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Engaging Payers

Partnership in Value-Based Care: Becoming and Finding Good Teammates

Authored by

Lili Brillstein, MPH—Column Editor

Affiliation

BCollaborative, Pine Brook, NJ

Disclosures

Ms Brillstein is the founder and CEO of BCollaborative, working with stakeholders across the health care continuum to make the move to value-based care. She was formerly the Director of the Episodes of Care program for Horizon BCBS of New Jersey.

Citation

J Clin Pathways. 2020;6(5):42-45. doi:10.25270/jcp.2020.5.00004

Value-based care is a whole-person philosophy that relies on the diverse expertise of various stakeholders and the ability of each and all to effectively collaborate to deliver the most effective and comprehensive care. It is about trust and respect—two concepts which have historically been lacking in engagements between various health care stakeholders working within a fee-for-service (FFS) construct. To effectively and consistently optimize care, particularly given resource limitations, we must figure out how to create strong integrated delivery teams with individuals who respectfully interact and coordinate to deliver the best outcomes and experiences for all of us.   


These are incredibly stressful times around the world. At the time of this writing (April 22, 2020), the global COVID-19 pandemic appears to be peaking, at least in the northeastern United States. While far from over, the experience of the pandemic has already taught us how truly interdependent we are for our individual and collective good health. Shared goals (avoiding infection), adhering to protocols (remaining at home), being respectful of others’ space (physical distancing), and communicating (potential dangers, downstream effects, research, potential new therapies) are all required if we are to flatten the curve, protect ourselves and others from becoming ill, and keep our health care system functioning. Being a good partner—one who is trustworthy and can be counted on to do their part and collaborate with others—is at the foundation for resolving this public health crisis. 

These are the very same principles that are at the heart of value-based health care. Unlike the existing FFS model, which views health care as disjointed units of care rendered to the same individual without any connection to whether the individual’s health improves, value-based care is all about communicating, coordinating, and collaborating around individuals’ care to ensure that everything that occurs related to one’s diagnosis or health care event is designed to achieve the best outcome. It is a whole-person philosophy that relies on the diverse expertise of various stakeholders and the ability of each and all to effectively collaborate to deliver the most effective and comprehensive care.  

It is about trust and respect—two concepts which have historically been lacking in engagements between various health care stakeholders working within a FFS construct. Rather than see themselves as partners in the delivery of care, the negotiating table is often the only time these stakeholders come together. They meet to fight over unit costs, often without much knowledge about how those units of care and attendant costs actually affect the individuals they are intended to help. With a primary focus on completing negotiations and maximizing their fees and then getting back to business, stakeholders often operate from a place of distrust and distaste. 

Just as behavior based solely on self-interest does not help resolve the current pandemic, this focus on increments of care delivered by one particular provider does not ensure the best outcomes for individuals who require health care. We are dependent upon one another. Patients are dependent upon a cadre of providers who are themselves reliant upon their colleagues to ensure that positive outcomes result from all of the care provided. Doing so requires that providers consider all of the care required for a particular patient and not just the singular portion that that one provider or caregiver may deliver. And let us remember that we all are or become patients at some point. 

To effectively and consistently optimize care, particularly given resource limitations, we must figure out how to create strong integrated delivery teams with individuals who respectfully interact and coordinate to deliver the best outcomes and experiences for all of us, while thoughtfully managing our collective resources.  

Health Care is a Team Sport 

For any team to succeed, individual members must focus on team success rather than on their individual achievements, and their commitment to shared goals must be strong.   

Each team member must commit to leveraging their unique skills and abilities in support of the team’s goals. Just as a pitcher, catcher, first baseman, and outfielder all have different positions in baseball, each must perform at a high level for the team to win. So, while each has a different role to play, all are working toward the same goal, and each commit to strengthening their respective contributions, knowing that that will strengthen the team’s ability as a whole. Winning is not about showcasing any individual player—the pitcher’s dynamic curveball or the strength of the catcher’s arm—just as it is not about highlighting the weakness of any particular player. Teams win when each player improves their skills and adds them to the team’s collective effort. Also, at times, players must make individual sacrifices to support the goals of the team. 

Consider this example. Patients’ diagnoses often come with multiple comorbidities or chronic conditions, many of which have a significant impact on a patient’s ability to achieve good health. In the FFS environment, the care rendered by multiple specialists to the same patient is often completely disconnected, with one not aware of the care provided by others or impact of their respective care plans on the patient’s overall condition and health. For example, in patients with rheumatoid arthritis, cardiovascular disease is the major predictor of poor prognosis.1,2 Would it not be useful, then, to have a care model that has rheumatologists actively partnering with cardiologists to treat these individuals?

Success depends upon regular, ongoing, clear, and truthful communication among the various stakeholders as well as the ability of each partner to respectfully consider the perspective of each other.  

Trustability, Transparency, Teamwork 

The spirit that one brings to the partnership is critical to the success of the engagement. Begin by understanding that no single stakeholder has all of the answers or all of the power, and no one needs to.  

Trust and respect are essential. This can be daunting in light of the considerable historic suspicion and distrust among those who must now come together as partners. Each stakeholder must work to dismantle this environment of distrust by first believing and acknowledging that each stakeholder adds value to the effort and that their collective efforts will have greater success than what might be achieved by any one partner.  

True teamwork requires the courage to step out of complacency. It requires allowing yourself the vulnerability to say that you do not know everything, you do not have all the answers, and a belief that that is ok. It is precisely what the team needs. Understanding your particular value—when to express it and when to listen—are essential to the team’s success.  

To be a good partner, one must be able to be trusted, transparent, and able to participate as a member of the team in a way that serves the goals of the team.  

Trustability—the ability to be relied upon to do the right thing. It is a higher form of trustworthiness, as discussed by Don Peppers and Martha Rogers, PhD, in Extreme Trust.3 Trustability is about affirmatively and proactively protecting your partners and customers. It means doing what is right because it is right and committing resources that might cost more in the short term but which will provide better experiences and deliver better outcomes in the long term. It is about respectability, and it is key to being an attractive and effective partner.  

Transparency—being open, honest, and willing to share. Transparency is characterized by a willingness to share information that allows other partners to understand the comprehensive picture of the patient and their journey. The ability to capture and mine data and use it to be able to course-correct in real time is critical to the success of these models. Sharing this data, as well as the varied experiences and perspectives of all partners, brings a much wider view of the care required than any one view alone. Sharing is required of every partner.

Teamwork—it does make the dream work. Be open to playing the role that will provide the greatest support for the team. Articulate your perspective. Listen to others’ perspectives. Consider the end goals. Have the courage to share your perspectives and abilities yet the maturity to stand down when your view or skill set does not serve the greater good of the group. Be willing to make sacrifices to achieve the agreed-upon group goals. Each partner must be an active and engaged member of the team. Each must be willing to welcome others in to broaden the perspective and opportunity for success.

Stakeholders across the continuum are trying to figure out the best way to “team up” with others as the move toward value-based care continues. Again, it is a difficult concept for many, as these prospective partners have, for decades, been suspect of one another and have perceived and interacted with one another as adversaries. Big groups, integrated delivery systems, hospitals and pharmaceutical companies, along with small independent practices and myriad vendors who have created tools to improve various aspects of health care are all working to understand how they can be and find effective partners. They want to build models that will deliver the best care to patients while rewarding partners for those outcomes and their effective use of seriously limited resources. They are looking to engage in this team-based care. 

How to Get a Spot on the Team

The question is, how do you get on the team? Show initiative. Reach out to payers and other prospective partners to understand their perspectives and pain points and to understand where you can add most value. Express your value clearly, succinctly, and directly. Be truthful about what you can and cannot deliver. Look for those with a similar mind set. Articulate the value you bring to the team. 

Not all partners will be able to implement your great idea, so try not to be defensive. Understand that while you need to build something that is clinically meaningful and economically resourceful, it must be able to practically be administered. Payers, who are often seen as the team captains because they administer most of the payments, may be very eager to engage in a value-based care model, but their systems, which sit on an FFS chassis, may not be ready.  (Note, the view of payers as captains of payment administration does change in models where risk has been shifted to providers or other stakeholders, but when that happens, those stakeholders will be looking for the same qualities in partners, ie, a focus on delivering the best outcomes at the lowest cost). It will be up to the partners to figure out how to begin to create models that can achieve the agreed upon-goals in a way that can actually be administered by the partners.  

The Strengths of Different Players

Payers have a plethora of stakeholders deluging them with ideas to solve all their problems every day. It can be very difficult to discern what some are seeking, providing, or offering. It is critically important to be thoughtful of your audience—their perspective and their time. Deliver your message in as clear a manner as possible and in a way that speaks to the issues your prospective partner has identified.  

Payers have the claims data that can provide the longitudinal view of the patient. Such data complements data from providers, which is limited to only the care delivered by that one provider/practice. Payers have analytics teams that can help work with providers and others to understand that comprehensive data and the variations in care and costs of care that appear to be driving inconsistent and suboptimal outcomes.  

Providers bring strong clinical knowledge of the patient experience. Their care teams usually have a good understanding of the social factors affecting their patients’ ability to achieve good health. This information is critical in bringing the payer data to life and in determining the most effective interventions to resolve the variations identified in the payer data. 

Pharmaceutical manufacturers have vast multipayer data sets that can help provide accurate baselines and benchmarks in specific markets, regions, or across the country. They also typically have extensive information regarding the patient journey and the challenges patients face in adhering to drug and other care protocols—information which can be critical in developing models to support patients’ successful treatment and care. Pharma companies also have extensive clinical knowledge within the specific therapeutic areas in which they operate, which can be very useful when designing specialty care value-based models.  

Rehabilitation therapists and other kinds of ancillary clinical providers offer yet another perspective on challenges facing patients which impact their ability to successfully get to a healthy outcome. They often have more time than other care partners with their individual patients, giving them unique insight into some of the social factors (ie, housing, food, childcare, transportation), which can so dramatically affect one’s health status and care access. Factoring these into value-based model design will improve the team’s ability to succeed.  

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Behavioral health providers also add great value in considering and treating the individual for their overall health. Individuals with chronic conditions have higher rates of substance use disorders and behavioral health issues. In addition, those with behavioral health disorders are more likely to have other chronic medical conditions like asthma, diabetes, heart disease, high blood pressure and stroke—all of which result in higher use of services and higher costs, including unplanned trips to the emergency department.4 Patients with untreated depression and a chronic illness have monthly health care costs that average $560 higher than those with just a chronic disease, according to the American Hospital Association.4 Integrating physical and behavioral health care is associated with improved outcomes and lower overall costs.5 

Innovative Tools and Nontraditional Partners

Vendors have developed tools to create value, eg, care management tools, novel technology, and data platforms, and the value each brings needs to be expressed in terms of how it impacts the patient’s outcome. In some cases, you may be providing a solution to a problem that the payers or others have yet to identify as a problem. It is absolutely critical to contextualize the issue to ensure that your prospective partners understand why it is an important area of focus, the impact to the team’s goals, and how you propose it be addressed.  

The extent to which these tools can be deployed with a light lift to the payer and other stakeholders will help determine the ability of the group to incorporate them into its model. Be clear and thoughtful about what you are asking of the group, and focus on your contribution and impact to the team goals.  

Nontraditional partners, ie, those who have not traditionally been covered under managed care benefit plans (eg, doulas, transportation, yoga), may play a big role in value-based care models. In a FFS environment, where focus is on process increments, they are often viewed as incremental costs with no medical basis and so are not covered. In a value-based model, where the collective goal is on outcomes, there is new opportunity to reconsider what actually impacts health. The key is to express the value to patient outcomes. Those who are able to demonstrate—or are willing to partner to test—their hypotheses that these nonmedical interventions have a significant impact on patients’ abilities to achieve greater health will find many opportunities within value-based care models.  

Conclusion

No matter what role one plays in the health care continuum—whether you are a payer, provider, or pharmaceutical company; a vendor with a new program or tool to support improved value; or whether you provide services that are traditionally or nontraditionally covered benefits—the focus must be on the greater goal of improving patient outcomes and experiences at the lowest overall cost (ie, the costs of care for all partners rendering service to the patient), and not on getting individual costs covered or approved. Ultimately, one’s support and payment will be based upon the overall success of the team. 

References

1. Sarmiento-Monroy JC, Amaya-Amaya J, Espinosa-Serna JS, Herrera-Díaz C, Anaya JM, Rojas-Villarraga A. Cardiovascular disease in rheumatoid arthritis: a systemic literature review in Latin America. Arthritis. 2012;2012:371909. doi:10.1155/2012/371909

2. Jagpal A, Navarro-Millán. Cardiovascular co-morbidity in patients with rheumatoid arthritis: a narrative review of risk factors, cardiovascular risk assessment and treatment. BMC Rheumatol. 2018;2(10). doi:10.1186/s41927-018-0014-y

3. Peppers D, Rogers M. Extreme Trust: Turning Proactive Honesty and Flawless Execution Into Long-Term Profits. New York, NY: Penguin Random House LLC; 2016.

4. American Hospital Association. Behavioral health integration: treating the whole person.  Published 2019. Accessed April 22, 2020.  https://www.aha.org/system/files/media/file/2019/06/Market_Insights-Behavioral_Health_Report.pdf

5. Floyd P. Integrating physical and behavioral health: a major step toward population health management. Healthcare Financial Management. January 2016. Accessed April 22, 2020. https://www.bdcadvisors.com/wp-content/uploads/2016/01/0116_HFM_Floyd.pdf

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