Role reversal: Providers, payers address partnerships during SIM Multi-Stakeholder Symposium

By Heather Grimshaw

When it comes to the sustainability of efforts to integrate behavioral and physical health, most conversations turn to reimbursement. Health plans (payers) and providers frequently have different perspectives on what support for these efforts looks like, which is why the second SIM Multi-Stakeholder Symposium included a role-play exercise so payer participants assumed provider roles and providers assumed payer roles.

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The second Colorado State Innovation Model (SIM) Multi-Stakeholder Symposium (MSS) May 18 drew about 50 representatives from SIM providers, health plans and practice transformation organizations, who discussed ways to build more effective partnerships. The twist: Attendees assumed different roles — payers played providers (and vice versa) during scenarios—to help them gain perspectives on the unique challenges their colleagues face. 

“This exercise made me appreciate initiatives like SIM that give us the opportunity to be at the same table and get on the same page of what’s going on in each individual realm,” said a cohort-1 practice representative. “At the core of good healthcare is relationships.”

Strengthening relationships between payers and providers is a key component to SIM, an initiative funded by the Centers for Medicare & Medicaid Services to help providers integrate behavioral and physical health and test alternative payment models (APMs).

Ninety-two SIM cohort-1 practices have completed the first of two years in the program, and about 150 cohort-2 practices will join them in September.

“One of our key roles is to strengthen relationships between payers and providers,” explains Barbara Martin, RN, MSN, ACNP-BC, MPH, SIM director. “We realize the value of sitting at the same table and talking through some of the issues that have created a wedge between payers and providers in the past.”

MSS attendees sat at tables of eight and addressed scenarios that were customized for SIM providers — from small practices to large health systems — as well as regional and national payers.

After the role-play, one attendee noted an ongoing frustration between providers and payers: “I’m talking business, you are talking health and that doesn’t always line up. Good business does not always equate to good health.”

Partners in health
Recognizing that providers and payers frequently see themselves on opposite sides of this issue, the SIM team is investing in data tools that help providers identify, mitigate and use cost and utilization data and clinical and claims data to influence operations and, ultimately, negotiate value-based contracts that reward value vs. volume.

Using data to identify at-risk patients with comorbid diseases that span physical and behavioral health improves health outcomes and reduces unnecessary or avoidable costs, Martin explains.

“Helping providers recognize the value of using data more effectively will help them transform healthcare in meaningful, sustainable ways” that benefits patients, care teams, employers and payers, she adds.

SIM team members shared some of the data collected through the initiative that shows practice progress along the integration continuum, which has six levels. SIM shared annual clinical quality measures with payers to illustrate practice work to deliver whole-person care, which improves health outcomes and reduces costs.

That type of data sharing will pave the way for different conversations between payers and providers, said some of the payer representatives, who attended the MSS. “We are starting to believe that what you say you’re doing you’re doing. It’s not just about the bottom line it’s about being partners.”

That sentiment was echoed by one of the SIM cohort-1 providers who participated on a panel later in the day. “I always call them ‘payer-partners’ because we get a lot of our data from our payers. For utilization, we do look to our payers to help us understand where we are, where we should be putting efforts and it’s a very important part of our relationship.