Can payers and providers transform healthcare by transforming their contracting relationships, and by collaborating on data? While there is no unanimity on the answer to that question, the members of a panel of industry leaders agreed that things are at least moving in that direction. The panel discussion, entitled “Transforming the Payer-Provider Relationship: Aligning Business Models for Improved Outcomes,” was held on June 10 at the Health IT Summit in Chicago, sponsored by the Institute for Health Technology Transformation (iHT2; since December 2013, iHT2 has been in partnership with Healthcare Informatics, through our parent company, the Vendome Group LLC).
Cynthia Burghard, research director at the consulting and research firm IDC Health Insights, moderated the panel. The panels other members were Cathy Dimou, M.D., chief medical officer at Rush Health, the physician-hospital entity within the Chicago-based Rush Health System; Dan Hounchell, COO of the Cincinnati-based HealthSpan health plan, which is owned by the Cincinnati-based Catholic Health Partners health system, the largest health system in Ohio, and which operates hospitals throughout Ohio and Kentucky; and Scott Sarran, M.D., divisional senior vice president and CMO, government programs, at the Chicago-based Health Care Service Corporation, an umbrella organization that encompasses the Blue Cross Blue Shield health plans of Illinois, New Mexico, Oklahoma, and Texas.
The panel members discussed broad issues around payer-provider collaboration, value-based contracting, and data-sharing. And each of the panelists shared perspectives gleaned from her or his organization’s work in this key sphere. Asked where the Rush Health people began their value-based healthcare work, Dr. Dimou said, “We decided to work with our employed population first, because we thought it would be a great place to start. We worked with Cigna,” she noted. “And we were able to actually look at shared savings with our physicians, and try to set up a pay for performance model that way. It was a good way of putting our toes in the water and trying to level off the cost curve in that way. We are just starting to see outcomes in select patient populations. We’re looking at diabetes and hypertension and are starting to see a decrease in cost. And we’re trying to figure out if the progress in terms of a decrease in cost and an improvement in outcomes is real, or is seasonal variation.”
HealthSpan’s Hounchell noted that being provider-based health plan within his organization’s umbrella has supported a great deal of activity. “We’ve got a lot going on,” he noted. “Cincinnati was selected for the Comprehensive Primary Care Initiative. And partnerships with several local health systems; and we’re working on partnerships with health plans. What have been the key success factors for us? I hate to sound so blunt about it, but money really does talk for us,” he said. Physicians, he emphasized, will respond to financial incentives, whether they bring gains or losses in the short term. With regard to his organization’s recent moves, he reported that Catholic Health Partners’ purchase last year of what had been Kaiser Permanente of Ohio, now HealthSpan, also included the purchase of the employed physician group of Kaiser Permanente of Ohio, now HealthSpan Physicians. “And it’s all prepaid care,” he emphasized. “And just in the last six months since that acquisition, we’ve seen benefits. We see the benefit of the Kaiser Permanente model, but how do we adapt that to the Midwest? That’s what we’re trying to work out right now.”
Importantly, said Dr. Sarran, “What creates sustainable change is when providers do things that reduce cost and improve outcomes. To [execute on] the Triple Aim, it’s going to require providers to reengineer care and processes. Our take on that,” from a health plan perspective, he added, “is that pay for performance is not sufficient. Simply changing from a volume- to a value-based payment system is necessary, but not sufficient. It’s got to happen in order to transform care for cost, but is not sufficient. So when there’s enough provider skin in the game, in terms of the percentage of their patient flow as well as dollars at stake per patient, to cause them to reengineer, and there’s enough physician leadership, and true support with data and analytics, that’s what we look for. On the flip side,” he added, “work with providers through some programs to focus on the very high-cost patients. There, we think value can be more immediately created.”
The panel spent some time discussing the potential outcomes involving physicians participating in accountable care, value-based purchasing, patient-centered medical homes, population health management, and other emerging payment and delivery forms. But the Blues’ Sarran warned that the landscape for health plan-hospital collaboration is more fraught than is the landscape for health plan-physician collaboration, in these areas. “With physicians,” he said, “it’s fairly straightforward to articulate the situation for physicians and to create win-wins between us and the physician groups and for the patients, and we can do that through HMO products or shared savings. And the reality is that simply by managing the network, we can create savings immediately. When we’re dealing with the hospital entity, though, the challenges are much greater. In the environment in which we operate,” he said, “there is an overcapacity of hospital beds. And the fundamental challenge is that in shared savings or ACO or anything else, we cannot pay more for a hospital to empty a bed than to fill a bed; so if there’s no substitute for filling beds, like maybe a lower-cost insurance product or something; if we can’t backfill, the hospital providers truly won’t do the heavy lifting to empty beds, or they’ll do it and lose on the deal, and it won’t be sustainable.”
Collaborating on data
IDC’s Burghard asked the panel members about the degree to which genuine data-sharing and data collaboration are taking place between health plans and providers right now. In response, Rush Health’s Dimou said, “Let me describe what Rush Health provides to our physicians. We have data on about 80 percent of our physicians on their claims, and we set up a data warehouse. On the employer side, we would need all of their claims data. So we get claims data on a monthly basis, usually with a two-month lag; but it goes into a data warehouse, to give us information that helps us to ascertain likelihood to readmit; so we get data that is actionable for the physicians to manage patients better.”
HealthSpan’s Hounchell noted that “We share a lot of data; having a provider and plan together under one roof is great. But the question is, what do you do with the data? How do you make it actionable? And we struggle with it,” he conceded. “We’ll say in a meeting, well, this data is great, but what do we do this? And we want to impact the total cost of care and outcomes, and we’re really struggling with that; that’s our experience right now.”
Asked about physicians’ resistance to receiving and working with outcomes data, the Blues’ Sarran said, “There’s actually less and less data skepticism among physicians now. And risk adjustment is forcing us all to pay more attention to diagnoses, because the government can and does audit how we do it. So we’re seeing a much more rigorous approach to capturing diagnoses in a complete and accurate fashion, on the part of providers. Because if it comes to us in an incomplete form, we can’t transform it.”
Rush Health’s Dimou added that “We try to marry the clinical and claims data, and basically, take the data out to the physicians, and not so much say you’ve done well or badly, but help us to understand what’s going on with your patients. And that’s the key to getting physicians interested, which is presenting it as a problem for them to solve. Tell us where the errors might be; and we’re able to use our clinical data to support our findings and then come up with a solution to improve patient care.”
Asked what have been learned so far at the Blues organizations regarding marrying claims and clinical data, Sarran said, “I think one take is to work backwards in data analytics from what you’re trying to do. So if we’re trying to save money and improve care on your highest-cost patients, it’s teasing out who the people are who are your highest-cost patients, and then look at the factors contributing to their being your highest-cost issues. And if you’re trying to improve Stars or HEDIS, you’ve got to have the right analytics loaded in your analytics system to spit out the exact event you’re looking for. So it’s really understanding in a very discrete way what you’re trying to do with the care event, and aligning the data and the analytics with that.”
