Care redesign can’t happen in a vacuum. Although care delivery enhancements are most visible at the frontlines of patient care, ensuring that payers and providers are aligned is critical to support sustainable and financially viable improvements.

Under the Advancing Integrated Models (AIM) initiative, made possible by the Robert Wood Johnson Foundation, the Center for Health Care Strategies (CHCS) supported eight health care provider organizations in piloting more person-centered approaches to care for people with complex health and social needs. Care transformation projects ranged from the Pediatric Practice of the Future at the Center for the Urban Child and Healthy Family at Boston Medical Center (BMC) where families helped reimagine the pediatric care model, to efforts by Maimonides Medical Center to create a single point of entry for patients to access disparate complex care management programs. While the pilots varied widely, one common thread across programs was a strong provider-payer partnership to support the design and implementation of more effective care models.

Under AIM, each participating health care provider organization partnered with a health care payer – a health plan associated with the provider health system or organization, a local Medicaid managed care organization (MCO), or state Medicaid agency – to improve care for people with complex health and social needs. Some of these provider-payer partnerships were new, and some provider sites focused on deepening existing relationships with payer partners. These collaborations highlighted the importance of provider-payer partnerships in supporting complex care models, and lent insight into what it takes to build these partnerships. This blog post offers four considerations to guide health care providers and payers in developing strong partnerships to support more effective care models for people with complex needs.

Tips for Building Strong Provider-Payer Partnerships

“Thinking about how to speak a common language [between payers and providers] regarding cost, utilization, and quality is very important.”

Carey Howard, formerly with Boston Medical Center’s Center for the Urban Child and Healthy Family
  1. Learn to speak your partner’s language. In any successful relationship, effective communication is key. The most successful partnerships under AIM understood the need to clarify the language they were using and have similar definitions for terms like “complex,” “high-risk,” or “high-utilization.” When Denver Health and its payer partner, the Colorado Department of Health Care Policy and Financing (Colorado Medicaid), began working together on a care continuum for high-risk patients, they realized they were not defining high-risk populations in the same way. Denver Health clinicians identified high-risk as patients receiving primary care who have multiple chronic physical and behavioral health conditions where appropriate intervention may prevent more serious medical issues in the long term. Colorado Medicaid defined high-risk based on cost. To align their efforts, Denver Health and Colorado Medicaid worked to establish the same definition of “high-risk” so that care and resources could be coordinated to improve outcomes and reduce costs. The two organizations continue to meet on a regular basis to share learnings about identification of patients with health-related social needs that may inform further refinements of high-risk definitions.
  2. Identify and align around shared goals. Under AIM, we observed that the strength of a payer-provider relationship often depended on alignment of each organization’s priorities. Stephen and Sandra Sheller 11th Street Family Health Services in Philadelphia, and their payer partner Keystone First, a local Medicaid managed care plan, worked to identify mutual goals to pilot a more integrated and equitable person-centered care model. They agreed on a prioritized patient population (people with hypertension) and discussed how each would define success, including achieving more equitable, anti-racist care and reducing health disparities and costs. 
  3. Align time frame used to assess success across providers and payers. The timelines plans may focus on for achieving financial outcomes are often too short to reflect the positive changes in people’s health that can result from care model redesign. Since improvements in health and well-being for people with complex needs can take years to play out, payers and providers may need to acknowledge that while financial savings often have a longer time horizon, there are opportunities to identify nearer-term outcomes that indicate whether care models are having their desired effects. They also may need to co-create short-term, as well as longer term, measures of success, so that promising approaches are not abandoned before their true impact on patients’ health and cost reductions can be measured. We heard repeatedly throughout the initiative of the importance of aligning around a time frame to assess success of an initiative and using a combination of short-and long-term metrics. 
  4. Create a unified data strategy to effectively measure impact. Data sharing and analytics support are key to measuring the impact of a redesigned care model and making the case for an alternative payment approach. Most AIM sites and their payer partners implemented care models focused on addressing physical and behavioral health needs, meeting health-related social needs (HRSN), and/or providing trauma-informed care ─ care that traditionally is not tracked in common measure sets such as HEDIS or other quality metrics. Provider-payer discussions made it clear that meaningful quality metrics needed to be created or adopted to identify impacts and thus support financial sustainability beyond the pilot stage.

Maimonides Medical Center and their payer partner, Healthfirst, created new data sets to measure equity and patient access to care management services. At BMC’s Center for the Urban Child and Healthy Family, the care team created metrics that aligned with the goals of their family-centered human-centered designed care model ─ measures of children’s social-emotional health, school-readiness, and other indications of health and wellness ─ and worked with BMC HealthNet to understand how or if they could track those measures. In some cases, payer-provider partners identified that it would have been helpful to work together earlier in the project to develop a coordinated data strategy to measure the impact of their work.

Looking Ahead

The AIM initiative underscored the importance of ongoing collaboration between health care providers and payers in sustaining complex care models that can significantly improve the health and well-being of patients. While there are arguably many factors that facilitate relationship development, AIM highlighted the importance of providers and payers aligning on what success looks like, to ensure that they are always working toward the same goals, as well as a shared time frame for measuring success. Aligning around key terms, definitions, and program goals is also essential. Thinking beyond traditional metrics to measure the true impact of a program is warranted. As an AIM team member at OneCare Vermont stated, “Continue to revisit the why and value of this work, and make sure all sides are aligned in the purpose of the work so you can all work towards one goal.”

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