Humana set a goal of having 75% of its individual Medicare Advantage members covered under value-based relationships by 2017. The insurance giant now has 1.8 million lives, or 85% of that population, in value-based care. As a result, costs decreased by 19%. Dr. Roy Beveridge, chief medical officer, is responsible for the company's clinical policies and overall clinical strategy and joined Humana in 2013. Board-certified in medical oncology and internal medicine, he previously was chief medical officer of McKesson Specialty Health, a subsidiary of McKesson Corp. He spoke with Modern Healthcare public health reporter Steven Ross Johnson. The following is an edited transcript.
Modern Healthcare: How has the transition from fee-for-service to value-based reimbursement driven your population health management efforts?
Roy Beveridge: In the traditional fee-for-service realm, you've got almost an adversarial relationship between fee-for-service providers and the payer. Once you're looking at outcomes, you have this phenomenal alignment. For example, if I'm a physician and I'm managing a patient with diabetes, I don't know whether the patient has gotten all of their prescriptions filled. I don't know whether they've had their eye exams done by someone else. I don't know whether they've had their kidney check done by someone else. The payer actually has all the data, but the provider needs it to manage the patient. And it's not just for diabetes. It's the same thing for every health condition. And if the patient is going to be in the hospital less, if they don't need as much medicine, I'm still getting paid. There are not many things in the world where every single person's interests are actually aligned, and that's what's happened in this value-based world.
MH: Then why has it taken us this long to get to value-based care?
Beveridge: When I started my training, I would see someone who came in with diabetes. I'd write a prescription for insulin. I'd give it to the patient. I'm done. I've just treated your diabetes. Now, what do you think the likelihood that the patient's diabetes actually was optimally controlled, given what I just did? It's not. And so, what we've done now with the use of technology and recognizing that we need to have clinical outcomes, higher quality, now I give the patient a prescription for insulin, but I say, "Hey, do you have the resources to pay for it, and if not, let's get the pharmacist engaged. Do you know that there is a class over here that helps you with diabetic cooking. Do you know that there's a grocery store over here that has classes every Thursday so that you're going to learn not to have starchy, high-glucose foods?" So there's more work on my part, and I'm actually being compensated more now that this patient's healthier.
MH: How do you see technology helping your population health management?
Beveridge: From an IT standpoint, it's not just who got their refill of their insulin. It's also the analytics to understand whether Mrs. Sanchez has a high likelihood of falling. From a scale standpoint, we actually have the analytics that come in from their records and from our claims and all the vendor stuff to know whether this 83-year-old lady in the next year has a high chance of having a fall. And we can give her an accelerometer that warns her if there's a problem.
If you're a smaller provider, you don't have that scale. We buy these things in tens of thousands. It tells us who's at high risk for something, and that's the fundamental change that's occurring. So, not that we should be the technology company, but we should be the company that understands the risks that people have. We should be going out to get what's best in Silicon Valley and bring that in so that our doctors, our providers have the best tools based on the insights that we can help bring our doctors.
MH: What role does Humana play in terms of addressing social determinants?
Beveridge: We looked at patients who had behavioral health issues. If you've got a behavioral health issue and you've got diabetes, your costs are four times higher if you've got diabetes by itself.
We're focused right now on social isolation as probably the greatest determinant of increased costs. We worked with the Robert Wood Johnson Foundation and asked what percentage of people are food-insecure? We guessed in one area in Florida that it was 25%. The number was 50%. Now, let's think this one through. If I'm your surgeon and you have the hip surgery done and I do the surgery—I'm a great surgeon and do everything perfectly—send you home, and you don't have food at home and you're socially isolated, what's the chance of you being readmitted? Astronomically high.
So in that case, we actually ship food to certain patient populations. You can say, well, that's a socially nice thing to do. No, it's actually the medically right thing to do. If we want to just think about it from a cost standpoint, we should be addressing those (issues). If you want to do it from a social standpoint, even better.
MH: On the issue of high drug costs, are there opportunities for collaboration among sectors of the industry to ensure that patients have greater access to medications?
Beveridge: Yeah. We're blessed in being in a country where we've got pharmaceutical companies that have invested tremendous amounts of money in coming out with things that, when I was training for oncology, I never thought I'd see.
The payer world needs to spend more time with the manufacturing world to figure out where these incredibly, wonderfully great drugs should be used, because sometimes expensive drugs don't work in certain people or are not as great as people want them to be.
So we're very, very comfortable using those drug breakthroughs and living in a society where there's a lot of innovation, which is great. Make sure you use the right thing at the right time at the right price point, too.
MH: How have you seen partnerships evolve around population health efforts?
Beveridge: Three years ago, we started something called Bold Goal. We've now done it in 17 cities, but in San Antonio, we work with the local grocery store. We work with a local YMCA. We work with the local government. We work with (more than 100) not-for-profit groups. We work with the big university groups, because we basically said, "Unless we come together as a community to improve the health of the community, we can't succeed."
There's not one entity here who can do it themselves, and if you think you can, you've got more hubris than you should.
So we came in and said we will fund this collaboration, this discussion amongst everyone, and we can get you the actual data, but we have actually improved the net health of the community as a whole significantly in the last three years. Now, I don't think that's happened anywhere else before. So we are using a Centers for Disease Control and Prevention measure called Healthy Days and we've been able to demonstrate an improvement in the population health by doing this collaboration. It's not Humana.
It's not the food bank. . . . HGB is the big grocery store down there. They actually have diabetic classes. They've got nutrition classes for the population. So we're a participant, but we're a community participant with everyone else, and that's how it has to happen.
MH: How has that move toward a greater focus on population health management changed your company's business model?
Beveridge: It makes us realize that our singular strategy is improving the health of these populations that we work with through all the things I've just talked about, and it's a good business model.
If we improve the health, if we financially do better, and the patients do better, our members do better, the community does better, I think that's a wonderful alignment of resources, and it really allows us as a company to get up in the morning and go, "Hey, I'm here. Everyone is here improving the health of the people that we work with."
That's a great way of getting up in the morning and that's a great business model from my standpoint. I'll do that all day long.