Creating a Relationship between Provider and Payer Built on Trust

It is a well-established fact that the provider-payer relationship has not always been a collaborative one. In fact, most physicians would think a collaborative relationship with a payer is a proverbial “red herring.” At CHESS Health Solutions we have a nearly decade long history of championing collaborative relationships with the payers.

From the beginning, CHESS Health Solutions set out to enable providers and health systems in their journey from fee-for-service to fee-for-value. This is not a path for the faint of heart and can be fraught with danger and frustration. It requires a new set of contracting skills in order to anticipate the implications on the provider and patients in the clinical setting as well as potential financial risks and benefits. Value-based agreements must primarily be sustainable, or providers will not step out and begin the transition.

CHESS has worked on behalf of its Value Partners to help payers understand these concerns and to see that a sustainable contract that is good for the provider is good for the payer and, most important, the patient. CHESS and its Value Partners have delivered high quality low cost care that demonstrates the strength of the CHESS-Value Partner relationship. But these outcomes also highlight what happens when the payer aligns financial terms with the necessary clinical processes to drive success.

Conversations About Patient Care are Changing Because of Value-based Care

Value based care, by design, is about transforming the way care is delivered. The value-based contracts provide the financial fuel to impact patients’ lives in a meaningful way when the patient is not in front of the provider for that 15 minute appointment four times a year. Care coordination teams assist patients through the treacherous journey from an inpatient setting to their home. These trained skilled nurses and CMAs identify and address social determinants of health issues during this transition.

Many times, readmissions are avoidable by addressing these non-healthcare related issues. A team of pharmacists and pharmacy techs is available to identify drug therapy problems and medication management issues. They identify when a patient has difficulty accessing prescribed medications and ensure to the degree possible that the patient is adhering to the therapeutic regimens prescribed by their provider.

Quality has always been part of the value based care equation. Initially, quality focused on processes. Today, quality measures are moving from simple process measures to outcomes measures. These measures, when properly defined, can truly drive improved care and quality of life for the patient. There is little doubt a Hgb A1c under control is more meaningful that simply making sure the test was ordered.

Patient Experience Driving Success

These “wrap around” services are valuable to the patients who receive them and to their providers. Providers rarely have time to explore the issues to the depth necessary to offer solutions. As patients become more aware of this team approach to their care, they come to rely on and reach out to the care coordination and pharmacy teams. This increases patient engagement, which can lead to improved adherence to recommended screenings and treatment regimens.

During the early days of the COVID-19 crisis, our complex multi-chronic patients were isolated from their healthcare providers. They had difficulty accessing them in person and via technology. The care coordination teams at CHESS quickly pivoted their routine work to serve this already vulnerable population, who now found themselves cut off from their usual means of receiving care. Using data, a “COVID Risk Score” was devised to identify our most at risk patients so they could be contacted first. Patients were offered COVID risk and symptom education, they were screened for SDoH needs, and connected to their primary care provider for a virtual visit or annual wellness visit.

Patient Loyalty Contribution to Value-based Care

Assignment of patients to a particular provider is a critical component of success in value-based care. There are several methodologies for assignment, or attribution, which are beyond the scope of this discussion. One method is patient choice. The patient can select their provider. The driving force behind a patient’s choice of a physician within a health plan is their existing relationship with or at least knowledge of a particular provider. Once assigned, patient retention becomes a major concern for providers in value based agreements.

Value-based care supports patient retention through many of the same mechanisms described earlier. Patients know their provider cares for them when a member of the provider’s team is reaching out to check on them, making sure they have meds, and in some cases, food and shelter. Through these value- based care services, health care becomes more holistic. Patients grow loyal to a system that meets them at their point of need with meaningful solutions.

Touch Points for Both Payer and Provider Lead to More Collaboration

As value-based services are being delivered, a 360-degree view of the patient is established. This is achieved through CHESS’s ability to merge clinical data with payer claims data, something the payers are not typically able to accomplish. This is important because it allows for the most accurate assessment of the patient’s status in applicable quality measures. Through data sharing agreements CHESS is able to provide documentation to the payer regarding quality data. Using ADT feeds from hospitals and other sources, CHESS is able to identify patients in real time as they move through different care settings. More important, this sets the stage for predictive analytics, which allows for intervention prior to an event as opposed to the traditional way of reacting to events once they have occurred.

CHESS understands all the components of a value based agreement. Over the last eight years, CHESS has streamlined processes in quality across contracts. CHESS understands how to interpret different financial targets and their short and long-term sustainability. This provides the opportunity to show the payer how best to align with a health system through well negotiated contracts that create sustainability. Once negotiated, the CHESS Operations team are experts at taking the terms of the agreement and making the necessary adjustments to succeed within the terms of the agreement.

About the Author

Yates Lennon, MD, MMM

Interim President and Chief Transformation Officer