Skip to Content (Press Enter)

Understanding your insurance

Value-based care programs

Your health, financial security and peace of mind are important to us. That's why we've been working with doctors, hospitals, and state and federal government organizations to develop value-based care programs in Arkansas.

Traditionally, when you go to the doctor, a set price is paid for the services your doctor provides. The more tests and services you get, the more the doctor or hospital is paid. This is called the fee-for-service payment model. This healthcare payment model doesn't factor in the quality of your care or whether you get better.

With value-based care, payments to doctors and hospitals are partially based on keeping people healthy, rather than the number of tests or services performed. It rewards physicians for coordinating care, providing appropriate care and for positive health outcomes.

We are involved in three types of value-based care models:

  1. Performance-based programs
    • Patient-Centered Medical Homes (PCMH)
    • Comprehensive Primary Care initiative (CPC, CPC+)
  2. Bundled or episode-based programs
    • Arkansas Healthcare Payment Improvement Initiative (AHCPII)
  3. Collaborative Health Initiatives (CHI)

Performance-based programs (PCMH and CPC+)

In performance-based clinics, doctors receive a portion of their payment based on the quality of care.

Patient-centered medical homes (PCMH)

These are clinics with medical teams that build relationships with patients and help coordinate their care with other medical services outside the clinic, including other resources within the community.

Most of these clinics offer:

  • 24/7 nurse help line
  • Priority appointment scheduling for high-risk patients
  • Same-day appointment slots for urgent care planned into the appointment schedule
  • Short wait times for appointments, and appointments with nurse practitioners and other medical personnel to keep the schedule moving
  • Email and websites for electronic communication
  • Surveys to improve the consumer experience
  • Access to an online care management portal
  • Focus on gaps in care, like preventive screenings
  • Care plans that track the clinic’s and patient’s health goals
  • Focus on health literacy and patient comprehension

The Comprehensive Primary Care Plus (CPC+) initiative

Through the Centers for Medicare and Medicaid Services (CMS), CPC+ supports 182 primary care practices in the state as they change the way they provide care. The state of Arkansas is one of 14 regions nationwide to participate in CPC+. The original CPC initiative lasted four years, included 69 clinics and brought more than $50 million to the state. Support for the initiative is provided by CMS, health insurance companies and state Medicaid agencies. Learn more about the CPC+ program.

Episode-based payments

Through the Arkansas Healthcare Payment Improvement Initiative (AHCPII), Arkansas Blue Cross and Blue Shield has joined with other payers, Arkansas Medicaid and the Arkansas Department of Human Services to reward care coordination, quality and efficiency. An episode of care is focused on all the care provided to treat a single condition for a given length of time.

The following health episodes are covered under AHCPII:

  • Asthma
  • Gallbladder removal
  • Colonoscopy
  • Congestive heart failure
  • Chronic obstructive pulmonary disease
  • Coronary artery bypass grafting
  • Hip & knee replacement
  • Percutaneous coronary intervention
  • Perinatal
  • Tonsillectomy/Adenoidectomy

Let's say you need a knee replacement. In the episode-based payment model, a doctor is designated as the principal accountable provider (PAP) for the knee replacement. The PAP is responsible for ensuring that all other medical professionals and facilities provide efficient, quality care to you related to the knee replacement. Doctors and hospitals share in the savings, or excess costs, of the knee replacement, depending on their performance.

Does it work? We have proven results! When reviewing the episodes of care for knee and hip replacements from 2013 through 2015, here is what we found:

  • Quality: The number of patients who ended up back in the hospital dropped 28 percent, and 44 fewer patients had to go back to the hospital because of infection.
  • Cost: There was a 2.5 percent decrease in the cost of the procedures.
  • Use of Resources: The length of hospital stays was 9 percent shorter.

Learn more about AHCPII.

Collaborative Health Initiatives (CHIs)

CHIs are groups of doctors, hospitals and other healthcare professionals that come together to provide coordinated high-quality care. They are similar to accountable care organizations.

Arkansas Blue Cross collaborates with primary care physicians within a CHI to jointly manage the quality and efficiency of your care. Arkansas Blue Cross produces monthly reports with high-level information to help with the overall management of the CHI as well as detailed reports to your doctor to support your care. Through this collaboration, the CHIs and Arkansas Blue Cross work to meet quality and financial targets.

How does this affect you?

Much of the inner-workings of value-based care go on behind the scenes, but the results can have a positive impact on the care you receive. You can find doctors and hospitals participating in some of these programs through our Find A Doctor or Hospital tool.