Finding ways to create a payment model that rewards high-quality outcomes, reduces avoidable costs and protects payer and provider margins is the ultimate goal of those working to reform the healthcare system today.
That was the focus of "Bridging the Payer and Provider Gap: Creating a Shared-Savings Payment Model for Increased Quality and Efficiency," an education session at the Healthcare Financial Management Authority's ANI conference and exhibition, held June 26-29 in Orlando, Fla.
To accomplish these goals, payers and providers must work to provide adequate access to healthcare while also keeping health insurance premiums at an affordable rate.
In many ways, the work conducted at Blue Cross Blue Shield of Alabama can serve as a model for other health insurance plans looking to forge closer relationships with the provider community while working to overhaul both the way payers reimburse providers and the ways that providers deliver healthcare services.
"We want a different relationship than we've had in the past. In Alabama, we pride ourselves on having a very collegial relationship with our physicians and our hospitals, but it needs to go to a new level," said Eddie Harris, BCBSA's vice president of health management. "The pace of change, the new benefit designs that are coming about are going to require a different working relationship with our provider partners."
Payers need to understand the impact that current changes to payment models are having on payer and provider margins and ways that organizations can adapt their payment models to reduce waste and avoidable costs, said Michael Nugent, director with Navigant Consulting.
While the long-term goals are ultimately to deliver on the much-heralded "triple aim" of improving population health, improving the patient experience of care while reducing overall costs, Harris said BCBSA knew it needed to set some short-term goals as first steps.
He said BCBSA made a concerted effort to meet with more than 40 healthcare societies last summer to begin the education process and open the lines of communication.
"These were largely designed to say, 'Here is the landscape. Here are the issues. How can we collectively work together to try to improve and understand what is going on?'" noted Harris. "We don't want to define quality in a vacuum."
According to Richard Bajner, a managing consultant with Navigant, once these lines of communication are open, payers and providers need to drill down into the cost data, by procedure, to better understand the drivers of associated costs and cost variations.
"We all know that variation in process is one reason costs can vary and input costs – the money spent on a supply – can also vary," Bajner said. "So we need to be able to take this kind of data and with our clinical brethren be able to develop standardized clinical care protocols."
It's also important for payers to have a better understanding of how their benefit design is affecting use of services. This includes urging employers to encourage employees to take advantage of health screening and preventive health services, while determining if there are any roadblocks in plan design that may be affecting benefit use.
As BCBSA looked to revamp its value-based payment approach by adding incentives tied to quality based mostly on the triple aim measures, Harris was quick to point out that there are many iterations that are similar but also take into account the particulars of each market.
Or as Nugent put it: "The moment we are all waiting for as payers and providers is to make this real. Let's make it real in Missouri, or Arizona, or Montana or Florida. What underlies a lot of this is a fundamental fee structure with a base amount and a different multiplier. This can turn into a risk field for some of you, or shared savings arrangement, etc. But trying to have an underlying fee schedule that binds us together is an important thing."