In an effort to accelerate the delivery of medical knowledge and the adoption of evidence-based practices at the point of care, the Alliance of Community Health Plans (ACHP) launched a project exploring the role of health plans in influencing physician behavior.
With funding from the Patient-Centered Outcomes Research Institute (PCORI), the ACHP studied its own members — 21 nonprofit, community-based health plans and provider organizations — and found that closely aligned payer-provider partnerships helped hasten evidence from the lab to the bedside. Indeed, these collaborative efforts have contributed to reducing opioid prescribing, eliminating unnecessary labor inductions, improving diabetes and hypertension control, increasing depression screening and treatment, and reducing surgery costs, among other results.
Our report, “Accelerating Adoption of Evidence Based Care: Payer-Provider Partnerships,” reveals successful payer-provider partnerships and what makes them successful — and, their practices are by no means proprietary.
Payer-Provider Partnerships: Five Best Practices
Nonprofit, community health plans can influence clinician behavior to ensure that patients are receiving the best evidence-based care medical research has to offer. Our research reveals replicable and scalable strategies that any committed health plan can employ to partner effectively with physicians to accelerate evidence to the point of care. These five best practices are applicable and adaptable to health systems of all sizes and models, and the most successful efforts will use these strategies in combination, reinforcing the collaborative approach throughout the process:
- Build consensus and commitment to change
- Create a team that includes the necessary skill sets, perspectives, and staff roles
- Customize education, tools, and access to specialized knowledge for physicians and for patients
- Share timely and accurate data and feedback in a culture of transparency, accountability, and healthy competition
- Align financial investments with clinical and patient experience goals
Case Study Results
The ACHP report outlines several case studies from diverse business models and communities across the United States. Any health organization may use these practices to strengthen payer-provider partnerships in the delivery of better health outcomes. Here are three examples of case studies that illustrate some of the replicable best practices our research uncovered.
Creating safe, cost-effective alternatives to inpatient surgery; Security Health Plan, Marshfield, Wisconsin
Many surgeries in the United States today are performed in ambulatory surgery centers. Marshfield Clinic Health System and Security Health Plan in Wisconsin reviewed the latest medical research that concluded ambulatory surgery centers provided higher-quality care at lower cost than hospital outpatient departments. The plan and provider also knew that, according to the Ambulatory Surgery Center Association, Medicare pays ambulatory surgery centers 55% of the amount it pays to hospital outpatient departments for the same procedures, generating cost of care savings of about $2.6 billion per year.
Aligned goals. Marshfield and Security determined that their existing ambulatory surgery centers were adequately staffed for surgeries but not for recovery. They estimated that if they could add skilled nursing services, they would be able to transition about 30% of hospital procedures to an outpatient setting.
By sharing a commitment to minimize stress and reduce recovery time for surgical patients, Marshfield and Security were able to develop an alternative patient experience that would go beyond the ambulatory surgery center. The plan and provider created Comfort and Recovery Suites, licensed skilled nursing facilities fully staffed by physicians and nurses.
Team approach. With a clinical work group of surgeons, anesthesiologists, and nurses to propose the new methodologies for the Comfort and Recovery Suites, the plan and provider engaged peers to gain physician acceptance. Marshfield formed a perioperative surgical home to coordinate and integrate the management of surgical candidates. A team of nurses and physicians reviews the records of surgical candidates and recommends the best setting for each patient, bringing as many cases as possible safely into the ambulatory surgery center.
Clinicians use an evidence-based protocol called Enhanced Recovery After Surgery to provide guidance to the care team and promote partnership among the surgical and anesthesiology teams. Marshfield uses multiple alternatives to narcotics for pain management, enabling patients to emerge safely from surgery awake, alert, and astute, with minimal pain.
Results. Marshfield and Security made a purposeful, joint decision to move qualified surgeries from the traditional hospital setting to the ambulatory surgery centers, based on medical evidence about patient outcomes and a desire to offer a better patient experience. In the first 24 months, more than 1,000 surgical procedures were performed in the ambulatory surgery centers, saving the health plan $4.7 million. ASC clinical outcomes were the same or better as compared to those who underwent the surgery in hospital inpatient settings and those who were admitted to a traditional skilled nursing facility for recovery. Patients who recovered in the Comfort and Recovery Suites were less likely to be admitted to the hospital after surgery than if cared for in the traditional skilled nursing facility. Two of the three facilities achieved five-star ratings and the third achieved a four-star rating per the Medicare rating of skilled nursing facilities. Press Ganey patient satisfaction surveys show a 98% satisfaction rate.
Data, healthy competition improve primary care and reduce costs; Capital District Physicians’ Health Plan, Albany, New York
In 2008, Capital District Physicians’ Health Plan (CDPHP), a fully networked plan in Albany, New York, launched its Enhanced Primary Care (EPC) program with a commitment to providing financial support and ongoing expert consultation. This collaboration between the plan and providers shifts payment for a patient-centered medical home model from fee-for-service to risk-adjusted capitation. The plan pays EPC practices 50% more on average than fee-for-service with the opportunity for a 20% pay-for-performance bonus. Advisory groups comprising EPC physicians and health plan representatives shape strategy around cost and quality initiatives for the program.
Physician engagement. CDPHP leaders recognized that face-to-face engagement with physicians is crucial to influencing physician behavior. To develop a physician engagement team composed of individuals who would excel in that role, the health plan hired former pharmaceutical representatives, trained in the art of persuasion, to work directly and effectively with physician practices on performance improvement and cost savings.
The physician engagement team customizes its approach to each EPC practice’s needs and preferences, based on sales theory that assumes at least six to eight conversations to influence behavior change. Most engagement team specialists meet with assigned practices monthly or quarterly, using customer relationship management software to track their calls and visits so that each interaction builds on the previous one.
Healthy competition. With New York State moving toward public release of performance data, CDPHP acknowledged the additional pressure on primary care practices to improve care and reduce costs. Through the CDPHP provider portal, physicians in EPC practices have access to data showing how their performance compares with that of their peers regionally and nationally on quality measures such as diabetes care and cancer screening rates.
The results tell the story: The EPC practices outscore non-EPC practices in providing higher-quality care and improving the care they provide at a faster rate. Between 2010 and 2014, quality scores for EPC sites rose from 71% to 77%, while quality scores for non-EPC sites rose from only from 65% to 68%.
In addition to the financial incentives of being an EPC practice, another element of the influence of competition is public recognition. For the second year in a row, CDPHP has publicly released a list of top-performer practices in its Top Doctors report. The practices are ranked on a series of quality and patient satisfaction metrics, and they are recognized within the report and at a public event. While there is no additional compensation for practices that make the list, the public recognition has proven to be an effective motivator. To date, the Top Doctors report, which is hosted on the health plan’s website and distributed to the entire provider network, has been read by more than 35,000 people.
Customized, ongoing support. CDPHP organizes an annual education program specifically for EPC physicians and practice managers that focuses on Healthcare Effectiveness Data and Information Set (HEDIS) measures. The health plan continues this training year-round with specific learning collaboratives on topics requested by the physicians, such as integrating behavioral health into primary care; this feedback loop, from physician to health plan, solidifies the collaboration. In the weeks following a collaborative, CDPHP’s engagement specialists visit each of their practices to review the seminar’s content and provide follow-up on sustaining change. The health plan also distributes one-page handouts, reviewing best practice protocols for specific conditions.
The engagement specialists provide tool kits developed primarily by the CDPHP quality department to EPC practices that are designed to support best practices. For example, a colorectal cancer screening tool kit details five different ways practices can meet the HEDIS measure, lists all appropriate codes, and offers specific strategies for success. A tool kit on appropriate use of antibiotics provides guides for conversations with patients who may lobby physicians for antibiotics when not warranted.
Alignment of financial goals. To reward value — not volume — CDPHP pays the EPC practices a monthly risk-adjusted global payment and offers them bonuses based on efficiency (the overall total cost of specific care elements including pharmacy and specialty care), quality (based on 18 HEDIS measures), and patient satisfaction results. Between 2012 and 2014, CDPHP realized a cost savings of $20.7 million directly related to the EPC program. Approximately 60% of the savings was experienced in the commercial line of business.
In 2017, in addition to reimbursing practices at rates greater than fee-for-service, CDPHP also distributed $3.1 million in bonuses to 175 EPC practices that improved quality, efficiency, and patient satisfaction scores. The bonuses have allowed EPC practices to invest in staff and technology that support improvements to benefit patients, such as expanded office hours, easier appointment access, more electronic communications, and coordinated care.
Diabetes management program in primary care; HealthPartners, Minneapolis, Minnesota
Recognizing that diabetes is a significant cause of death in the United States, HealthPartners Medical Group in Minnesota launched system-level changes back in 1997 to create an enhanced primary care approach to diabetes management. Over the course of 2 decades, this approach has resulted in significant population-based improvements in diabetes care.
As one of the founders of Minnesota’s Institute for Clinical Systems Improvement, HealthPartners has had a longstanding commitment to such system-level changes. Together with Minnesota Community Measurement, the institute today works with the state’s health organizations to build and spread evidence-based practices to improve patient care and reduce costs.
Data sharing and transparency. HealthPartners and its clinicians recognize that quality diabetes care requires staying abreast of the latest evidence-based guidelines and paying attention to a cluster of symptoms and screenings for possible complications, such as heart disease, stroke, kidney failure, lower-limb amputations, and adult-onset blindness. HealthPartners clinicians receive and evaluate data that encompasses the entire care process for diabetes patients. Rather than solely relying on medical records, claims data informs the health plan of care a diabetes patient receives outside the clinic system, e.g., an eye exam.
Through the Minnesota Community Measurement and HealthPartners’ electronic medical record system, practices and clinicians have access to a wealth of performance data. Optimal diabetes care is measured using five distinct measures, called the D5 for diabetes, that look at a patient’s LDL or statin use, A1c, blood pressure, documented non-tobacco use, and aspirin use.
HealthPartners provides practices with performance data and helps create action plans for quality improvement. Physicians receive regular data on their personal performance at the work unit level and at the clinic levels, where it is comparative in nature to identify quality leaders who can share insights with others.
Telementoring. HealthPartners uses a range of methods to provide education to clinicians in its network, the most unique of which is the ECHO (Extension for Community Healthcare Outcomes) model, developed by the University of New Mexico. Also known as telementoring, the approach shares evidence-based research through a “hub-and-spoke knowledge-sharing network.” By linking expert specialist teams at an academic “hub” with primary care clinicians in local communities (i.e., the “spokes”), these “virtual grand rounds” promote multi-directional learning and create communities that provide ongoing support to one another. Medical specialists train primary care clinicians to treat patients instead of referring patients to specialists, resulting in care that is as safe and effective as that of specialists.
Primary care physicians at HealthPartners have participated in ECHO model learning groups in endocrinology and psychiatry to build their knowledge and skills specifically in caring for patients with diabetes. By transporting knowledge rather than patients, the ECHO model provides patients with timely access to the care they need from their primary care clinician, which improves health outcomes, reduces costs, and reinforces the provider-patient relationship.
Results. Because of the complexity of treating diabetes, most measures of the quality of diabetes care involve several components. By finding ways to embed expertise in its primary care clinics, HealthPartners’ rate for Optimal Diabetes Care as measured by the D5 bundle was 49.7%, compared to a statewide average of 44.7%, in 2017. The National Committee for Quality Assurance (NCQA) rates HealthPartners 4.5 out of 5.0 for diabetes care.
In the last 10 years, HealthPartners saw complications of heart attack, stroke, amputation, and retinopathy in diabetes patients decrease by 50%. HealthPartners’ 41,488 members with diabetes in 2017 suffered 361 fewer heart attacks, 20 fewer leg amputations, and 954 people did not experience eye complications, compared to what would have happened to the same 41,488 members in 2000.
Replicable and Scalable Strategies
The U.S. health care community continues to struggle with the transition to value-based care, as is apparent in a 2018 NEJM Catalyst Insights Council report that found a widespread lack of alignment among health care stakeholders trying to achieve value-based care. The exception? Integrated payer-provider systems; fully 66% of survey respondents find that segment of the industry is achieving strong, very strong, or extremely strong progress toward innovative, risk-based payment arrangements.
But as these case studies from the ACHP research demonstrate, nonprofit, community health plans are proving that they can work collaboratively with clinicians to adopt the best available evidence-based care. The results are seen in improved clinical and satisfaction outcomes for patients, and in better financial metrics that include both reduced cost of care for organizations and enhanced reimbursement for clinicians. And — importantly — these payer-provider strategies are replicable and scalable today.