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By Sarah C. Threnhauser

This week we kicked off The 2019 OPEN MINDS Management Best Practices Institute with a discussion on how to negotiate value-based partnerships with health plans in the seminar, How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating, & Contracting With Health Plans. For provider organizations, building those health plan partnerships starts with the development of a brief “pitch deck” that outlines an organization’s value summary, including quality and cost differentiators. During the presentation, OPEN MINDS Senior Associate Deb Adler noted that one of the important differentiators health plans are looking for from provider organizations is the ability to improve access to care (see Brief Is Best).

Why is access such a major priority for health plans? Improving access to care promotes better consumer engagement, increases consumer satisfaction, and results in better positive clinical and financial outcomes. Ms. Adler took a deep dive into this topic in the session, Prioritizing Access To Care: How Health Plans & Provider Organizations Are Improving Consumer Access, featuring Guy Maytal, M.D., Chief Integrated Care & Psychiatric Oncology, Weill Cornell Medicine; Richard Rodriguez, Director, Behavioral Network Services, Optum; and Michael M. Siegel, M.D., Medical Director, Molina Healthcare of California.

While access to care is widely recognized as a major issue, there is still a lot of difficultly in measuring access issues and determining what is adequate availability for consumer populations. So, how do you determine if access is an issue in your market? In today’s session, Ms. Adler discussed several sample measures that health plans analyze when determining access and availability to care, including:

  • Structural measures, such as the percent of the of population covered by insurance. For example, currently, about 90% of the U.S. population is insured by managed care organizations, but coverage varies by geography and population.
  • Utilization measures to examine the use of services. For example, the penetration rate for Medicaid is in the teens, while the penetration rate for a commercial employee assistance program would be much lower, somewhere less than five percent.
  • Density measures to explore the ratio of clinical professionals to consumers in a geographic area. For example, typical managed care standards average out to about one provider for every 1,000 members; one inpatient provider for every 10,000 patients; and one psychiatrist for every 2,000 members.
  • Distance measures that examine how far consumers need to travel to receive care. The standards for these measures vary by location; for example, in an urban setting, a health plan may look for 95% of the membership to have access to outpatient behavioral health services within 20 miles, while in rural areas that may expand to access within 60 miles.
  • Time to appointment is a common measure that is frequently guided by the National Committee for Quality Assurance (NCQA). The NCQA accreditation standards for network management for behavioral health call for regular/routine access within 10 business days; urgent care appointments within 48 hours; and non-life-threatening emergencies within six hours.

For health plans, these measures help to paint a picture of access among their members and can help provider organization executives to determine payer “pain points” when it comes to access issues within their market. But this is only part of the access equation. As Ms. Adler pointed out, access is about so much more than just making an appointment—it’s also about the consumer experience. Consumer experience is about creating positive interactions and meaningful relationships with consumers (see Navigating The Performance Loop – Customer Service, Consumer Experience & Consumer Engagement).

Dr. Siegel noted that barriers to care aren’t always in the form of geography. Many consumers also face language and culture barriers, which can be a major detriment to receiving care. Dr. Maytal expanded on this, explaining that different populations have different needs, which may require added services and supports to ensure that consumers are receiving the most effective care—whether this is conducting comprehensive exams in the home and community to assess where there are gaps in care, delivering culturally competent materials in different languages, or providing care coordination for follow-up care and community resources.

Mr. Rodriguez discussed the importance of convenience, highlighting Optum’s ability to allow clinical professionals to provide their appointment availability as part of their telehealth platform. This feature of their platform improves the consumer experience by allowing the consumer to make an appointment online and in a more timely manner (ideally, with the time to get an appointment being under a week) compared to face-to-face appointments. Mr. Rodriguez also noted that in addition to convenience, there needs to be a focus on the quality of care, not just the quantity of services and provider organizations. He explained that Optum is focused on making it easier for consumers to have access to evidence-based practices, as well as the specialists and prescribers they need, as part of their assessments of network availability.

Improving access and availability are about delivering care in a timely manner and a convenient location—but it’s also about delivering effective quality care that is built around the needs of the consumer. It comes down to the ability to provide consumers with access to the “right care, in the right place, at the right time.” For provider organizations looking to demonstrate their value to health plans, the ability to improve access to care will continue to be a clear differentiator. Demonstrating the ability to deliver tech-enabled, person-centered, evidence-based, culturally competent care will give your organization the competitive advantage when building new payer partnerships.

For more live coverage from Long Beach, tune in this week when we report on The 2019 OPEN MINDS Management Best Practices Institute—be sure to check out our ongoing live and archived coverage of the event on Twitter @openmindscircle – #OMBestPractices.

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