Beyond letting providers assume more risk and savings from it, health insurers can put them one step closer to the aim of better care, improved outcomes and lower costs.
In the shift from fee-for-service to value-based payment models, healthcare providers are changing their contracting strategies so they can add new revenue streams and drive more growth. Many are also collaborating with payers to speed this transition and increase market share.
Early results show these new value-based risk models are working. Both organizations bring distinct capabilities to the table. If payers and providers fully commit, they can generate improvements in quality, ongoing savings and a better patient experience. There are specific resources and knowledge that payers can bring.
Laying the groundwork
Payers have years of experience in risk management, consumer marketing, membership acquisition and retention. This, along with their claims data and analytics, can empower providers with a great deal of insight and expertise to effectively transition to a value-based model.
This foundation promotes long-term success by allowing providers to drive more volume and achieve market growth. Having access to a payer's national, multi-channel distribution capabilities gives providers a fast and efficient path to directly connect with purchasers.
By leveraging a payer's access to individual markets and exchanges, and their relationships with plan sponsors, employers and brokers, providers can quickly tap new markets and increase patient volume. They can also receive valuable guidance on the best exchange strategies.
In addition, when providers need to ramp up their marketing efforts, payers can support them with proven strategies and tools. These resources make it much easier for providers to increase their exposure in the local marketplace. They can then differentiate their brand and attract new patients.
Payers also offer reporting capabilities and insights that give providers a better understanding of which services their patients are using outside of the network. For example, an analysis of a health system's utilization by service line may reveal it is losing diagnostic imaging referral volume to a nearby competitor despite the fact that it offers broad access to those services. This knowledge, along with standardized referral management processes, can help the organization recapture lost business, build loyalty and keep existing patients within the network. This is key for any successful market growth strategy.
Shift from episodic care to population health
Payers can help providers stratify risk and identify those individuals most in need of intervention. This enables the transition away from reactive, interventional care to more proactive population health. Payers support providers in pinpointing high-risk, high cost patients, and they can assist in improving health outcomes through outreach and care management programs.
The integration of clinical and claims data supports these efforts by painting a broader picture of an individual's overall health status, powering better insights and outreach. For example, if a patient leaves a prescription unfilled or visits the emergency room (ER) when on vacation in another state, these details are reflected in payer claims data but not in a health system's clinical record system. Having access to both claims and clinical data gives providers an opportunity to analyze valuable patient information and give it meaning. Then, they can address potential risk factors before they become costly.
Consider another example of a patient who delivered her baby 10 weeks early by C-section. Because data is shared daily between the provider and Aetna, a trigger identifies the woman as being at high risk for depression due to the early delivery. The case manager contacts her to screen for depression. Although she doesn't show signs of depression, the patient tells her case manager that her incision is inflamed. The case manager notifies her doctor, who prescribes antibiotics immediately, avoiding complications.
Determine the right contracting arrangement
When providers accept greater financial risk for patient outcomes, they also have the potential for greater reward. Payers can match a provider's specific objectives for speed, risk tolerance, investment and profit expectation. They do so by offering a variety of value-based contracting options. For example, the levels of compensation at risk may vary from pay for performance to shared risk to full capitation.
Since every provider's goals and readiness level are unique, payers can work with them to create a plan for success. The payer should outline the specific steps providers must take to be more efficient, reduce costs and improve care quality so they can successfully perform under the contract. It also lets providers see how their health improvements affect the bottom line.
As providers work toward these rewards, payers can help align incentives for all doctors and practices. By encouraging specific behaviors, these incentives ensure that any investments in new processes and technologies are effectively incorporated into value-based workflows.
Operate a health plan to share in the profit and loss
For providers looking to launch a health plan, joining forces with a payer can bring significant value. Payers can deliver the entire infrastructure required to effectively run a plan, provide the risk management expertise to help the plan succeed. This includes licenses, actuarial expertise, sales and distribution expertise, population health management and back-office operations. With these assets, providers can go to market with new value-based insurance offerings more quickly and efficiently than they could on their own.
Payers can also help combine payer and provider functions in one administrative platform through a co-branded or joint venture health plan. They can help providers create benefit designs tailored to their specific objectives. For example, a benefit structure that financially incentivizes members to pursue wellness opportunities and seek preventive care will help a health system achieve strong population health management.
Payers can share their expertise in managing health plans for multiple lines of business, including commercial, Medicare Advantage and Medicaid, and also help eensure compliance with the Affordable Care Act and well as other federal and state regulations, including Centers for Medicare & Medicaid regulations.
Daniel Finke is CEO of Accountable Care Solutions from Aetna.