More on Reimbursement

Engaging providers means aligning their goals with that of the consumer

In our last column, we took a look at how U.S. health plans operate in a world of rising expectations based on: value-based reimbursement; consumerization; healthcare cost management; and regulatory compliance.

In this second part of the series, we'll give the best strategic plan of attack for each of these four trends.

Value-based reimbursement

Design provider networks to steer consumers toward the providers with the best value measures, i.e. the best health outcomes in proportion to cost.

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While new care models elevate the role of the consumer -- for example, by encouraging them to demand less expensive early interventions over more expensive hospitalizations -- we also need to ensure the economic and contractual incentives for providers are aligned in the same direction.

Providers must be incentivized to encourage healthy behaviors and order preventative tests, such as cholesterol screenings and mammograms.


Design custom networks for targeted populations. Give consumers the current and accurate information they need to choose a plan and providers within the network. We're expecting consumers to take on more financial and decision-making responsibility in this new era of healthcare, but we need to meet them halfway. We can't expect them to become economists or legal experts. We need to explain their options in plain language and provide tools for calculating the costs of alternative plans.

But costs are not the trickiest part. One of the most important considerations for consumer plan choice is what providers are included in a given network. It is crucial to ensure that provider directory data is accurate and up to date. The worst thing we can do is encourage consumers to choose a plan they believe includes a favorite primary care physician, only to find out later the provider has dropped out of the network or had their practice acquired by a non-participating organization.

Healthcare cost management

Streamline processes to reduce the cost of claims and other administrative overhead, keeping expenditures focused on actual care. Our dialog with providers should revolve around quality care and positive outcomes rather than administrative functions and transactions.

We can do this by eliminating unnecessary rework, resubmission of claims, and appeals; by allowing providers to see their claims processing status online; and by paying them right the first time.

In a similar way, when a customer calls, we want to provide them with the right answer on the first call as often as possible. This needs to start with streamlined provider enrollment, during which we clearly communicate to providers how they will be paid for participation in the network and then promptly update the network provider directory. Delays and errors in this process have a ripple effect, presenting consumers with a false view of what services will be covered, frustrating consumers and payers with unpaid claims, and wasting time and effort trying to reconcile inconsistencies.

Bureaucracy doesn't make anyone healthier or happier.

Regulatory compliance

Stay ahead of government requirements. For example, provider directories are expected to be accessible to the public and machine readable, so they can be consumed by other healthcare apps.

Directories must also be updated regularly. The exact time limit might change according to rules either pending or in force, but we expect the time window to shrink to a matter of days before long.

Several of these points touch on the importance of the provider directory. Keeping the directory current might not sound like a big deal, but it is. A single payer may be supporting hundreds of provider networks, each targeted at a different demographic and with different providers enrolled. Simply keeping all of them straight becomes a challenge.

In our experience, we see up to 3 percent of provider directory data becomes outdated monthly on average. Providers move, stop taking new patients, drop out of the plan, or have their practices acquired by hospitals or larger practice management groups. Without continual updates to an online directory, those discrepancies accumulate rapidly.

The threat of fines and other regulatory action related to inadequate networks and inaccurate provider directories should get your attention. We're at the beginning, and the crackdown on inaccurate directory data has been limited to a few egregious examples. We expect to see more of this if payers fail to take these new regulations seriously. Consumers who feel they've been misled about the scope and quality of a network will make sure their legislators hear about it.

But that's not the biggest reason to change how we do business. Instead, we need to ask, "What if we're thinking and going about this all wrong?"

Instead of lamenting the consequences of failing to act, why not celebrate this transition as an opportunity to excel? Instead of focusing narrowly on the regulatory or technical challenges associated with providing accurate provider directories, consider getting that more accurate information as part of a broader redesign of your relationship with providers.

By definition, a good relationship is not an adversarial one. Too many providers have been trained by negative experiences with payers to treat them as the enemy. When providers are dissatisfied, they're not shy about sharing their opinions with patients. And more so than ever before, those patients are the consumers we need to impress if we are to win and keep their business.

Consumer satisfaction, provider satisfaction, and the design of a high quality and cost effective provider network are all interrelated goals. Providers who have the right quality characteristics and know they're in demand will sign up and stay with payers who are easy to do business with. The presence of those quality providers will then make a network more attractive to consumers.

In a nutshell, transforming your provider relationships can be the key to: engaging consumers; reducing friction with providers; aligning your network with value-based reimbursement; containing costs; and mitigating regulatory risk

This is the strategy being pursued by Florida Blue, which believes the provider relationship with the payer is core to the entire provider and member experience. As a result, Florida Blue is breaking down silos in their organization and technology infrastructure to make certain data can flow between internal systems and both consumer and provider portals.

To present accurate information to consumers, Florida Blue is striving to make it as easy as possible for providers to update their information.

In fact, Florida Blue understands it must be easy to do business with in general by providing accurate and up-to-date information on fee schedules and credentialing information as well. New providers should be able to enroll and self-create a profile the same way.

Florida Blue's goal is an easy self-service experience that rivals online banking, another consumer experience that has set high expectations for what people expect from a digital business. Think about that for a minute: How many of us physically go to a bank branch and fill out a deposit slip anymore? We expect up-to-the-minute, accurate information about our bank balances, which checks have cleared, auto-payments, and so on. Why should healthcare be different?

Florida Blue has its share of high-cost, inflexible legacy systems standing in the way of this vision, and anticipates a three-to-five-year migration to a new platform. Still, the goal is clear, and the plan is in motion.

As you think about your network design and provider relationships, we encourage you to think big about what's possible. How do you compete differently and attract consumers to the network that's right for them? How do you steer them to the right providers who will provide high quality, high value care?

The initial concern we're hearing is about making sure consumers understand who is in the network. Long term, that needs to evolve to helping them understand the pricing, quality, and value associated with each provider. That, in turn, will make it even more important to court the providers who shine by those measures.

Fortunately, as you improve cost and quality transparency, you also make it easier for the highest value providers to benefit from membership in your network. Handled properly, this transition should benefit payers, providers, and consumers, too.

Dianne Wagner is senior director of Provider Engagement and Enablement at Florida Blue (Blue Cross Blue Shield of Florida).
Carolyn Wukitch is senior vice president and general manager of McKesson Health Solutions.