HFMA Roundtable participants
Michael Funk is vice president in the Office of the CMO for Humana in Louisville, Kentucky.
Gabriella Gold is manager of payment transformation for CareFirst BlueCross BlueShield in Baltimore, MD.
Jim Grana is chief analytics officer at Rush Health in Chicago.
Teresa Handy is vice president, revenue cycle for Legacy Health System in Portland, Ore.
Sheila Hayden is corporate director, payer relations at Ballad Health in Bristol, Tenn.
Billie Jean Mounts is chief revenue officer for Bon Secours Mercy Health in Cincinnati, Ohio.
Philip Boyce is senior vice president and chief revenue officer for Baptist Health System in Jacksonville, Fla.
Lynda Rowe is senior advisor for value-based markets for InterSystems in Cambridge, Mass.
Effective collaboration can be challenging even when everyone is on the same team. It becomes increasingly difficult when it involves crossing traditional boundaries, such as those between payers and providers. The move toward value-based payment has created the need for more data transparency to enhance and streamline quality measurement, close care gaps, generate operational efficiencies and remove administrative overhead. To be successful with evolving models, payers and providers need to build a strong foundation of shared information, which requires relationship-building and partnership. In this roundtable, sponsored by InterSystems, several payer and provider leaders discuss the challenges of breaking down barriers and making progress toward more transparent data sharing.
Where is your organization along the value-based continuum? What kinds of risk-based contracts are you in or considering?
Gabriella Gold: CareFirst BlueCross BlueShield’s value-based journey began nine years ago with our Patient Centered Medical Home (PCMH), which has shown robust results as validated by an outside consulting firm. This model is meant for primary care physicians and began as upside only, with the incentive being paid out on a fee-for-service adjustment. Starting in 2019, we introduced two-sided risk. We provide an initial upfront investment in the form of an increased fee schedule for participation.
Building on our PCMH work, we are now moving into more models, allowing us to engage with more providers, specialists and systems, which we are starting to operationalize. As part of the effort, we are working collaboratively with our provider partners. We have a data plan and strategy and require our partners to assume risk. The risk is two-sided with a ramp up over a five-year period.
Michael Funk: Humana currently has about 58,000 providers under contract for value-based care. Our strategy is focused on meeting providers where they are. We’ve learned from the 1990s that it doesn’t make sense to push providers to risk if they’re not ready to assume it. Our suite of products allows providers to put their toes in the water, and then grow through bonus upside programs and gain sharing. And then when they’re ready, they can take on more risk. About 65% of our individual Medicare Advantage membership is somewhere along this continuum. We also offer a product for our STARs program, which isn’t part of our value-based programs per se, but it does let providers experience what it’s like to be rewarded for hitting certain measures. We have several bundles as well, including total joint replacement, spine, orthopedics, and we just started a commercial maternity program.
Philip Boyce: In the mid-1990s, Baptist Health System created an accountable care organization (ACO). It covered 200,000 lives under global capitation. For four and a half years, we tried to make it work but ended up filing for bankruptcy. For the next 10 to 12 years, we worked to dig out of that hole. In 2012, we started ACO 2.0. Our system is now more cautious to make sure that arrangements are solid every step of the way, and we have tools in place to manage following best practice. Fast forward to 2019, our ACO is in a Medicare Shared Savings Plan (SSP), an MA Plan, and we have several commercial contracts in place. We know the move toward downside risk is again underway, but we are being deliberate in our progress, making sure we have the tools and infrastructure to succeed.
Billie Jean Mounts: To date, Bon Secours Mercy Health’s value-based care focus has been around the ambulatory space where we participate in shared savings and risk-based arrangements. For these, we do a good job with data sharing, closing care gaps and managing patients. However, on the acute side, it’s more challenging. We built this great infrastructure for ambulatory, but there are different stakeholder groups on the acute side, which can make it challenging to align on action plans to improve results. On one hand, you can be doing well with ambulatory metrics, but it doesn’t mean you will perform well on the acute care side. We are faced with a tough decision: Should we make the investment to improve acute performance, or just forego the money on the table?
What are some of the challenges you’ve experienced in realizing success in value-based arrangements?
Sheila Hayden: A big issue we’ve seen at Ballad Health relates to data sharing methods. More specifically, it’s difficult when payers want their portals used to access and share data, which has already been stored elsewhere. This results in a duplication of efforts on our side. We’ve worked with many of our payers to allow submission of a separate file generated from our systems, which will close gaps in a more effective and efficient manner. There have been situations where the data files were either not received or processed by the payer, but they failed to recognize an error had occurred. Timely and actionable exchange of information between both parties is critical to determine that errors have occurred, and gaps have not been closed properly prior to the end of a reporting period.
Jim Grana: Rush Health has had some concerns about payer portals as well. Since every payer has its own portal, trying to understand, summarize and communicate this diverse information to providers can be challenging, especially if you have six to ten payers. It’s not the most efficient process, and you don’t get a full picture of your performance — you only get a picture of whatever sliver that portal gives you. To get all the data in one place, such that you could assess your providers in a more effective way, would be better. Right now, it’s just a lot of data coming at us at once. In my opinion, the industry needs to dedicate time to making sure that data is standardized, actionable and delivered at the right time to enable stronger performance.
Another thing that would be helpful would be complete transparency around risk adjustment methods and the application of those methods. Because we want to reconcile financial performance statements to ensure that we are paid properly, we must try to replicate these algorithms. We can’t always do that because we don’t necessarily have clarity or even licenses for all the risk adjustment models used by the different payers.
Mounts: It’s frustrating that we are trying to solve data sharing issues as one-off initiatives instead of striving to develop something bigger than ourselves and standardize. This second approach would avoid recreating the wheel every time we want to work with a payer, which is probably one of our biggest pain points right now. If we can come up with a common dataset of what needs to be shared instead of creating different definitions and tying things up with contractual arrangements, it would help us get more efficient at data sharing and not inhibit innovation.
Lynda Rowe: What’s difficult is that payer-provider collaboration is simultaneously a source of friction and an impetus for moving forward as an industry in terms of how we get information out and moving. It can be an opportunity but also a time-consuming, resource-intensive effort. Finding the right balance is a hurdle for every organization, but it is something we must commit to so we can better navigate the future.
On a scale of one to five, how aligned are you with your payer-provider counterpart?
Hayden: I would say we are at a four with our payers — we don’t have perfect relationships, but both sides are trying to foster partnerships. When problems arise, we are committed to working together to resolve them.
Funk: I was going to say three, but I’ll add a caveat. I think when we talk with our provider organizations, what we learn is that those entities that have made the journey with us to risk are usually fairly satisfied with the relationship. In addition, those organizations that remain fully in fee-for-service are satisfied. It’s the providers in the middle — those that are on the road to value but haven’t made the cross over to risk — that are struggling and are probably the least satisfied.
Boyce: I would say two, because we do have a couple of solid contracts with insurers, with some incentives in terms of quality and cost. However, there are big gaps between payers and providers around data flow. Even though fee-for-service should be an easier model with which to work out any data sharing bugs, the industry has not addressed these hurdles in fee-for-service. Since that’s the foundation for assuming risk, I don’t see how we resolve the disconnects and reach an aligned position. The question becomes how do we move to the same side of the table in a risk-based environment when the underlying processes for data sharing are broken? To make real progress, we need to reset expectations for perfection and focus on what’s best for the patient, even if that means there are mistakes on both sides. The key is to resolve the mistakes and move forward, not place blame and assess penalty.
Grana: Although our payer relationships used to be around a two, I think they are moving toward a four at this point — largely because of the teamwork that is necessary to succeed in a shared- risk or shared-savings arrangement. There needs to be collaboration, or neither of us will succeed or even survive in this increasingly competitive industry. Both payers and providers better understand how much we need each other and are learning that we could get much more accomplished in a collaborative partnership.
Rowe: These responses are interesting because there is a national provider survey that asks this same question. Across the industry, about 77% of providers say they are at a one or a two (not aligned) with their counterparts, but you all seem to be slightly more optimistic.
What kind of trust will be needed to more reliably share data? What is it going to take to achieve this goal?
Terrie Handy: I would say trust has improved over the last 20 years; however, we need to continue to collaborate, and there are many opportunities within the industry to do so. Payers and providers need to continue to partner on administrative efforts and denials. Legacy Health provides care in good faith, yet many times we receive denials even if we have done everything right. In addition, we all need to work together on reconciling outstanding claim status activity or on the aged trial balance as often we are told by payers that their numbers are significantly less than ours. As a result, we go back and forth, which wastes time and resources on both sides. That said, there remains some areas where we don’t have as much transparency as we need. Many years ago, both sides weren’t as open as they are today, so there is hope, and I know we’re making progress by working together.
Where have you seen success in data sharing?
Gold: For our value-based contracts, we are moving to a bidirectional interface — technology that sits on top of the electronic health record (EHR) and allows us to have insight into clinical data and lets providers send additional data back to us. In exchange for connecting to this interface, we provide all our provider groups with full claims details. This has been a way to build trust, making sure we can sit on the same side with the provider when it comes to sharing data. Our hope is that the bidirectional interface will start eliminating things like prior authorization and clinical necessity — no more faxing full medical records back and forth.
Funk: We currently have a tool that houses our clinical and financial information, and we open it up to our risk partners as well as our value-based partners, to help with managing our patient population. We supplement that with provider engagement staff who are interacting with individual provider groups, talking about the data and working with the provider organizations around the data. The system is definitely not perfect. It’s a learning journey for all involved.
Mounts: We see success more around conversational progress. Before, some entities would not be willing to even have a discussion about risk. Now, the engagement you see across clinical and financial areas, how we are coming together internally, is quite exciting. We may not fully agree on the strategy, but the fact that we’ve had some wins on certain Medicare Shared Savings Programs, we are able to then use that as a springboard to continue to put our toes in the water and go down this path.
Rowe: InterSystems has a customer that looked at all the dynamics at play and realized they needed to think differently about how they work with their provider network. They started by asking, “What if there were no prior authorizations for certain services?” Since they know the risk around these sets of services, the cost bands are relatively predictable, too. They committed to robust data sharing and put some stopgaps in place to keep value in network. They provided transparency to the member upfront about associated costs. While they’ve only done this for a subset of their membership in a narrow network, they’ve seen some positive results. They are still kicking the tires, but they now have other entities lining up at their door wanting to participate. That sort of information-sharing and trust creation is starting to encourage real change. One thing this customer says is: “Evolution tells us that when the pH in the water starts to change, that one set of life will become extinct and new ones will evolve.” Because of the shift to value-based care and better data sharing, the pH in the water is changing, and they don’t want to be the extinct species.
Funk: Although we’ve seen good success so far, it’s early in our evolution. We are seeing higher quality care and our costs are lower than what we see on traditional Medicare. This is encouraging. However, the real question we must ask ourselves is, are we improving the overall health of the population in the long run? And if we are not, then we are failing at this. There is also a much larger calling for us. If you look at the numbers, healthcare is destroying our ability to grow and develop as a country and put dollars where they need to be placed. We as an industry have to step up to that challenge. The time is now for us to take on that larger responsibility and find a way to control healthcare for the sake of our country’s long-term viability.
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