Payer Provider Convergence: A Payer’s Perspective

October 03, 2017
Geneia


Two doctors smiling and looking at computer with quote to the left

Guest Perspective: Dr. Denise Harr, Senior Medical Director of Medical Value Initiatives at Capital Blue Cross, on Payer Provider Convergence

In your role, do you have any thoughts on what we’re calling payer-provider convergence? Clearly, a value-based contract is between providers and payers, but then it can branch into a thousand directions, focusing on how important it will become to collaborate, to partner, and to share care management roles and responsibilities.

Talking about technology and care management, the challenge is how you separate the two. In order to provide care management services, to have a coordinated approach, you need data, and you need technology to drive that. It’s probably going to be a bit challenging, in my opinion, to talk about technology over here but talk about care coordination over there.

You have to develop a collaborative relationship if you’re going to enter any value-based model. Look at traditional care management; it was delivered in a vacuum. I never knew it existed when I was a practicing physician. Apparently, my patients were reached out to and potentially engaged with their insurance companies in programs such as disease management, and periodically the payers would have sent me letters. I would like to think that I didn’t completely ignore them, but it just wasn’t on the forefront of what I understood was actually happening, so there was a disconnect.

Now that I sit on the other side of the table and understand the programs that payers do have to offer, I have a completely different appreciation of what payers are doing.

As we move to value-based care, providers are also trying to figure out what they need to do to be successful, and payers still have a lot of these traditional programs. When I look at the continuum of different programs that we have, even for providers that are in similar models, as much as we try to take a standardized approach - “Here’s how we’re going to engage in this type of model with this provider” – there’s always the need for customization. Providers are on a continuum of readiness to take on some of those care management responsibilities that, historically, only payers have provided. Each time we enter a relationship with a new provider entity, we ask some questions: “What are you doing? How can we support you? This is what we’re doing.”

It takes time. It doesn’t happen in one conversation, or five conversations. It’s only after really sitting down and having several conversations, “You are going to do this. We’re going to do this. We’re going to try to fill gaps that you may not have a resource for. We’re going to do complementary things, but not duplicate services. Our main focus are our members (the patients) and making sure that they get the right care but don’t get bombarded by five or six different people calling them about the same kinds of things.”

Is it an important topic? Without a doubt. Is there a standardized approach to it? Not as much as we would like. Much of what we do becomes customized based on the readiness of the provider.

On the payer side, you believe that everybody knows all about existing care management programs – and you wonder, why don’t providers want to take advantage of them? Why do providers generally dislike it when their patients get called?

Recently, we were sitting across the table from a provider organization that we were starting a new relationship with, and the CMO of the medical group asked, “So are you actually sending us letters? I didn’t even know that these kinds of programs existed.” I laughed and I said, “Well frankly, five years ago, I didn’t know they did, either.”

Even today, despite what we think we’re doing effectively, it’s often never getting to the providers. But this is where some of the providers are building their clinical teams. There’s more of an acknowledgement or understanding from the clinical staff that they are the ones who are going to drive engagement and enrollment in care management programs, more so than the providers themselves – the physicians, the nurse practitioners, and physician assistants. At least, that’s what we find in a lot of our relationships.

The provider may say, “I have this problem,” and it’s a nurse or an allied health professional who says, “Hey, I know what the solution is. Let’s get the patient engaged in this type of program,” whether it’s something that we offer as a payer or a program that a provider might have internally developed. When we think about some of the transitional care management services, that’s where I think we as payers have taken a step back, since the providers – because there’s reimbursement now for transitional care management – are anxious to get in to that space.

When it comes to executing care management convergence, what’s the ideal situation? That the provider doesn’t have to worry about it, and clinical office staff will know what programs are available and channel patients the right way – that the provider presents the problem and the provider’s staff help solve the problem? Or, do you think it would ideal to have, say, in the EHR, all the members’ benefits right there? I’m thinking there is nothing like your doctor looking you in the eye when you’re diabetic and saying, “I expect you to join this program and be compliant. Stay with it. It’s offered by your payer. They’re going to call you.” Reinforcement from the actual provider is certainly more impactful to the consumer. How involved does the provider need to be?

Because of the relationships that patients have with their providers, they’re more likely to follow his/her advice than they are to follow a cold call made by payer.

Providers are expanding their clinical teams in delivering services to patients. They’re trying to build a model that historically has been provided only by the payer. Admittedly, patients typically trust their providers more than they trust their insurance company, so to be most successful, we need collaboration between payers and providers along with providers reinforcing care management program offerings to maximize engagement and avoid member/patient abrasion and duplication of services.

How do you customize? How do you get to the point where you avoid the duplication – or maybe you haven’t yet? How do you truly turn off one as you turn on the other?

In your “normal” payer/provider relationship, there’s probably duplication. As we move into these value-based programs, where we as a payer have more one-on-one conversations with the provider entities – and, again, these are typically larger independent physician groups or health systems – we identify appropriate points of contact and we sit down and say, “OK, we’re going to do this and you’re going to do this. Here’s our roles and responsibilities.”

If we’re outreaching to identified members for care management programs, but they’re just not responding, we’re going to go back to the provider and say, “Here’s a list of people we’ve been trying to get engaged in a program. This is the piece that you’ve asked us to continue to support, but yet we can’t reach them. How can you help us?” Again, each provider has a different approach, but a lot of times, they either do their own outreach or, the next time that patient comes in to the office, they introduce the program to the patient. Sometimes it’s just, “Here’s another resource to help you with the current challenges that you’re facing.”

Businesswoman on the phone and computer in officeGeneia is a subsidiary of Capital Blue Cross. One of the things that Geneia did, as a way to facilitate conversations between providers and payers, is create a new primary role called a Population Health Consultant. This clinician is that point of contact between the payer’s traditional case and disease managers and the provider’s office. They talk about difficult cases, making sure members are getting the right care, and discuss those who have been difficult to engage and who may be driving inappropriate utilization. We have a Population Health Consultant assigned to each of our value-based partnerships, and they’re helping to coordinate the most appropriate care and services for or members and drive improved health outcomes.  

Sometimes you can make the argument that a liaison role serves as just another layer in an already complex structure. Why not just assign a designated payer employee to each provider group to do that outreach, rather than a third part vendor? What lead to that decision?

Being separate entities, there are resources on the Capital side and there are resources on the Geneia side, but they intersect in different ways with the provider organizations.  We also have our colleagues in the network and contracting area, who have their own peer contacts in these partnerships.  

When you sit down to take that customized approach and say, “You take this responsibility, I’ll take this one”, the example you mentioned was the hard-to-engage patient or member. “We’ve already have this program from the payer side, these ones are falling out, not engaging.” Do you find that’s the most common type of care management convergence happening in value-based arrangements? Or is convergence occurring more so within transitional case management? When patients get discharged from the hospital, provider groups seem ready to take those on.

In our experience, transitional care management mostly happens on the provider side. When we talk about traditional case and disease management, it’s happening more on the payer side. There’s definitely flavors of that depending on the individual entity.

In our programs, we are mostly working with primary care providers. Some of the information we provide is information that is not known to the PCP, because everyone is not on the same platform or system. We provide this information and they say, “Oh my goodness that fills in a whole bunch of gaps.” Sometimes, when they give us clinical detail that we don’t have from claims, all of a sudden it puts a big picture together, and we can develop a better way to manage that patient. There is opportunity to have a broader view of the patient through this exchange of information.  

Is transitional case management a place where providers prioritize care management efforts because they can bill for it?

That’s been our experience. They feel better equipped to provide these services and get the necessary follow-up care scheduled and coordinated.  

Denise Harr, MD, is senior medical director of Medical Value Initiatives at Capital Blue Cross. Her department supports the value-based programs that the insurer has implemented with providers across its network, with an emphasis on clinical quality and improved outcomes. Nearly 3,000 providers and 360,000 Capital Blue Cross members participate in Capital’s value-based models. Before joining Capital Blue Cross in 2012, Dr. Harr spent 15 years as a practicing family physician in Central Pennsylvania.

Dr. Harr is a featured speaker at Chilmark Research’s Convergence 2017 Conference, October 4-6. At Convergence, Dr. Harr is providing both strategic and practical insights regarding disease management, transitional case management, and other forms of care management that will play a key role in payer-provider convergence models.


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