For provider organization executives looking at recovery planning, “top of the list” is different relationships with payers. In most of my discussions, higher rates, less administrative costs, standardized performance measurement, and sharing in savings are the key talking points. The question—how do you get to that new kind of relationship? The health plan executives in our session, Health Plan-Provider Partnerships: Improving Care Through Collaboration, at The 2020 OPEN MINDS Strategy & Innovation Institute, had an answer—reach out to health plan managers and let them know both what you can do and what you want.
Alexsis Desrochers, vice president of value-based programs at Magellan Complete Care; and Neha Patel, director of care delivery transformation, southeast region at Anthem, Inc., provided some very useful perspectives on what health plans are looking for, and how they evaluate provider organization partnerships. Magellan Complete Care is focused on whole person care (physical, behavioral, and social needs), and is present in six markets—Arizona, Florida, Massachusetts, New York, Virginia, and Wisconsin. They have a range of value-based reimbursement (VBR) arrangements with their network provider organizations on the physical health side, and their behavioral health-centered VBR programs are still in negotiation.
Ms. Desrochers explained, “We have a lot of programs along the continuum, from basic administrative tasks, to shared risk. A lot depends on the sophistication of the provider organization, their staff, and their capabilities. Usually our VBR sits on top of our normal fee-for-service (FFS) contracts, although we can go further to do some wrap around type contracts.”
Anthem’s approach to VBR is exemplified through its Enhanced Personal Health Care (EPHC) program. Launched in 2013, it’s a consumer-centered, value-based care program focused on collaborating with provider organizations by providing the necessary tools, resources, and consulting to achieve VBR success. They have a continuum of VBR programs dependent on the capabilities and willingness of provider organizations. It is also Anthem’s largest value-based initiative. Ms. Patel noted, “This is not an easy conversation to have because the stigma of the payer as the enemy is hard to combat. One of the ways we have tried to do this is to bring in the tools and resources, and to support them from a PMPM rate perspective as a part of our program. We also provide people power to really bring this all to life.”
As provider organization management teams think about telling health plans about “what they do,” it is important to think about your presentation (in a document and in person) from the perspective of the health plan managers. Ms. Desrochers and Ms. Patel recommended that the discussion include three key issues—readiness and experience with VBR, current performance and outcome measures, and the ability to participate in integrated care initiatives.
VBR competency is an issue—While many provider organization executive teams may say they are ready to assume some type of financial risk, health plan managers are hesitant to accept those assurances at face value. Sharing data is the key to convincing the payer. Ms. Patel explained, “It’s hard getting provider organizations to sit at the table with us, to look at their own data, and to see what their practice looks like from a data perspective. They say they are doing things, but is it showing up in the data?”
Health plans look for provider organizations with an integrated technology platform with all-inclusive clinical data, performance management analytics, and care coordination functionality. They look for experience with data-informed decisionmaking in real-time, as well as a thorough understanding of service delivery cost variables and the risk-based contracting process. Mastery over administrative functions can help land contracts reimbursing an administrative fee for services or offering quality incentives that reimburse for individual metrics and targets.
Ms. Desrochers noted, “No matter where you come out in an assessment, there is an opportunity, but you need to understand where you are along the continuum. Are you just activity based, or are you ready to move into the outcomes-based programs? You need to come into the negotiation understanding what you are ready for, and what you are not.”
Current measures of success—Every executive believes their organization has good outcomes and solid performance. But that needs to be demonstrated in metrics. What are your current performance stats? How do they compare to competition? To answer those questions, provider organizations need to be strategic about what data to collect and analyze, and the story that data is telling to payers. The key is not to silo what is reported to payers from what is used to make internal decisions about clinical efficacy, productivity, and growth (see Reducing The Cost Of Reporting 558 Unique Performance Measures).
Creativity and dialogue about what to measure are also encouraged (see Think Like A Health Plan). Payers are willing to admit they don’t have all the answers and to factor in perspectives from the frontlines.
Ms. Desrochers suggested going through all of the Healthcare Effectiveness Data and Information Set (HEDIS) measures, but not being limited to those. She said, “In general, there is no set game plan or cemented playbook for what measures VBR must include. Come to the table with your own suggestions. For example, daily living activities that can measure consumer functionality, or any social determinants of health.”
Be sure to provide feedback to payers on what’s working and what’s not. Ms. Patel explained, “Whatever your current relationship is, be willing to share your thoughts, experiences, and barriers. We gather that feedback. We don’t have answers to everything, but we must make decisions on the short, medium, and long-term impacts. Hearing provider organization feedback helps us understand the impacts and engage.”
And provider organizations should seek benchmarks, set goals, and not hesitate to ask payers how they compare against their peers and competitors.
Ability to participate in integrated care initiatives—The key to improving consumer care and reducing use of unnecessary resources is coordination, which drives health plan interest in integrated care models. Provider organizations must be prepared to outline how their organization would “fit” into those initiatives. They must demonstrate how they can support interoperability; drive referrals; and expand the scope of services delivered, geography covered, or consumers served.
Health plans also look for experience in whole person care and population health management. This is where the specialty provider organization takes on a role more akin to primary care to “quarterback” consumer care, and take total responsibility for physical health, medication, and other costs, while ensuring better outcomes. In addition, provider organizations must be ready to openly discuss how they can manage social determinants of health, pharmacy, or social services. Executives need to be prepared to show that their organization can cover every element of consumer care. Ms. Patel explained, “We are firm believers in looking at populations and looking at the trends in the data to improve care. But we need to decide who should be the quarterback, such as community mental health care or primary care. The ability to transition back and forth is the evolution and success is about who is on my care team.”
If the future of health and human services is value-based, then the future requires a different relationship between health plans and the provider organizations—one based on the ability to come to the negotiating table with confidence. The most confident organizations will be able to step up and push for integrated care with value-based strategies.
For more on advancing conversations with payers and managed care organizations, check out these resources from The OPEN MINDS Industry Library:
- Negotiate Those Contracts
- Identifying Strategic Opportunities: Cultivating, Negotiating & Decision-Making
- The OPEN MINDS Health Plan Partnership Summit: A Guide To Developing & Negotiating Partnership Agreements With Health Plans
- Identifying Strategic Opportunities: Cultivating, Negotiating & Decision-Making – Sponsored By Credible Behavioral Health Software
- Executive Compensation: How To Negotiate & Manage The Compensation Process
- Are You Ready For Risk-Based Reimbursement? How To Assess Readiness & Negotiate Contracts
- 3 Keys To Building A Strategy For Growth
- Developing Case Rates? Better Find Your ‘Single Source Of Truth’
- Performance Management Is Never Done
- VBR—Where’s The Beef?
And be sure to join my colleague and OPEN MINDS Senior Associate Paul Duck on August 6 at 1:00 pm EDT for his web briefing, Getting Paid – More – For What You Do – Tactical Approaches Of Increasing Fees & Rates From Payers & Moving To New Reimbursement Models With Payers.