A couple weeks ago at The 2017 OPEN MINDS Strategy and Innovation Institute, I had the opportunity to hear from two health plan executives about what they are looking for from provider organizations. Most interesting to hear was what they were not looking for – more contracted provider organizations. What they are looking for is provider partnerships that improve performance: in terms of consumer outcomes, access to service, HEDIS measures, and financial alignment.
Speaking to this trend, I heard from Matthew O. Hurford, M.D., Chief Medical Officer, Community Care Behavioral Health Organization and Alyssa L. Rose, JD/MSW, Director, Network Strategy, Beacon Health Options during the session, Finding New Opportunities With Health Plans: How To Market To Managed Care, led by OPEN MINDS Senior Associate, Steve Ramsland Ed.D.
From the perspective of Dr. Hurford there are three keys to contracting with health plans—clarity, alignment, and flexibility. Clarity refers to having an ultimate and clear end goal to what you want to accomplish by contracting with a health plan. Surprisingly, this is much more important than the service delivery process, which will be fleshed out throughout the development process. The second key is alignment with both your goals as an organization and the health plan’s goals. If the health plan isn’t interested in the same goals or mission as your organization, than a partnership is unlikely to be successful – and you should already know that your goals are aligned before you approach the payer. (This also applies when a health plan proposes a partnership with your organization.) Finally, it’s important to be flexible. Often, health plan contracts change and provider organizations need to be adaptable.
An example of these principles in action came after Community Care Behavioral Health Organization (CCBH) found that individuals in assertive community treatment (ACT) programs had more than two weeks of hospitalization each year. In response, the CCHB team created three new provider relationships to address the problem and, over a 12 to 18 month period, lowered inpatient utilization. The new provider contracts provided incentives, in terms of withholds and bonus payments focused on lower inpatient use. The new model caused provider organizations to focus more on population health management and restructure their services. Within three years, inpatient utilization was just under one week for all three organizations.
Alyssa Rose of BeaconOptions provided a different example. For BeaconOptions commerical health plans, they are looking for provider organizations that can provide faster access to services for consumers, while improving their care. She said there are three ways Beacon is working to complete this goal:
- Same day/next day appointments – Beacon is moving to facilitating same and next day appointments, achieved through warm transfers, interconnected scheduling platforms, open access provider scheduling, telehealth, and value-based payments.
- Consumer option of care platforms – Beacon is developing a system to give consumers the ability to choose how their services are delivered whether that be in-person, via telehealth, or through text messaging.
- Channeling consumers to high-quality providers – Beacon is planning to increase channeling of consumers to high-value provider organizations through the creation of tiered networks and consumer-facing provider quality reports. These provider organizations will participate in value-based reimbursement arrangements working on improving provider organization quality through the creation of tiered networks, value-based payment.
Both speakers acknowledged that this focus on provider partnerships, alignment of financial interests, and value-based reimbursement requires financial resources that many provider organizations do not have. Beacon Health Options is working on creating a menu of programs that provider organizations can choose from based on their organization’s capabilities. Community Care has developed value-based purchasing programs with provider organizations that help minimize their risk. One example is an inpatient pay-for-performance program that will pay provider organizations a fee-for-service (FFS) rate and – depending on how they score on the agreed upon metrics – will result in an increase or decrease in their FFS rate next year.
In the end, for provider organization executives to succeed, the key is to demonstrate quality and access in a structured reimbursement environment. For more on managed care contracting and value-based purchasing see: The Business Model Transition To Value-Based Care, The Financing Challenge For Providers With Increasing Managed Care & Value-Based Contracting, and Four Keys To Success With MCO Contracting.
Couldn’t join us for this session? Join Steve Ramsland and Dawn S. Kingsley, MSHA, Vice President, Payer Contracting & Strategy, Centerstone America, on August 16 for the session, “Finding New Opportunities With Health Plans: How To Market Your Services To Managed Care” at The 2017 OPEN MINDS Management Best Practices Institute in Long Beach, California.