Executive Briefing | by Sarah C. Threnhauser, MPA | September 11, 2017
We’re at the stage where the field is moving from talk to action on value-based reimbursement (VBR) and health plan/provider partnerships. While our January survey found only 40% of specialty provider organizations had some type of VBR arrangement in place (see The 2017 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value?), the majority of these were fee-for-service arrangements with performance-based penalties or bonuses. What we’re seeing now is a move to more advanced VBR arrangements, such as bundled payments, case rates, and capitation fees.
This change brings the need for more mature (and integrated) relationships between health plans and provider organizations. And if provider organizations expect to be successful in that environment, then there are various “hurdles” such as organizational competency, culture, and infrastructure to be overcome (see The Value-Based Reimbursement Steeplechase). But another key challenge for top executives and their teams is to form the necessary “partner relationship” with payers.
That was the topic of the session, “Building New Payer/Provider Partnerships: A Town Hall Discussion On How To Collaborate With Managed Care Organizations,” at The 2017 OPEN MINDS Management Best Practices Institute in Long Beach, California. The session was led by OPEN MINDS Senior Associate Steve Ramsland and featured: Carole Matyas, Vice President of Behavioral Health Operations, Wellcare; Elena Fernandez, Director of Behavioral Health, St John’s Well Child and Family Center; Richard Knecht, M.S., Principal Consultant, Integrated Human Service Group; and Chris Daher, Manager of Provider Partnerships, Beacon Health Options.
What are the keys to forging payer relationships? Each of the presenters had a slightly different take on what specific aspect of relationship building was the most important but all touched on the importance of bringing data to the table when working with payers; committing to an integrated, community-based approach; and knowing exactly what your costs are and the value you can offer in the relationship.
Mr. Daher explained that Beacon Health Options operates in all 50 states and partners with health plans while specializing in behavioral health (for more from OPEN MINDS on Beacon, check out What Health Plans Are Looking For? Hint: It’s Not A Bigger Provider Network) – and key to making that work is provider organizations that can cooperate with payers to “crunch the data.” He said:
I go out with providers we are contracted with and I share a full continuum data with them – things like readmissions, average length of stay, follow-up after hospitalization. This is aggregate data and we look at all of it together. I go to all the federally qualified health centers in the Los Angeles County area, looking for people who are open to communication. We really want someone who is going to do a team approach. If there is a unit with the old “managed care is the enemy” mentality, that’s really hard. We want people that will work with us and sit down at the table.
When it comes time to start a relationship, we want provider organizations to have one person to call. I’m the main contact person in Los Angeles for our strategic providers, like a concierge service so that providers have that one person they can always connect to for questions or issues.
Beyond that, it’s important to remember that every value-based contact is different. You have to find different value in each contract. You can start with a fee-for-service (FFS) contract, and then over time, we can look at the data and numbers while working together.
Ms. Fernandez shared her work at St John’s Well Child and Family Center, which provides primary care, dental care, behavioral health services, and care management, and that contracts with Beacon and other health plans to support an integrated approach in the community. Her key to payer/provider relationships is the ability simultaneously integrate while focusing on the community. She said:
I came here to do an integrated program and I had to ask, where is the behavioral health? How do we develop that kind of relationship with payers? It really has grown to establishing a healthy relationship, where now I get data. I think care coordination is a huge piece that goes unfunded or isn’t reimbursed.
We need approaches that really support the community. This is a community that transitions a lot, what we may see is that we need more clinicians here to address the community. I’m looking for a MC that is flexible, access to communicating. My question is, how quickly can you see people? There is always flexibility in our schedule and the goal is to see them in 7 to 10 days after getting a referral from a medical provider. Technically they have access for walking on a weekly basis, and triage.
Mr. Knecht shared his work as a consultant and founder of Integrated Human Service Group, where he assists California state agencies and partners in design and implementation of Foster Care reforms and the Katie A class action lawsuit – both of which are seeking to close service gaps for youth and families. His message was straight forward – provider organizations need to be adaptable. He explained:
State and county agencies are looking for a lot of things from partners. Government often doesn’t adapt very readily, so we’re looking for the adaptability that integration requires. If you can bring responsive, creative and nimble resources and organizational behaviors to the table, government will see value in working with you. Specific to managed care service organizations, the two most critical organizational behaviors needed presently might be the ability to create capacity for clients and patients, and the ability to effectively and authentically engage with patients and their families. To the extent that provider organizations can quantify and communicate the effectiveness of their engagement, there is tremendous value for public funders.
Ms. Matyas explained that she was hired at Wellcare to build an integrated model in their health plan, and they now have integrated behavioral health, in-house. When she works with provider organization, she noted it was paramount that they understand their costs.
Her message: Wellcare has a whole-person care model with a coordinated effort and works in a variety of states, meaning that it’s important to understand that what integration means is different from state to state. What you as the provider organization can do is to demonstrate your ability to work across multiple provider entities, a connection to community-based services and programs for keeping members healthy in a non-institutional environment.
Wellcare cultivates provider systems, oriented on medical with behavioral health, or community-based behavioral health organizations billing medical services. They lean toward the integrated health home model to the extent that provider organizations can do that care coordination.
Ms. Matyas talks with community mental health, challenging them to “get out of the box.” Her first question is, do you know what your costs are? What is it that creates the deficit? She then begins to show them the integrated health home model, where you can have a capitation, or a case rate. There are a variety of ways the discussion can go, but unless you truly understand the cost, your value, and your outcomes, you will struggle to build a relationship that can get a return-on-investment.
For more on forming partnerships with payers, join Martha R. Temple, Senior Vice President, Behavioral Health Services, Optum, on September 26 at The 2017 OPEN MINDS Executive Leadership Retreat, for her session, “The Future Of Health Plan/Provider Organization Business Relationships.”