The Importance of Payer, Provider Collaboration in Payment Reform Efforts

Although the country is moving toward value-based payments, for providers it’s basically still a fee-for-service world, said Charles J. Fazio, MD, MS, of HealthPartners Health Plan, at America’s Health Insurance Plans’ Institute & Expo, held June 9-10 in Austin, Texas.

Providers still live in a mindset that in order to get paid, they need a billable encounter. So they aren’t viewing technology in a positive light, Fazio explained. Instead, every new piece of technology that prevents a face-to-face interaction represents money that providers are losing out on.

As a result, the challenges that these providers are facing include an uncertainty of when things will actually change; multiple priorities and contracts to determine success; and caring for populations, which is especially difficult for providers who haven’t done that before.

The good news, though, is that there is change occurring. “There are some really interesting things going on around the country,” Fazio said, such as regions where payers are getting together and aligning their quality measures or aligning the formats they are using.

“So where’s the tipping point?” he asked. There remain many practices that receive a contract and can still tell that the incentive still doesn’t outweigh volume and they understand volume best.

“So when do we get to the point when success is determined by the health of the population you’re taking care, and their satisfaction with their care, and the efficiency of that care?” Fazio asked. “That’s what we need to look like for success.”

Alicia Berkemeyer of Arkansas Blue Cross and Blue Shield then took the stage to outline the work they are doing in this space, which started in 2011 when Arkansas’ Medicaid, Arkansas Blue Cross, and QualChoice got together. They quickly realized that they might call things by different names, but they were doing similar things to meet the same goal: save money and still provide better care for Arkansans.

“It’s critical for the provider success, and really for the state success, to be closely aligned with as any payers as possible,” she said.

While the idea of working with a competitor may seem like a poor business practice, Berkemeyer said they are bringing competitors together to coordinate and collaborate on care. But this alignment is important for future business.

“If you’ve been in health insurance for any period of time, you know that eventually we’ll lose a member, they’ll go somewhere else, but then we’ll get them back again,” she explained. “So if we get them healthy, eventually they come back to us.”

She ran through some of the different payment models Arkansas Blue Cross has in place, such as episodes of care. Transparency really helped here because the different payers were able to have identical reporting delivered in the same format to the providers.

Arkansas was also one of the first states that joined CMS’ State Innovation Models initiative and used the funding to support quality of care, population health, and cost efficiency through episodes of care and the medical home. Arkansas Blue Cross began working with patient-centered medical homes in 2010.

However, the payer ran into the issue that it only accounted for a small proportion of payments for many providers and they weren’t being paid enough by Arkansas Blue Cross to make all the changes that would be needed. That was when Berkemeyer realized there was an opportunity for CMS’ Comprehensive Primary Care Plus model, because all the payers could support the same initiative and have aligned incentives. Now the payers meet with the providers and align the quality metrics.

These initiatives represent big changes that can be difficult for providers, and success is largely reliant on group culture, such as common values, compensation mechanisms, and internal transparency, said Fazio.

“You have to have a physician champion; a physician who will lead this, because it’s difficult,” Berkemeyer said in agreement.