Can the relationship between health plans and providers evolve?

I came across an image of a puppy and kitten cuddling the other day when searching for a definition of “coopetition” – one of those made-up words to describe the evolution of competitors who collaborate –and found myself wondering … why can’t we all just get along?

The reality is, health plans and provider organizations need each other. Consumers – when they become patients – need physicians who take the proper amount of time to diagnose, treat and/or refer to a specialist. Physicians need the right environment and business models that enable them to best doctor and care for their patients. This can be done as an independent physician or as part of an owned practice group, yet many of the keys to success are the same.

Hospitals and health systems need motivated physicians with financially sound practices so they can be free to refer in or practice as part of the organization. Health plans need consumers – when they become the health plan’s members – to take greater control of the decision-making responsibility for their own healthcare choices, as well as hospitals and physicians that correctly code and follow protocols for payment. And hospitals need health plan partners who create a supportive framework and payment mechanism for doing absolutely the right thing, at exactly the right time, with precisely the right resources on behalf of the patient – who always has been a consumer.

That’s a lot of needs, and if any one of those relationships breaks down, the entire ecosystem is disrupted. Today, every group is more interconnected than ever.

While much has been written and spoken about the doctor/patient relationship, finally we’re beginning to hear and read more about the relationship between health plans and providers that have become so critical to the evolving and delicate healthcare ecosystem. Certain situations may always lead to fierce battles and sabre rattling, yet new relationships are emerging and growing. Reasonable is the key driver of success today.

In fact, what we’re hearing now in our many conversations with regional and provider-sponsored health plans, is a void neither filled with contempt nor favor. There seems to be a slight chill in the air, and it’s marked even those relationships between providers and regional plans or state Blues that were reasonably positive in the past. In the spirit of fostering relationships that could be well on their way to coopetition by year end, and possibly stronger partners in 2016 and beyond, might we suggest establishing some better lines of communication?

We suggest provider engagement. Health plans should create communication, information, and education programs aimed at the very providers who deliver care for their members, and who can become the best ambassadors for the health plan’s brand. Imagine a well-informed and benefit-educated physician having a 1:1 conversation with his or her patient. Or a hospital administrator and chief of staff providing meaningful reimbursement and coding updates to physicians so process and protocols can be streamlined. Or a physician office manager, or hospital employee, recommending certain insurance to a consumer because they’re so easy to work with.

Operationally, there are myriad opportunities for health plans and provider to partner on benefit and product offerings, data sharing, price transparency, incentive alignment, and other approaches. No single dominant model is likely to emerge from the evolution of the relationship between health plan and provider as it will and should look different from market to market.

The bar is low and so are expectations. And this is exactly the right time to do something … anything. Amid the complexity, tension, confusion, paralysis and ever- present lack of trust between health plans and providers, even modest communication overtures can facilitate a thaw. Given the history of the industry, regional and state Blues are uniquely positioned to make the first move.

Here are a few simple, first steps:

  1. Understand your key provider audiences and then develop no more than three key messages and proof points – “reasons to believe” – for each audience that will become the building blocks of your provider engagement initiative.
  1. Deconstruct your language and nomenclature, and stop using terminology that adds to confusion and frustration. You can’t expect a provider to truly understand the Resource-Based Relative Value Scale (RBRVS) any more than non-clinicians can comprehend the complexity of an Anterior Cervical Discectomy and Fusion (ACDF) procedure.
  1. Communicate more than once. Think conversations vs. monologues. Provide a mechanism for feedback and even pushback. And keep talking. Tone is critical and so is frequency.

Even a little can mean a lot at these early and delicate stages. Who knows … you may just wake up one day next to your “frenemy.” After all, more can be accomplished between partners than adversaries.

September 9, 2015
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