Cynthia Kilroy is a healthcare consultant with experience with managed care, hospital, and physician organizations, with an emphasis on helping these entities prepare for existing and emerging value-based care models. One of her projects involved developing and executing an accountable care organization (ACO) strategy among a payer, hospital system, and independent practice association. At Convergence, Kilroy will address how various care management models, including disease management and transitional care management, can align with payer-provider convergence models.
This is the latest in a series of interviews that Chilmark Research is conducting with Convergence speakers prior to the event. The interview has been lightly edited for grammar and clarity.
How are you seeing provider-payer partnerships come together? What do you see in your work that makes this important to you?
Payers and physicians have traditionally had an adversarial relationship due to opposing goals. As value-based care is top of mind for payers and physicians, new partnerships are forming to better serve the market. The payer and provider relationships are continuing to gain traction as both the public and private markets are focused on lowering costs while improving quality.
The partnerships are not a one-size fits all model as I have seen many different models: joint ventures, partnerships, and not-so-formal relationships with payers. The payers are providing physicians and hospitals information including gaps in care and high-risk patient lists, to better manage their population. Physicians and hospitals are investing in payer-like capabilities including predictive analytics and care management platforms; all with the goal of managing risk.
I’ve recently been working with several start-ups that are focused on improving the communication between the payers and providers. Currently, payers are providing information to the provider community but for many of the smaller physician practices it’s a challenge keeping up with the requests.
The industry still has a long road to convergence. It’s going to take years for providers and payers to gain an understanding of the capabilities each other has but over time they will compliment each other to improve quality and drive down costs. But you’re starting to see some positive movements in that way.
The partnerships are not a one-size fits all model…joint ventures, partnerships, and not-so-formal relationships with payers. The payers are providing physicians and hospitals information…to better manage their population. Physicians and hospitals are investing in payer like capabilities including predictive analytics and care management platforms; all with the goal of managing risk.
Which stakeholders need to be at the table when strategic conversations about convergence take place?
On the payer side the leader of Network Management or ACO programs initiate the conversation. They are the ones putting the contract and the deal together. When you think about health systems, they have their peer sitting on the other side – the Vice President of Managed Care or the VP of Managed Care Contracting. They collaborate together to understand the goals of the partnership, the support teams, and how the numbers are going to work from both a membership, financial and utilization perspective.
The provider C-level suite including the CEO, CFO, CNO, CSO and CMO are usually at the table with senior leadership from the payer. In addition to the contract team, physicians and clinicians need to be included in the conversations. If you do not include the physician and clinical community it will create a challenge when trying to deliver on the partnership. Once the conversations become more targeted including scoping the partnership the technology, care management and analytics teams become part of the planning and execution.
When you think about population health management (PHM) you have to ingest data from various sources and conduct care management, engaging the patient appropriately without redundancy. Out of these areas, do you think convergence focuses in any particular area, or is this all over the place?
I think we are still in the early phases of convergence and the needs are all over the place but I would identify three areas of focus: 1) improved payer-provider communication tools, 2) data aggregation and data analytics, and 3) care management capabilities.
The payers are making investments in better communication with the providers. From a tactical point of view, payer-provider communication is fundamental to the success of the new partnerships. The current state of payer communication is fragmented and single-payer focused. Payers have no strategic framework for who, what and how information is shared, prioritized and acted upon. The result: frustrated physicians that receive multiple and uncoordinated requests from different departments within the payer organization. While many of revenue cycle challenges are address through third party vendors – clinical, care management and quality reporting issues continue to challenge the physician.
The aggregation of quality data and analytics are top convergence priorities for both the payer and provider. The capabilities are a little bit different if you think how the reimbursement model is changing the ownership of risk. Traditionally, analytics has focused on retrospective analysis but now you need to understand potential risk and manage that risk. The market is starting to mature around prospective analytics which focuses on real-time clinical knowledge management at the time the care is being delivered by the clinician.
From a provider perspective, providers are investing in changing and implementing care management capabilities from resources to technology. Providers are now employee inpatient and outpatient care managers, along with new clinical models such as patient-centered medical homes (PCMH) or Ambulatory ICU. I would say that they’re investing more capital in data aggregation, because we need tools, whereas with care management, they’re investing more on resources, hoping that their EMR is going to be able to support them.
As for patient engagement, I think everybody is thinking about it in a much more active way. It’s beyond just the payer-provider convergence the healthcare community realizes they need to engage their patients. Because people realize they need to engage their patient. We see that in Amazon or Facebook, where it’s very easy to engage a customer. The healthcare system needs to think about that on a bigger perspective.
When I think of how it relates to convergence, we keep hearing stories of the poor member who got eight outreach calls from her provider or hospital, and then some from the payer or pharmacy benefits manager. It’s just a redundancy.
That’s where the partnership come into play. I have worked on numerous partnership – all which focused on value-based care models – and we looked at who and what were calling the members. Many times payer’s care managers are calling a patient and the provider does not know that this is taking place. It’s not that they don’t want the help – they do – but they want to understand the interaction and the recommendations the care managers are making so they can reinforce if a member appears. Studies have shown that when somebody reaches out from the health plan and tries to talk to a member or a patient around their care, they’re not as respective as if you call from representing the physician’s office. Even if it’s telephonic and it’s the payer’s care manager it becomes an extension of the practice.
I think the payer side is thinking more and more about what care management solutions it has – and are they the right ones? The telephonic care management solutions – I call them the old disease management programs – haven’t been as successful as we want them to be. It’s really the high-touch, evidence-based programs that have strong patient engagement, physician engagement and care managers where you really engage that patient at the right place at the right time. I have seen more and more payers or large providers systems who are taking on risk create field-based care management programs.
Have you seen examples of this data sharing? We talked about analytics and the ingestion, and we see all kinds of examples, but it’s so early on shared platforms, as opposed to sending a report once a month, or once a week. Can you think of an example where providers and payers actually look into the same platform and see the exact same data in real-time?
Traditional payer communication strategies push information to the physician in emails, faxes, paper reports and CD’s (yes this still occurs) regarding chart requests, gaps in care and care management enrollment. Payers have created portals to offer self-service to physicians that require practices to navigate multiple sites and workflows.
Recently, payers and EMR vendors believe access to the EMR is the holy-grail for solving all the problems but it only helps with gaining passive access to the clinical record for coding exercises. You have to think about how different types of provider practices from large practices to small practices to independent practices and their investment capabilities. The large systems with large physician groups are investing in data warehouses. The ACO are trying to aggregate information, but a lot of that information is still being pushed more on a monthly basis than it is on a daily basis.
I have seen some of the payers push information to the provider portal that allows them to look at billing/claims information. They upload reports for the physician but again it’s hard for a physician to go to multiple payer portals.
Is there a particular niche within care management – case management, transitional care management – where you see greater convergence?
Its care management of high-cost, high-priority, high-risk patients where they come together and work together more so than anything else. I see the payer maybe stepping back a little bit from that role, because being in the practice or extending the practice into the home is where you can have a real impact on an individual, and people just aren’t receptive when it’s coming from the payer.
Is it super-utilizers, or the 3% to 5% who cost the most?
That’s where most payers and providers have started as they work on partnerships. They pick a particular condition, develop evidence-based care management protocols and processes to manage the patient and then start the outreach. The payers are trying to give the provider the information and some of the tools. The more sophisticated ACOs working with payers are probably saying, “OK, this is how we can work together, and here’s how the process can work.”
When it comes to the challenges, they just don’t know each other’s DNA. They’ve lived in very, very difficult worlds in all these decades. Do you think it’s more operational, tactical, or strategic? Why does this take years?
First of all, it’s trust. It’s challenging the payer-provider relationship. The traditional relationship was around negotiating contract rates for services but now it’s become a partnership play. Being able to develop that trust is extremely important; getting the right people at the table who understand how to build that trust is really, really important.
Second, creating the transparency to identify the issues and be open to making the changes. There’s going to be things that you did well and you didn’t do well, and I did well and I didn’t do well. We should have that trust and transparency to say, “We’re going to come together and make it better for our population, our patients, and our members.
There is a strategic play for the partnership – it’s to lower costs and improve the member experience. Payers are not creating these partnerships with every physician group, they are strategic in picking the market, selecting the partner and identifying the partnership model. But once the deal is done it becomes extremely tactical. It’s not a roadblock; it just takes time and energy to do it. How do you push it down to the practices? It takes time. How do you educate the docs? You can have all these great care management programs, but you have to get it into the practice. It just takes time and acceptance.
Do you think it’ll get to a point where there’s going to be some agreement that, say, payers will always own data warehousing, so providers don’t need to invest the capital in it? Payers will own identification and stratification, and they’ll hand the list to the providers, who then own patient engagement and care management?
It’s too early to say but as the market moves to value-based care roles will become more defined. There are reasons why a payer is going to engage a member at the time of enrollment – finding a doctor, paying a bill or filing a claim. That’s one piece the payer will own. But then there is the patient engagement piece, which is also really important. “How do I engage somebody about their care or keep them healthy?” That tends to be more on the provider side, but I think there’s room for coming together and doing interesting operating models to support patients. Most providers do not have the capital to invest health and wellness programs but payers have developed these programs that can be leveraged by the provider.
As for data analytics the large systems aren’t going to trust the payer to give them the information. They’re going to run their own analytics and have their own data warehouse. They’re big enough to do it.
Convergence and value-based care are closely linked. What will it take for the industry to accelerate the shift toward value-based care?
Convergence is closely link to value-based care as I have outlined in my comments above. Providers and payers are testing the water to see what works and does not work. Nobody wants to mess with happened in the 90s – some of us lived through that and hopefully learned valuable lessons.
There are over 850 Medicare and Commercial ACOs out in the market right now, covering about 28 million members. Collaboration is a high priority for both payers and providers. Aetna and United Healthcare have hundreds of value-based and accountable care relationships with physicians and hospitals across the country.
In addition, when you start thinking about MACRA, it goes into effect in 2019, based on 2017 and 2018 performance years. There’s two tracks: MIPS and the advanced payment model (APM). Under MIPS, you can get penalized if you’re not performing well in quality, cost, improvement activities and technology. It could be anywhere from 4% of your Medicare payment in the first year up to 9% by 2022. Whereas if you’re in APM, which is where the ACOs fall, you get an automatic 5% bonus for you fee-for-service rate.
What organizations do you consider to be leaders in convergence?
I know Aetna and United/Optum – along with many of the other payers – have internal teams that go in and support the provider to move to value-based care. From a provider perspective some of the Next-Generation ACOs are very interesting because they’ve shown more maturity in their capabilities. But the Next Generation ACO were provider organizations that were mature in managing risk and had 3 or 4 years to invest in the value-based care capabilities.
