An overview of key vendors and providers at the intersection of care coordination, value-based care, and tech-enabled care delivery

INTRODUCTION TO THE MARKET

In 2010, Donald M. Berwick, Thomas W. Nolan, and John Whittington, published a now-famous report titled, "The Triple Aim: Care, Health, And Cost", which laid a framework for improving the value of health care in the United States via the simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. The paper added a third pillar, patient experience, to Michael Porter and Elizabeth Teisberg’s previously established definition of value-based care (VBC), which introduced to the world in his 2006 publication, “Redefining Health Care: Creating Value-Based Competition on Results,” using a simple equation:

 Patient Value =

Patient-Relevant Outcomes / Costs Per Patient to Achieve These Outcomes

Ever since these two reports initially defined VBC, fixing the healthcare value problem in the USA has become an increasingly hot topic across the industry, especially as organizations like The Commonwealth Fund began measuring and reporting, in 2014, the dire state of affairs in our nation relative to other parts of the world:

The United States reportedly ranked last across eleven developed countries based on various value-based measures: quality, per capita cost, access, efficiency, equity, and healthy lives. With the total US healthcare spending exceeding $3.8 Trillion in 2019, there is a pressing need to reduce cost but maintain quality. To fix the problem, providers and payors began working to address the healthcare value problem in three main ways:

1. Alignment of Incentives: Payors and providers began to contract with each other in new ways, moving away from fee-for-service towards reimbursement linked to improving cost, quality, and patient experience
2. Longitudinal Care: Payors and providers began to invest in programs focused on improving care across a continuum versus treating point-in-time ailments on an encounter-by-encounter basis
3. Innovations in Technology: Payors and providers began to invest more heavily in technology aimed at improving performance across value-based contract and care coordination program measures

To achieve VBC, data is of penultimate importance to track patient-oriented outcomes. Arguably, with the rise of novel machine learning algorithms, better technology management services, the integration of novel health monitoring devices, and interoperability of data flow from EHRs and other health portals, it is now possible to better tie patient outcomes with cost spent on their care. The recognition that value can be grouped to specific patient needs has changed the approach towards achieving VBC with medical services. This activity has spurred the development and rapid growth of three new healthcare vendor and provider market segments:

1. Value-Based Care Vendors: These vendors primarily sell solutions to payors and providers to improve contractual performance across three domains: 
2. Risk Adjustment: Focused on increasing risk-based reimbursement through specific & accurate diagnostic hierarchical condition coding (HCC) coding
3. Quality: Focused on increasing care outcomes and associated reimbursement through performance against the defined Healthcare Effectiveness Data and Information Set (HEDIS), Medicare Stars, and other quality measures
4. Population Health: Focused on reducing per member per month costs through longitudinal, data-enabled, clinical workflows while improving performance across Medical Loss Ratio- & Capitation-based contractual measures
5. Care Coordination Vendors: These vendors primarily sell solutions to payors and providers to support four main types of programs:
6. Care Management: Focused on enhancing coordination of care, eliminating duplication & waste, and helping patients and caregivers more effectively manage their health conditions by coordinating care teams
7. Disease Management. Focused on disease-specific care interventions and communications for defined patient populations with specifically defined conditions & needs
8. Transitions of Care: Focused on coordinating care for patients as they move from one healthcare setting to another such as when a patient is discharged from an inpatient hospital to their home
9. Utilization Management: Focused on eliminating waste in healthcare by evaluating the efficiency, appropriateness, and medical necessity of treatments, services and procedures provided to patients on a case-by-case basis
10. Risk-Bearing, Tech-Enabled Providers: This new wave of next generation providers has four main characteristics:
11. Investment into Technology: Focused on building care delivery and reimbursement models around VBC and care coordination technology that helps optimize performance across risk-based contracts and quality/cost measures
12. Risk-Bearing Entities: Focused on entering into a higher ratio of VBC contracts versus fee-for-service contracts with payors when compared to “traditional” primary care providers, these providers then use value-based care and care coordination technology to drive performance across their risk-based contracts
13. Home Health: Although it is not a strict requirement, these providers often focus on caring for and tracking their members not only in their offices but also in their homes
14. Virtual Care: Again, it is not a strict requirement, but these providers often use remote patient monitoring and/or telehealth capabilities to enhance to track and care for their patients no matter where they are which has seen expansive growth given the Covid-19 Pandemic

While these three new technology market segments are distinct from one another in a myriad of ways, they also share enough similarities that it is very common for one organization to offer capabilities in one or more of the three areas. Considering the possible overlap of these technology innovations and possibility for consolidation of services, progressive companies are looking to offer multiple options. Companies will likely advance one key area or expand to other markets, as seen with a series of acquisitions and partnerships formed in the past decade.

This market research report highlights a select handful of key incumbent and emerging pioneers in each of these new market segments and offers insights on the three sectors with recent advancements in investments, changing landscape, and factors impacting growth.

KEY TRENDS / EXECUTIVE SUMMARY

The Covid-19 pandemic, regulatory environment, and evolving consumer preferences have served as a catalyst for advancing the development of multiple health industries within the United States. All three sectors are assessing how the pandemic has shifted health care needs and have begun integrating new services (e.g., telehealth) to maintain relevance. Multiple companies are expanding their services digitally to their members and pivoting away from a reliance on direct face-to-face care. With a drop in volume of direct patient care, providers and organizations who primarily contracted under fee-for-service (FFS) payment schemes saw decreased revenue, and placed a larger focus on their VBC contacts and other revenue generating services or cost-minimization tools (e.g., care coordination). Nonetheless, all three sectors have seen major changes as highlighted below:

Market drivers for adoption

Value-Based Care

●        5% of the US population accounts for 50% of national healthcare spending. Adoption of VBC will be further developed to address the most resource-intensive populations.

●        60-70% of total US health spending will be tied to quality and value by 2025.

●        CMS’s Medicare Access and CHIP Reauthorization Act (MACRA) forces all providers to choose a reimbursement program that includes value-based incentives to receive full federal insurance payment in 2019 for quality & cost measures from 2017 dates of service.

●        CMS’ alternate payment programs such as their bundled payment programs require providers to deliver lower cost & higher quality care for business model continuity.

Care Coordination

●        Up to 80% of medical errors are related to lack of communication in patient care coordination.

●        The Pathway to Success and Promoting Interoperability programs proposed by CMS have created a regulatory tailwind for care coordination organizations. The pandemic has required HCOs to increase staff for care coordination services.

●        New reimbursement codes for remote patient monitoring and chronic condition management have created new revenue opportunities for providers.

Tech-Enabled Providers

●        Consumer demands due to the pandemic have increased the demand for direct-to-consumer digital health companies that provide on-demand clinical services (e.g., lab testing, prescriptions, disease management).

●        Telehealth acceptance and utilization has increased by more than 150% since the onset of the pandemic.

●        CMS interoperability rules  require core provider & payer systems to share data with third-party apps with appropriate consents, making it easier for tech-forward providers to access the data they need in workflow.

Overall solution area maturity

Value-Based Care

●        Despite increasing value-based reimbursement under government contracts, the top three commercial insurers still report that 35% - 60% of their agreements are tied to fee-for-service.

●        This percentage is expected to drop to 30% - 40% of payments tied to FFS models by 2025.

●        Much progress has been made since 80% - 90% of payments were tied to FFS five years ago; however, the evolution of patients under VBC contracts is only one piece to the puzzle.

●        Core provider workflow systems (e.g. EHR and RCM platforms) still need to evolve to support new care delivery needs since deliver high-value care during potentially longer but fewer encounters requires new features than were required under FFS models.

Care Coordination

●        The 21st Century Cures Act and CMS Interoperability Rules have effectively forced core provider and payor (e.g. EHR & core claims admin, respectively) tech vendors to start sharing data with standalone care coordination platforms where HIPAA consents are in place, which has increased maturity of the segment.

●        HIPAA remains a barrier though, even under new CMS Interoperability Rules, since engaging the patient to sign off on sharing their medical data can be a challenge for care coordination vendors.

Tech-Enabled Providers

●        This segment is the least mature of the three segments covered in this whitepaper.

●        VBC & Care Coordination software vendors evolved first and then tech-forward providers increasing began building new business models around these tech stacks with the goals to enter into and perform against risk-based contracts

●        Several of the first wave of companies from this segment are now expanding steadily into new markets (as seen in our company snapshots),including ChenMed and VillageMD

●        Expansion into new technology capabilities such as remote patient monitoring (RPM) remain on the horizon as providers evolve their platforms.

Equity investment & M&A activity, , market sizing, and projected compound annual growth rates (CAGRs)

Value-Based Care

●        The Covid-19 Pandemic caused one subset of the VBC market, the global value-based payment market, to decrease in size from $1.66B to $1.52B from 2019 to 2020, which is expected to  by 2023 to $3B with a CAGR of 25.81%.

●        VC investments in the value-based care segment set records in 2019, with funding up 80% since 2018 and 300% since 2014.

●        Signify Health went public via IPO on the NYSE in February 2021 raising $564m at a valuation of $5.3b

●        Bright Health and Oscar Health raised $500m and $225m Series E financing rounds in the private markets, respectively

Care Coordination

●        The care management software market, arguably the largest subset of the larger care coordination market, is expected to hit $3B by 2022, with a projected CAGR of 15.4%, and the overall care management solutions market (inclusive of services in addition to software) projected to reach $19.28B by 2023 with a CAGR of 16.1%

●        GE Healthcare’s Care Coordination department was spun off by Veritas Capital in July 2018 and was rebranded as Virence Health

●        PatientPing, a platform that automates care coordination notifications between providers & care managers, raised $60m in a Series C at a $218m valuation in 2020.

●        Wellframe, a care coordination platform backed by BlueCross BlueShield Ventures, raised $20m at a $104m valuation in early 2020.

Tech-Enabled Providers

●        With the ongoing pandemic investment in companies focused on telehealth services has risen dramatically with a recent report mentioning that global telehealth market size was USD 61.40 billion in 2019 and is projected to reach USD 559.52 billion by 2027, exhibiting a CAGR of 25.2% during the forecast period

●        Partnerships with employer programs and other health care businesses have increased, such as VillageMD’s partnership with Walgreens that included an $1B investment.

●        One Medical entered the public market raising $245M

●        Telemedicine investments nearly tripled in Q1 2020 with $788M in VC funding compared to $220M during the previous year

●        Cityblock Health achieved unicorn status as of early 2021 when they raised $160m at a $1b valuation

●        In 2020, Somatus raised $64m in their Series C to improve their kidney care delivery operations

Willingness to buy/invest in focus area by customers

Value-Based Care

●        The pandemic has required HCOs to innovate and VBC has allowed them more flexibility and stability compared to fee-for-service, which was a challenge due to decreased elective procedures during the early stay-at-home period.

●        Stark and Anti-Kickback Laws passed under the Trump administration may come under scrutiny of the Biden administration, which may create regulatory barriers to investment growth trajectory in the VBC segment.

●        Further moves towards reimbursement reform by CMS make VBC more attractive for investment than FFS productivity-based technologies.

Care Coordination

●        The emergence of the Fast Healthcare Interoperability Resources standard by HL7 and regulatory tailwinds to adopt it through 21st Century Cures Act legislation will set the table for increased investment activity in the care coordination segment over the next five years.

●        Care coordination vendors themselves have reached late-stage maturity as it related to creating longitudinal health datasets; however, they will need to make increasingly growing investments into technology that leverages AI/ML to better process data and remain competitive.

●        EHRs and other patient management platforms are adding care coordination tools that interoperate with other EHRs and core clinical workflow systems, which may make it hard for standalone care coordination vendors to compete for share of provider IT budgets.

Tech-Enabled Providers

●        Amazon and other larger commercial companies continue to explore tech-enabled primary care delivery, including Amazon’s exploration via Amazon Care (despite the Berkshire deal falling through).

●        Walmart and Oak Street Health are collaborating to expand clinics together in a new Fortune 100 partnership

●        Michigan Blue Cross Blue Shield demonstrated their interest in investing in the space in early 2020 when they partnered with ChenMed to create six primary care clinics for seniors.

●        Iora Health demonstrated VC interest in the space when they raised their $350m Series F at a $692m valuation in early 2020.

VBC, care coordination, and tech-enabled provider organizations will see drastic changes in addressing the needs of dynamically changing patient populations in the United States. The digitalization of services, health consumerism, and increased data access in real-time will impact how companies will work with their patients, provider networks, payors, and partners. As the US government undergoes changes and organizations explore best practices for the implementation of new technologies, current incumbent companies are likely to expand offerings across the three segments while other new players also enter the market, especially in the comparatively immature tech-enabled provider space.

VENDOR OVERVIEW

Companies in these three sectors are growing at increasingly fast trajectories due to regulatory, pandemic-related, and consumer-preference tailwinds , which have all escalated in the past year due . Many vendors have been exploring VBC for over a decade, but new startups with easier access to data due to CMS Interoperability Rules are steadily coming to the market, posing new competition for current incumbents, which had larger barriers to accessing data when they first got started. Most companies are now turning towards remote services or improved direct-patient care mechanisms in order to evolve their care models going forward in a post-epidemic world.

Expansion into the VBC, care coordination, and tech-enabled provider markets has led to many companies developing proprietary data analytic engines to analyze health data across many normalized data sources (e.g., clinical, pharmacy and medical claims) to identify and stratify member risk for intervention. Some VBC and Care Coordination vendors conduct their own interventions with employed care teams and providers through physical or remote visits, effectively acting as a tech-enabled providers, while other companies partner with third-party primary care or specialist care provider offices to conduct member interventions. Both models have become increasingly attractive to employers as a means to engage with their employees earlier and prevent job loss or time out of work, reducing self-insured medical and pharmacy costs to improve overall financial performance.

This report covers an assortment of pioneers in each of the three covered market segments, including both emerging players and incumbents, highlighting their business operations, services, target markets, and how they have responded to pandemic-related headwinds. Profiled vendors include: Evolent Health, AdvantMed, Matrix Medical Network, Signify Health, CareCentrix, Medecision, Quantum Health, Crossover Health, VillageMD, ChenMed, SteadyMD, and Oak Street Health.

EVOLENT HEALTH

Evolent Health was founded in 2011, in Arlington, VA, and went public in 2015 via an IPO. As of March 2021, the company was valued at a market cap of $1.73b. Evolent acquired the VBC & Care Coordination company, Valence Health, in 2016 for $219M to expand its care coordination and VBC capabilities in Medicaid and pediatric risk populations. Their business focuses on selling technology and services to providers and payers with offerings in each of the care coordination, value-based care, and next-generation tech-enabled provider segments.

Evolent Health’s business is broken into three core solution areas. Evolent Care Partners offers solutions for independent providers to engage in performance-based contracts, aided by population health tools and care coordination resources, enabling their clients to perform oncost and quality measures. New Century Health delivers specialty care services, targeting cardiology and oncology providers, accepting fully-delegated contractual risk for decreasing client costs, which it aims to improve through specialty benefit & clinical programs. Evolent Health Services offers payor and provider clients with administrative and clinical tech-enabled support, including but not limited to outsourced pharmacy benefit management, risk adjustment, quality, population health management, care management, disease management, utilization management, and actuarial services.

Evolent has several branded tools in their platform focused on reducing total cost of care, improving risk-adjusted revenues, and improving quality outcomes through both clinical and administrative workflows. Their proprietary solutions include: CarePro (specialty care management and clinical decision support platform), Identifi (population health performance management platform), and Precision Pathways (point of care decision support and analysis tool offering evidence-based clinical pathways).

Evolent Health’s recent 2020 Investor & Analyst Day report highlighted that their use of tech-enabled services to build clinical value by enabling payer-provider relationships, and current competition with Livongo and Progyny. Their Q2 revenue for 2020 was ~$239M with 3.1M patients and 35+ partners on the platform. Recently, they added new customers including Centene Corp, Emblem Health, Neighborhood Health Plan of Rhode Island, Molina Healthcare. and Passport Health Plan. Seth Blackley, a co-founder of Evolent Health, was made CEO as of October 2020. They recently published a peer-reviewed analysis titled, “Effective Care Management by Next Generation Accountable Care Organizations”, in The American Journal of Managed Care that showed how a complex care management program that Evolent implemented at five Next Generation accountable care organizations (ACOs) reduced all-cause inpatient admissions and total medical expenditures for participating beneficiaries.. Patients (n= 1897) were identified via predictive risk stratification through proprietary ML models and enrolled as needed into the programs, resulting in a 21% reduction in all-cause inpatient admissions and a 22% reduction in total medical expense, demonstrating the value of centrally-staffed Evolent Chronic Care Management (CCM) programs.

ADVANTMED

Advantmed is a privately held company that was founded in 2005 out of Santa Ana, CA, which offers on value-based solutions, specifically risk adjustment and quality improvement solutions, to health plans and risk-bearing entities. The company delivers industry-leading coding accuracy, medical record retrieval, and patient and provider engagement rates through their solutions. Advantmed has a suite of risk adjustment solutions (analytics, record retrieval, coding, claims/data validation, and health assessments) and quality solutions (measurement reporting, record retrieval, HEDIS abstraction, and member engagement). They recently received certification from the National Committee for Quality Assurance (NCQA) for the Integrated Healthcare Association’s (IHA’s) Align. Measure. Perform. (AMP) measure set.

Advantmed’s core platform is called ELEVATE!. The platform integrates risk adjustment and quality improvement operations, analytics, and work flows for their customers to have real-time insights. It facilitates medical record reviews and health assessments (at home or in clinic) that help clients close their members’ Hierarchical Condition Category (HCC) and Healthcare Effectiveness Data and Information Set (HEDIS) gaps in care to improve risk adjustment factor scores and quality measure performance. The platform also helps clients submit risk adjustment data (RAPS,EDPS, and EDGE) and quality measure data (HEDIS) to federal program sponsors. They have not published any research highlighting the impact of their platform aside from internal data reports for marketing, which indicate a 90% chart retrieval rate, a 30% improvement in risk score accuracy and a 20-30% increase in health assessment completion rates.

Due to the Covid-19 pandemic, Advantmed had to expand their solutions into the telehealth sector to maintain their health assessment program’s competitive position. This included expanding a suite of HIPAA-compliant software across mobile devices and computers to allow clinicians to interact with their patients.

Advantmed leadership includes Akash Patel who has served as founder and CEO for the past fifteen years. He had served as a CFO previously in the tech space in California.

MATRIX MEDICAL NETWORK (CCHN)

Community Care Health Network, LLC (CCHN) was founded in 2001 in Scottsdale, AZ, and operates as Matrix Medical Network (MMN). They are offer value-based care solutions to health insurance companies and risk-bearing providers, primarily offering in-person and virtual health risk assessments aimed at closing risk adjustment and quality gaps in care for their clients’ members. They were acquired by Providence Service Corporation (PRSC), now ModivCare, in 2014 for $400M, and still operate as Matrix Medical Network, fitting into ModivCare’s larger portfolio of US-focused social services companies reimbursed by government programs.

Matrix provides a broad spectrum of services across four distinct lines of business, including Matrix Clinical Care (offers comprehensive home & virtual health assessments aimed at closing care gaps), Matrix Clinical Solutions (offers workplace health solutions from testing to clinical care), Matrix Clinical Trials (offers decentralized trial solutions), and Matrix Clinical Labs (offers diagnostic and clinical testing services via a CLIA-certified and CAP-accredited laboratory). For more than twenty years, the organization’s network of approximately five thousand clinical has met individuals wherever they are to assess their health and safety, identifying and closing care gaps in the process. Their core business model involves selling health assessments to government-sponsored health insurance companies or providers in value-based contracts to help improve revenue through accurate risk adjustment and quality reporting. The company also offers quality improvement programs (diabetes care intervention, corporate wellness, community assessments), chronic condition management (CCM), post-acute transitions, and worksite services to risk-bearing entities.

Recently Matrix, in collaboration with Cleveland Clinic, launched a new employee health and wellness service for companies with critical operations still functioning during the pandemic. The program focuses on a multi-disciplinary approach for on-site assessments based on the latest guidelines from the Centers for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), and state regulations, creation of protocols to address safety gaps, and continuous management of Covid-19 guidelines/regulations. Matrix rolled out these services with several notable recent partnership announcements, including: 1) a collaboration with Tyson Foods to deliver vaccination education and coordination; 2) a collaboration with Fenway Health to deploy mobile health clinics to participate in ongoing Covid-19 clinical trials; and 3) a collaboration with AstraZeneca to accelerate a clinical trial in the US for AZD7442, AstraZeneca's long-acting monoclonal antibody (LAAB) combination for the potential prevention of COVID-19 whereby Matrix Clinical Solutions will meet eligible volunteers where they live and work with a fleet of Mobile Health Clinics and skilled clinicians.

Walt Cooper was the previous CEO who left in October 2019 before joining Precision Health Solutions as their new CEO. Mr. Cooper was replaced by Keith Henthorne, the previous founder of Auditz, LLC, a healthcare services organization that used sophisticated proprietary technology to help healthcare providers identify and recover payments, which was sold to TransUnion in 2016. Matrix’s parent company, ModivCare, desires to ramp up in-home and telehealth assessments as a core component of its business per a Q4 earnings call. There has been limited research from Matrix demonstrating their clinical impact, cost savings, or value-improvement at large; peer-reviewed journal articles are available from members of the network, including articles that discuss:

1)   early advanced care planning and anticipatory decision making as a strategy to improve managing uncertainty around common decisions;

2)   a day in the life of a Nurse Practitioner who performs in-home physical exams;

3)   the need for increased home-based primary care visits; and

4)   comprehensive foot care education in home-based settings

SIGNIFY HEALTH

Signify Health (Dallas, Tx) was founded in 2017, after a merger between CenseoHealth and Advance Health, to expand value-based care and tech-enabled provider capabilities with a focus on in-home health evaluations (IHEs) and complex care management. On February 11, 2021, Signify Health went public with their initial IPO (SGFY) at a valuation of $7.12B, raising $564M. Signify Health’s main business operations focus on selling various value-based and care coordination services to six main segments:

1)   Payors: Signify Health partners with health plans in risk-based arrangements to offer in-home health evaluation services, episodes of care programs, and clinical as well as social care coordination

2)   Providers: Signify Health partners with providers to offer episodes of care, transition to home, and clinical as well as social care coordination programs

3)   Employers: Signify Health partners with employers to implement episodes of care payment programs with guaranteed prices, better quality, and seamless coordination around sites of care for a wide range of conditions and procedures

4)   Biopharma: Signify Health partners with biopharma companies to provider support for running effective clinical trials and help commercialize their life-change therapies by bringing clinical and social services into the home

5)   Community Organizations: Signify Health partners with community-based organizations to help them safely collaborate with social service partners, as well as the broader health ecosystem, to improve the lives of the families they serve

6)   Health Plan Members: Signify Health helps keep individuals and families safe and healthy in their homes by supporting those that support them: their health plans, doctors, nurses, and social workers. .

Per Signify Health’s S-1, as of early 2021, they served 47 Medicare Advantage plans as well as over 9,000 providers and 200 community-based organizations, offering their in-home evaluations and payment models around individual episodes of care (e.g., surgical care).  Their S-1 also demonstrates that their “episode payment platform managed $6.1 billion of spend under the Medicare Bundled Payment for Care Improvement Advanced (“BPCI-A”) program in 2019, and the BPCI-A episodes we managed which were initiated in the last quarter of 2019 resulted in approximately 15% greater discharges home from acute-care facilities and approximately 10% lower readmissions when compared to the historical performance of our provider partners for similar episodes”. Risk factors identified for Signify Health in the IPO filing included risks that the COVID-19 pandemic may slow down the demand for and/or the ability to deliver in-home assessments as well as the risk that the company may be required to offer virtual assessments with reduced fees due to the pandemic.. As such, their business is reliant on attaining and retaining customers. They are trusting technological innovations to help them with this, such as their proprietary analytics and cloud-based software platforms.

Signify Health proprietary platforms target IHEs primarily but also social care coordination and biopharma services (e.g., patient support platforms and clinical trials support). Their episodes of care services target Bundled Payments for Care Improvement Advanced Model Participants (BPCI-A), commercial payors, Accountable Care Organizations (ACOs), transition to home model participants, and Chronic Care Management (CCM) companies. The company markets and sells several technologies, including, Episode Connect, which helps manage episodes of care programs, provide actionable insights, and use predictive analytics to identify risks.

Since the creation of Signify Health, Kyle Armbrester has held the CEO role. Kyle came from AthenaHealth where he was SVP Chief Product Officer from 2011-2018. The company rapidly grew in 2020 and opening an additional 750 positions across its business. It is increasingly playing a role with pharma for remote study inclusion.

CARECENTRIX

CareCentrix was founded in 1996 and is based in East Hartford, CN. The company has several offerings across the care coordination and value-based care market segments.  Their business operations are focused upon home health benefit management solutions for coordination of cost-effective care including post-acute, home nursing, infusion, sleep, respiratory, wound, and home medical equipment (DME) care. They have a network of 8,000 home healthcare providers across the US and manage 17.5M members. Through advanced analytics, the companies helps its health plan customers determine the appropriate site for post-acute care, and provides support and coordination for patients and their families throughout care transitions, including to and from Skilled Nursing Facilities (SNFs) and through home health, home DME, home infusion, and home sleep services.

Several CareCentrix proprietary platforms are focused on:

 1)   creating Intelligent Pathways to guide patients to the ultimate site of care, or their homes.

2)   engaging patient and caregivers, coordinating care transitions, improving clinical outcomes, and doing all that they can to help patients health and age at home.

3)   continually finding new ways to break down the silos across the care continuum, capturing savings for their health plan clients along the way.

CareCentrix’s HomeSTAR Program focuses on risk assessments, coaching, and care coordination based on protocol-driven interventions. HomeBridge is their platform that is designed to connect care managers, post-acute providers, patients, and families. Their Sleep Management Solutions are designed to supply in home sleep study diagnostics by coordinating equipment and managing remote patient monitoring. Their programs then use their proprietary analytics engine to collect data to manage to predictive quality outcomes with their patients across their core areas of intervention and reduce possible fraud.

CareCentrix expanded into palliative care with their acquisition of Turn-Key Health in May 2020, anticipating increased Medicare Advantage (MA) plans interest in this sector, with over 60 MA plans across the US now offering in-home services.

John Driscoll has served as CEO of CareCentrix since 2013.Mr. Driscoll was the previous president of Castlight Health and Medco Health Solutions. In July 2020 CareCentrix hired Scott Markovich to serve as the company’s General Manager of Medicaid. Mr. Markovich previously served as a Regional Vice President at Aetna and, prior to that, he serviced as the President of Emerging Markets at Magellan Health. Scott’s hiring may indicate a possible move to capture a wider market with Medicaid programs in the US.

CareCentrix has conducted research associated with cost savings from their platforms along with improved outcomes. One case study cites an employer group that enlisted CareCentrix to address its growing concerns with sleep disorders. The results included an increase from 0% to 74% of patient receiving home sleep testing and an increase from less than 50% to 81% of patients adherent to sleep therapies with $6.2m in cost savings over three years and 96% of patients satisfied. CareCentrix-affiliated authors also co-wrote a peer-reviewed study in 2015 that describes the rationale, background, general methods of development, and considerations in implementation new quality measures related to five common sleep disorders: restless legs syndrome, insomnia, narcolepsy, obstructive sleep apnea in adults, and obstructive sleep apnea in children.

MEDECISION, INC.

Medecision was founded 30 years ago in 1988 and is based in Wayne, Pennsylvania. The company has various offerings across the  care coordination and value-based care market segments. Their business operates within more than 85 health systems in the US and manages more than 50M patients. Their core proprietary software is what they call the Aerial Experience, which is an integrated platform that can be personalized towards patient care plans, integrate with the care team and family, and offer continuous new data to support and recommend interventions, and serve as the data management and billing system for care management organizations. Medecision also has a division called Aveus, which is a consulting firm that works with health systems. Their customers include some of the most renowned health plans and care delivery organizations serving commercial populations as well as Medicare and Medicaid beneficiaries.

As mentioned, Aerial is their proprietary platform, which provides personalized member and patient engagement. This consists of multiple tools , including but not limited to:

●    Aerial ePHR Health Summary is a product that provides health information on the patient over a longitudinal view of multiple health statuses and care plan goals

●    Aerial InCircle is a social mobile communication platform for care team and patients

●    Aerial Consumer Care is a product that provides self-assessment and goal setting tasks for members

●    Aerial Complex Care Management is an analytics driven product that builds evidence-based care plans and identifies interventions using the patient clinical status while validating medical necessity and engagement actualization

●    Aerial CarePlanner 360 is an interface that continually updates on new care plans based on patient data and guides workflow with nursing and staff

Deb Gage has been the President and CEO of Medecision since 2011.. In 2020, Jan Berger, MD was made chair of the company’s advisory board. Dr. Berger is CEO of Health Intelligence Partners and previously was CMO of CVS Health. She is a board member of Tabula Rasa Health Care, UCB, Voluntis, and GNS Healthcare. Tommy Duncan was added to the advisory board as well, and brings his knowledge and connections as CEO of Jetdoc (a virtual health company).

QUANTUM HEALTH

Quantum Health is a private company founded in 1999 and based in Dublin, Ohio. They are focused on care coordination, consumer healthcare navigation, validated claims savings, and increasing satisfaction rates for self-funded public and private sector employer clients. As of 2021, they service over 1.7M members across the US.

Quantum’s key software is their Real-Time Intercept model which identifies areas of early intervention for members. Their proprietary mapping technology utilizes patient data, medical guidelines and clinical input to intervene with members early to encourage cost-effective healthcare services such as primary care visits or preventive services to avoid expensive or wasteful outcomes (e.g., readmission, unnecessary ER visits). Their patient engagement stack includes features that support prior authorization, care coordination, and referral management workflows. Quantum Health’s QHealth program leverages Pods, or teams that have multi-disciplinary expertise, to conduct communication with patients and bring a personalized level of care. Quantum’s services have recently expanded to telemedicine, remote monitoring, and onsite clinics and wellness programs.

Kara Trott has maintained her role as CEO of Quantum Health since she helped found the company in 1999. Under her leadership, the company has recently expanded its business operations and has received several awards including being recognized as: 1) one of the 5,000 fastest-growing privately held companies in Inc. magazine's Inc. 5000 list; 2) a Best Workplace and a Great Place to Work by Fortune and Entrepreneur magazines; 3) one of the 50 Fastest-Growing Women-Owned/Led Companies by the the Women Presidents' Organization; 4) a Best Place to Work by Columbus Business First magazine.

The company is reported to have grown from 850 employees to over 1,400 employees over a 12-month period in 2020. Quantum has raised several rounds of funding from both private equity and venture funds at an undisclosed amount. They recently received backing Great Hill, a Boston-based private equity firm, to expand their operations.

Quantum Health has not published any large scale clinical or economical study evaluating the impact of their work. Their internal releases have demonstrated a Net Promoter Scores (NPS) at 77 (an increase from previous years and highest over 20 year history) as well as cost savings with an average employer cost savings of 5.7% over the first year and then 9.2% cumulative average savings over 3 years.

CROSSOVER HEALTH MEDICAL GROUP

Crossover Health was founded in 2010 and is based in San Clemente, CA. The company is a next-generation tech-enabled provider who intentionally built and structured their care delivery business around proprietary care coordination and value-based technology and workflows that allow their providers to perform against their risk-based insurance contracts. It has raised, at this point, over $113M with backers ranging from Gurnet Point Capital ($92M) to Norwest Venture Partners ($15M). Crossover offers a mix of onsite, near site, and virtual health centers to deliver personalized care to self-insured employer programs and reduce their direct employee plan healthcare spending. Crossover utilizes their Enterprise Data Warehouse to aggregate personalized health information (e.g., medical and pharmacy claims data) to identify high-risk and high-cost employees to enable enables our advanced analytics and predictive / proactive care planning. The company also helps employers evaluate and validate the best digital health apps and devices. Crossover Health partners with a handful of select evidenced-based digital vendors that are deeply integrated into their provider care delivery workflows to extend their care teams’ reach and deliver hard cost savings.

Their services include primary care, mental health, optometry, health coaching, physical medicine, and acupuncture. They utilize care teams to engage health members directly to coordinate care and manage their conditions. They have a digital-first business solution seeking to address employers in multiple locations based on a virtual care interaction to triage members' issues prior to more expensive services. The company has completed 1.5m member visits with a 96% reported patient satisfaction score.

Crossover is a digital native company seeking to curate digital health apps and devices that produce the best outcomes for their members. The team employs the use of wearables, telehealth, as well as health and wellness apps that have demonstrated value in their care delivery framework. Using a mix of data collected from their warehouse, associated digital health products, they employ a predictive analytics engine to allow Crossovers Care Management teams to understand what to target for individual members, along with care navigators, helping members seek high-value care in secondary networks.

The company was founded by Scott Shreeve, MD, who has served as CEO since. He was previously CMO at Medsphere Systems Corporation. Crossover acquired Sherpaa in February 2019 to expand their virtual primary care solutions. Jay Parkinson, MD, stayed on the team and remains the leader of the Sherpaa business inside of Crossover Health. More recently, Crossover set up a strategic partnership to create neighborhood health clinics for Amazon employees and their families, which will be located near fulfillment centers. Crossover internal data has reported that they can handle 2,500 complex conditions online with their care team, producing30% total healthcare savings for highly engaged members. They have published retrospective research demonstrating that the clinical and economic outcomes of their programs decreased the wait time for employees to access services, resulting in improvements to functional status in fewer visits compared to standard community approach. This demonstrated a significant cost savings and a decrease in the use of opioids amongst workers.

VILLAGEMD

VillageMD was founded in 2013 and is based in Chicago, IL. The company operates as a next-generation tech-enabled provider with software that offers advanced care coordination and value-based care capabilities. VillageMD has raised $1.241b in total funding, including a $275m Series C that they raised from Walgreens Boots Alliance and Kinnevik AB in July 2020.

VillageMD operates a high value national primary care network, which contracts with health plans primarily outside of a fee-for-service model, focusing instead on performance-based risk contracts. The Village Medical brand provides primary care for patients at traditional free-standing clinics, Walgreens co-located clinics, as well as in the home and via virtual visits through a proprietary technology solution.

VillageMD, a subsidiary Village Medical, currently operates traditional free-standing clinics in highly accessible neighborhood locations, where patients and providers live and work.. In November 2019, Village Medical opened one of its first full-service, state-of-the-art primary care clinics co-located at Walgreens in Houston and has since opened more. Village Medical at Walgreens integrates the pharmacist as a critical member of VillageMD’s physician-led, multi-disciplinary team. This integrated model has never been more important—6 in 10 Americans today live with at least one chronic condition requiring multiple daily medications. Outside of their owned medical group, Village Medical, VillageMD also maintained a network of independent, affiliated primary care physicians that operate as partners for success in value-based healthcare under the VillageMD Affiliate Physicians subsidiary.. Finally, VillageMD partners with health systems to build a comprehensive strategy based on success in risk and shared savings contracts, while pursuing narrow network payor contracts and direct employer relationships to simultaneously enhance market share. Combined, through their employed medical group, affiliated independent physician network, and partner health systems, the company operates in nine markets including: Arizona, Texas, Illinois, Indiana, Michigan, Kentucky, New Hampshire, Georgia and Florida. They report to have over 2.8k PCPs across their combined network with 1k+ clinic locations and 600k lives under management.

VillageMD uses a proprietary system called docOS (launched in 2018) to support their care model. VillageMD’s docOS™ breaks down information silos with patent-pending technology to extract over 3,700 clinical and financial data elements from dozens of EHR’s and practice management systems, over 70 payer claims systems, and 100’s of hospitals, skilled nursing facilities, and socio-economic data sources across the care continuum. This data is aggregated and analyzed in real-time, where proprietary algorithms perform tasks such as predicting missing diagnoses, analyzing patient schedules for enhanced engagement opportunities, surfacing outstanding care gaps for clinicians and care givers to resolve, and reacting real-time to acute patient illnesses.

There have been no large-scale peer-reviewed studies published demonstrating the value of their model from a cost perspective or the improved patient outcomes that they might generate; however,, VillageMD has made some claims in their marketing materials and case studies that are very exciting. VillageMD has a NPS at 93, claims to reduce unnecessary acute admissions by 39% compared to market average, and also claims to increase adherence to diabetes medications by 85%. VillageMD is under a period of rampant growth, with recent news highlighting that CMS accepted their new direct contracting program focusing on chronic condition management. The company recently expanded their operations in Houston, Chicago and Atlanta according to a recent interview with their CMO who also mentioned future plans to further expand into the home health care space.

CHENMED

ChenMed is a family-owned organization based in Miami, FL, which was founded in 1985. The company operates as a next generation, tech-forward primary care provider with advanced care coordination and value-based care workflow and program capabilities. Their business offerings focus on delivering senior care utilizing concierge-style, high-touch medicine, using their own medical, care management, and technology resources to differentiate. ChenMed has a specific strategic focus on serving Medicare patients, primarily contracting in risk-based models with private Medicare Advantage health plans. The company is currently in network with twenty Medicare Advantage health insurance plans. ChenMed’s value-based contracting model allows them to remain financially healthy in serving small patient panel sizes through higher tough care delivery models where other fee-for-service providers would likely struggle due to lower volumes..

The company operates under three principal brands, including Chen Senior Medical Care (FL), Dedicated Senior Medical Center (FL, OH, TN, PA, MO), and JenCare Senior Medical Center (GA, IL, KY, LA, VA). ChenMed’s three brand operations provide similar services for their members, albeit with differing providers. Services include primary care, onsite diagnostics testing, medications directly given to patients during visits, and door-to-door transportation. Due to the VBC approach, they staff separate medical specialists on-site, such as cardiologists, nephrologists, endocrinologists, dermatologists. Their care teams also includes social workers, skilled nursing and wound care providers, and acupuncturists and the company also offers pacemaker checks, imaging services (e.g., sonography, X-rays) and nuclear stress tests in their services. If care cannot be provided on-site, the medical team will coordinate the referral process. During the first weeks of the Covid-19 pandemic, conduced 90% of their visits virtually using Sitka's video software platform for telemedicine. They initiated a strategy to keep in contact with their elderly patients and support them, using  their branded Love Calls to help combat loneliness and isolation. Even during the ongoing pandemic, they have expanded, offering almost one hundred practice locations.

Christopher Chen, MD has served as CEO of the company since 2009 and Gordon Chen, MD currently serves as CMO. Both of their spouses also maintain  leadership roles across the company. The Chen family has been highly involved in academic research and is closely involved with the University of Miami. They have collaborated to publish several peer-reviewed studies. One such 2018 study highlights the value of ChenMed’s high-touch primary care model, demonstrating $87 per member per month in total medical costs for Medicare Advantage (MA) patients in the ChenMed model versus $121 per member per month for similar MA patients in a traditional PCP model. These results are staggering, especially given higher utilization of primary care visits & preventive medications for patients in the ChenMed model versus the standard PCP program that ChenMed was compared to. The same study also showed reduced hospital admissions from ChenMed’s programs versus ‘traditional primary care’. More recently, ChenMed evaluated the use of both Propeller Health electronic medication monitors (EMMs) to monitor short-acting beta-agonist (SABA) use and as well as a smartphone app to track use trends and receive feedback from COPD patients. The pilot demonstrated a significant reduction in SABA use and increased SABA-free days among Medicare-eligible COPD patients. Further, patients readily adopted the digital platform and demonstrated strong engagement and retention rates at 6 and 12 months. It is not clear whether or not ChenMed continues to employ Propeller Health’s digital health tools in caring for their COPD patients (they probably do); however, it is encouraging that ChenMed takes an academic approach to validating the impact of technologies on patient outcomes and costs before scaling them out. From the two studies that were reviewed in this article, it is clear that ChenMed has found success in using technology and new clinical programs to achieve high-value healthcare for their patients.

STEADYMD

SteadyMD is a relatively new health startup focused on delivering a modern approach to primary care. Their doctors only see a limited number of patients so they can spend more time with each. Their concierge telehealth service service is completely online, which means that members get comprehensive, personalized care from anywhere in the world, on any device.. The company was founded in 2016 and is based in St. Louis, Missouri. To date, they have raised $9M in total equity funding with a recent $6m Series A round, which included funding from CrossCut Ventures and Pelion Venture Partners, that was raised in April 2020 at an $18m valuation..

The company’s care delivery model centers around the proprietary SteadyMD member app, which offers asynchronous and synchronous communication functionality to their doctors and members in all 50 states. The SteadyMD platform focuses on matching a patient member with a provider for virtual touchpoints & clinical encounters. SteadyMD focuses on offering preventative care services, such as labs, screenings, urgent care, chronic condition management, and primary care medicine. If a SteadyMD provider thinks a patient needs to be seen directly for testing, referrals are made to a local specialist, urgent care facility or testing lab (e.g., Quest, LabCorp). Their clinical services cover pediatric medicine, family medicine, internal medicine,  and functional medicine with each appointment spanning an hour in length if needed. Members can set up appointments for same-day needs and can chat via text with their provider on-demand. Additional capabilities focus on fitness and diet coaching with supportive tools for members to track and report performance against goals.

The SteadyMD direct-to-consumer business model SteadyMD includes a $99 monthly premium for individuals or a monthly $178 premium for families. They also have options to contract with employers to create concierge medicine plans specifically tailored to unique employee populations. ,

Guy Friedman (CEO) and Yarone Goren (COO) co-founded SteadyMD and maintain leadership roles in the company. They have formed partnerships with GoodRx, CareDash, Whole30, Precision Nutrition, Trifecta, InsideTracker and Invictus. The company appears to have grown rapidly due to COVID-19 related tailwinds and continues to expand using recent Series A financing dollars to penetrate new tangential markets.  

OAK STREET HEALTH

Oak Street Health is a VBC-focused, tech-enabled primary care provider founded by Geoff Price and Mike Pykosz in 2012 that is headquartered in Chicago, IL. They recently went public (NYSE:OSH) in August 2020 and the stock is trading at a market capitalization of $12.51b as of March 2021. Oak Street Health’s business model is focused on operating primary care clinics across thirteen states (IL, IN, MI, NC, SC, OH, PA, RI, TN, TX, NY, MS, & LA) for Medicare and Medicare Advantage patients with more than 97% of their revenue tied to value-based contractual agreements or government programs. The company has advanced state care coordination and value-based care workflow technologies to support performance against their risk contracts.

Oak Street Health operates over eighty clinic locations staffed with primary care providers in addition to behavioral health specialists and podiatrists where needed. The locations include community gathering areas, traditional patient rooms, laboratories, and some have in-center pharmacies. They are known to have a fleet of vehicles that can drive patients to and from appointments, social activities, health seminars or other events. The company also offers a 24/7 support line. With the onset of the pandemic, Oak Street expanded their telehealth services and used their vans to transport food to impacted patients at risk of going hungry.

Oak Street Health originally started taking on Medicare patients via fee-for-service contacts but transitioned to primarily value-based contracts via Humana in the mid-2010s. The company produced revenues of $556M in 2019. Oak Street Health PCPs managed care for 85K patients as of March 2020 with two-thirds under capitation-based and/or at-risk agreements. As most of their revenue is tied to VBC contracts, the pandemic has not impacted their operations as much as fee-for-service providers were impacted by reduced volumes.

Oak Street has not published any peer-evaluated studies regarding their impact; the company claims in their S-1 IPO filing that they have cut hospitalizations and ED visits by 50% for their patient population. The company has achieved significant revenue all while spending significant cash to fund capital expansions.

CONTRIBUTORS

Russ Cobb, VP Enterprise Technology Marketing

Trey Rawles, Director Market Intelligence (Emerging Technologies)

Laura Griffith, VP Market Intelligence

As of 2021, Change Healthcare is powering nine of out of the twelve leading value-based care and care coordination companies profiled in this report through a variety of solutions, including but not limited to: 1) Payment Accuracy; 2) Medical Network; 3) Decision Support; 4) Rx Benefit Admin; 5) VBC Transformation Services; 6) Value-Based Payments Analytics; 7) Communications & Payments

To learn how your value-based care, care coordination, or tech-enabled provider organization can leverage Change Healthcare data & workflows in ways like digital health pioneers are, please send me a direct message on LinkedIn to discuss strategic partnerships.

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