LIVE FROM HIMSS16: Are We At an Inflection Point into True Provider-Payer Convergence?

Oct. 4, 2016
Two presentations at the Business of Healthcare Symposium Monday at HIMSS16, as well as HHS Secretary Sylvia Mathews Burwell’s comments, spoke to a fundamental realignment of interests in U.S. healthcare

The closing keynote presentation in the Business of Healthcare Symposium on Monday at HIMSS16 really helped crystallize so much about this moment in healthcare. Even the professional title of the presenter spoke to it. The presenter was Veeneta Lakhani of the Indianapolis-based Anthem, which insures 38 million covered lives across the U.S., and which has contracts with 796 hospitals and 54,000 providers, and has over 4.5 million members in more than 154 ACO contracts nationwide.

Ms. Lakhani’s title? Vice president, provider enablement.

Indeed, everything about Veeneta Lakhani’s presentation on Monday after spoke to the current moment in U.S. healthcare And, following immediately after the excellent presentation, “The ROI of ACO,” by Douglas J. Van Daele, M.D., vice dean for clinical affairs at the University of Iowa Health Care, Lakhani’s presentation spoke to the massive shift in perceptions and interactions that has taken place among providers and payers in the past decade.

Ten years ago, it would have been virtually unthinkable to have a provider leader (not to mention a physician executive at an academic health system) and a health plan senior executive, follow one another on a symposium program, and say essentially the same kinds of things—from the provider and payer perspectives of course—about payment incentives and collaboration. And yet these were exactly the kinds of presentations that took place at the Business of Healthcare Symposium on Monday. Indeed, the subtitle of the symposium, or its tagline, was this: New Payment Models: Are You Ready?”

What’s more, both Ms. Lakhani and Dr. Van Daele both spoke extensively and clearly about the criticality of strategic information technology, and of the participation of healthcare IT leaders, in the needed transformation of the U.S. healthcare system that both presenters agreed was and is needed.

As Lakhani said to her audience, speaking of health insurers, “We need to play a role in transformation. That started with the incentive system. Our framework for thinking about it is that there’s are three kind so relationships we seek,” she said. “One is a payment innovation relationship—value-based payment. The other is partnerships—product partnerships; Vivity is a good example in California. We’ve essentially partnered with seven systems in CA and launched. The third is payment reform.”

Veeneta Lakhani at the Business of Healthcare Symposium

Essentially, Lakhani said, she and her colleagues at the massive Anthem are seeking to create repeatable payment and partnership models we can scale across the country.” And that statement reflects what are apparently the sentiments of senior executives at all the largest for-profit health insurers nationwide, as well as those of executives of the Blue Cross and Blue Shield plans and other not-for-profit health plans across the U.S.

As Lakhani noted, “We committed to this”—to partnering affirmatively and collaboratively with providers—“in 2012. About 37 percent of our medical spend is under a value-based payment arrangement today, and we’re moving to a strong commitment to 50 percent by 2018. We’re in this, we’re committed,” she repeated, adding that “We see payment innovation as a part of a spectrum.” That spectrum, she said, includes a vast range of possibilities, including “global capitation, shared savings/risk, bundled payment, P4P, tiered benefits, reference-based benefits, transparency. We ultimately do want to get to global capitation,” she emphasized.

Not only are the senior executives at the major private health plans committed to partnering collaboratively with providers to improving clinical outcomes and bending the cost curve—and in that, their interest in transforming U.S. healthcare through collaborative models mirrors that of the federal officials overseeing the Medicare and Medicaid programs—they recognize that healthcare IT strategy—and people—will be crucial to the success of any such ventures.

IT and data will be essential for establishing and measuring outcomes (there are currently 34 measures in Anthem’s quality scorecard, for example—the use of portals for plan members parallels very closely the development of portals for patients on the part of patient care organizations); IT and data will be vital to the marrying of clinical and claims data and its analysis on the part of collaborative health plans and providers; and it will be vital to the engagement of physicians in clinical performance efforts.

Indeed, as Lakhani noted, she and her colleagues have been measuring and continue to measure, progress with providers in moving forward to cut costs and improve clinical and health outcomes. For example, she noted, “We established a risk-based control measure,” in moving forward with provider organizations on risk contracts, “and matched members in our cohorts to a control group.” The results? The ACO model-based providers achieved a $9.51 per member per month in reduction against the control group.”

What’s more, Lakhani said, “We have some really great positive signs of success in our cohorts. The performance [among providers] is not equal; we do see variance. We’re very committed to making sure we really understand what drives the best, and what capabilities we need to bring to bear.”

The short version of the formula? “People plus process plus technology plus culture equals success. That is enablement,” Lakhani said. “We believe that these elements, when structured and targeted correctly within our population, deliver success. It all starts with physician engagement,” she added. What’s more, she said, with regard to solutions, “No one size fits all; scalability requires commitment; and capabilities must balance short and long term trends. There is power in putting claims and clinical data together,” she added, and emphasized that “It’s an evolution, not a revolution.”

In short, Lakhani said, “We really want to meet the providers where they’re at, and bring solutions to them. Having said that, scalability absolutely requires commitment,” she added.

All of this, in a session at a HIMSS pre-conference symposium, truly speaks to this moment in healthcare. It is one in which payers and providers, facing a leap over a cost cliff on the national level (as the Medicare program’s actuaries predicted last autumn, total U.S. healthcare spending is expected to go from its current $3.1 trillion per year now, to $5.5 trillion per year in ten years), are coming together out of necessity, and because the healthcare system has spent so many years working under an operational model that was primarily oppositional, and that did not work.

And collaboration around data, information systems, and analytics, is at the core of what payers and providers can gather together around. Indeed, senior leaders from all sectors of healthcare—hospitals, medical groups, private health insurance companies, federal and state government insurers (Medicare and the Medicaid programs), and policy leaders and legislators—are relying now more than ever on healthcare IT leaders to save the day and help to facilitate transformative change.

As HIMSS16 moves forward, it will be interesting to hear presentations and participate in discussions that elaborate on these themes. What is clear is that the old, somewhat unthinking, oppositionalism and sides-taking that healthcare has historically fallen into, are beginning to fall away, in the face of dire necessity, changing attitudes, progress towards success, and continually improving technology. And that positions healthcare IT leaders, as never before, to be the facilitators of change—as Health and Human Services Secretary Sylvia Mathews Burwell noted later on Monday afternoon in her opening keynote address to the conference.

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