of incentives to reduce barriers to high-quality, high-value care. We strongly encourage efforts to drive adoption of rational, creative alternative payment models and commend Altarum’s efforts to innovate with MESA,” said Stephanie Clouser, Kentuckiana Health Collaborative data scientist.
A New Path Forward
Each MESA benefit is finely tuned to incentivize the physician/patient relationship towards mutual cooperation and motivation to do the right thing, at the right time, in the right place—in a fully transparent marketplace. Information on the benefit model is available in the MESA blueprint, which provides employers and payers with a practical understanding of the framework, including compliance with legal and regulatory statues and actuarial equivalence to existing group health plans.
“MESA provides a comprehensive plan that marries payment reform with benefits reform, provider engagement with consumer engagement, and physician accountability for costs of care with patient accountability for managing their health and costs of care,” said Emmy Ganos, program officer at the Robert Wood Johnson Foundation. “Many of the concepts aren’t new—they are tried and tested—but their combination is, quite simply, a better solution.”
That solution will be tested in selected pilot sites throughout the United States in years to come. The criteria for sites to become pilots include willing employers and providers, current engagement in and familiarity with alternative payment models, and a commitment to price and quality transparency. Those interested in becoming pilot sites should contact Altarum at firstname.lastname@example.org.
From Payment Reform to Benefit Reform
Over the past ten years, the Center for Payment Innovation’s PROMETHEUS Payment® model has revolutionized the way we pay for medical care. PROMETHEUS packages payment around a comprehensive episode of medical care that covers all patient services related to a single illness or condition. The model has been used as a basis for most of the public and private sector bundled payment models that are implemented in the United States today. One of its offshoots is the PROMETHEUS Analytics® software, which can help power the MESA model and now revolutionize health benefits.
Starting next month, Anthem Blue Cross Blue Shield of Georgia will no longer cover emergency department services it determines are unnecessary for members with individual plans.
The insurer said the policy aims to steer patients with nonemergent symptoms to see a primary care physician, urgent care provider or use its LiveHealth telehealth app to limit costly ED visits. If a BCBS of Georgia policyholder receives care for nonemergent symptoms, a medical director will use the prudent layperson standard to deem whether the service is necessary.
Jeff Fusile, president of BCBS of Georgia, told WABE, “The cost of care’s been going up so much faster than people’s earnings. We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system.”
The policy does not include referrals from a physician to the ED for nonemergent services, nonemergent services provided to children under age 14, instances when an urgent care clinic is more than 15 miles away and when care is administered on Sundays and major holidays.
“We’re not trying to steer people away from the emergency room if they have a serious condition,” Debbie Diamond, director of publications for BCBS of Georgia, told Becker’s Hospital Review. “If a member is having chest pain that they think is a heart attack, they should still go to the emergency department.”
Ms. Diamond said similar policies have been enacted at Anthem-affiliated plans in Missouri, Kentucky and Virginia. Missouri said it would reinforce the program June 1 and Kentucky enacted the policy in 2015.
Donald Palmisano, president of the Medical Association of Georgia, told WABE the policy disproportionately affects the elderly, rural residents and children over the age of 14. He added physicians are concerned the policy places “the patient, who doesn’t have the clinical background, to determine whether their condition is of an emergency nature.”