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Engaging Payers

Health Care Delivery Needs an Attitude Adjustment

Authored by

Lili Brillstein, MPH—Column Editor

Affiliation

BCollaborative, Maplewood, 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. 2021;7(2):32-33. doi:10.25270/jcp.2021.03.00004

New reimbursement models, along with the rise of accountable care, episodes of care/bundled payments, and vertical integration require the need for increased collaboration between payers and providers. While the payer-provider relationship is a historically adversarial one, these groups need to work on lowering their guard if they want to succeed as health care evolves to a value-based reimbursement system.


One of the most interesting things about building collaborative models in health care is that so few really understand what is required and how to do it.1 Payers and providers have rarely ever really worked together; rather, for decades, they have viewed one another as adversaries—dishonest players in an ongoing game of “gotcha.”2 Secrecy, suspicion, and anger have dominated most of their interactions. Perhaps most unfortunate of all is that patients often never come up in those interactions—it is simply a boxing match about cost per unit of care.

As for other stakeholders in the industry, some of whom have brilliant ideas and tools that could help improve collaboration and patient outcomes, most have absolutely no idea how to present their value proposition in a way that can be understood by payers or others in the health care industry, or whether their proposed tool is something that can actually even be administered within the existing constructs.

This last note is a critical concept which is often overlooked, ie, can the ideas that are being proposed be
executed effectively in the real world? It is one thing to come up with an idea for a model that will improve outcomes, but, if it cannot be implemented or enacted in practice, it is of little use to anyone.

The dual challenge of a combative approach and ineffective communication leaves patients (reminder: we all are or will be patients at some point) isolated and with little information. On top of this, these times are usually when we/patients are unwell, and so we are not physically or mentally at our best to figure out how to navigate the very complex US health care system.3 We wind up with care that is inefficient and disconnected. The results can and have been devastating, both in patient outcomes4 and wildly out-of-control costs.5,6 In no other industry is the need for collaboration more critical than in health care.

So how do we fix this? What is required—practically, not just theoretically—to change the paradigm and create models that are truly accountable to patients and to producing consistently high-quality outcomes and experiences
while also managing costs, so that we can ensure there are sufficient resources to provide necessary care to all who need it? It begins with an attitude adjustment.

Culture Shift

An unhealthy culture leads to unhealthy outcomes. The inherent distrust that permeates the industry and interactions between those who have the most direct impact on patient outcomes is a primary cause of disjointed care and inconsistent outcomes. The path toward healthier outcomes requires a healthier culture—a culture of respect and humility, which not only allows but promotes and supports a complete re-examination of what really impacts patients’ experiences and outcomes (hint: it is not simply what health plans have defined as covered benefits). It requires partnership and ongoing collaboration, commitment, and engagement.

It is not easy to effectuate a true culture change. A change in culture—particularly a culture that is steeped in suspicion and distrust, and which has the potential to impact individuals’ (including physicians and other caregivers) livelihoods—requires a giant leap of faith. It requires a willingness to partner with those you might never have anticipated partnering with before7 and trusting that they will act for the greater good.

Change begins with respect. But to receive respect, you must show respect. Mutual respect is at the foundation of the most functionally collaborative relationships and business models. If the team achieves a level of mutual respect, even the most challenging obstacles can be overcome.  Without it, there is no chance of success (Box 1).Box 1

Change also requires humility and a willingness to believe that you, alone, do not have all the answers, but together, you can build something more robust and more meaningful than anything you could have designed or built alone. Understanding the limitations of your own skills can be difficult for some, but it is essential in teamwork.

We must think about the bigger picture, ie, not just about who should pay for what individual pieces, but what, overall, impacts a patient’s health outcome. We need to think about, not just traditionally covered benefits, but contemplating the role that exercise, behavioral health, location/transportation, and ability to adhere to prescribed therapies play in ensuring the best outcomes and use of resources.

Finally, you must be committed to continuous communication and review to ensure that the model the team builds continues to be effective.

As we have seen so clearly during the COVID-19 pandemic, our collective good health is very much dependent upon the activities of not just ourselves, but of others, and on our being thoughtful partners. The global collaboration between science, technology, and industry is a good example of how respectful collaboration across multiple disciplines can work to resolve the most complex issues8,9—and also what happens if collaboration fails to occur.10,11

Getting Started

If you want to make a difference, you need to reach out to start conversations. Approach your prospective partners with authenticity and respect. Seek out those who, within various organizations, have the spirit to understand what you are trying to accomplish. Go into the conversation without any preconceived notions of how it will all get done. There are possible outcomes that you cannot yet imagine. It is okay to go into a discussion not knowing what it will look like at the end, that is why you
must simply start with a conversation about potential partnership strategies, to leverage the ideas and expertise of many and to build something together that is more meaningful than anything you could have thought of or designed on your own.

Take note: not everyone will be the right partner and you may have some failed attempts. But there will be others who want to improve their skills and services without their ego getting in the way, and you can find them if you are persistent. Success requires a disciplined focus on outcomes that are best for the patient—not for the physician, not for the health plan—and a dedicated team that will work together
toward a common goal.

References

1. Mitchell R, Parker V, Giles M, White N. Review: toward realizing the potential of diversity in composition of interprofessional health care teams: an examination of the cognitive and psychosocial dynamics of interprofessional collaboration. Med Care Res Rev. 2010;67(1):3-26. doi:10.1177/1077558709338478

2. How payer-provider relationship enables value-based care success. Healthpayer Intelligence. January 29, 2020. Accessed March 3, 2021. https://healthpayerintelligence.com/news/how-payer-provider-relationship-enables-value-based-care-success

3. Graham J. Even doctors can’t navigate our ‘broken health care system.’ Kaiser Health News. May 2, 2019. Accessed March 3, 2021. https://khn.org/news/even-doctors-cant-navigate-our-broken-health-care-system/

4. Tikkanen R, Abrams MK. U.S. health care from a global perspective, 2019: higher spending, worse outcomes? Issue brief. The Commonwealth Fund. January 30, 2020. Accessed March 3, 2021. https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019

5. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150

6. Ways and Means Committee Staff. A painful pill to swallow: U.S. vs. international prescription durg prices. Waysandmeans.house.gov. September 2019. Accessed March 3, 2021. https://waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/U.S.%20vs.%20International%20Prescription%20Drug%20Prices_0.pdf

7. Brillstein L. Partnerships in value-based care: becoming and finding good teammates. J Clin Pathways. 2020;6(5):42-45. doi:10.25270/jcp.2020.5.00004

8. Powell A. COVAX program to roll out tens of millions of vaccine doses globally. Voice of America. March 2, 2021. Accessed March 3, 2021. https://www.voanews.com/covid-19-pandemic/covax-program-roll-out-tens-millions-vaccine-doses-globally   

9. Merck will help make Johnston & Johnson coronavirus vaccine as rivals team up to help Biden accelerate shots. The Washington Post. March 2, 2021. Accessed March 3, 2021. https://www.washingtonpost.com/health/2021/03/02/merck-johnson-and-johnson-covid-vaccine-partnership/

10. Eliasen B. Failing states of health - How broader collaboration can bring us closer to the future of health. HealthcareITNews. July 22, 2020. Accessed March 3, 2021. https://www.healthcareitnews.com/blog/emea/failing-states-health-how-broader-collaboration-can-bring-us-closer-future-health

11. Khazan O. The 4 key reasons the U.S. is so behind on coronavirus testing. March 13, 2020. Accessed March 3, 2021. https://www.theatlantic.com/health/archive/2020/03/why-coronavirus-testing-us-so-delayed/607954/

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