How Health Plans, Providers Can Find Common Ground 

As health care costs continue to rise, providers and health insurance companies often are at odds. It’s a constant push and pull relationship, as physicians and hospitals try to get paid for services, and health plans try to streamline patient utilization to appropriate use to reduce cost.

Patients sometimes face gaps in care, end up paying more than expected for premiums and out-of-pocket expenses, or being denied coverage for a procedure altogether. This is a big reason why better collaboration between providers and health plans is necessary – finding ways to meet in the middle while benefiting the patient, says Tramico Herman, author of The Crux Of Care Management: Steps to Managed Care and Patient-Centric Service Excellence for Leaders.

“The relationship between health care providers and health plans is often antagonistic, and the patient suffers as a result,” Herman says. “To sustain our delivery system, the future of health care must include productive partnerships between providers and payers. They must tackle the utilization, increasing cost and gaps in care issues in a collaborative fashion.

“To succeed long-term, collaborative models must keep the best interests of patients at the forefront, finding new ways for them to become healthier while reducing the cost of their care.”

Herman says value-based care is a critical outcome of payer-provider collaboration and notes that one example is payvider, which a Guidehouse report defines as a contractual or joint ownership arrangement between payers and providers. “Such an arrangement centers on delivering value through efforts to increase access, improve quality and reduce waste,” she says.

Herman points out the following elements of value-based care, reasons why providers and health plans should collaborate, and how it could pay off for them and patients:

• Improve coordination and care management program delivery. With our population getting older and sicker and exacerbation from Covid-19 causing missed appointments, mental health crisis and delayed treatment, Herman says this is an important time for providers and health plans to understand the roles and responsibilities of their core care management team members, including utilization reviewers, care managers, social workers and administrative staff supporting these roles during the patient health care journey.

“All the roles and responsibilities that these individuals are performing is within a technology system,” she says. “Everything is driven now by technology. There needs to be a technology system enhancement with interface features of all software applications accessible to the internal health-care team members and external providers to promote full collaboration.

“There is a critical need for standardized training, provider education, and ongoing communication with built-in audit processes to promote accountability and meet contractual obligations.”

Herman notes that providers and payers have accelerated efforts to transform their workforces and processes to better deliver and cover remote care solutions. “Patient outcomes are improved and unnecessary costs are avoided when chronic conditions are properly managed,” Herman says. “There’s an opportunity for transparency in that virtual context where payers and providers can find common ground.”

• Increase provider partnership. Herman says growing in-network providers, expanding across more geographic areas and targeting patients living in rural areas will reduce gaps in care. At the same time, she says that approach will increase provider payments from higher patient volume based on in-network status.

“The mission is l​owering patient cost and ensuring providers follow the health plan value-based models mandated by CMS (Centers for Medicare & Medicaid Services), which include evaluating specific data about patient opportunities and potential gaps to provide appropriate services,” she says. “Health plans need to keep in mind provider engagement if they want buy-in from providers, especially independent physician practices,” she says.

• Support telehealth medicine expansion. “Telehealth has been around since the 90s but unfortunately was not very popular and faced several obstacles with broadband capabilities and provider/health plan adoption,” Herman says. “The pandemic was a catalyst to the recent exponential growth, giving our providers another option to continue care. It’s here to stay, but much work is required for regulation expansion to provide appropriate reimbursement with approval of more service codes. Financial and resource support is needed to increase broadband infrastructure, relax laws around pharmacist/clinician multi-state licensure requirements, and ramp up community engagement/education.”

“If providers and payers are to succeed at collaborating, patient health and financial and quality incentives must be aligned,” Herman says. “It starts with honest conversations about common priorities and values.”

Tramico Herman is author of The Crux Of Care Management: Steps to Managed Care and Patient-Centric Service Excellence for Leaders and is known as a compassionate health-care executive and transformational leader in care management and health-care disparities. She began her nursing career leading medical-surgical and intensive care units, then transitioned to healthcare administration with a focus on care management. Herman advanced to leadership roles while developing strategies for processes improvements, reducing employee turnover and supporting recruitment and quality compliance with executive leaders. She holds an MBA in project management and became an executive consultant for various Fortune 100 health plans and providers.