Reduce risk through pay-provider partnerships on the path to value-based care


Health plans saw claim volumes drop significantly as in-person visits were limited to the sickest patients and preventive care was postponed. Suddenly, payers discovered that the data they were relying on to identify and manage risk (claims data that could indicate changes in health status)slow motion to a trickle. The primary payers began to think, “How can we work with health care providers to ensure members receive the right care and that provider relationships remain intact during the pandemic?” “

The experiences of healthcare organizations in the first year of the COVID-19 pandemic point to four ways to strengthen the payer-provider collaboration and reduce risk – lessons that can be applied during the pandemic and beyond.

1.) Work with providers to develop a longitudinal view of limb medical history.
Research shows that comprehensive population health initiatives for patients in managed care decrease in COVID-19 death rateseven among high risk members. When providers in managed care programs use data to determine which patients are most at risk for COVID-19, they become better able to monitor these patients closely and treat them early, ideally on an outpatient basis. This reduces the risk for patients of life-threatening complications. More frequent contact with high-risk members also helps optimize care for existing chronic conditions and increases member engagement.

Health plans can enable providers to improve health outcomes and reduce risks for their most vulnerable members by sharing data that can provide a 360-degree view of members’ health history, such as treatment which takes place at several care sites. Access to data not only informs clinical decisions at the point of care, but also helps predict the risk of COVID-19 infection of limbs, their likelihood of experiencing an adverse event and their Risk of COVID-19 mortality. With this information in hand, payers and providers can jointly develop interventions that keep members healthy and promote better COVID-19 outcomes.

2.) Strengthen service providers’ response by preserving the financial health of shared risk contracts.
Fee-for-service providers suffered a financial blow during the pandemic, when in-person visits suddenly ceased. Unless providers had the ability to not only run virtual tours, but also involve at-risk members in telehealth and online tours, they struggled to stay afloat for the first few months of the tour. the pandemic. Even now, some are struggling to track down pre-pandemic volumes for patient visits. Some payers offset the financial risk for providers by advance incentive payments for service providers under shared risk contracts based on the performance of the previous year. They also worked with vendors to identify members who faced an increased likelihood of contracting COVID-19. These included not only members with co-morbidities, but also those with chronic conditions that may not be well controlled during the pandemic, such as hypertension.

For example, a review of pharmacy claims data can identify members who are not filling prescriptions for high blood pressure, cholesterol, etc. From there, health plans and providers can work together to engage members and overcome barriers to optimal health behavior, for example by making it easier to buy and access medicines. The goodwill demonstrated by prepayments and information sharing helps solidify the payor-supplier relationships, establishing a value base during and after the pandemic.

3.) Enable providers to easily improve the health of the population.
During the pandemic, health plans communicated more frequently with providers about ways to improve the health of specific populations. Some plans provided suppliers with lists of members who would benefit from follow-up. These payers then facilitated connections between providers and members so members continued to receive the right care at the right time, despite the hurdles the pandemic presented.

For example, Highmark Health found that using secure texting with members, rather than phone calls, resulted in higher member engagement. As a result, two-way texting between this health plan and its members increased 450% year over year, connecting members to transportation for health appointments and COVID-19 tests or vaccinations; home support for members with chronic illnesses; and basic necessities, such as groceries, to maintain the health of the limbs. The health plan also held weekly calls with 100 providers across the country that allowed providers to share best practices in care during the pandemic. Collaborative approaches such as these have deepened the impact of providers and payers on member health during a public health crisis.

4.) Be vigilant in preventing fraud, waste and abuse, but don’t let a small group of bad actors influence your entire approach.
The pandemic underscored the need for payers to have a strong fraud, waste and abuse program: the Office of the Inspector General conducted a nationwide investigation into healthcare fraud in September 2020 , which identified more than $ 6 billion in alleged losses, including 4.5 billion dollars linked to telefraud schemes. Granted, health plans have seen unusual cases of telefraud and other forms of abuse during the pandemic, such as a claim for telehealth surgery or a claim for a hip replacement procedure for an intubated COVID-19 patient. . But while having a waste elimination program in place is essential, payers must ensure it is done while protecting relationships with the majority of providers who commit to the rules.

One way to do this is to establish a ‘gold card’ approach in which COVID-19 claims from vendors who have a strong track record of payment integrity are automatically forwarded for reimbursement. This ensures that providers have the financial foundations to continue to expand access to care for vulnerable populations, for example by bring COVID-19 mobile vaccination clinics to rural, urban and suburban communities where residents find it difficult to register for appointments due to lack of internet access, transportation and more.

A new path for the payer-supplier partnership

The COVID-19 pandemic has pushed payers and providers into uncharted territory, but those who partnered to meet members’ care needs and eliminate disparities in care were in a better position to reduce risk, both clinical and financial. In 2021 and beyond, applying these lessons collaboratively will deepen pay-provider relationships and accelerate the movement towards value and better results for members.

Emad Rizk, MD, is President and CEO of Cotiviti. Brian Setzer is Executive Vice President of Business Planning and Operations at High health.

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