Payers and providers are going to have to align incentives and share relevant data to improve both quality and...
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cost of care, said speakers at the 10th Annual World Health Care Congress in National Harbor, Md.
In a session titled, Collaborative Care Models -- Programs Designed to Achieve the Triple Aim, four payer executives discussed best practices for payers and providers on collaborating to improve the patient experience, as well as how to improve population health and reduce the per-capita cost of health care.
We're not in the business of curing people; we're in the business of putting an overlay on the provider's business to improve care.
CEO, Universal American Corp.
Richard Barasch, CEO of Universal American Corp., said payers and providers must share both risk and opportunity from "the first dollar down to the last dollar." He said aligning payer, provider and patient incentives can be key to improving care quality, while at the same time can cut unnecessary spending.
Universal American provides capital, systems and compliance expertise to provider groups, who then channel it into quality of care improvement projects and efforts to lower costs.
"This puts us directly in partnership with primary care physicians," Barasch said. "We're not in the business of curing people; we're in the business of putting an overlay on the provider's business to improve care."
Universal American obtains patient population data from the CMS and interprets it to determine gaps in care where providers can focus their efforts, Barasch said. This forces more traffic in the primary setting, as doctors streamline their practices to prevent, rather than treat, patient illness. At some of Universal American's provider facilities, doctors have added their own weekend and night hours to be able to treat certain patient issues before they turn into emergencies.
"All of these services are on our dime, but we're convinced it is much, much better for both member and capita costs to get people into facilities first and then close the gaps," Barasch said. "We help physicians look at referral patterns; we get the data in a form that they will be able to act on."
Provider groups shouldn't underestimate the role individual physicians can play in reducing overall costs, either, said Debbie Zimmerman, chief medical officer at Austin-based Lumeris, which provides technology supporting accountable care organization (ACO) rollouts. She added a fourth element to the triple aim: physician satisfaction.
"The closer you are to the delivery of care, the more effective you are," Zimmerman said, calling hospitals the "lowest hanging fruit" for cutting costs in the accountable care model.
For its part, Lumeris discovered two areas of mutual interest between most provider groups and physicians: reducing readmissions and improving care transitions. Like Universal American, Lumeris works to align individual incentives with group incentives, often via internal compensation. At one ACO, readmission rates dropped 18% and follow-up after high-risk discharge increased by 16% at one ACO when it implemented such a physician incentive program.
Zimmerman advocated making particular clinical details transparent for physicians, specifically medication costs. Doctors can then offer patients more accuracy and insight into the true value of their care.
More collaboration will be needed, the panelists agreed. Payers and providers won't have to own each other, but it's becoming increasingly clear they will have to work together to reduce costs of care because of the separate-but-valuable clinical data streams they control.
"Hospitals are slowly getting together and becoming single-specialty or multi-specialty systems," said Paul Kaplan, senior vice president for provider strategy and integration at Pittsburgh, Penn.-based Highmark Inc. "But we also have vertical integration where payers acquire delivery systems [or] hospitals start to sell insurance. The medical world is in chaos, and quite frankly it's expensive."