While the payer-provider relationship is often described as contentious, even adversarial, forward-looking payers are prioritizing collaboration as a means of furthering the industry's evolution toward value-based care in the face of regulatory uncertainty.
Lynn Garbee is the senior director of strategic reimbursement and accountable care for Cigna. Prior to joining Cigna in 2013, she served as assistant vice president of claim analytics and consulting for McKesson. Ms. Garbee recently spoke with Becker's Hospital Review about payer-provider relationships, provider consolidations and Cigna's journey toward value-based care.
Editor's note: Responses have been lightly edited for length and clarity.
Question: What are payers looking for in their relationships with network hospitals?
Lynn Garbee: Payers are looking for meaningful data and information exchange for the purposes of improving collaboration, outcomes and care efficiency. Cigna has previously focused on value-based care to improve efficiency, but we can also be a critical lever in helping partners reduce unit costs.
Ultimately, payers want to partner with providers to help keep customers healthier and reduce utilization for healthcare services now and in the future. Providers and payers need to work together to reduce both unnecessary and inappropriate care utilization, encourage the more appropriate use of healthcare services and champion lower-cost, equally effective alternatives for care.
Q: Besides payment methodology, where and how can hospitals and payers partner?
LG: Cigna has achieved a 25 percent reduction in opioid use among our customers, reaching this key metric one year ahead of our ambitious initial goal1. We continue our collaboration with doctors and other prescribers to further reduce opioid misuse. We've added the opioid pledge for our hospital partners as well as the health equities pledge to limit disparities. We've also added the goal of helping to reduce opioid overdoses.
We also plan to enter collaborative relationships with providers like "Medical Neighborhoods," which help support the health of communities. We also work with providers to address issues around surprise billing.
Q: Where are you today in your journey to value-based care? Where is your organization going with value-based care in the future?
LG: The industry shift to value is underway.
Cigna believes value-based relationships with providers are key to continually improving affordability, quality and experience. We launched our first Cigna Collaborative Care®relationship with a large primary care physician group in 2008, and since then, have expanded Cigna Collaborative Care to include hospitals and specialty groups. Today, we have relationships with more than 240 ACOs in 32 states, serving more than 2.8 million customers2 — this collaboration has generated an average of $118 in additional savings per customer and contributed to an overall 64 percent reduction in inpatient readmissions3. We also now have relationships with more than 270 specialist programs across six disciplines, more than 155 hospital programs and six delivery system alliances2.
Q: What is your view on provider consolidation? Specifically, do you think it impacts care delivery, costs, outcomes and the patient experience?
LG: I'll start by saying that not all markets are the same and not all provider consolidations are the same. In some cases, we see consolidation occurring because providers want to gain capabilities and deliver care more efficiently. In other cases, the strategy is more defensive and/or offensive to gain market share and maintain the status quo. From a contracting perspective, when consolidation occurs, we often see price increases right away from pre-determined rates at the time of expansion or from independent physicians joining larger groups resulting in a more highly compensated organization in the market.
The opportunity to deliver more efficiencies and better outcomes is largely still a promise, but many organizations are working hard to deliver it. It takes time for the return on investment of expansion to be felt by customers and clients, especially for integrated delivery systems or specialty groups, such as anesthesia and OB-GYN, that expand across markets. Provider consolidation can improve efficiencies and outcomes if resources are focused on those areas, however, it is important to not use provider consolidation for rate negotiations and driving healthcare costs.
Q: How are you collaborating with providers to move them along their journey to value-based care?
LG: We meet providers where they are in their innovation journey in terms of risk readiness, experience, and their own strategic goals, and work with them to help ensure their success in value-based care. We do this through aligned incentives, peer-to-peer consultative support and actionable information.
Our focus on quality and affordability has enabled us to exceed our 50 percent alternative payment goal in key markets and drive better health outcomes, increase affordability and improve patient experience4. With 70 percent of medical cost managed by specialists, we have a strong focus on having more specialist groups in value-based arrangements5. For specialist groups, including episodes of care, our goal is to establish more than 330 initiatives by the end of 2020.
Q: How does your organization's alignment with providers influence your perspective?
LG: Value-based care has brought significant alignment between payers, providers and clients. All stakeholders have a vested interest in value-based care and a role to play in the construction of the value-based care models of the future. Collaboration is key to the success of value-based care.
Q: Why is communication so important in healthcare? Why do payers, clinicians and employers need to be on the same page?
LG: Communication is essential to meeting our individual and collective goals. In order to be successful, value-based models require good communication and connectedness. We meet frequently with our provider partners to make sure our goals are aligned, and we discuss patient care on a regular basis. Cigna provides actionable clinical data to help providers identify and close gaps in care.
Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company or its affiliates. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. This article is not intended for residents of New Mexico. As to Cigna content/properties, © 2019 Cigna. All rights reserved.
1. Cigna Press release, Cigna's Partnership with Physicians Successfully Reduces opioid Use By 25% - One Year ahead of Goal, March 2018
2. Cigna internal analysis of existing arrangements as of April 2019
3. Cigna May 2018 analysis of 2017 data of Accountable Care program groups nationally, active at least one year, that achieved savings. Compared to market PMPM trend for 2016 and 2017. Individual customer/client results will vary.
4. Cigna 2019 analysis of national Accountable Care program groups with effective dates from 2013 through 2017. Reimbursements already paid to groups are subtracted from the savings to reflect overall investment.
5. Cigna August 2017 internal analysis of book of business total spend for 2016