Flourishing As a Collaborative Payer Model in Missouri

Feb. 4, 2014
The collaborative payer model is a dynamic partnership between a payer and a medical organization, built on aligned incentives, shared control, transparency, and joint accountability. In Missouri, a health plan’s commitment to collaboration and information transparency has enabled it to achieve the Triple Aim “plus one.”

As reimbursement cuts and other payment changes put intensifying pressure on physicians and medical groups, accountable care offers new opportunities for collaboration between payers and providers. Over the last decade, health insurers across the country have been practicing aspects of accountable care through the collaborative payer model, a care delivery innovation jointly developed by a payer and provider in which operational support tools, information, and technology help manage patient populations.

In Missouri, Esse Health—a group of about 70 primary care physicians in the St. Louis area—started Essence Healthcare in 2004, an insurer that offers coverage under the Medicare Advantage program, serving more than 40,000 members. Essence Healthcare provides its network of providers a collaborative payer model.

Essence was an early adopter of the St. Louis-based Lumeris’ (Lumeris provides operational support to Essence Healthcare and Esse Health) cloud-based accountable delivery system platform (ADSP), which was purpose-built for population health management, and helps the plan integrate claims and patient data from across the continuum of care to create a holistic and accurate view of plan performance against various cost, quality and utilization metrics, says Deborah Zimmerman, M.D., who is chief medical officer of both Lumeris and Essence Healthcare, a role that allows her to focus on clinical quality. “This position suits me perfectly as a physician, because I get to help other providers succeed in value-based care,” she says.

Via the ADSP, Essence pinpoints opportunities for improvement in these areas and then engages primary care physicians in the network to address them via a host of web-based platform applications and tools. There are more than 150 quality metrics in the platform, including the 33 metrics part of the Medicare Shared Savings Program (MSSP) accountable care organization (ACO), HEDIS (Healthcare Effectiveness Data and Information Set), NCQA (National Committee for Quality Assurance), payer-driven, and other evidence-based care measures. “Our commitment to collaboration and information transparency has enabled the plan to achieve significant reductions in overall costs while improving quality performance, as well as member and physician satisfaction,” Zimmerman says.

According to Zimmerman, the ADSP aggregates and analyzes data from across the continuum of care— including electronic medical record (EMR) encounters, claims, pharmacy, lab, and other available data. It rationalizes that data to establish a unified, accurate view of patient care and population health, she explains.

“As CMO of Essence, I use the ADSP every day to evaluate performance on quality, cost and utilization measures, and look for both clinical and financial improvement opportunities,” Zimmerman says. “My care managers use the platform to manage high-risk patients and close gaps in care.  My director of quality improvement uses the platform to monitor performance on quality metrics.  Our networked physicians use the ADSP to manage the health of their patients to view care reminders to close gaps in care, as well as to stratify their patient populations by needed interventions, outreach score and disease state.”

But the underlying key to success, says Zimmerman, is physician engagement and satisfaction, something that she strives for as Lumeris CMO. “Through the right incentives, tools and information, we empower physicians to change their behavior and make better-informed, value-based decisions. The results that we’ve achieved with Essence Healthcare map well to the Triple Aim “plus one” in terms of cost, quality and patient plus physician satisfaction,” she says.

In terms of cost, Essence has seen a 30-percent reduction in cost when compared to fee-for-service Medicare, reports Zimmerman. In terms of quality, the health plan has maintained Centers for Medicare and Medicaid Services (CMS) 4.5-star rating for three straight years, and in terms of patient satisfaction, ratings for the health plan are consistently above the national average in CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys, and 95 percent of patients are seen annually. “[And] our plus one—physician satisfaction—is reflected in more than 80 percent of physicians rating that they are satisfied with Essence, Zimmerman says.

While accountable care involves risk and reward sharing, and is a departure from the fee-for-service, volume-based care that the industry is used to, Zimmerman believes it is truly the nation’s best hope for achieving better health outcomes, lower costs, and improved patient plus physician satisfaction. “As the market evolves from fee-for-service to value-based care, [we are] helping providers assume more risk for managing their patients and populations,” she says. “And [to do that], technology-enabled solutions [are needed] to solve some of the industry’s biggest challenges.”

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