Commercial Population

Contributing experts: Morgan Kendrick and Tich Changamire, MD

Commercial health plans serve a range of customers — from individuals to large, multinational, self-insured employers. In the U.S., employers have a long history as the predominant buyer of health insurance, covering approximately 45% of the population.¹

Our Commercial health plan affiliates serve more than 27 million consumers in 14 states.^{2, 3} Through our local density and national scale, we have been well-positioned to advance the shift to value on behalf of employers. Our health plan affiliates designed networks that offer choice and incentivize value over volume to deliver employee coverage that leads to better health outcomes at lower costs.

Care providers of all types — from primary care to specialty to hospital and post-acute care — participate in and perform well in our value-based care arrangements.

A Conversation on Value-Based Care

Listen to Tich Changamire, MD, Vice President and Chief Medical Officer, Commercial Health Benefits, Elevance Health; and Kevin Wang, MD, Chief Medical Officer, apree health, discuss the benefits they have seen from value-based care for the commercially insured population, including how it helps drive quality and affordability.

Dr. Tich Changamire:
Kevin, thanks so much for joining us this afternoon to talk about value-based care, a very important topic in the industry. What has been your experience, just providing whole health in a value-based care setting compared to a fee-for-service setting?

Dr. Kevin Wang:
We see the vast majority of a member's barriers to care are not clinically related. Perhaps it's affordability; perhaps it's access to care; perhaps it's some combination of both.

And so, when we look at value in totality, really, it's, hey, can we address the totality of a member's needs? And oftentimes that gets very expensive when you think about a legacy fee-for-service model, because every intervention then has some cost to it, which then has some reimbursement to it.

And the biggest inflection point we saw was, hey, can you bundle those pieces into one payment mechanism so that your members with the highest needs can access care without feeling like there's a hindrance or financial burden to it?

Tich Changamire:
Can you talk a little bit about what you have learned along the way from all the stops in your career in terms of value-based care, and what has convinced you that, actually, value-based care works for the Commercial population?

Kevin Wang:
I think number one is access to the Commercial population. You have to be able to get that member. You have to be able to engage that member over time.

Two is you have to have a means in which you can engage that member in different modalities. Sometimes that's digital. Sometimes that's rural and remote. Sometimes that's in-person care.

Third is, when you actually deploy value-based care, we believe that primary care is at its center — the ability to deliver preventative care and address gaps in quality, and enough acute care to address more transient transitional needs.

We just had a case last month where, you know, a member came in for, you know, blood in the urine. Sometimes that's a small thing. In this particular case, primary care was able to work up the member faster than perhaps waiting for a specialist appointment.

Not only that, they were able to get another third party test, like a cystoscopy, even faster than a member self-navigating. And that's one of those cases where, hey, if you leave the complexities of that up to a member, it's very hard for a member to know where to go.

'Where do I go for this test? How do I get an appointment? What if I call and the first available appointment is six to eight weeks from now?'

A lot of those things are not acceptable. And so, when primary care is at the center, and primary care can help enable a member to make the right decisions and, oftentimes, help them get care they need, even if that's outside primary care, that's an element that needs to be ingrained in order to manage a population effectively.

Tich Changamire:
There are still some employer groups that are skeptical about value-based care. What advice or what words would you say to them?

Kevin Wang:
Number one: There are organizations out there, on the carrier side, the payer side, as well as other employers, that are absolutely in this value-based Commercial space today, that have demonstrated outcomes. So, number one: Seek to find those to understand. We can connect you.

Two is, if you're a provider group watching this, look to see where your current blind spots or known unknowns may be. And so, when we think about the construct about knowing the population, engaging them, and managing them, where is it on there that you think there's the biggest delta? And oftentimes, again, you can find organizations there that can help to connect to you.

And number three is, you know, we talked about the actual, you know, reimbursement mechanism of value-based care. There are lots of different ways this manifests today that align better between a provider, payer, and patient — better in terms of the reimbursement mechanism, more aligned to clinical outcomes, more efficient with the areas that are incentivized. And again, those have been out there and in play for many, many years now.

So, I would say, you know, seek to understand, know your current gaps, look at where to engage groups that have been in this space, and know it's possible.

There are close to 1,800 care provider organizations, representing over 100,000 healthcare professionals, participating in our value-based payment arrangements.⁴ Through these solutions, we've driven measurable improvements in the quality and affordability of care for our Commercial population.

Enhanced Personal Health Care

Enhanced Personal Health Care (EPHC) is our health plan affiliates' main value-based payment arrangement for the Commercial population and is the nation's largest value-based solution tailored to meet local market needs.⁵

EPHC is designed to improve quality outcomes and control cost-of-care trends in local markets. Care providers participating in EPHC are incentivized to deliver quality, efficient care by focusing on prevention and wellness, offering personalized plans, and coordinating treatment across the care spectrum.

When comparing critical health indicators among our Commercial consumers in value-based arrangements to those who are not, we've seen an impact on that population's health.

Our decade-long experience with Enhanced Personal Health Care has facilitated our understanding of what helps care providers succeed in value-based care arrangements. Now, we are bringing that experience to bear as we expand our value-based care work in medical specialties, including oncology.

Commercial: Value-Based Care Versus Non-Value-Based Care⁶

Medication Adherence for Cholesterol: 2.9% higher
Breast Cancer Screenings: 6.5% higher
Colorectal Cancer Screening: 7.1% higher
Well-Child Visits in the First 30 Months of Life: 7.7% higher

Oncology Medical Home Plus

While much of the conversation around value-based care focuses on investing in primary care, we are working to enable specialists, too, particularly to drive outcomes for consumers with more chronic and complex conditions. Launched in 2022, the Oncology Medical Home Plus (OMH+) program incentivizes high-value care by leveraging digital resources, population health analytics, and practice transformation tools to support improved care provider decision-making and access to equitable, quality, and more affordable cancer care for our consumers.

With close to 100 care provider practices participating in 14 markets across the country, OMH+ was designed to accelerate momentum, shifting medical oncologists in all practice settings to value-based care.⁷ The program leverages our collaborating vendor's broader network of existing relationships with smaller oncology care providers.

OMH+ features financial incentives for care providers who prioritize patient-centric oncology care and drive better outcomes for their patients in an upside-risk arrangement that introduces accountability for quality and cost performance.

With projected cost-of-care savings of 2.2% in the Commercial line of business, the program's success will help us build value-based care arrangements for other medical specialties, including programs that will be managed with support from our subsidiary, Carelon.⁸

1 Kaiser Family Foundation, Health Insurance Coverage of Nonelderly 0-64 (2022): kff.org. 2 Elevance Health press release, Elevance Health Reports Q3 2023 Earnings (October 18, 2023): elevancehealth.com. 3 Elevance Health, Q3 2023 Corporate Fact Sheet (2023). 4 Elevance Health, internal reporting (December 2023). 5 Elevance Health, EPHC Longitudinal Impact on Cost and Quality: Health Affairs Publication (February 2023). 6 Elevance Health, internal reporting (2022). 7 Elevance Health, internal reporting (2023). 8 Elevance Health, internal reporting (2023).

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