Health Plan Leaders Range Widely Over Payer-Provider Collaboration Topics

May 13, 2021
In a webinar sponsored by World Congress Healthcare, senior health plan executives discussed how health plans can improve relations with providers and support payer-provider collaboration

On May 3, the World Congress-Healthcare presented a webinar, sponsored by the Harrisburg, Pa.-based Geneia, entitled “How Plans Are Supporting Providers on their Value-Based Care Journey: Using a Phased Approach to Accelerate Success in VBC Arrangements.” The discussion plumbed numerous issues facing health plans and providers, as both types of entities move forward to collaborate around value-based care and payment.

Lori Logan, chief product and client officer at Geneia, led a panel whose discussants were Oraida Roman, vice president, value-based strategies, at the Louisville-based Humana; Karen Amezcua, senior director, provider partnerships, at the Egan-based Blue Cross Blue Shield of Minnesota; and Brian Wheeler, vice president, provider collaboration and transformation at the Baltimore-based CareFirst BlueCross BlueShield.

Early on in the discussion, Humana’s Roman said that “We recognize that our providers work hard, and want to reward them wherever we can.” She summarized some of the health plan’s bundled payment programs, noting that “We’ve grown from one specialty bundle, total joint replacement, in 2015, to four in 2020: total joint replacement, maternity, spinal fusion, and CABG [coronary artery bypass graft]. We now have 138 agreements representing a little over 1,300 physicians in 26 states,” she reported. “We want to see the same results across the healthcare system. We’re seeing reduced readmissions and infection rates. And 88 percent of our bundled payment providers received shared savings in 2020.”

Further, Roman said, “In the last three years, we’ve grown between 300,000 and 500,000 members a year. And to make sure we keep 67 percent of our members aligned with value-based providers, we need to keep that membership level in value-based programs. And just staying at that 67 percent is a challenge. We also have a lot of local, state, and regional variation. So we continue to focus on areas where we don’t have quite the same level of penetration, and try to grow it wherever possible. Our success has been concentrated in Medicare Advantage, and as we grow our commercial lines of business, we’re dedicated to expanding our value-based contracts in those areas as well,” she added.

CareFirst BlueCross BlueShield’s Wheeler reported that “We actually began our journey to a value-based delivery system more than ten years ago. We created our patient-centered medical home 11 years ago. And we heard from both primary care physicians and specialists. And we’ve recently expanded our value-based care model to bring more providers into the model. Our philosophy was to be inclusive and bring more people into the program; and also, to accommodate the fact that healthcare is very local. Some markets have highly integrated health systems, while others have largely unorganized primary care physician practices. And some practices are more rural, or suburban, or urban; they’re in different financial situations. And we need to be adaptable. And the solution is that we’re making progress together. We all know we need to change the nature of relationships. And to say that it’s fine to moving from sitting on opposite sides of the table, to the same side of the table, was important. The relationships needed to be built with empathy as well.”

What’s more, Wheeler said, “There’s an awful lot of complexity in insurance and in benefit designs; and all that makes it complex to create new program designs. And we’re building on the foundation of the patient-centered medical home. And we’ve got a consulting team that helps partners to understand the model and to implement practice changes to optimize outcomes; and we’ve got the care management team, to help them get to their outcomes goals. And everything is grounded in principles of quality and health equity.”

Examining how payer-provider relationships have changed because of the pandemic

“I think that 2020 brought issues of relationships front and center, during the pandemic,” Logan said. “And we’re coming into month 13 and 14 now. How have relationships changed as a result?”

“The conversation has changed, and the relationship has flipped on its head; we’re trying to tackle a problem together rather than battling it out,” BCBS Minnesota’s Amezcua said. “It’s hard work; there’s a lot of historic baggage that we have to shed around these relationships. And really, showing what the plan is willing to do to support the relationship. So what are we willing to bring to the table, to produce the data that they need in order to be successful? So what we’re talking about now is different. And, with the pandemic, the other interesting development is the flourishing of telehealth. And we totally support telehealth. But how do we support telehealth over the long run? And how do we pay for it? And how do we work together differently? We can manage the population better and we can do better to support these relationships.”

“If you look at it nationwide, provider visits plummeted during the pandemic; they dropped more than 90 percent during the opening months of the pandemic,” Humana’s Roman noted. “And for providers whose operational model was based on FFS payment, the pandemic was really devastating. But some of our value-based providers had a lot more flexibility in weathering some elements of the pandemic, whereas FFS-based providers had their revenue plummet, and many had to reduce hours and close facilities and lay off staff. Meanwhile, many value-based providers had those monthly payments and they really yielded consistent cash flow, and that really allowed them to evolve forward their practices much faster. We’ve analyzed it, and found that our most advanced value-based providers were able to pivot most quickly to telehealth, versus the fee-for-service providers. We saw a lot less medical distancing with our value-based providers than we saw with our fee-for-service providers. And our value-based providers, many have care managers and care coordinators, who were already engaged in reaching out to patients regularly, so they were able to easily reach out to patients. So we saw much less medical distancing among our value-based providers,” she said.

“Now, with that said,” Roman continued, “we had a couple of programs already in development prior to the pandemic or that we’ve developed since, to address issues. We’ve all been focusing in the last few years on the social determinants of health. And we’ve launched an SDOH [social determinants of health] value-based pilot, and we’re partnering with five health systems to address those needs. The pilot aligns resources for screening, coding, and connecting patients identified with needs, with resources in the community. And achieving those connections, we believe, will improve outcomes. We launched the plot in February 2020, so it was an interesting first year. We’re continuing it throughout 2021. And when we look at the importance of SDOH and underserved populations that came out during the pandemic, we think we’ll learn a lot from that pilot.”

What’s more, Roman noted, “We have launched a Primary Care First model. As you know, CMS [the Centers for Medicare and Medicaid Services] created a Primary Care First model to support the delivery of advanced primary care. CMS launched that as a multistate model, with the goal of encouraging other payers to move into value-based care models. And as we were working to create our PCF model, we decided to offer the model in all of our geographies, not just the ones in which CMS was sponsoring their model. And in exchange for very limited financial risk, they get reduced administrative burden and financial stability through capitation. We’re getting ready to launch this program in the latter part of 2021.”

“Early on in the pandemic, the bottom dropped out of providers’ revenues, when patients weren’t accessing care,” Wheeler noted. “And a number of practices had fewer than 30 days cash on hand; it was an existential threat. So we used supports like PPP from CMS, and advanced incentives for some primary care physicians, and provided some stabilization funds. But once we had put the fire out and stabilized our partner practices, the next thing was the realization that if ever there was a good time to move away from FFS, this would be the time. And the data and technology have evolved considerably from when the first generation of capitation didn’t work. And if you believe as I do that the economic model drives the business model, and you change the economic model in the right way, you’ll get better outcomes—business and patient care outcomes. And if continue on the model that the most expensive person in your practice has to be seeing patients constantly, we’ll never get to the new model of care delivery. So if we can change the model, we can achieve better outcomes. So within the next year, we’ll begin to change models, and will encourage practices to adopt them. We’ve had a collective teaching moment in the last 18 months, so I think we’ll move faster than we otherwise would have.”

Looking at how health plans have invested in provider relations

“Thinking about all of these issues, let’s go around the circle and talk about the roles you’ve invested in, in order to flip towards more of a relationship-based interaction with your providers,” Logan said. “Karen, why don’t you start?”

“It’s really about elevating the contract management role to be almost more of a program management role, because you’re really entering into this partnership together and trying to figure out how to get from Point A to Point B; and that might involve pulling in consultative teams from data management, for example,” Amezcua underscored. “So the role of a negotiator is become more of an account management role from a sales perspective—how are we going to support that representative? And the other big investment we’re making is investing in new data and analytics tools through Optum, to figure out what the problems might be and how we can fix them. And then lastly, we have a provider enablement team, to support providers through conversation and to help project-manage them. And last but not least, it involves the investment to help primary care providers be successful in their clinics.”

“Given your organization’s focus first on primary care, how have things changed as you’ve moved out to connect with specialists as well?” Logan asked.

“That’s a great question,” Wheeler replied. “For years, we had a team of folks focusing specifically on primary care; they understood population health and risk stratification and how to focus on utilization in the practice. And we’re still very focused on primary care, and have a well-seasoned team. But we had to expand, to help specialists as well. So we have specialty management folks who think only about one area, such as orthopedics, gynecology, and so on. They know the business. They know what kinds of care can be done outside of the hospital, etc., and can have really intelligent conversations; and on the hospital side, focusing on individual service lines. So we determine whether the opportunities are and help them. And when it comes to large organizations with multiple service lines, it really is like sales management, as Karen mentioned. So bringing the best types of managers together is important. And it’s not always something that the provider needs to change; there might be tremendous pain points where we’re driving dissatisfaction in the provider world; what can we do? So lots of new roles are evolving, and we have to properly staff them and support them, in order to achieve results.”

What new roles have emerged in health plan organizations?

“How do you work with your teams to work with providers, and what new roles have evolved in your organization, Oraida?” Logan asked.

“Great question,” Roman said. “We started really intentionally growing and investing in value-based care, and that’s when we created our national value-based strategies department. We’re really focused on creating technology infrastructure to support our local teams. So we have a national provider engagement infrastructure that’s locally deployed. So every region has a team of provider engagement representatives; they don’t do contracting; they’re solely focused on the success of the provider in value-based care models. And my national team provides the same platform for data-sharing with all those providers, and we do a lot of training around best practices. And we had over 75,000 provider engagement interactions in 2020, solely focused on helping them to achieve success. And as we contract with a provider, we make sure to assign an appropriate provider engagement team. There’s nothing worse than drawing up a value-based contract that’s beyond where the provider is in their development. So we do a lot of assessment at the beginning of a relationship, but then these provider engagement representatives are focused on providing continuous engagement, so that we’re making sure that we help them move forward on their journey, versus just telling them what to do.

“You’ve all mentioned a bit about the give and take,” Logan said. “And it’s a lot for a practice or health system to transform in this way. Maybe any examples of efforts towards administrative simplification? Any thoughts on efforts on administrative simplification for your providers?”

“The chasing of medical charts is a pain point for everyone,” Wheeler emphasized. “It drives practices crazy and is administratively cumbersome for us. And honestly, EHR [electronic health record] adoption is still relatively recent; but how can we pull from EHRs and pull data from them to reduce the burden on providers? So we’ve launched a data management initiative in that area. And this is the beginning of a new age of data; and we know that if we’re all looking at the same data, it will help everyone. And as we’ve moved more and more providers into two-sided risk, there will be opportunities as those incentives get more aligned, especially with our self-funded accounts, there will be opportunities to reduce the administrative burden. And as we get more aligned over time, some of that will change as well.”

“Yes, I agree that a lot of the administrative burden comes out of the plan making sure that things are working correctly, and to drive a lower cost of care,” Amezcua said. “And we can be more nimble in certain areas and turning things off. We might start off with endoscopy, while the provider is working on reducing total cost of care. So we’ve been working with providers to reduce administrative burden where it’s possible. And a lot of the mistrust comes out of headaches the providers have to deal with. So our commitment to making it a win-win is huge.”

“And I’ll build on what Karen and Brian have said,” Roman said. “Sometimes, the lack of simplification shows up in how we interact with our members; we get a lot of complaints when we and our providers are both doing the same things. When both we and the provider are trying to do post-discharge calls—the patient has gone home, and the provider is calling the patient, too—that really upsets patients. So we’ve been able to start creating—we’ve taken up the model of ‘complement, don’t compete’ with what providers are doing. If a provider has a post-discharge program, we are able to turn off our post-discharge calls for those patients, and we let the provider manage those calls. And there’s complexity around the fact that some providers do certain things and others don’t; so maintaining the flexibility to be able to turn on and turn off specific elements of administration, is very important.”

Measuring success in the real world

“How do you determine what the metrics of success are?” Logan asked the discussants.

“It’s important for the plan and provider to agree on what the definition of success is,” Wheeler emphasized. “And there’s not one definition. There do have to be some minimal standards relative to national benchmarks; but it’s also about what’s important in a particular community. I remember a few years ago, in one community, we had an extraordinarily high level of mammograms; but that hid tremendous variation under the average. So you need to find ways to individualize in order to drive more value and better outcomes.”

“I agree; it’s a combination of cost, quality, and patient experience,” Amezcua said. “We’ve received feedback from providers in the past, around their not wanting to have to track different measures from different plans. We’re also just trying to continually improve how we track data and provide more recent data to providers. And I agree, aligning around long-term measures of success, in terms of our headline to the community and commitment to the community, and how we’re going to get there, is very important.”

“First, I’ll focus on our specialty programs,” Roman said. “And we have more flexibility on the specialty side, as we’re designing new bundles and are able to focus on the clinical elements that result in better health outcomes and lower costs. So we’re able to create pretty tailored goals based on the particular bundled, for example. If you look at our total joint replacement bundle, we have a quality trigger where specific quality measures must be met. Thirty-day readmissions, for example. We want to design elements that make sense to providers. What becomes more challenging from the provider perspective is that all payers seem to have different metrics. So what are we as health plans being held accountable for on the part of purchasers? With MA, while we have the same metrics, we all perform differently, and that can become a source of confusion and even out-and-out frustration for providers, when providers score differently on different measures; that reflects our looking for and incentivizing different things. So in an ideal world, we’d have fewer metrics; and then we could hold providers accountable more consistently. And having spent time as a provider, the amount of time, money, and energy I spent trying to satisfy plans’ needs, just drove me crazy. So we need to focus on those things.”

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