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How Payers Could Assist Primary Care Docs with Value-Based Care

By sharing timely data, healthcare payers could help primary care practices succeed in value-based care.

Value-Based Care

Source: Thinkstock

By Vera Gruessner

- How can health insurance companies improve their relationship with primary care practices? How can payers work with primary care providers to expand value-based care reimbursement? 

For answers to these questions, spoke with Sabra Matovsky, MBA, Executive Vice President at Integrated Health Partners of Southern California, and Vernita Todd, MBA, Senior Vice President of External Affairs at Health Center Partners of Southern California. Matovsky began by explaining some of the issues that primary care practices experience with their health plans.

“One of the things I hear from the primary care providers is that there are oftentimes competing or discrepant pay for performance programs between the health plans and they may use different codes to track a visit,” Matovsky said. “They may use different standards in terms of performance and achieving different metrics. The more complicated those programs are and the discrepant they are from health plan to health plan, it makes the whole system less effective because it is a lot of variables to juggle.”

“The other complaint that we hear pretty frequently is the importance of feedback in terms of performance,” Matovsky continued. “More frequent information could be coming back to the primary care provider about missed services, gaps in care, and how they are performing. Getting one or two reports a year on how a provider is performing doesn’t give them a lot of time or information to improve.”

Health insurance companies looking to improve their working relationship with primary care providers should increase the feedback they provide in order to garner greater quality improvement. This is especially true in a value-based care reimbursement environment, which relies on quality metrics.

READ MORE: Value-based Payment Models Pose Challenge to Physicians

“When we’re talking about the timeliness or frequency of data, if we’re sharing information about a patient’s use of the emergency room or utilizing additional services, by the time that information comes from the insurer back to the health center, it could be three months,” Todd said. 

“It’s very difficult for a primary care provider to do the necessary outreach to patients to suggest a follow-up or to find out what the actual issue was. They may be able to explain to the patient that this was an issue you could have seen your primary care provider for. We would have been able to handle these things at a lower cost.”

A delay of several months for patient data to be transmitted to primary care practices could be leading to higher spending for both payers and providers. Within those months, the patients may end up back in the more costly emergency room instead of seeing a primary care doctor for a non-acute issue.

“The delay in that feedback is costing the system because in those three months the patient could go back to the emergency room or access other innapropriate healthcare areas without using the resources of the primary care provider,” Todd continued. “It’s integral that this level of communication is improved especially with as much technology as all these practices are using.”

When healthcare payers are working with providers through a value-based care reimbursement contract, sharing data in a timely manner will be integral for improving quality care and patient health outcomes. Matovsky went on to explain some of the ways that primary care practices are working with payers to transition to value-based care reimbursement.

READ MORE: Primary Care Payment Reform Targeted in Multi-Payer Initiative

“Health centers have been encouraged at the federal level to form health center control networks look at their data, share best practices, and implement operational reform to help them better achieve the Triple Aim,” added Matovsky. “There’s been a considerable body of work underway with health centers for a number of years. Those in San Diego have taken the additional steps beyond forming networks that share best practices to really look at integrating from a multiple health center environment to operating as a single entity.”

“A lot of the aggregation and consolidation has to do with data - being able to get clean data and that we have a good understanding of the services we provide to move the needle through our efforts in terms of improving quality and the patient experience,” she commented. “One of the things we’re doing in terms of data is making sure that the services we provide at the primary care level are completely and accurately transmitted and accepted by health insurance companies. We started to really dig into the data component and issues with data.”

Matovsky explained how her organization works to stop any inaccurate reporting and mistakes from being sent to health plans after a patient visit. The organization supports primary care providers in ensuring that only clean and accurate data is sent to health plans.

“One of the things that’s a challenge in changing things up and doing things differently is that you get used to getting paid in a particular way. There may be a gap than what you’re used to in terms of reimbursement before payment under the new model kicks in,” Matovsky continued. “That’s a real potential issue for primary care providers. If you’ve gotten used to a monthly payment and now you’re going to get paid under an APM model that pays you every six months or pays for outcomes at the end of the year, you need to be prepared to weather that on a financial level.”

Matovsky went on to explain some solutions that healthcare payers should incorporate to ensure their provider networks succeed in a value-based care reimbursement model.

READ MORE: Humana’s Value-Based Care Platform Decreased Costs by 20%

“Number one would be meaningful dialogue and timely feedback on how practices are performing and how partners in contractual relationship are operating,” Matovsky offered her first piece of advice. “Sometimes there are meetings that payers have and they invite all of their providers into one meeting twice a year. However, an ongoing dialogue about programs and opportunities that may be specific to certain subsets of the network that a health payer may have would be more productive than a twice-a-year meeting structure.”

“I would encourage a partnership-level of communication as opposed to bringing providers together a couple of times a year,” she concluded. “It would also help if health plans provide timely feedback of data and performance regarding how the primary care practices are performing and what’s going on with the patient outside of the primary care environment. The more information that the primary care doctors can get about situations affecting their patients, the more likely the physicians could impact change.”


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