In the not too distant past, the relationship between health plans and the provider organizations that served their members could best be described as a “vendor” relationship. Health plans “shopped” for provider vendors based on service characteristics, location, and price.
But the market changed with the end of preexisting condition exclusions and no annual/lifetime limits – and the move of health plans into Medicaid and Medicare. More members with bigger needs were being served within the health plan. And, the ability of the health plan’s network of service provider organizations to manage consumers with high-needs and complex support requirements has evolved into a significant differentiation.
The new relationship is moving toward interdependence, with health plans expecting care collaboration, health information, and gainsharing from their contracted provider organizations. All have a common requirement: organizational leadership that can recognize the interdependence that can make organizations successful. That was the message given by Ravi Ganesan, chief executive officer of Core Solutions, and Adam Bauer, senior manager with Deloitte Consulting, in their presentation, The Next Generation Of Care Collaboration: Building Your Business Case In A Value-Based Market, at The 2017 OPEN MINDS Performance Management Institute last month.
If you are familiar with the concept of interdependence, that’s because Dr. Stephen R. Covey uses it in his book, The Seven Habits of Highly Effective People. Why is it important? The short answer: The move to value-based reimbursements will require the kind of interdependence with health plans that many provider organizations don’t currently have.
The changes in relationships are on a continuum. Provider organizations that are dependent on grant funding tend to have a narrow focus. Organizations that are independent tend to rely on fee-for-service (FFS) billing, offer interdisciplinary services, and have limited governance. And finally, organizations that are interdependent tend to have contractual relationships with value-based reimbursement, offer collaborative services, have strong governance and health information technology systems, and are data driven. Currently, most provider organizations fall into the category of independent, but they’ll need to become interdependent in order to remain sustainable in the years ahead.
How do organizations move to from being independent to interdependent? Mr. Ganesan and Mr. Bauer offered two steps — first, organizations must have the right data systems in place to measure value, and second, organizations must figure out what to measure.
Having the right data systems in place doesn’t mean having one magical product that addresses the entirety of an organization’s technology needs. Instead, Mr. Bauer explained that organizations need an information platform that aggregates data from multiple sources such as electronic health record (EHR), care management, client engagement, agency management (billing systems, transportation fleets), and mobile devices (wearables, workforce tools, apps).
Additionally, organizations need to consider interoperability of these systems both internally and externally. Right now, there are three ways to exchange information — via EHRs, health information exchanges (HIEs), and direct secure messaging (see Making Behavioral Health System Information Exchange Work and Tips For Using Direct Secure Messaging). Provider organizations need to begin either using these systems or building partnerships with HIEs in order to share and exchange data. Sharing and exchanging data will eventually lead to a more concrete demonstration of value through improved communication with other provider organizations and a better grasp on the health of a consumer.
After developing the data systems to measure value, organizations need to figure out what to measure. As Mr. Ganesan explained, provider organizations already have a lot of data, it’s figuring out how to leverage that data that allows organizations to make their business case. And organizations cannot use the excuse that “we can’t measure what we do.” In order to measure value, provider organizations need to begin looking at the data they have available and tell a story with that data that reliably demonstrates value.
Provider organizations that work towards interdependence are going to be the organizations that survive in the simultaneous shifts to integrated care and value-based reimbursements. Currently, there are more than 60,000 provider organizations compared to 6,500 hospitals. Mr. Ganesan’s prediction: As the shifts occur, maybe half of those provider organizations will survive them.
For organizations that want to survive, having the information platform to analyze data, coordinate care, and measure value will be crucial. For more, check out The ‘Five-Step Formula’ For Making Data-Driven Decisions. And mark your calendar to join Mr. Ganesan on June 6 at The OPEN MINDS Strategy & Innovation Institute when he will again deliver the session, “Title is Connecting the Dots From Data to Value.”