How employers, health care purchasers, and providers can improve value-based care delivery

doctor providing value based care for a mom and daughter

Employers, healthcare purchasers, and America's leading medical groups are collaborating to find solutions to fix the fragmented US healthcare delivery system; a fragmentation exacerbated by the COVID-19 pandemic, but surely not caused by it.

In a recent report from the National Alliance of Healthcare Purchaser Coalitions and the Council for Accountable Physician Practices (CAPP), it was suggested that enhanced care coordination, greater investment in delivery systems and primary care, and aligning reimbursement with patient outcomes will be needed to transition to delivering high quality and affordable care.

What do employer-purchasers want from healthcare?

This report, "Exploring Employer-Physician Collaborations to Deliver Quality Care," presents the results of a first initiative, a series of listening sessions with National Alliance Coalition and CAPP members in five states, including Texas. The goal was to open up a direct line of communication between the purchasers and the providers, without going through middle men. Both purchasers and providers want patients to receive good quality, affordable healthcare. We believe that together, we can collaborate on broad-based initiatives to close those gaps and provide better, lower-cost healthcare.

The findings of these listening sessions showed what self-insured employers want in a healthcare plan;

  • Coordinated care
  • A value-based business model
  • A robust primary care delivery system
  • Transparency in healthcare billing.

Coordinated care

Self-insured employers want their employees to experience seamless care, and to receive additional support navigating the medical system when they have a health problem or serious illness. We know that the more you can coordinate the care around the patient, the better the experience for the patient, and therefore the more likely they are to get a good outcome. One way to do this is by investing in delivery systems so that we can make those connections and fill in the communication gaps.

Employers also said that they recognize the importance of mental health and its link to productivity. They want employees to have timely access to needed specialized services. If it is possible to bring behavioral health into the exam room and it is, particularly now with telemedicine, we can improve the patient experience and really avoid some of the failures in delivery. Most of the CAPP groups have been engaged in telemedicine for many years, but even for us, it's been something of a revelation during this pandemic of how well accepted telemedicine has been when it was the only alternative.

Value-based business model

Health care providers have been slow to adopt value-based payment models, despite the understanding of how the predominant fee-for-service payment system affects cost, quality, and patient experience. The fee-for-service model dictates that providers only get paid if they do something to a patient, as opposed to being paid for keeping people healthy and well, which should be the goal.

Some groups, like CAPP groups, have had great success enacting contracts with health plans and employers that include upfront financing allowing us to build an infrastructure to help patients take care of themselves. We are able to do outreach to monitor quality and to connect the system together. Electronic medical records (EMR) have allowed entities to connect with other entities and provide more integration and prevention in the care delivery.

Robust primary care delivery system

There have been many studies over the years that show that patients who use primary care as their front door to health care do better, have less expense, have better outcomes, and are more satisfied with the care they get. Unfortunately, primary care is poorly reimbursed in the US, which again leads back to fragmentation. Specialists get paid enormous sums of money and primary care does not. This has led to an underinvestment in organizing primary care and making sure primary care can act as a real facilitator for patients care. It has also led to barriers to access include provider shortages, especially in rural areas.

Self-insured employers want providers that have a strong investment in primary care systems, which in turn helps employees better navigate the healthcare system and find the coordinated care they need.

Transparency in healthcare billing

The report made it very clear that employers are dissatisfied and exasperated with the lack of transparency of how healthcare is paid for. Beyond affordability, employers want simplicity in billing and estimates, as well as price transparency. Employers and employees who need and want to understand the cost of care can't determine the prices for specific services, and when they can find price estimates in advance of receiving the service they don't understand why there is such variability between service providers.

More discussion between our groups--the CAPP groups, and the National Alliance groups of health care purchasing organizations and coalitions–will help us to understand each other better and lead to the desired outcome, transparency and simplicity.

Success stories

The current reimbursement structure for many healthcare providers does not encourage, incentivize, or reward physicians for continuity of care for their patient. Medicare Advantage is a successful example of change in the way health care is reimbursed, where the delivery system is reimbursed for good outcomes, for measured quality, for patient satisfaction, and access.

A recent study suggests that health plans that contract with physicians who are more exposed to the quality measures established under a value arrangement are more likely to succeed. In particular, health plans with contracted physicians who focus their Medicare practice on Medicare Advantage patients performed better than physicians whose practice included a smaller than average share of patients enrolled in private Medicare Advantage plans. In short, it pays for health plans to contract with physicians who are going "all in" on value-based care.

Next steps

It's clear from our discussions that employers want clarity how the system works. They want to understand where the incentives are, how the system works. Employers have had to rely on outside experts or intermediaries to explain the system to them, but they have made it clear that they want know themselves.

The next steps in the ongoing dialogue will be virtual round tables held with National Alliance coalitions and CAPP physician leaders to further define such goals and craft possible solutions.

Find out how ARC can be a part of your self-insured plans.

Dr. Chenven discussed this report and other findings in more detail in a podcast with the American Journal of Managed Care. Click this link to see the entire podcast.

Want to learn more about self-insurers want? Attend SIIA's 40th Annual National Virtual Conference & Expo. Dr. Chenven will be speaking further on this topic in a session called "What Employers Really Want: Results from a National Dialogue".

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