Just as providers have reimagined their clinical and business models in light of the pandemic, there is an opportunity to reimagine their relationship with health plans. Particularly in the context of evolving value-based contracts, there are a variety of “asks” that are likely to find receptive health plans. Three issues that are particularly important to health plans are administrative efficiency, quality measures, and overall cost of care. Each one creates opportunities for providers to offer and ask for help.

1. Administrative efficiency. Providers complain about the administrative burden of prior authorization. What they may not realize is that the burden for the health plan is also significant. Because they require a large number of physicians and nurses, prior authorization programs represent a significant expense for health plans. Most health plans would also acknowledge that these programs are quite inefficient. Prior authorization denial or modification rates are generally in the range of 10 to 15 percent.  That means that 80 to 85 percent of the time, the entire process has no impact on the outcome.

There are a variety of ways that providers, particularly larger groups, can offer efficiencies that benefit both parties. Considering direct access to the providers’ electronic health records (EHR) by a health plan nurse would save both parties’ time and work. This has been done routinely between health plans and hospitals, but is much less common in ambulatory settings. Alternatively, asking the health plan for a dedicated nurse to serve as the clinical liaison can achieve some efficiencies by eliminating redundant requests for information, and establishing a trusted and accountable channel for communications.

A more progressive approach to this issue is for the provider to add auditable decision support tools to their EHR in return for special status that exempts them from clinical review (“gold carding”).  For example, a provider might implement decision support software for diagnostic radiology in return for gold carding of all their clinicians for radiology prior authorization.

2. Quality improvement. Increasingly, both health plans and providers are at financial risk for the performance of clinical quality measures. In parallel to providers, health plans have historically performed direct outreach to their members in an attempt to close gaps in care.  As providers have “skin in the game,” it is increasingly in their interest to do the same. They might consider leveraging health plan outreach resources by suggesting co-branding of communications.  Adding the primary care physician’s name to a health plan outreach reminder can significantly increase the likelihood of follow-through by the patient, even as it lowers the administrative burden for providers¹

Another potential to improve quality is for embedded or dedicated health plan staff to perform telephonic outreach to a provider’s patients with gaps in care on behalf of the doctor’s office. Dedicated support staff could directly book appointments for patients. This approach may prove particularly attractive for practices with large Medicaid or Medicare populations.

3. Cost reduction. The final area for potential collaboration is cost reduction. There are a variety of cost savings opportunities that are painless or beneficial to providers. Management of both prescribed and administered medications is one such area. For example, providers can ask for a different approach to paying for office-administered drugs. Rather than have the plan pay a percentage mark-up related to a drug’s cost, have them pay an absolute dollar mark-up, thus removing the financial incentive to use more expensive drugs.

Expensive, out-of-area testing is another category of costs that providers might inquire about with their payers. The plan could save significant dollars if providers used a preferred lab for certain tests and should be willing to include these savings in a value-based arrangement.

Another creative approach to this issue is in the area of tertiary and quaternary care. Providers can ask the health plan if there is a particularly cost-effective hospital system in their referral region. Channeling patients in this way can generate significant gainsharing opportunities.

Innovative pilots

Health plans are always looking for ways to improve in these three arenas. As a result, they may be open to pilot projects with individual provider groups as a relatively inexpensive way to test a potentially scalable solution. This can be done successfully for practices of all sizes. These might include a new care model, back pain management, transitions in care, and emergency room avoidance. Any idea that can be tested on a small scale to achieve efficiency, quality improvement, or cost savings is a candidate for a health plan pilot. You won’t know until you ask your health plan.

Martin Lustick is a physician and senior vice-president and principal, NextGen Healthcare.

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