The Road to Payer Provider Convergence is Paved with Analytics

September 21, 2017
Mark A. Caron, CHCIO, FACHE, CEO


Provider shaking hands with payer 

Notwithstanding the decision in August by the Centers for Medicare and Medicaid Services (CMS) to cancel three mandatory bundled payment programs and roll back a fourth, I concur with the thinking of many healthcare leaders that value-based care is here to stay.

To refresh your memory, as a follow up to my keynote at the Healthcare Informatics Denver Health IT Summit, I wrote a blog last month that reviewed the market and government forces driving payer-provider convergence as well as the current state of value-based care adoption. Today’s blog discusses how to facilitate and increase payer-provider alignment and convergence.

Undoubtedly, payers are motivated to increase alignment, collaboration and convergence with network providers, and have embraced value-based care as the mechanism for achieving this laudable goal. Aetna, Anthem and UnitedHealth all report approximately 50 percent of reimbursements are distributed through value-based care models, and Aetna has pledged to grow it to 75-80 percent by 2020.

Capital BlueCross Uses Advanced Analytics to Drive Convergence with Network Providers

The shift to value-based care isn’t limited to national payers. A plan with which I am quite familiar, Capital BlueCross, launched its first accountable care arrangement in 2011. Today, nearly 3,000 providers and 360,000 members participate in the payer’s performance-based models.

Capital BlueCross has reported significant success with its initiative to drive payer-provider convergence.

Data for a recent 12-month period show Capital’s accountable care providers are outperforming their peers:

  • Acute inpatient hospital admissions are 4.7 percent lower for employer group customers and 7.2 percent lower for Medicare plan customers.
  • Hospital readmissions are 8 percent lower for employer group customers and 14.8 percent lower for Medicare plan customers.
  • Emergency department visits are more than 8 percent lower for employer group and Medicare plan customers.
  • Accountable care partnerships are meeting or exceeding agreed-upon quality goals and are exceeding the regional average for Healthcare Effectiveness Data and Information Set (HEDIS®) measures for chronic disease management

It is worth noting that the use of a shared analytics platform is critical to Capital’s success. Capital provides all of its accountable care partners with Geneia’s Theon® advanced analytics and insights platform. Key staff from Capital and network providers work in a shared cost and quality improvement platform, one that provides all users with:

  • A comprehensive, stratified view of members and member populations
  • Timely, prioritized care and intervention recommendations
  • Simplified and real-time care gap identification and closure

Just as importantly, providers can pay an additional fee to use the Theon® platform to manage all of their value-based contracts regardless of the payer.

Capital BlueCross seems to have been at the leading edge of giving its accountable care partners an analytics tool that is critical to their shared success. The availability of the Theon® platform likely increased provider willingness to evolve from fee-for-service payment models to value-based reimbursement arrangements. In fact, a recent survey of more than 450 primary care physicians and payer executives by Quest Diagnostics found 85 percent of health plan executives said co-investment in health IT by payers and providers would accelerate adoption of value-based care. Other interesting survey findings are:

  • 83 percent of physicians and payer executives agreed that alignment between payers and providers is more important than ever to provide value-based care
  • 87 percent of physicians and payer executives agreed the providers need access to patient-specific quality and performance measures specific to achieve value-based care success
  • 87 percent of physicians say they are likely to use a tool that provides on-demand, real-time, patient-specific data to identify gaps in quality, risk and utilization as well as medical history insight within the clinical workflow

Population Health Experts

In the six years since Capital BlueCross created its first value-based relationship, it found technology and analytics are critically important, but in many cases, not enough to build the kind of collaborative relationships to deliver year-over-year improvements in the cost and quality of member health care.

That’s why Capital has deployed a Geneia population health expert to each of its value-based partnerships. This clinician is the key point of contact between the payer’s traditional case and disease managers and the provider’s office. They work collaboratively and consistently with physician leadership to dive deep into the Theon® platform’s analytical insights and develop action plans to address variations across members, providers and facilities.

Our population health experts are directly responsible for coordinating the most appropriate care and services for Capital’s members and drive improved health outcomes. Indirectly, they are on the frontlines of increasing alignment and collaboration between the health plan and its network of providers.

ACOs and value-based care contracts are the important first step in achieving payer-provider convergence. It’s my belief that the next steps are the payer helping its provider network to achieve success in value-based arrangements by providing technology and analytics along with population health experts to help prioritize interventions and lighten the load for providers.


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