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 a recent education session, "Bridging the Payer and Provider Gap: Creating a Shared-Savings Payment Model for Increased Quality and Efficiency," at HFMA's ANI conference and exhibition held at the Gaylord Palms Resort in Orlando, Fla., June 26-29.
In order 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 that are looking to forge closer relationships with the provider community while working together 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 VP of Health Management at Blue Cross Blue Shield of Alabama. "The pace of change, the new benefit designs that are coming about are going to require a different working relationship with our provider partners."
One vital lesson for payers is for there to be a greater understanding of the impact 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 Richard Bajner managing consultant of 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, BCBSA knew that it needed to set some short-term goals as first steps.
Getting provider buy-in is key for payers looking to effectively revamp how they pay for care. To that end, BCBSA made a concerted effort to meet with more than 40 health care societies last summer to begin the education process and to open the lines of communications.
"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?' We want to try to share our data not to say 'this is the problem, you need to go fix it.' But how can we collectively understand completely what is going on?" noted Harris. "We don't want to define quality in a vacuum. We want to do that with our provider partners and that was very valuable in the process."
It is also important for payers to have a better understanding of how their benefit design is effecting utilization of services, which also requires payers to have an effective line of communication with their employer customers. This includes trying to send the message to employers about the importance of encouraging their employees to make sure they are taking advantage of health screening and preventive health services, while determining if there are any roadblocks in plan design that may be effecting benefit utilization.
As BCBSA looked to revamp its value-based payment approach by adding incentives tied to quality based mostly on triple aim measures, Harris was quick to point out that there is no single payment model, rather there are many iterations that are similar but also take into account the particulars of each market.
Or as Bajner 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."