Patients Win When Payers and Providers Speak the Same Language


Discouraging headlines remind us daily of the ugly battles between payers and providers. Fighting for their slice of the $3.5 trillion health care pie, these companies often seem to leave the consumer out of the equation.  But it is not the case across the board. Our latest research documents that when doctors and health plans drop their guards, align incentives and focus on the mutual goal of delivering the best possible care, patients win.

For example, when SelectHealth in Utah partnered with obstetricians and refused to pay for medically unnecessary — often  dangerous — early inductions of labor, procedure rates dropped from 28% to zero, leading to shorter labors, fewer C-sections and $2.5 million in annual savings for all. When Kaiser Foundation Health Plan execs collaborated with Permanente doctors around opioid safety, prescriptions for the often-deadly drugs dropped 40%. And, when Security Health Plan in Wisconsin enlisted physicians and surgeons to develop a new outpatient surgery and rehab center, health outcomes improved; patient satisfaction jumped to 98%; and they saved $4.7 million in the first two years.

These productive partnerships occur in multiple communities across the nation as illustrated in in “Accelerating Adoption of Evidence-Based Care: Payer-Provider Partnerships,” a new report by the Alliance of Community Health Plans. With funding from the Patient-Centered Outcomes Research Institute (PCORI), the 18-month project uncovered five best practices in effective collaboration for health plans:

  1. Build consensus and commitment to change;
  2. Create a team that includes the necessary skill sets, perspectives and staff roles;
  3. Customize education, tools and access to specialized knowledge that the audience needs;
  4. Share timely and accurate data and feedback in a culture of transparency, accountability and healthy competition; and
  5. Align financial investments with clinical and patient experience goals.

We see these best practices at work in the examples above and also at UPMC Health Plan in Pittsburgh, which introduced a frailty screening tool for surgical patients. Led by a surgeon-champion, the introduction and integration of the simple questionnaire required education and socialization, and a timeline that laid out increasing expectations and financial incentives. After using the tool for more than 200,000 assessments, UPMC leaders have validated its predictive capacity with data; higher scores correspond with higher rates of mortality and readmissions, and longer lengths of stay.

We’ve seen health plans take different approaches to achieve similar success in improving depression screening and behavioral health care. Group Health Cooperative of South Central Wisconsin embedded behavioral health specialists in primary care clinics and trained physicians in screening and orchestrating a “warm handoff” of a patient directly to a behavioral health provider. Usually the patient does not even leave the exam room.

HealthPartners in Minnesota added prompts and reminders in the electronic medical records of three vulnerable populations: post-partum women, adolescents and seniors. Behavioral health screening rates have climbed for all three groups, and new moms are even screened at their baby’s check-ups. About 90% of HealthPartners’ adolescents ages 12-17 have a documented mental health and/or depression screening on file within a year of their well-child visit, compared to a statewide average of 73%.

To develop clinical and operational best practices for treatment of Hepatitis C virus (HCV), Geisinger Health Plan in Pennsylvania assembled a team of pharmacy leaders, health plan medical directors, service line physician leaders, nurses, case managers, data experts and benefits managers. With an evidence-based CarePath, they achieved a cure rate of 97.5% by reducing treatment time from 12 to 8 weeks and allowing physicians to use fewer doses of medication. Geisinger’s chief medical officer John Bulger, MD, explains: “We found a shorter treatment plan provided the same patient outcomes. Allowing us to use fewer doses of a preferred drug reduces costs by 30 percent. That means for every two patients we treat, the third is free.”

These examples and others in the report include replicable, scalable steps that any health plan in a genuine partnership with patients and providers can employ to improve care and outcomes. It is a model that speeds adoption of evidence-based care and reduces costs.

While some payers and providers sit across the bargaining table haggling over payment, nonprofit community health plans are positively influencing the behavior of doctors through collaboration and consensus-building. They are ensuring patients get the latest treatment as soon as possible, and they are leading the way toward a higher-quality health care system for all.

Ceci Connolly is president and CEO of the nonprofit Alliance of Community Health Plans, a national consortium of 34 health organizations, and a former national health correspondent for The Washington Post.

1 reply »

  1. All is well until the first patient without a cure initiates legal action based on the FDA approved use of the treatment cycle. Then who pays up for the resultant legal process? Even with each person’s acknowledged consent for the novel care plan, everyone loses with the public’s loss of trust – institutional codependency at its worst.