Payer transition from insurance to services promises longitudinal impact

By Carley Thornell | March 6, 2023


Radical changes are underway in healthcare that will have a monumental impact on medicine for decades to come. Most surprising is that many of those changes are not only being driven by traditional ecosystem players like physicians who deliver  care – but also those who pay  for patient services.

That could be just what the doctor ordered for an ailing system, says Dr. John Farley, chief medical officer for Complete Health. “[The future of sustainable care hinges on] getting away from transactional care into what I call managing your patient population,” Farley told attendees at athenahealth’s recent second annual Payer Symposium. A key part of managing that patient population, said Farley and his fellow physician panelists? Continued  collaboration with payers for data exchange, and technology and workflows that support access to curated, quality information.

For panel moderator and athenahealth chief medical officer Dr. Nele Jessel, context is another pillar of advancing medicine and how it’s delivered. Where and by whom diagnoses are made “makes a big difference,” she said. “Were diagnoses delivered outside of a provider’s office during a hospital visit, where the coder actually put a diagnosis in their chart? Was it diagnosed by a home health agency, or from a lab result? Was it diagnosed by a specialist?,” she said. “The source is very important.”

As the breadth of delivery settings and modalities continue to expand because of or in tandem with valuebased care, it’s more crucial than ever to connect the dots across the ecosystem.

Infrastructure, investment, and scope support new paradigms

The lines will only continue to blur in the transition from fee-for-service, notes the Advisory Board, in a recent industry readout that finds vertical integration in U.S. healthcare ascending rapidly. For instance, UnitedHealthcare and Optum’s growth plans acquiring LHC and Change Healthcare broaden patient service capabilities, while the breadth of Cigna’s investment in Bright HealthCare expands with a share in VillageMD’s Summit Health acquisition. Broadly, commercial payers’ wider footprint of investments in the provider space can tap into the promise of the care delivery profit pool, while also serving the dual purpose of enhancing payers’ roles developing comprehensive care strategies for patients. That’s a positive trend in medicine’s gradual segue from episodic care to longitudinal approaches.

Models like federally qualified healthcare centers (FQHCs) — which are stood up to address not only patients’ physical needs but emotional and behavioral ones, too — have long been able to offer a more complete perspective on what works when it comes to care and access to that care. At Chicago-based FQHC Esperanza Health Centers, for instance, the volume of demand for mental health delivery services can be met by offering patients what they need, when and where they need it. For a population often challenged by stigma and transportation issues, that’s via telehealth. Insurers compensating for virtual care services has added a whole new, positive dimension to the U.S. healthcare system.

So what’s next? There are other lessons to be learned from addressing the social determinants of health, like the impact of nutrition and shelter, or even the influence of faith and friends in patient engagement. Payers’ ongoing recognition of the patient as a whole person — along with the capital, infrastructure and scope to support such models — shifts healthcare from a smattering of largely regional tactics to broader strategies with promise.  In a world that has long recognized the opportunities of genomics when it comes to prescribing, that’s a fundamental shift in a direction that considers the factors besides physical ones contributing to overall health.

To meet those needs, payers are continuing to innovate. Elevance’s collaboration with Harvard University for an organization-wide health equity initiative recently earned three-year accreditation from NCQA. And at the end of 2022, Blue Cross Blue Shield of Massachusetts announced the state’s first value-based contracts tied to equity. Where that state — long a national leader in healthcare reform — and other geographies like California are going, the rest of the country is more likely than not to follow.

Better documentation yields results for patients and providers

In a system that’s struggled with incredible challenges in the past few years, sustainability is more important than ever, notes Farley. For him and the other 100 physicians at his Florida-based primary care group, that comes via a focus on risk.

Documenting risk has multiple purposes – clinical, operational, and financial – Jessel shared. “RAF is about capturing the entire holistic illness of the patient, the severity. Because if the patient is very ill, they consume a lot of resources – but it’s also important for us to ensure they get appropriate services,” she said. “The RAF rate can really be used as an educational factor.” It’s long been an ideal that robust data is just as important as the stethoscope in a doctor’s toolkit. But it’s a view founded in fact, recent data show.

Through an integration with payers, athenahealth ingested nearly 2 million diagnosis gaps and care gaps from March through September 2022. Nearly 80% of those gaps would not have been presented to providers for pre-chart preparation or in the exam room without such integration.  That’s especially crucial given the recent release of metrics surrounding Stars and HEDIS, which showed a steep decline in ratings across most of the country.

Data is only one part of the puzzle

Perhaps one of the most notable recent Medicare Advantage scoring amendments is the move by CMS to put more weight on the patient’s impression of their experience. Reconfiguring the equation between clinical efficacy and members’ opinions (via the Consumer Assessment of Healthcare Providers and Systems survey) puts more onus than ever on the importance of patient engagement. That’s a challenge – and an opportunity – in establishing a new future for medicine, noted Ryan Buell, a Harvard Business School professor and symposium presenter. 

“Problem identification is a solo sport. Problem solving is a team sport,” Buell said.

Few can deny the promise and importance of advances in data analytics to identify potential health problems and address them at the point of care. But in a system that’s long focused on patient consumerism, widening the scope of who addresses those health challenges and how is paramount. Payers are in a unique position to move the needle when it comes to engagement beyond the traditional providerto-patient expectation, and some have risen to the task. 

Leading Medicare Advantage plans are increasing investment in digital communication and virtual health capabilities for members, including Elevance’s digital-first strategy. Humana’s center for digital health and analytics is intended to create personalized, “whole person” health experiences. One Humana model has members paired with virtual access care navigators to address unique needs. And Alignment Healthcare’s virtual-first health plan includes a technology monetary supplement; coaching to help Medicare Advantage members schedule their initial appointments; and a dedicated primary care provider for a sense of ongoing connection. 

What’s notable about all of these? Beyond the traditional “If you build it, they will come” philosophy, payers are doing more than simply giving patients tools. They’re recognizing that technology holds the promise to connect the dots between processes and the people those tools are intended to serve.

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