Teaming with Providers: Collaboration to Achieve Results

When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs).

As health plans continue adapting to the growing influence of quality metrics on their provider network operations, building an effective team with your providers has never been more important or more challenging.

However, factor in the necessities of compensating members of the team for their role, of each side meeting its profit targets, and the competing priorities faced by often short-staffed offices, it should come as no surprise many health plan staff members and providers are left wondering how to make it happen.

We have focused on designing incentive plans to promote compliance with regulatory requirements but to also meet our clinical and financial goals. To remain provider centric, it is imperative we as plans understand where providers are in the spectrum, not only in their ability to take on risk and make the shift from fee-for-service (FFS) to value-based reimbursement, but also in their overall infrastructure. During various projects, we have shadowed highly-skilled provider relations representatives as they travel in the field to meet with office managers and providers. Often we have found plans have incorrect office addresses. If internally we are not able to easily find our providers, it is doubtful our members or the vendors we hire, for example, Star Ratings and risk adjustment vendors, will have an easy time finding our providers either. This lack of correct provider demographics affects your sales and marketing team, enrollment, member services, and clinical teams. It prevents your internal team members and vendors from gathering the information they need in a timely manner.

How do we as a health plan balance the range of providers in our network? How can we ensure the employed doctor with a large integrated delivery system has his/her needs met while at the same time engaging the single-office practitioner and ensuring his/her goals are met?

Meeting the needs for each of these scenarios and others starts with how well defined our provider incentive programs are. Do they adequately support the clinical and financial goals of the plan and the provider? Have we built an incentive program that has achievable and actionable benchmarks for each type of provider in our network?

Whether your providers are still FFS or at full percentage of premium risk, a few building blocks will ensure success:

  1. Healthcare Is Local: Have we done our benchmarking for incentive programs at the local/regional level to ensure we are measuring apples to apples and taken into account the local practice of medicine?
  2. Prioritization: Ensure Clinical, Risk Adjustment, Star Ratings, Claims, and Network Operations are all collaborating and prioritizing their “asks” of the providers and working together to ensure the needs of the providers are met.
  3. Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
  4. Data Validation Reviews: Data integrity starts with collecting and configuring the provider data at the start of the contracting and credentialing process and becomes critical for downstream health plan operations.
  5. Focus on Actionability: Health plans often provide catalogs of reports each month showing providers numerous views of their panels and sometimes forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let providers be providers.
  6. Continuous Measurement, Re-Evaluation, and Reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a “thank you” are often simple but overlooked motivators.

There is no one straight line to navigate the path from FFS to pay for performance to risk for the plan or the provider, but there is one way to ensure success on that path ‒ collaboration between the plan and the providers. At Gorman Health Group, we are experienced in breaking down the silos and barriers and helping health plans be transparent in their actions and reporting. We can support your health plan to build the trust needed to ensure it is more than just “checking the boxes” on the incentive plan but rather seeing the success in better patient outcomes and lower expenditures.

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Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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