How Value Based Care Works

We work with doctors to establish benchmarks for care based on national data and best practices.  Providers then demonstrate that they’re meeting or exceeding expectations by providing us with specific performance metrics.  As a result, patients receive the best coordinated and evidence-based care possible.  And providers are rewarded for the quality of care they deliver. 

In a value-based care arrangement, the patient’s primary care physician manages and coordinates all the patient’s care, not just the care he or she provides. This gives the physician a more complete picture of the patient’s health and interactions with the health care system. This results in better care more effectively delivered, which in turn results in less fragmentation, confusion and frustration for patients.

We provide PCMH and ACO providers with in-depth data about their Blue Cross and Blue Shield of Nebraska patients’ health care, in¬cluding emergency room visits, medications and summarized claims data from other providers so they could get a complete picture of their care, not just the care obtained from them. We also help them understand variations in the cost of treatment options and hospitals.

PCMH and ACO physicians are provided care coordination payments every quarter.  The payments are risk-stratified so that providers are receiving more financial support for care coordination and case management activities for their patients with the highest illness burden.  

If the physicians perform better than expected at keeping their patients healthier, avoiding complications and unnecessary care over the course of the year, they are rewarded financially. In addition to being rewarded for better than expected outcomes, ACO providers also share in the risk, meaning that if their costs come in higher than projected, they are required to pay back a portion of the payment.

 

HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.