First-Ever National Principles for Value-Based Payment

To conform to best practice, a health plan’s value-based payment (VBP) model should meet the following criteria:

Person-Centeredness

1. Defines intended value to patients. At a minimum, the value should include improvements to clinical quality and may also include access, cost savings; health outcomes; efficiency; patient experience; care coordination; equity; and addressing behavioral and social needs.
2. Defines the eligible/relevant patient population.
3. Considers what disclosure or education about the VBP program should be provided to patients about the value-based care arrangement.
4. If there are incentives for cost savings, the VBP arrangements describes and documents how it will monitor and mitigate potential negative impacts on patient access to care.
5. Includes VBP design input from representatives of other health plan departments and functions, including benefit design, provider relations, and medical management.
6. Includes a mechanism to gather and use patient feedback during the design, implementation, and evaluation processes, particularly in accountable care arrangements and relationships.

Provider Engagement and Support

7. Health plans consider and plan for the infrastructure and resource requirements necessary to implement the value-based payment
8. Makes key elements of the program transparent for participating providers. Depending on the design of the value-based payment arrangement, these elements may include:
   • eligible/relevant patient populations
   • performance goals and measures
   • clinical process improvement programs
   • data reporting
   • financial/payment structures
   • administrative requirements
   • patient access expectations
   • data exchange, documentation expectations, and meetings with the health plan
   • discloses the level of risk (including any downside risk) for the provider organization

9. Includes a process for provider appeal of VBP payment decisions, either through existing provider appeals processes or a new process specific to VBP arrangements.
10. Includes a mechanism to gather provider feedback during the design, implementation, and evaluation processes, particularly in accountable care arrangements and relationships

Health Equity

11. Program design should include strategies and capabilities for reporting cost and quality measurements by population segments such as age, race, ethnicity, language, etc.

Program Design

12. Includes measures relevant to the program goals and patient population.
13. Program design should address strategies and capabilities for stratifying cost and quality measurements by population segments such as age, race, ethnicity, language, etc.
14. Considers alignment of measures with those used in similar programs by other health plans (including different lines of business), provider organizations, and government programs.
15. Includes payment incentives for quality. Elements of quality may include patient safety, clinical process quality, equity, patient outcomes, and patient experience.
16. Includes payment incentives for efficiency. Elements of payment incentives may include reduction of total costs of care, avoidance of unnecessary or wasteful care, avoidance of complications of care.
17. Categorizes the structure of payment incentives in accordance with the HCP-LAN framework.
18. If the VBP arrangement includes a prospective payment for a defined patient population, it maintains a process to attribute patients to the appropriate health care provider organization.
19. Defines the data expected from and provided to participating health care providers.

Purchaser Engagement

20. Provides purchasers with a program description sufficiently detailed for the purchaser to understand key elements of the program, including:
    • Performance improvement goals, including any intended benefits to quality and cost of care
    • A description of the patient population the program is intended to support
    • Any additional costs associated with the program, and how such costs are included in claims or administrative fees paid by the purchaser
    • Addressing outlier and high-cost cases

21. VBP arrangements that include performance guarantees should disclose the guarantees and process for remediation if the guarantees are not met.
22. Upon request, provides purchasers access to data specific to the plan sponsor’s population, including:
    • Description and demographics of the population served by the VBP program
    • Performance metrics included in the VBP arrangement, including any quality, cost, utilization, or patient experience measures
    • Evaluation results for the VBP program, including results specific to the plan sponsor’s population.

Program Evaluation

23. Includes a process to identify and mitigate any adverse or unintended consequences of the value-based payment arrangement.
24. Includes a process for periodic formal evaluation and review of the APM, no less than every three years.
25. VBP monitoring and evaluation includes data collected from patients and health care providers. Such data is not required to be specific to the value-based payment arrangement but rather can pertain to overall experience and outcomes.