Engaging Payers in Specialty Care Value-Based Care Models
Most providers and their partners have difficulties understanding how to work with payers. Physicians and other care partners want to build care models that are clinically meaningful, and they perceive that payers only want models that cut costs.
Payers, on the other hand, may believe that providers are out to game them—providing unnecessary services just to get additional payment—since the fee-for-service payment methodology prioritizes volume over value. The more services one provides, the more income is earned, as payment is made regardless of the impact on individual patients’ health.
Neither of these perspectives is entirely accurate. Providers and payers, together, are responsible for the management of care and the cost of care of their individual patients/members.
There is a need to build models that are both clinically meaningful and thoughtful about use of limited resources, and that can be administered by a payer. If a model cannot be administered by a payer, it does not matter how good it is. It is critical to engage with payers.
It is true that the way we pay for care determines how it is delivered. In the current and predominant US fee-for-service payment methodology, contracts are written and payers reimburse unit costs based on individual units of care delivered (ie, physician visit, lab test, etc). As a result, care is often disjointed (ie, physicians and other care providers often must deliver care for a particular diagnosis or symptom without holistic knowledge of their patient or the impact of another provider’s care). Physicians may have information from the individual patient, but there is no mechanism for providers to spend time connecting with other providers to discuss the whole of the patient, all of the care the individual patient requires, and the clinical implications of various treatments on the patient’s comorbid conditions. The focus is on all of the care rendered by one particular provider at a time, rather than all of the care that is required for the particular individual patient over time.
This is particularly difficult for those living with and/or managing chronic conditions. Patients wind up having to navigate the complicated health care continuum on their own, and often have no basis for assessing the quality of available providers. Decisions are made on the advice of family or friends who think the doctor “is so nice” and, therefore, must be the best.
Value-based care models attempt to address this by aligning stakeholders on delivering consistently optimal outcomes at the most optimal cost. They agree on outcomes first—the shared goal for which they all are aiming. Each partner participates, sharing their particular expertise, to create collaborative processes and workflows that will deliver consistently positive outcomes.
Having access to the longitudinal data is critical to ensuring that providers are able to see the variations in care and cost of care based on the historical delivery of care, so that they may assess and determine the proper clinical and operational workflows to implement in order to address that variation as well as to get to the best outcomes on a consistent basis.
Leveraging the expertise of each stakeholder (ie, clinical expertise of specialists, longitudinal picture of the individual patients as tracked by payer claims, etc) allows each team member to participate at the top of their license/expertise to create a comprehensive model of care that is intended to improve patient outcomes and experiences while reducing unnecessary and duplicative care. No one partner has all of the information.
Clinicians must be able to define the clinical pathways and make decisions at the point of care delivery about what is best for their patients without having to first call a health plan to ask permission from someone who almost certainly does not have the specific knowledge of the specialist treating the patient. Time is wasted, money is wasted, and patient conditions worsen.
So, how do you effectively engage with payers to build models for specialty care?
Payers are reeling from the pandemic and having overspent premiums during the omicron portion of the COVID-19 pandemic. They are very skeptical about promised long-term return in investment (ROI) programs right now, particularly if it involves any upfront costs, which is especially difficult in today’s financial market. While payers are very interested in managing care and cost of care for patients with chronic conditions, and they recognize that they do not have the clinical expertise and resources to effectively do that, they are looking for ROI in the short term as they recover from the effects of the pandemic. It is important to identify opportunities for short-term improvements in care and cost of care while continuing to focus on and work toward the longer-term goals to get the attention of payers in today’s post-pandemic financial market.
Flexibility is key. Payers are not nimble, and they need and respect partners who are. If you bring third-party partners (eg, digital or other solution partners), be prepared to speak about the value-add in a way that resonates with a payer (ie, express the impact of the solution on patient outcomes and predictability of cost).
Solutions that work within existing payment and other systems will be most attractive. Differentiate yourself in a way that matters to the payer (ie, bring expertise that the payer does not have, using a payment model that is synchronistic with the payer’s systems).
Express the issue in a way that a payer can understand, remembering that predictability of cost is critical for this stakeholder. Focus on how your solution can help ensure that patients get the best care and consistent outcomes while creating a model that will effectively manage costs.
If you’re willing and able to take on some portion of risk, that is always appealing to payers, who are looking to create predictability of cost as a way to keep premiums affordable for their members. However, it is important that this move be made thoughtfully. Taking on too much risk before you’ve had time to work within the model, could be dangerous—make this move after studying the data and creating plans based on the evidence (ie, the impact your proposed process will have on the agreed-upon outcomes goals).
Many payers have innovations teams, value-based care teams, and others working on alternative fee-for-service models. Seek out these people in your market. Reach out to set up time to brainstorm and begin to cultivate relationships.
The key is to approach the discussions with an open mind, and in the spirit of partnership, bring what you do best to the table, and allow others to bring what they do best.
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