In a recent survey, more than one-third of providers, or 39 percent, said trust with commercial payers needs to be improved.
Trust has always been an important part of the payer-provider relationship, but now it is even more important as a growing number of providers transition to value-based care models and assume more risk for the quality and overall cost-effectiveness of patient care.
Providers and payers can each benefit by working together to establish accountable care organizations (ACO), introduce ACO-based products and even form joint ventures. However, the ultimate success of these arrangements depends on how well each party can establish appropriate trust and leverage the other's strengths.
For example, when an ACO starts from a basis of trust, payers and providers can openly review each organization's capabilities in care management, data analytics and patient engagement. Then, they can decide together on the programs that are best suited to support the patient population and achieve quality and cost outcomes.
This may involve uniting a provider's expansive health care professional network and care management (CM) and disease management (DM) programs with a payer's analytics capabilities. Together, these combined strengths enable an ACO to identify high-risk, high-cost patients that need more focused, hands-on care. The ACO can then use a provider's existing relationships to initiate proactive outreach to give those individuals the care they need.
An important step is then to collectively engage patients and enroll them in a CM or DM program to promote positive, lasting behavior change. Consistent outreach and communication between all members of the care team – patient, payer and provider – ensures recommended screenings and treatments are delivered at the appropriate time and place.
When payers and providers use each other's capabilities and expertise to work together in new ways, they can achieve a deeper level of trust and a higher quality of care.
Three building blocks for successful payer-provider relationships centered on trust
Building trust between providers and payers takes time. However, there are steps payers and providers can take to begin their collaboration on a positive note.
- Identify opportunities for data sharing and transparency. Providers participating in a 2014 KLAS survey ranked greater transparency and access to data as the capabilities they needed most from payers to take on more risk. Traditionally, payers rarely make claims and other data available to providers. However, having this information is critical for delivering more proactive, value-based care.The integration of claims and clinical data supports value-based care by offering a more complete picture of a patient's treatment history and health status. It gives providers insights into patient compliance with care plans, such as medication adherence, and allows providers to identify and address risk factors before they become costly. Sharing data with providers about their clinical and financial performance, how it compares to other organizations and how health improvements affect the bottom line is another way that payers can instill more confidence in providers and encourage a more open dialogue. This approach enables payers and providers to discuss new ways to improve care, impact costs and enhance the patient experience.
- Be flexible. In a value-based care world, payer-provider collaborations can succeed if they learn how to coordinate their efforts to address a common set of goals. This important step requires trust in each other's abilities and an openness to work together in new ways. As one provider explained in the KLAS survey, a payer's willingness to trust, adapt and change its model throughout the accountable care journey is a major factor for success. By meeting providers where they are and giving them the flexibility to choose the level of risk they want to share, payers can form relationships that allow trust to deepen over time. Offering a variety of options across the spectrum of risk – from pay-for-performance arrangements to ACOs to joint ventures – allows providers to gradually assume more risk as the payer-provider relationship evolves.
- Align incentives. Instead of being on opposite sides of the negotiating table discussing price points on fees, providers and payers can find common ground in establishing value-based goals. The next step is to tie incentives to these goals. This may include financial rewards for reaching performance targets such as increased screenings for preventive health, fewer unnecessary emergency room (ER) visits and decreased readmissions. When goals and incentives are properly aligned and everyone on the care team is working toward the same objectives, providers, payers and patients can share in the benefits of coordinated care and improved outcomes.
A strong foundation for lasting results
While there is still work to be done, the good news is that relationships between payers and providers are improving. Two prime examples are Memorial Hermann Accountable Care Organization (MHACO) and Banner Health Network. Both worked with Aetna to create branded accountable care networks built on a foundation of mutual trust.
When Memorial Hermann Health System and Memorial Hermann Physician Network initially formed MHACO to achieve their goals in a value-based model, they found that Aetna shared a similar mission and vision. Both MHACO and Aetna were looking to develop a new model of care for patients and create a health plan product designed and priced around that new care model. They wanted to find new ways for everyone involved in the care of a patient population to collaborate with one another.
Their joint efforts have led to positive results so far. These include consistent membership growth – showing that this type of care model and health plan is resonating – and cost and quality improvements. Memorial Hermann has consistently improved efficiencies, and thereby lowered costs, in the self-insured population from 2013 to 2014 by:
- Increasing generic prescribing rate by 21.3 percent
- Reducing avoidable emergency room visits/1000 by 13.5 percent
- Reducing 30 day admission rate by 1.3 percent
- Reducing impactable medical days/1000 by 55.8 percent
- Reducing impactable surgical days/1000 by 49.3 percent
In addition, all six quality metrics that were measured during the same period of time exceeded their targets. These goals included improved screening rates for cancer and increased testing for patients with diabetes, according to Aetna internal data.
Likewise, Banner Health Network has experienced positive results through its collaboration. During its second year of working with Aetna, Banner saw the following results in the Aetna Whole Health fully-insured commercial membership:
- 5 percent medical cost savings;
- 9 percent reduction in radiology services; and a
- 9 percent decrease in avoidable admissions.
The health network's leadership attributes much of its success to the mutual trust it built with Aetna. By building a relationship based on common objectives, Banner and Aetna were able to design aligned incentives where both parties win.
These successful collaborations show what is possible when payers and providers align strategically and trust one another to promote innovation beyond what each could achieve on their own.
Looking ahead, a growing number of payers and providers see this mutual trust as so advantageous they are forming joint ventures such as new, jointly-owned health plans. These arrangements allow both parties to share equally in the risk and rewards of caring for a population of patients. Inova Health System, a five-hospital health care system based in Northern Virginia, and Aetna formed a joint venture and established a new insurance company called Innovation Health. This new company achieved 157 percent member growth and exceeded its revenue goals by 37 percent in its first year, and it continues to show promising growth.
Working toward a better future
Providers and payers can establish a relationship of trust to succeed in accountable care. They can share and learn from each other's data and expertise. With mutual accountability and common goals for patient outcomes, providers and payers can get one step closer to the three-part aim: improved care quality, lower costs and a better patient experience.
Daniel Finke is CEO of Accountable Care Solutions from Aetna.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.