Shrinking the Divide Between Health Plans and Providers

Bridging the trust and knowledge gap between insurers and providers remains the stubborn challenge that it has been for decades. As Walter J. McNerney, President of the national Blue Cross and Blue Shield Associations observed well over 40 years ago, payment and delivery are two sides of the same coin. In other words, little care gets delivered without payment, and payment remains inert absent high quality and high value delivery system resources.

Clearly there are large and vibrant integrated systems that closely align delivery and finance (think Kaiser). However, the predominant relationship that characterizes provider/payer relationships are too commonly built on a thin veneer of trust buttressed by often obtuse contract-based arrangements.

For many years, we’ve worked with some pretty unique organizations that live in the rare air of integrated delivery systems. These are different places. They are much more focused on managing the entire payment dollar. They are increasingly focused on moving beyond managing volume to managing populations. They have “rediscovered” the relevance of the research that Barbara Starfield did at Johns Hopkins demonstrating that health is better in areas with more primary care physicians, people who receive care from primary care physicians are healthier, and that the characteristics of primary care are associated with better health” (1) All of this is hard work. However, it breeds and rewards innovation.

We are convinced that this kind of population-centric approach to delivering and paying for care does not need to reside only in a corporately integrated model. It can be achieved through innovative virtual, contract-based relationships that bring payers and providers together around a shared vision and purpose.

Health plans and provider organizations can address many issues together. Creative relationships can drive collaboration around addressing risk adjustment documentation. They can rationalize quality metrics that are too often applied in “cliff vesting” arrangements where providers lose all shared savings incentives when they miss one target. They can address slow credentialing processes by payers as well as opportunities to partner with providers to support network and enrollment growth. Primary care can be incentivized with augmented payments for creating robust medical home infrastructures. Bundled payments can be structured even if Medicare walks back their current initiatives. Hospital systems can help identify and preferentially refer patients to the highest value post-acute care resources. All of this takes education, careful planning, trust building, and persistence.

Frankly, we’re in the midst of a transition that could drive a greater wedge between providers and payers if we’re not careful. Medical underwriting may again push patients with chronic diseases into underfunded high risk pools. High deductibles frustrate some opportunities. But the fact remains that providers and payers live in a symbiosis that will never disappear.

If you’re thinking about how to reconcile issues between the providers and health plans in your world, give us a call. We’re not civil engineers, but we have deep experience in building the types of bridges you need.

  • “Contribution of Primary Care to Health Systems and Health,” BARBARA STARFIELD, LEIYU SHI, and JAMES MACINKO

Marc Voyvodich is founder and chairman of the Stroudwater Board of Directors. Contact Marc at 207-221-8258.