Changing Care Models Require Payer-Provider Collaboration

Care models are shifting, with pure fee-for-service reimbursement models fading even faster than expected, according to a session at NAMCP on care model transformation and payer-provider collaboration. 

While fee-for-service had been predicted to account for 40.9% of reimbursement in 2018, it ended up representing just 37.2%, presenters Elaine Taverna, vice president of revenue management and risk adjustment at the Health Alliance Plan of Michigan, and Cindy Garvin, senior manager of consulting services at Change Healthcare, told attendees. By 2021, fee-for-service is forecast to account for just one-quarter of reimbursement.

As payers transition to value-based reimbursement models in both commercial as well as Medicare and Medicaid plans (for the first time, commercial business lines are leading government in the crossover to value-based care), they are reporting compelling success in cutting medical costs, Ms Taverna and Ms Garvin said. An average 5.6% in medical cost-savings was reported in one poll. Nearly a quarter of payer respondents said they saved 7.5% or more.

Quality of care, too, is improving with value-based care, according to the presentation. Nearly 80% of payers reported improvement in care quality, 73% said patient engagement has been enhanced, and 64% reported better provider relationships. 

The presenters reported “significant headway toward achieving the elusive ‘Triple Aim’ of healthcare through value-based care initiatives.”

The transition to value-based care requires agility and speed, Ms Taverna and Ms Garvin coached—features both payers and providers may struggle with. 

Between 43% and 58% of payers are reporting difficulty in getting providers on board with episode-of-care bundled-payment reimbursement programs. Yet, episode-of-care models are proving effective in improving care quality across all types of episodes, including acute medical, maternity, cancer, and chronic specialty care. They also delivered average savings of 5% to 5.4%. Some payers reported savings of 7.5% or more.

The key to success, the presenters emphasized, is payer and provider collaboration. 

They ended their session by sharing a case study of a Michigan-based provider-payer collaborative. Its implementation was made up of seven specific steps presenters outlined for attendees to use with their own collaborative projects: (1) evaluate the current state and infrastructure; (2) identify key issues and areas for improvement; (3) develop a multiyear strategy; (4) begin implementation; (5) monitor and track performance; (6) identify process improvements; and (7) refine the next year’s plan. —Jolynn Tumolo