From Contention to Collaboration – How Payers Can Make Progress with Providers to Better Serve Medicare Advantage Members

Medicare Advantage plans are facing financial pressure across multiple fronts, including a CMS crackdown on prior-authorization rules, a steady stream of scrutiny around risk adjustment strategies and a consistently rising bar for star ratings. A recent McKinsey report suggests that plans should “focus on building better provider partnerships and improving member engagement in their own care.”

Meanwhile, providers of all stripes are struggling with increasing workforce shortages and mounting financial pressures of their own.

Both sides are being asked to do more for the individuals under their care, a population that is growing older and sicker by the day. Both sides need each other to succeed. Given the historically adversarial relationship between these two groups, it is a fair to ask how they can lean in and collaborate better together.

Let’s set the stage. According to research, half of providers say that strategic partnerships with payers is their top external challenge. The same survey revealed that almost 60% of health systems were considering becoming a payvider and entering into risk-based Medicare Advantage payment models the following year. At the same time, as doctors and hospitals have experienced increased friction with MA plans, older adults have shown increased interest in them.

Both payers and providers should take ownership and make strides to work better together. For this discussion, we are focused on considerations for payers who want to be proactive and take the first step to enhancing these relationships.

Acknowledging Common Ground

A report published by Capgemini said that payers and providers can unlock a new level of value. According to the report, “By reducing administrative friction and breaking down information silos, payers and providers can reap the full benefit of a changing healthcare landscape, and further their common goal of delivering high quality care to patients.”

The last part of that quote is the most important takeaway. At the end of it all, payers and providers truly have a common goal. If patients receive high quality care, they will be healthier and happier. They will also cost the healthcare system less overall. The complicated nature of delivering and financing care can cloud this reality. It is imperative for both sides to keep top of mind that they both want the same thing when all is said and done. This would set a positive tone for collaboration.

Approaching with Empathy

The provider shortage is only worsening. Burnout among providers or all types is following suit. In this environment, payers are not able to place any additional burden on providers in order to accomplish their goals. There is some empathy required when engaging providers, because at the end of the day two things are true. The majority of providers are in the field of medicine because they genuinely want to deliver the very best care to patients. And, they currently need help to achieve that goal. Approaching providers with an understanding of their challenges and a solution-oriented perspective is the most effective path.

Finding a Way Home

Data shows that 77 percent of adults 50 and older want to remain in their homes for the long term. The following is also true. Among older adults who report needing help with day-to-day personal care or household needs, about 40% say they could use more help or that they have no help at all.

Lots of life happens between visits with a provider, and most of that for older adults happens in the home. Gaining access and insight into what’s going on in the home benefits payers and providers. Without this type of access, both sides are flying blind for the majority of a member’s needs. As a result, if payers can invest in programming that opens the door to members’ homes and then create a conduit of information back to providers, they will create opportunities to drive positive outcomes. This specifically helps address health equity issues for patients by identifying and addressing SDoH needs. When you bring care to the home, you naturally knock down several barriers, and you are able to quickly identify remaining obstacles that are preventing individuals from reaching their health goals.

Making Value-Based Models Possible

“There is no longer any doubt about how to increase the value of care. The question is, which organizations will lead the way and how quickly can others follow?’

That question was posed by authors Michael Porter and Thomas Lee in a Harvard Business Review article. The article was published in 2013. More than a decade later, the answer to this question is unfortunate. We have yet to make significant strides in the widespread adoption of value-based models.

The reasons for the delayed adoption of value-based care are myriad. However, moving forward, every provider should get comfortable with the idea of taking on appropriate financial risk. Every payer should get comfortable with meeting providers where they are and making such financial risk realistic and palatable.

Value-based care only works if payers and providers are fully aligned, and if there is a full understanding of what is required for success in a risk-bearing arrangement. This includes data sharing, intervention tools and measurement. Even though there is a lot required for value-based arrangements to work, they will work if payers and providers come together and rally around the needs of patients. This is at least part of the formula moving forward for payers and providers to work more effectively in partnership. But the bottom line is that payers will have to help equip providers for success in these models.

Creating Infrastructure to Facilitate Longitudinal Care

Providers are trained and equipped to address acute problems and “in the moment” or “episodic” needs. Payers, on the other hand, have the ability to consider longitudinal approaches to care. Better collaboration with providers could include taking additional steps to connect these two worlds. Payers would see great benefits from creating additional capacity and infrastructure on their end to operationalize more preventive care. This means using their own teams and technologies to become an extension of the physician’s office in order to be more proactive with patients. Don’t ask providers to hire staff, find a service or invest in extra technology. Assuming those burdens on the plan side will lead to benefits that far outweigh the cost.

Removing Referral Friction with Programs and Services

Providers often aren’t aware or fully educated on all the available patient benefits offered by payers. Even when they are, there can be unnecessary friction. When a provider meets with an individual and identifies a specific need that could be met by an existing payer program or benefit, the process for actually “prescribing” or recommending that offering to their patients is an obstacle. Typically, providers have to go through a justification process with the health plan to ensure a patient can qualify for access to a given offering.

What if payers put more trust and responsibility on providers to steer their members to benefits that could benefit them, benefits the plan has already invested in, and believes in? Whether it’s a first alert bracelet for a patient who is a fall risk, or an in home foot care benefit for a patient with severe diabetes, making it easy for providers to “onboard” members into key programs could be a game changer. It would not only increase engagement with members, but it also would change the dynamic with providers.

The next evolution of healthcare in this country needs payers and providers transforming a historically contentious relationship into a collaborative one. It isn’t a straightforward proposition. It will require commitment from both sides. But it’s a critical piece of the puzzle as we try to mend our broken system.  

Want to talk further about how we view effective payer-provider collaboration and how our solution helps build bridges? Contact us today.