Eight best practices drive payer-provider collaboration and value-based care success.
Health Plans

Payer-provider collaboration and value-based care best practices

May 11, 2021
The heart of payer-provider collaboration is building trusted relationships.
Chief Product and Client Officer

The early evidence is in. A year into the COVID-19 pandemic, more physicians are choosing value-based and risk-based contracts with health plans.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC), for example, recognized that many independent practices were at risk because of COVID-driven revenue declines. The plan created a program, Accelerate to Value, to provide financial viability to these practices while moving to value-based care. In return for financial support from Blue Cross NC through 2021, providers had to:

  1. Commit to provide access to care for Blue Cross NC members.
  2. Move toward “shared accountability for total cost of care by joining a Blue Premier accountable care organization (ACO) by December 31, 2020.”

More than 400 practices signed up, and as of mid-December 2020, 52 percent of members see a provider who is in a value-based arrangement.

Accelerate to Value stats

Payer Provider Collaboration

Payers like Blue Cross NC understand that value-based care, and in particular capitation, provide a more repeatable, reliable revenue stream so physician practices can stay viable in times of uncertainty. The payment model also allows providers to put their focus on patient care. That’s because the tools, data and analytics needed for value-based care are foundational to good healthcare. The crux of value-based care is to provide the right care at the right time in the right setting, and being compensated for that care. Without a doubt, data analytics and tools are needed to make that happen. Payer-provider collaboration is critical too.

The heart of payer-provider collaboration is building trusted relationships. Like all relationships, communication is critical. So are these eight best practices:

  1. It’s all about the relationship. Focus on it. Nurture it.
  2. Truly respect each other’s roles.
  3. Create the partnership from the person’s perspective as well as the financial and business perspective.
  4. Empathize and understand goals and constraints.
  5. Be willing to bend a little.
  6. Use the COVID-19 pandemic as a time to build trust and collaboration.
  7. Identify small wins to build common ground. Start with a specific initiative. Pilot new programs. Success breeds success so celebrate success.
  8. Enable shared decision-making. For example, if there are opportunities for improvement within the patient population, let the clinical team on the provider side decide where to start.

The pandemic experience of plans like Blue Cross NC and others has reinforced the importance of starting small and building common ground. In other words, health plans are phasing in value-based care programs.

A Phased Approach

For example, a regional health plan operating in parts of four states with more than three million members favors a four-phase approach to value-based care. About 40 percent of the plan’s providers are in value-based care contracts. One of the key challenges is value-based care providers lack insight into care that has been delayed due to the COVID-19 pandemic and are struggling to determine which patients to prioritize.

Phase 1:  Health plan analyzes COVID-19 deferred care

Phase 1: Health plan analyzes COVID-19 deferred care

  • Use analytic model(s) to determine population at high risk for COVID-19 severe impacts and also at high risk for complications or health deterioration from deferred care, such as those with heart failure and diabetes
  • Among this population, prioritize members for outreach by utilizing an identification and stratification model to determine which of these members have the highest number and/or most significant gaps in care
  • Refine the target population by adding in an age band of 65+ years old and members with an overall risk score of five or more

Phase 2:  Share insights with value-based providers

Phase 2: Share insights with value-based providers

  • Health plan provides identified population to value-based providers
  • Using templates and scripts supplied by the payer, provider offices outreach to identified members

Phase 3:  Performance reporting

Phase 3: Performance reporting

  • Leverage off-the-shelf, easy-to-implement dashboards with actionable insights
  • Understand and risk-stratify member population aligned to value-based providers and provider groups
  • Improve provider performance
    • Identify population and member care gaps aligned to value-based contract financial and quality goals
    • Monitor and share progress with providers

Phase 4:  Payer enterprise platforms integrated with patient relationship and care management functionality

Phase 4: Payer enterprise platforms integrated with patient relationship and care management functionality

  • Use a data analytics system with population and individual-level views such as:
    • A holistic, longitudinal member view with integrated claims and social determinant of health (SDoH) data
    • Timely patient and population analytic insights
    • Simplified, care gap identification and closure
  • Outreach with pre-configured care management workflows:
    • Cohort identification
    • Referral workflow management
    • Call scripts
    • Program enrollment
    • Care management reporting
    • Clinical quality by provider practice
    • Quality gaps in care closure performance
  • With a patient relationship management platform, engage members proactively with automated marketing campaigns to improve HEDIS® and Star ratings.

To read more health plan examples, download the white paper, How Health Plans Are Using a Phased Approach to Value-Based Care: Four examples of health plans building provider engagement.