On a scale of one to 10, how important is your “performance” in your strategy to “sell” your services to payers and health plans? If your answer is below a “5,” read on!
Last month at The 2016 OPEN MINDS Strategy & Innovation Institute I asked Thomas Lindquist, Plan President, Molina Healthcare of South Carolina how important provider organization performance is to health plans. His answer was unequivocal: “Very, very important.” We discussed the reasons why in the session, Using Medicare Star Ratings & HEDIS Scores To Develop New Opportunities With Health Plans, which was facilitated by Melissa Odorzynski, PharmD, MPH, Vice President, Marketing and Strategy at Genoa, a Qol Healthcare Company.
In case you don’t know why, the answer is simple. Health plans are rated by payers and consumers using NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) and the Centers for Medicare and Medicaid (CMS) Medicare Star Ratings. We’ve covered HEDIS and the CMS Star Ratings, and the large role that they play in today’s health care market before – see The Dominant Performance Standards Of Today – CMS Stars & NCQA HEDIS, A Few More Drops In The Performance Measurement Bucket, and Who’s Measuring Performance? An Overview Of The Measures, By Market.
But the question is, why do these health plan ratings systems matter to provider organizations? Because health plans are interested in working with provider organizations that can provide services in a way that improves their HEDIS and STAR ratings. Mr. Lindquist said, “From a health plan perspective, a quality department is not just about paying claims, it’s also about engaging with provider organizations, health services teams, case managers, and community connectors, and helping members holistically. All need to be focused on quality.” He said that improving health care quality in an environment that relies on these measures requires provider organizations and health plans to build a collaborative relationship.
If you are an executive with a provider organizations that wants to work more with health plans, you need to be able to show that you are part of their quality improvement team. To do this, Mr. Lindquist presented a five-step process that provider organizations can use to demonstrate their value-add to health plans. Those steps include:
- Select a topic that is critical for the health plan’s Star ratings or HEDIS scores – Start by reviewing health plan ratings and determining where there is a significant need for improvement. What do health plans need that your organization can provide? (To review the health plan ratings, check out Adherence, Coordination & Integration: What The New SMI HEDIS Measures Mean For The Field and Are You Suffering From Measurement Fatigue?).
- Whatever service you select, be sure that the interventions are based on strong clinical evidence – Health plans are looking for interventions that have a strong evidence-base, so be sure that you can demonstrate that your program is both clinically and cost effective.
- Assuming your organization gets the “green light” on your proposed idea, assume you will need a “learning” implementation with ongoing feedback, barrier identification, and measurement – Long-term success of any program requires a strong relationship between the provider organization and the health plan. Many of these arrangements start with a pilot program, or a small group of consumers so that both parties can measure progress and make adjustments as needed.
- Re-measure to determine effectiveness – Once the intervention has been in place for a select period of time, you can reevaluate the effectiveness of the program. This requires your organization to have performance measurement and reporting capabilities in place – now is the time to demonstrate the value of your program by showing how it has affected the health plan’s performance.
- Modify interventions to address barriers and drive improvement – Finally every solution-focused relationship between provider and health plan is an evolving relationship. If you have real-time data reporting and a collaborative partnership with the health plan, you should be able to make program adjustments that will continue to improve performance.
This process gives provider organizations a clear path to demonstrating their value through real-time results for the health plan. Mr. Lindquist noted – “If there is a clear return-on-investment (ROI), that’s usually a no brainer. It’s about the [pitch] that can demonstrate what you can bring, with what we can bring, and what we can even change that can improve the pitch. Incentives and payment structure is all on the table. This is less about the mechanisms and more about the outcomes.”
For executives in provider organizations, there is a clear need to improve the performance of health plans in order to maintain long-term and sustainable relationships. To do this, it is essential to build a performance-based culture – managing performance internally, building performance-focused relationships with health plans, and being able to report on that performance to demonstrate your value (see Is Your Culture Performance-Driven? Take The Test). For more from The 2016 OPEN MINDS Strategy & Innovation Institute on building relationships with payers, see ‘Winning The Game’ and Four Keys To Success With MCO Contracting. And to learn more in person, join my colleague Steve Ramsland, Ed.D. at The 2016 OPEN MINDS California Management Best Practices Institute on August 25 for the session, “Optimizing Your Business Development Budget: How To Develop A Focused Plan For New Contracts.”