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HTN Lunch & Learn: Novel Payments Models for Specialty VBC Models with Accorded

We discuss novel payments models for specialty VBC with Frank Cheung, Co-Founder of Accorded & Mike Goodman, Co-Founder of Oshi Health.

​Value-based specialty care models are the topic of discussion across the Health Tech Nerds community and the broader healthcare industry. From founders tackling emerging VBC models to investors diving heads in first to support them to clinicians delivering care to these specialty populations, stakeholders across healthcare are wrapping their heads around the dynamics of VBC-enabled specialty care and looking to shape the future of these care models.

​Of course, these are complex and ranging care models - from cardiology to oncology to chronic kidney care - each with unique payment structures. 

To help bring clarity to the emerging payment structures, we sat down with Frank Cheung, Co-Founder & CEO at Accorded, and Mike Goodman, Co-Founder & Head of Strategy & Operations at Oshi Health, to discuss how Accorded is simplifying value-based contracting for emerging VBC specialty care models through its actuarial expertise and data platform.

We walked through a case study example from Oshi Health to unpack how to handle attribution, claims analysis, and more for its unique GI care model.    

Below is a summary of key takeaways from our conversation. 

Table of Contents 

  • Introduction to VBC in Primary Care

  • VBC Challenges in Specialty Care

  • VBC Contracts Take Many Forms

  • Key Tenants of GI Claims Analysis

  • Technology and Standardization in Claims Analysis

  • Specialty Care Provider Considerations

You can check out the full recording of the live interview below. 

Now, onto the highlights!

Note: The following interview has been summarized for brevity of key points. Please watch the full recording for in depth answers from Frank & Mike.

Introduction to VBC in Primary Care

The session kicked off with a foundational overview of the progress of VBC in primary care, specialty care and its significance in the healthcare landscape. 

See full recording snippet here: (1:16)

  • While progress has been made on implementing VBC in primary care, only ~30% of spend is addressable by primary care. Specialty care models are needed to address the remaining 70% of spend. Notably, most of those specialty care contracts are still FFS.

  • Large investments from VCs, established incumbents, and other institutional investors have helped provider groups, MA plans, and ACOs establish the infrastructure to manage those primary care risk contracts.

VBC Challenges in Specialty Care

Frank delved into the specific challenges that specialty care faces in adopting VBC contracts, highlighting the complexities of the current system. 

See full recording snippet here: (2:47)

  • Frank outlined the concept of specialty care models and the hurdles in implementing value-based care - specifically diving into the difficulties with payer contract terms, reimbursement models, and the role of data analytics in specialty care. 

  • The need for a comprehensive approach in reimbursement models was emphasized to better define specialty care. 

VBC Contracts Take Many Forms

Frank provided an overview of the spectrum of contract forms that exist - from FFS to global capitation through the lens of specialty care. 

See full recording snippet here: (5:28)

  • He highlighted the reason for having so many types of contracts is due to the fact that there is no standard way to reimburse for specialty care. This is a result of the variance of specialty care models, due to condition type, point of patient interception, and more.

Key Tenants of GI Claims Analysis

Reimbursement models are a critical component in the value-based care equation, as discussed by our speakers. 

See full recording snippet here: (14:36)

  • Mike shared insights from Oshi Health's experience in analyzing specialty care spend, ultimately realizing that they needed to create their own methodology.  

  • To set up this GI claims analysis, they dig into the comprehensive approach to capture relevant ICD-10, CPT, DRG, NDC codes, understanding of practice-driven coding variance when defining condition spend, isolating the GI care journey to ~12 months of spend surrounding the visit, and acknowledging patients suffering in silence due to stigma, etc. 

Technology and Standardization in Claims Analysis

Mike discussed the role of Accorded’s actuarial platform to help process the analysis and standardize the methodology across various populations, ultimately helping them in contract negotiations with payors. 

See full recording snippet here: (23:47)

  • He dug into the potential avenues for claims analysis, discussing the approach, considerations, and risks to each. The avenues were as follows:

  • Utilize claims framework and code set to perform analysis with internal data, analyze MarketScan claims data filtered on specific geographies, leverage an actuarial partner (Accorded) to generate claims analysis.

Specialty Care Provider Considerations

Looking ahead, the presentation briefly touched on the evolving landscape of value-based contracting and considerations for specialty care providers. 

See full recording snippet here: (25:20)

  • Mike went on to discuss opportunities beyond the initial agreement to contract terms, talking about expansion opportunities and future considerations.

  • He highlighted the need to balance the tension between what payors want (standardization) and what providers want (uniqueness), having a fully fleshed out model when approaching payors, and data sharing & reporting.  

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