Denise Harr, MD, is Senior Medical Director of Medical Value Initiatives at Capital Blue Cross. Her department supports the value-based programs that the insurer has implemented with providers across its network, with an emphasis on clinical quality and improved outcomes. Before joining Capital Blue Cross in 2012, Dr. Harr spent 15 years as a practicing family physician in Central Pennsylvania. At Convergence, Dr. Harr will provide both strategic and practical insights regarding disease management, transitional case management, and other forms of care management that will play a key role in payer-provider convergence models.
In your role, do you have any thoughts on what we’re calling provider-payer convergence? Clearly, a value-based contract is between providers and payers, but then it can branch into a thousand directions, focusing on how important it will become to collaborate, to partner, and to share care management roles and responsibilities.
Talking about technology and care management, the challenge is how you separate the two. In order to do care management, to have a coordinated approach, you need data, and you need technology to drive that. It’s probably going to be a bit of a gray line, in my opinion, of how do you talk about technology over here but talk about care coordination over there.
You have to develop a collaborative relationship if you’re going to enter any value-based model. Look at traditional care management; it was delivered in a vacuum. I never knew it existed when I was a practicing physician. Apparently, my patients were reached out to and potentially engaged with their insurance companies, such as disease management programs, and at certain periods the payers would have sent me letters. I would like to think that I didn’t completely ignore it, but it just wasn’t on the forefront of what I understood was actually happening, so there was a complete disconnect.
Now that I sit on the other side of the table and understand the programs that payers do have to offer, I have a completely different appreciation of what payers are doing. I did my medical school training at Hershey, and I practiced in this community, so I know a lot of the providers that I now sit across the table from.
We provide this information and they say, “Oh my goodness, that fills in a whole bunch of gaps.” Sometimes, when [providers] give us clinical detail that we don’t have from claims, all of a sudden it puts a big picture together, and we can develop a better way to manage that patient. It’s a broader view of the patient through this exchange of information.
As we move to value-based care, providers are also trying to figure out what they need to do to be successful, and payers still have a lot of these traditional programs. When I look at the continuum of different programs that we have, even for providers that are in similar model, as much as we try to take a standardized approach — “Here’s how we’re going to engage in this type of a model with this provider” – there’s always the need for customization. Providers are on a continuum of readiness to take on some of those care management responsibilities that, historically, only payers have provided. Each time we enter a relationship with a new provider entity, we ask some questions: “What are you guys doing? How can we support you? This is what we’re doing.”
It takes a lot. It doesn’t happen in one conversation, or 5 conversations. It’s only after really sitting down and getting to say, “You guys are going to do this. We’re going to do this. We’re going to try to fill gaps that you may not have a resource for. We’re going to do the same thing, but not duplicate services. Our main focus is the member (the patient) and to make sure that they get the right care but don’t get bombarded by 5 or 6 different people calling them about the same kinds of things.”
Is it an important topic? Without a doubt. Is there a standardized approach to it? Not as much as we would like. Much of what we do becomes customized based on the readiness of the provider.
On the payer side, you believe that everybody knows all about existing care management programs – and you wonder, why don’t providers want to take advantage of them? Why do providers generally dislike it when their patients get called?
Recently, we were sitting across the table from a provider organization that we were starting a new relationship with, and the CMO of the medical group asked, “So are you actually sending us letters? I didn’t even know that these kinds of programs existed.” I laughed and I said, “Well frankly, 5 years ago, I didn’t know they did, either.”
Even today, despite what we think we’re doing effectively, it’s really never getting to this physician. But this is where some of the providers are building their clinical teams. There’s more of an acknowledgement or understanding from the clinical staff that they are the ones who are going to drive engagement and enrollment in these types of programs, more so than the providers themselves – the physicians, the nurse practitioners, and physician assistant. At least, that’s what we find in a lot of our relationships.
The physician says, “I have this problem,” and it’s a nurse or an allied health professional whose says, “Hey, I know what the solution is. Let’s get the patient over here to this type of program,” whether it’s something that we offer as a payer or a program that a provider might have internally developed. When we think about some of the transitional care management services, that’s where I think we have taken a step back, as the providers – because there’s reimbursement now for transitional care management – are anxious to get in to that space.
When it comes to executing care management convergence, what’s the ideal situation? That the provider doesn’t have to worry about it, and clinical office staff will know what programs are available and channel patients the right way – that the provider presents the problem and the provider’s staff help solve the problem? Or, do you think it would ideal to have, say, in the EHR, all the members’ benefits right there? I’m thinking there is nothing like your doctor looking you in the eye when you’re diabetic and saying, “I expect you to join this program and be compliant. Stay with it. It’s offered by your payer. They’re going to call you.” Reinforcement from the actual provider is certainly more impactful to the consumer. How involved does the provider need to be?
Because of the relationship that patients have with their providers, their physicians, or their allied health professionals, they’re going to follow that advice more than they might follow the advice of another clinical team member in the provider’s office – but they’re certainly going to follow that person’s advice more than they’re going to follow a cold call made by payer.
It’s not just that a clinician, or this whole clinical team, is delivering services to a patient. They’re trying to build a model that historically has been provided only by the payer. Admittedly, members/patients trust their doctor more than they trust their insurance company, who are still viewed as, when we make a call, we’re asking for some kind of payment. If we really want the payers to do some of this, we need provider input or reinforcement of the program – but it’s also a balance between what a provider’s office may be able to support and do on its own so that a payer nurse is not calling and some other clinician on the provider side is also calling about the same issue.
How do you customize? How do you get to the point where you avoid the duplication – or maybe you haven’t yet? How do you truly turn off one as you turn on the other?
In your standard payer-provider relationship, there’s probably duplication. As we move into some of these value-based programs, where we as a payer have more one-on-one conversations with the provider entities – and, again, these are larger independent physician groups or health systems –we have those points of contact and we sit down and say, “OK, we’re going to do this and you’re going to do this. Here’s our roles and responsibilities.”
If we’re outreaching, we’re doing care management and we get people engaged, we feel like these are people who need services but they’re just not responding, then we’re going to go back to the provider and say, “Here’s a list of people we’ve been trying to get engaged in our program. This is the piece that you’ve asked us to continue to support, but yet we can’t get them. The next time they come in to the office, how can you help us?” Again, each provider has a different approach, but a lot of times, they either do their own outreach or, the next time that patient comes in to the office, they say, “Hey, we’re working closely with this other clinician.” Sometimes, they introduce you on the payer side. Sometimes it’s just, “Here’s another resource to help you with the current challenges that you’re facing.”
Geneia is a separate entity that’s closely affiliated with Capital Blue Cross. One of the things that we do with Geneia, as our way to facilitate that conversation, is create a new primary role in Geneia but a secondary role in Capital – a complementary resource that we call the Population Health Consultant. It’s that point of contact between the traditional case and disease managers and the provider’s office. They talk about difficult cases, making sure that we get the right care on the provider side and fill the gaps into the payer side. They talk about those members who have been difficult to engage with, who’s getting readmitted, where do we need help on either side? We have a population of consultants tied to each of our value-based programs, and they’re helping to be that liaison between what we’re doing on those sides of the table.
Sometimes you can make the argument that a liaison role serves as just another layer in an already complex structure. Why not just assign a designated payer employee to each provider group to do that outreach, rather than a third part vendor? What lead to that decision?
Being separate entities, there’s a resource on the Capital side and there’s a resource on the Geneia side, both of which intersect in different ways with the provider assets. We have our teams in the network and the contracting area, too, which interface with the financial executive on that side of the table.
I agree that it’s an additional layer, but it’s a layer coming from the provider side. It’s a streamlined way to get into the right program on the payer side. That person can direct a referral to the right place quicker than some of those standard processes and has the ability to access the provider’s EHR and send comments back and forth with clinical teams. There’s probably less of that now, but that one-to-one exchange with a key person on each side of the table has enabled our success. They’re in touch. That’s what they do all day long. They’re not necessarily navigating, at least on our side, any kind of patient care responsibilities and the like, but they are able to pick up the phone and talk to that contact on the other side of the table quickly.
When you sit down to take that customized approach and say, “You take this responsibility, I’ll take this one”, the example you mentioned was the hard-to-engage patient or member. “We’ve already have this program from the payer side, these ones are falling out, not engaging.” Do you find that’s the most common type of care management convergence happening in value-based arrangements? Or is convergence occurring more so within transitional case management? When patients get discharged from the hospital, provider groups seem ready to take those on.
In our experience, transitional care management mostly happens on the provider side.When we talk about traditional case and disease management, it’s happening more on the payer side. There’s definitely flavors of that depending on the individual entity.
In our programs, we mostly talk to primary care providers. Some of the information we provide is information that not everybody has, because not everybody is on the same platform or system – it’s the care received by some patients that’s outside their health system or information that they may not otherwise have access to. We provide this information and they say, “Oh my goodness, that fills in a whole bunch of gaps.” Sometimes, when they give us clinical detail that we don’t have from claims, all of a sudden it puts a big picture together, and we can develop a better way to manage that patient. It’s a broader view of the patient through this exchange of information.
Is transitional case management a place where providers prioritize care management efforts because they can bill for it?
That’s been our experience. They feel better equipped because it’s based on getting that appointment with the provider as that patient is transitioning from the different level of care.