Whole person health: A SIM blog (09-30-18)

Redefining health care partnerships together: Payers and providers share successes

By Heather Grimshaw


Power dynamics are important in all types of business. In health care, the power dynamic between health plans (payers) and health care providers has historically been described as imbalanced, which has created tension and frustration. Yet some providers are evening out the playing field with payers using practice data to show how their care teams are improving patient health while avoiding or reducing unnecessary costs.

The shift from a traditional health care environment in which providers are paid for services delivered (volume) to one that rewards value or better health outcomes, has exacerbated historical tensions because success with new payment models requires providers to retool approaches to patient care, invest in new or expand care teams and ensure that data proves their unique value. That takes time and money. There is also confusion over how payers define quality and value and which payment models will sustain the delivery of integrated or whole-person care.

“We keep hearing that health plans want more value and want providers to take on more risks,” said a health care provider, who participated on a panel during the September Multi-Stakeholder Symposium (MSS). “We are trying to work together on how we define value and quality so that we can come up with a common definition for that.”

The key word in that sentence is together.

Closer partnerships
The symposium is hosted by the Colorado State Innovation Model (SIM), a federally funded, Governor’s office initiative, to encourage honest discussions between payers and providers that lead to mutually beneficial partnerships. Discussions center on the ways in which delivering whole-person care in primary care settings achieves better health outcomes and avoids or reduces unnecessary costs, and how this work helps providers succeed with value-based payment models.

"For the first time in my life I get to sit in a room with payers next to me and we can talk about how we work together to get this done," said a SIM provider panelist.

“We are committed to bringing behavioral health services into primary care,” said one SIM provider, who attended the MSS. “About 20-30% of my patients have co-morbid health diseases and having a psychiatric nurse practitioner has enhanced our patients’ lives. Once patients, who have depression, anxiety, post-traumatic stress disorder and other behavioral health issues see a behavioral health provider, she said, “their diabetes numbers go down, they go back to school and to work, and it saves money for the community. Whole-person care delivers real benefits,” she added.

The key is to show those benefits to payers during regular discussions that include practice data that substantiates or proves how provider work influences outcomes.

One provider representative on the panel described a collaborative approach to reviewing data to show how health care reform efforts are paying off.

“We’ll look at data together,” said the provider representative, who gestured to a payer representative to her right. “We have gotten to the point where we trust each other to say, ‘This is not actionable for us right now. Let’s look at the data and agree on something that we can move.’”

There will always be some quality measures that practices cannot meet, due to information technology or population health issues, she said and added, “I’ve told her, ‘I can’t do this one. Let’s find something we can do.’”

Successfully integrating care and sustaining that investment in primary care practice sites of all sizes requires new approaches to care team staffing and communication, education, processes and the ability to collect, report and use trustworthy data.

“Data, data, data—it’s what we all want and it’s so hard to get,” said a payer panelist. A colleague agreed. “Data is powerful,” she added. “It helps us both be transparent and work together to solve problems.”

Again, the key word is together.