Where is the payer-provider relationship headed? 17 healthcare execs weigh in

At the AHIP Institute & Expo in Nashville June 19-20, Becker's Hospital Review asked 17 executives from health plans and providers one question: What is the future of the payer-provider relationship?

Below, C-level leaders, presidents, vice presidents, directors and advisers from payers and providers nationwide share their perspective.

Editor's note: Responses have been lightly edited for length and clarity, and are listed in alphabetical order by name.

Himanshu Arora, chief data and analytics officer at Blue Cross Blue Shield of Massachusetts: "In Massachusetts, as one of the drivers of value-based care, the incentives across payers and providers have been aligning more than you might see in other parts of the country. Risk arrangements, but even beyond risk arrangements to things like consumer experience, are focus areas and investment areas for us."

Ian Blumenfeld, chief data scientist at Clover Health: "The interoperability issues create tremendous opportunity to give a provider a hand. On top of that, the more you can do to relieve the back-office burden so that they're able to focus on helping the patients, if you're able to collaborate with them and help them with technology and software, you make their lives easier. The patients win. And you win."

Eva Borden, senior managing director of behavioral and medical solutions at Cigna: "How do we help providers partner across the medical neighborhoods that they interact in? From a medical neighborhood perspective, if I'm a PCP, that's one thing. But I need to be able to interact with cardiologists, behaviorists, oncologists, orthopedists, etc., to reflect and respect their practice patterns while trying to make sure we get the best-quality outcome for the patient."

Tina Brill, vice president of long-term services and support at Amerigroup: "In the LTSS space, we work much more collaboratively and much more in a two-way, long-term relationship with providers. We share patient plans with providers and ask them to partner with us. These providers are in the homes, sometimes multiple times a week, for months, maybe even years. They're a long-term partner with us, not an acute situation. There's a variety of goals that are beyond your traditional payer-provider [relationship], where you support preventative care, your mammograms, your diabetes management. We work with providers who maybe haven't done some of the community integration and some of the quality of life goals with individuals before."

John Bulger, DO, CMO of Geisinger Health Plan: "That relationship has to be as close as it can be. We try not to have an adversarial relationship where providers are saying to health plans, 'Mother may I?' but be proactive and say, 'Hey, let's come up with guidelines of when we should do things and when we should not do things upfront.' … Kaiser is maybe the poster child example, but they're almost fully integrated. I think you're going to see more and more of that. How do providers and payers work closely together, realizing all of us aren't going to become Kaiser?" 

Denise Corcoran, senior vice president of healthcare network strategy at Capital District Physicians' Health Plan: "To move the relationship forward and change the trajectory of where we are going in healthcare — which is extremely expensive; not everyone has access to care — we have to change conversations. It's discussing and having conversations not really about dollars and cents, but more about, 'What do you want to do? What's your organization looking to do to improve your outcomes? What are your values? What do we value? Where do we have common goals? How can we work together?'"

Kumar Dharmarajan, MD, chief scientific officer at Clover Health: "I think payers and providers are going to increasingly need to work closer together to drive better clinical care and health outcomes for health plan members and cost savings to Medicare. At Clover, we're committed to presenting what we believe is very important data to our provider network at the point of care. It's not just important to give them data, but it's important to give them data in useable forms at the time they're seeing patients, because if you give them data at a different time, they're not going to necessarily use it to meaningfully affect the care that a patient receives."

Andrea Gelzer, MD, senior vice president of medical affairs for the AmeriHealth Caritas Family of Companies: "Closer. Ever closer. There has been a lot of consolidation in the industry and I'm sure we'll have some more of that. To succeed, providers need data in a timely manner. We provide online resources and every month update those resources so that providers are able to manage the contracts with them. I see us continuing our partnership and collaboration and becoming ever closer."

Joe O'Hara, director of accountable care organization solutions at Horizon Healthcare Innovations, Horizon Blue Cross Blue Shield: "I think the future of payer-provider relationships is around outcomes and consumer engagement. The path of [the] payer-provider relationship has largely been around money and membership. The relationship was largely driven by the number of patients that a payer could drive to an in-network practice, and the amount, compared to market, that a provider could negotiate from a payer or with a payer based upon what they could deliver. In a future space, 1) consumers will have better access to data, and 2) less and less need of direct access to clinicians, in which case payers and providers will need to use information and insights to deliver an experience that consumers are willing to pay for."

Susan Keser, vice president of network development and management at Fallon Health: "Ultimately, I think what it ends up being for both payer and provider is the collaboration. It's data exchange, it's understanding who has the touch points for the member and how we can help each other. If we can define that end picture of what it needs to look like, and then have the conversation of how do we get there ... there's not one miracle that's going to work. You have to understand the practices and the providers you're working with and what the members need."

Stephen Klasko, MD, president of Thomas Jefferson University & CEO of Jefferson Health, both in Philadelphia: "The way I see the future, by definition, every large provider will have or be a strategically aligned payer. If you just think about it, it makes absolutely no sense if we're going to transform healthcare and increase access, quality, patient experience, decrease costs, that you can separate out the data and have this thing called insurers that are sort of a buffer between employers, patients and providers. We see it at Jefferson with how we're able to treat our 32,000 employees [as] the payer, provider and employer versus the rest of the world where we have six different payers with six different sets of rules with six different data sets."

Dan LaVallee, director of government programs at UPMC Health Plan: "Value-based reimbursement asks members to access care differently. It asks providers and PCPs to provide care differently. We at UPMC Health Plan understand if we're moving into value-based reimbursement, we have to be ready and willing to pay for care differently and get away from that fee-for-service mindset and think about attaching ourselves to different and cutting-edge payment methodologies. That's vitally important because if you don't do that, what's going to happen is you've got the physicians doing one thing, you've got the members doing the other thing, but the payment mechanism is same-old same-old. What happens is that nobody wins. While value aligns incentives, we also have to be cognizant of the fact that we have to align payment methodologies."

Douglas Nemecek, MD, CMO of behavioral health at Cigna: "We take that partnership with the physician very seriously. We think that's the key to truly helping our customers get the optimal health outcomes as well as making healthcare as affordable as it needs to be for everybody. We're really working hard to build those relationships and identify how we can best support our physician partners in all our communities."

Hank Schlissberg, president at DaVita Health Solutions: "We have a belief that broad-based shift of risk from payer to provider isn't the answer, and that payers should be aggregating risk around what we would call natural owners of risk. In dialysis, the patient sits in our chairs 12 to 15 hours a week. The PCP in fact isn't the quarterback of the care — the nephrologist is the quarterback of the care. So we would argue that the dialysis provider and nephrologist are the natural owners of all the risk, not just the dialysis. If you believe you should build a different care model … then we should also have the payer align pockets of risk around natural owners."

Andy Slavitt, senior adviser at the Bipartisan Policy Center and former acting administrator for CMS: "The answer really largely differs community by community. We should think about payers as a function done well [when people] look at populations, figuring out which people are the sickest, figuring out how best to account for risk, figuring best intervention strategies and how to segment and target conditions and populations. We should think of a provider function as how to deal with the whole person, and I think increasingly that means both clinically and socially. Those functions are the functions that need to get done. They can get done by the same person, by the same entity, or by different parties, but what's fundamental to it is there's a place for a patient to have a relationship in a community that's holistic and comprehensive and where they can have a regular source of care, and then those functions blend together based on expertise and how different markets look." 

Mike Sweeney, vice president of provider relations, contracting and reimbursement for UPMC Health Plan: "Being a part of an IDFS is a game changer and a differentiator for what we can do. Take housing and employment as an example. We have nearly 90,000 employees at UPMC across [Pennsylvania]. For us, we're looking at ways we can provide more of those opportunities for our Medicaid members to find career paths and get into meaningful work and join us in another way. We talked to a lot of our provider partners as a part of UPMC to help us with the Z-coding to demonstrate [members' housing needs]. There's new and different partnerships that 10 years down the road will be very special for us."

Mark Steffen, MD, vice president and CMO at Blue Cross and Blue Shield of Minnesota: "It's getting the right people to the table so that it's not a transactional relationship, which unfortunately I think sometimes it defaults to a contractual, financial relationship. We've found success with bringing together some of the care management entities that sit on the provider side and the care management entities that sit on the payer side. When they sit down at the table, they understand we're reaching out to the same person. We want that messaging to be consistent and we want to understand the full picture of what's going on."

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