Keith Florance, SVP and GM of the Payer vertical at Clarify Health, recently hosted a panel of leaders shaping the future of value-based contracting design, management, and engagement. Michelle Marchese, director of care delivery analytics for Blue Cross Blue Shield of Michigan, Malia Read, vice president of provider performance management at Elevance Health (Anthem, Inc.), and Lisa White, a transformation executive at Clarify Health, joined Keith to discuss what it takes to drive engagement in value-based care programs. The conversation ranged from how health plans are shifting their approach to focus on helping providers succeed in their value-based contracts to strategies for building trust and how to achieve the alignment and engagement necessary to get to the results and outcomes that we expect.

One of the most powerful takeaways from the webinar that all three panelists agreed on is that in order to drive engagement in value-based programs, health plans must create a foundation of trust with their provider partners. Some of the key elements the group shared for building trust were: 

1. personalizing programs to fit the strengths of the providers, 
2. having shared data and insights that everyone trusts, and 
3. providing timely and actionable insights about how to improve outcomes that don’t disrupt physician work streams.

Watch the recording or read the transcript below for strategies that actually work to drive provider engagement in value-based programs.  

Meet our panel of value-based care experts

Michelle is an epidemiologist and a director of analytics at Blue Cross Blue Shield of Michigan. She joined Blue Cross nine years ago with an interest in applying epidemiology to value-based reimbursement programs. Michelle has dedicated these last nine years to driving value-based care, starting with the nitty-gritty of coding metrics out, to leading an elite team of fun and impactful analysts.

Malia leads provider performance management at Elevance Health, where she’s focused on giving providers actionable insights and data that they need to succeed in their value-based contracts. A big focus of hers is on changing the provider experience so that they view value-based programs as a partnership and less as a contractual relationship.

Lisa is a value-based care expert who made the leap from leading value-based innovation and strategic partnerships at a single-state Blues plan to a strategic advisor role at Clarify. Lisa works with Clarify’s health plan partners to make their value-based engagements successful. 

Where is your organization in its value-based maturity model, and what types of contracts do you have in place? 

Michelle:
As a data analyst, one of the things that I love about my job is that I get to do the ‘carrot’ side of things, so less of the ‘stick.’ And what I mean by that is the analytics that my team does is all incentive-based. We like to reward as opposed to taking away different sums of money. 

That said, Blue Cross of Michigan does have a very wide range of value-based contracting that’s in place, and I think what we’re realizing is the importance of enablement in building and creating these value-based contracts. So from my perspective, a lot of the work that my team and I do is in conjunction with our Provider Group Incentive Program, which it encompasses almost 20,000 practitioners across the state of Michigan. It’s a huge program where we’re looking to support the providers, whether it’s the practitioner, the provider organization, or if it’s at the individual practice units.

And so once you build that enablement and that support, which looks very different from a PCP perspective versus a specialist perspective, then you can start doing more things like introducing different quality metrics, introducing different utilization targets. And then, the contracting sits on top of that. So it has been a very step-wise function. We’ve been on this pathway since the early 2000s and it continues to grow. As we get more and more into specific contracting, we’re looking at more specific areas of health. So, for example, chronic conditions, members that need more support at home. There’s different contracting that’s addressing that type of a membership as opposed to our commercial PPO membership.

Keith:
Incentive models are near and dear to my heart. You mentioned the incentive programs being important for enablement. What’s one innovative or effective incentive that you think has been important for BCBS of Michigan?

Michelle:
So there’s definitely a dichotomy between the PCP arena and the specialist arena, and I think that it’s a lot easier to find success on the PCP side. I think Blue Cross’s proudest accomplishment right now is our Provider-Delivered Care Management Programs, which we’ve been able to expand across the state. And no matter which way you cut the data, you can see that you’re helping members, you’re decreasing inpatient utilization, and you’re improving their quality of care. So that one has been a great project that I’ve been a part of for the past five, six years. Lots of fun.

Keith:
Lisa, can you tell me a little bit about some of the orgs that you’ve been in, where they were on the value-based maturity model, the contracts, and sort of your journey as well?

Lisa:
I’ve been across the entire possible spectrum of these. When I was at a Medicaid payer, we were just launching our very first value program. And that was in Kentucky so that in it and of itself had enough challenges. That was more of a simplistic PCMH model. 

My most recent organization, a single-state Blue, we had pretty much everything across the board. There were some that were in plain regular shared savings, upside, downside, and some taking on risk. We launched a new global cap program that we were just standing up. But that organization has actually been doing value programs for about ten years.

The challenges are universal in that we still need to get to a place where providers look at this as a partnership where we all come together for the benefit of the patient. So I think the model is important, but I think the buy-in is the winning token right there to make sure that we are all kind of marching in the same direction. Incentives are awesome, and I know we talk about the alignment of incentives a lot. What we don’t talk about a lot is the alignment of stakeholders.

Keith:
And Lisa, what do you think is the biggest reluctance or biggest critique of providers saying this is not a partnership?

Lisa:
I think, oftentimes, it is perceived that a value program is more of a way to take money away from providers. It is a huge lift to look at your value programs holistically with your fee-for-service. And frankly, if you’re paying a provider 57% of the 2014 CMS schedule, they’re not going to be terribly excited about you putting this bonus program in front of them when they’re concentrating on that. I think one of the pain points is we’ve spent so much time in a system where payers and providers have been put at odds. Everything is headbutting, and it’s a hard thing for both sides to come together and say, “Yes, but now we got to focus on the patient.”

In my years, I’ve worked with providers since the early 1990s, and like Michelle, I’m actually a scientist by training, and I have never found a provider that was not looking for a way to take the best care of their patients. And I think that’s where we’ve kind of failed in a lot of these early partnerships is, “Hey, we’re going to tell you what to do and how to do it. And if you actually do it in 18 months, we might give you a bonus.” So I think we’re now having these really healthy conversations to reframe what that should look like.

Keith:
Malia, how about your journey and what’s going on at Elevance right now?

Malia:
I always like to preface that I’ve been with Elevance for about 18 months, so I can’t speak to their entire history. What I know is in terms of the early days of value-based care, we were very much on the cutting edge, building very new, very innovative programs. As we’ve gone through that maturity over time, to Lisa’s good point, my focus now is on saying, “How do we create a partnership where you get the information that you need at the time that you need it to make the best decision possible?” So when a provider is seeing a patient in an office, he’s not looking at it going, “Oh, this member is in my value-based care program, and this member is not.” To them, a patient is a patient. So how do we provide them with the information that they need to maximize the performance of their patients and get them as healthy as they can?

Because in my view, if you do all of the things that we want you to do, it will naturally create a healthier member. And so it’s, “How do we give you the information on what those steps are, and then make sure we’re incenting those steps?”

I very much agree with Lisa; we often make decisions on what that program should be and look like with no input from the provider. So over the last three months, I’ve been meeting with providers to say, “What do you need from us? How do we help you?” And what I find fascinating is how much they want to have that conversation. They don’t want this, to Lisa’s point, arbitrary “me versus you” relationship. They want to be part of the process. They want to be included. And so I think the more we open that up and co-develop, the better off we can all be in the value-based space.

Keith:
Malia, you talked about getting the right info at the right time. There’s already a lot of info at the point of care that’s coming to a physician. Do you think we’ve done our best already to avoid that overload of action items or data that they have to do? Where do you think we have to change that engagement approach to be more effective?

Malia:
So I think a couple of things. I think one, no. We haven’t made it as simple as we can. And in large part, because our members are not the only members that a provider sees. He’s going to see patients from every major payer and then every regional payer as well. It’s very difficult for them to say, ‘Well, I’ve got a panel of 1,000 attributed members. You represent 300 of them. And then a different payer represents 200,’ and so they’ve got to sort of mush all of this information together. I think part of this is an industry issue is we are not making it simple for providers.

So one of the things that we can do is to say if I’m giving the provider information, whether that’s a CFO, a care manager, or an analytics team at a provider facility, it’s, “How do I give it to you in the simplest way that you can then integrate into your day-to-day functions?” Please don’t hear me saying it as “integrate into workflow” because I know that’s like the golden goose everybody wants to go after. I do think there are ways we can make it simpler without having to configure ourselves to every single EMR that exists in the industry.

Keith:
And not everything has to be synchronous. There is a lot of value in understanding patterns and delivering broadly applicable advice that is asynchronous as well. I’m totally with you on that. 

What are the challenges of implementing and scaling value-based care programs? 

Keith:
Let’s flip over to some of the challenges that you’re all having in your space. What are some of the biggest challenges that you’re still seeing? What are the most significant pain points that you have seen with adopting or growing the contracts that you’ve got today? Has it gotten easy over time? And what are some of the specific things that you’ve done to get those game-changer moments, or where you’ve had a much broader spread of adoption or growth? 

Lisa:
I think the number one biggest problem that we still have to solve universally is getting, to highlight and underscore Malia’s point, the right information the right way. What a lot of people don’t understand is these Primary Care-Centric Value Programs; a lot of times, these primary care physicians cannot see what’s happening with their patients. So if they’re going outside a health system and a provider’s in the health system, or the provider’s not part of a health system, they have enormous black boxes of information. And historically, payers have come in and just handed them, “Well, here’s your total cost of care right now. Here’s where you sit. Do something about it.” And the provider, rightly, is going, “And what is that exactly that I’m supposed to be doing?” So I think one huge shift that we made at my prior organization was launching a toolset that is provider-facing, that actually lets those providers see that.

You’ve got a couple of different buckets of providers, and one of them is the independent providers who really want to stay independent. And this is one of the strongest ways to help them do that, but they have to be able to see where their patients are going, when they’re going, what they’re going for. And Keith, to your point, patterns. Clinical cohorts. If they can see how their clinical cohort for cardiology overall is performing and what the opportunity is there … or orthopedics or diabetes management … if they have a good view into a particular clinical cohort, it makes for a really robust conversation for both. When I was in Kentucky … I love to use this example. I had a practice out in Hazzard, Kentucky … which, yes, is a real place. The Dukes of Hazzard are from a real place.

They had 1,700 diabetics on their panel. 1,700. The very first conversation we had with them was, “Let’s talk about diabetes care management, and let’s focus 100% on that for the first six months because that’s going to be a huge lift for you.” I think those types of focused conversations is also where we’ve missed the boat historically. We give them this big pile of data, “Here’s all the stuff that you have to work on,” and the rule of thumb is if you give them too much to focus on, they focus on nothing. So I think that that is one enormous opportunity that we have shifted well in some respects is opening up those black boxes of information, so they know what they’re supposed to be working on.

Keith:
Did you find that there were any key pieces of data, or aggregated data, missing to be able to get those docs over the hump of, “This is what I really need to do for my panel?”

Lisa:
Yeah, it’s interesting. We, as an industry, have been talking about PCP-treatable ED utilization since the dawn of time. NYU even came up with a logic for it. But we’ve never been able to tell them who, what, or why. That was actually one of the very first magic bullets for us, was providers being able to see not only who was going to the ED … which sometimes they can find out after the fact … but what clinical cohort they belonged to, why they went to the ED, and, “What am I supposed to focus on with this particular group?” Before that, it was just this big buckshot approach of, “Hey, you got all these people using the ED for regular treatment, and we can’t tell you where to focus.” But that’s just a perfect example of one of those pain points that we’ve all driven ourselves bananas over for years. And even as the payer, when we were able to see, “Who are those patients and why are they going?” that was an entirely different conversation.

Keith:
Michelle, how about you?

Michelle:
You want your programs to be simple enough that everybody can understand them and that your metrics are all aligned. But at the same time, specialists especially are incredibly special, right? And what I mean by that is a cardiologist. There could be six different subspecialty types for cardiology, and so you want to develop programs, and you want to incentivize in ways that ensure that you are engaging everybody appropriately. And the same thing happens when it’s a value-based contract. You want to make sure that the right people are being held accountable for having those positive health outcomes. So it is, “How do you do that balance?” And at Blue Cross, we have been struggling with that quite a bit, and I think our pendulum has swung.

On the one hand, we were doing large metrics, so looking at the overall cost of care, EDIP rates. But then, especially on the specialist side, they say, “Well, we don’t directly influence that,” so how do you reach us? How do we reach out to those practitioners, give them ways that they can improve, and that they can help their patient panels? And so some of the things that we’re doing, as we’re revamping our value-based reimbursement programs, is looking at, “What does it make sense to have a specialist held accountable for?” Those would be things like keeping blood pressure. Everybody can agree that it’s important for your patient panel to keep blood pressure under control or your HbA1C rates under control. So there are certain things like that. But then, can you attribute to a specialist as well so that you’re actually holding that specialist accountable for the services that he or she is rendering? There are all of these other different tactics that we’re trying to be a little bit more specialized in so that we can reach out to all of these different provider types and engage them in the right ways.

Keith:
Have you found success in real specialty carved-out risk? Sorry, that was a loaded question.

Michelle:
Yes, yes. Our specialists are part of our provider organization, so they’re part of the PCP group. So in terms of a specialty carve-out, that doesn’t exist for us.

Keith:
We’ll get there.

Michelle:
Yeah.

Keith:
Malia, how about you?

Malia:
I just want to say I find it very fascinating because of the three of us, we all come from such a different angles in terms of the work we do, but our thread is very similar. So from my perspective, I think, as Michelle said, not only have our programs been “generic’ that “This is the program. We’re going to fit everybody into it,” it’s also then in how we give them their information against how they’re doing or what they could be doing better. One of the shifts that we’re starting to make as we speak is to say the solution that we give to a small independent practice or a provider that might be Medicaid-only and doesn’t have deep analytics staff versus an aggregator who has reams and reams of people who can go through all this data … the solution we offer has to be different.

And so as we’ve gone on these provider interviews, we have some providers who are like, “Just give it to me with a bow wrapped around it. Tell me exactly what you want me to do, and I will go do it.” And we have to be able to do that, right? That has to be a solution we offer. Then we have other practices that are like, “I want to verify that I believe the data that you’re giving us. So I want all of my raw data, and then I’ll do all the machinations. And then I’m going to compare it to what you’re telling me to do to make sure that we’re aligned.” And so I think as we evolve in this journey, especially as we try and move to more downside risk, there has to be an inherent trust which comes through more customized solutions. And then there has to be, again, back to that partnership that says, “This is what we’re seeing in your business. What are you seeing in your business, and then how do we bring those together?”

The example I love to give is in a lot of places when the payers started their value-based journey, we were on the iPhone 5 or the iPhone 6, back when we had the home button. And today, we’re at the iPhone 13, where you can shoot a movie on it. Nobody wants to go back to the iPhone 6. Nobody’s going to trade their iPhone 13 for the 6. So to me, it’s how do we bring all these capabilities up in that same way, where how I have my iPhone set up is going to be very different than Michelle’s and very different from Lisa’s, but we’re both using it in a way that meets our individual needs? And to me, that’s the next part of the journey.

Keith:
Are you finding any better or worse results/outcomes or levels of engagement between those two segments? So when you just give it as a package with the bow on top, is that really working? Is that driving savings for you?

Malia:
So I don’t know yet because we’re not quite there. This is the way I think about it, and it’s hard, is instead of the incremental … which is what we all do because there’s money and investment and all of those things … it’s how do we create a leap that says, “Without making it less complex,” because these programs are very complicated, they’re hard math, “make them easier to understand your performance and the outcomes of these very complicated programs, so you’re not in the weeds of, ‘Well, is my quality measure a two or is my quality measure a three?’” Instead, it’s to say, “If you do these ten things, your quality measure will just naturally go up.”

Keith:
Yep. That’s great. And honestly, that’s the kind of approach that I think starts to really resolve the issues that I think Michelle, you brought up earlier around only having part of every provider’s panel too. So what are the general things that they can do to improve their quality? Both so that it covers most of the contracts that they’re in, but also because I think, Lisa, you said it before. They all want high quality. They all want higher outcomes. So that kind of support, I think, is really important. 

What are the key aspects of a successful provider engagement strategy for value-based programs?

Keith:
So now, I’d love to ask you all a little bit about the keys to success that you’ve seen. So I’d like to ask each of you, actually, what are the three elements that you feel have been key to driving success in value-based care, and how does that relate to the guiding principles of your provider engagement strategy?

Again, that’s sort of a running theme throughout this that I’ve heard from each of you is how do we get that engagement? We’ve talked about sticks versus carrots. We’ve talked about segmenting our program in ways that we give different data to different types of providers. But I’m going to jump right back to you, Malia, and ask you to talk me through what are those three elements that you’ve been most successful with?

Malia:
It’s a hard question because just getting to three is tough. I think one is very open communication. When you’re discussing performance, do it in a way that allows everyone to ask their questions and be engaged, so whether that’s through joint operating committees, whether that’s through how you present the information. But do it in a way that is simple, easy to digest, and then easy to take action on. 

First, it’s keep it simple. Again, I’m going to beat my dead horse. They’re very complicated, mathematical things that we built. The execution of it needs to be very simple. So I think that’s part of it. I think, too, ensuring that whatever analytics, data, information, whatever word you want to use there, is believed to be true is the next big thing. So if a provider doubts that your data is accurate or doubts that you are reflecting their performance, then you’re going to spend all your time arguing about the data. So the second piece is to make sure that you all agree on what the data is saying.

And then the third piece is when you get into the contracting side of it, the more consistent we can be in our contracts, the better off we all are in terms of how we deliver information. And I know that sounds … I don’t know if trite is the right word … because every provider or every organization says, “But I need this,” or, “I need that,” or, “I’ve got a state reg,” or, “I have whatever this is.” But when you create 100 different versions of something, you’re going to get 100 different answers. And so, for me, it’s simple, open communication and then consistency.

Keith:
Got it. I like that. I like a simple mnemonic. That’s good. I do want to probe on the second one, though, “Agree on what the data is saying.” What type of data and reporting are you finding most valuable with providers to manage your patient populations and risk?

Malia:
If you can show them what’s driving the behavior… I’m going to totally make this up. Let’s say that I say, “Keith, your organization is performing at a three-star, and you’re like, “No, I really think I’m a four. And I think I’m a four for these reasons.” And I say, “Well, I think you’re a three for these reasons.” Right now … and excuse my language, but now you’re in a stupid argument. 

Instead, it’s saying, “Keith, what is going to drive your success is,” to Lisa’s point earlier, “for the next quarter, you should really be focused on making sure you get your Medicare members in for their semi-annual wellness check, whether that’s their mental health, social determinants of health, or whatever it is that could be driving more negative outcomes. If you can close that gap, you’re going to fill these other four.” It’s being very directive and very specific instead of arguing over, “Well, if you do this, you’ll be a four-star. Where if you do this, you’re a three-and-a-half-star.”

Keith:
How important do you feel it is to have that information, in some way, tied to the financial achievement or the contract achievement?

Malia:
In government-based programs, I think it’s huge because the government incents us that way, right? That which gets measured gets done. So I think having the philosophy that that which is rewarded gets done, let’s make sure we’re aligned on what those rewards are and then focus on getting those done. And what should be happening then is, and again, off the top of my head, if we all say H1C, mental health checks, and low ED are going to be the most important measures this year, let’s make sure we’re giving you that information in a very simple, easy to ingest manner so that that’s what you’re really driving because that’s the outcomes folks are looking for.

Keith:
Michelle, how about you for your three keys to success?

Michelle:
Yeah, I’m afraid I’m not all that different from Malia. I totally agree with her. Would just emphasize that I think provider partnerships and trust with the provider community are key. And how do you build that trust? You have to have relationships. I was planning on sharing a story here about how we have a quarterly “all providers on deck” type meeting with the Blue Cross team, and one of the medical directors came up to me and started asking me rather vigorously about our risk adjustment methods for determining past trends. She was going on and on and on for a good 10 minutes, took me to the side of the room, and took me to task because the way that we were risk adjusting was just wrong. And it wasn’t my program, so I will deny all culpability for the risk adjustment issues. But it was fantastic, and I think back to that all the time because I’m grateful that the provider partners are comfortable enough, and they know us well enough, to come and have these very robust discussions.

And so I think there is a lot of give and take because none of us have really done this before, right? We are all in this together. We all have to figure out the best way to move forward to keep healthcare costs under control. And how better to do that than in conjunction with the provider partners, and to see them as partners, not adversaries. So I think that it’s really important to continue building those partnerships, keeping communication lines open, and good data as well. It’s not only data that everybody agrees on, but it’s data that’s free from mistakes. It’s data that when it’s submitted or sent out to the provider partners, to use Malia’s words again, they accept it.

They accept it, they use it, they trust it, and you can do something with that information. I think the other piece of that, then, is identifying those opportunities. That’s something that we’ve been working with, and Lisa and I were just discussing this last Friday about what are the right opportunities to align everybody on and is it the biggest opportunity? Is it the most achievable opportunity, that low-hanging fruit? But how do you identify opportunity, and then how do you align around that opportunity?

Keith:
How, if at all, do you think that those three areas change if you’re talking about specialists versus talking about primary care?

Michelle:
Yeah. In some ways, it changes a lot, again, because the specialists are special. I think that you’re finding that with PCPs, it’s a lot easier to do a “one size fits all” because you do have the same types of chronic conditions that you’re caring for, things along those lines. I think specialists, especially from a value-based reimbursement … so a carrot program, as opposed to a risk program … there’s less motivation to participate in that when you can just have two or three more procedures, and it makes up that 5% value-based reimbursement. So you do have to think through how a specialist is treated very differently. But still important to have that good data, still important to have open communication, and to try to develop the programs that are the best fit.

Keith:
Lisa? 

Lisa:
I cannot overstate the value of a physician advisory board in your market. One of the things that I think we have failed at historically is putting together a group of physicians that become our advisors on how we’re building these programs. It’s been my experience that when you do that … and I’ve had that in two different markets … you actually find blind spots that you, as the payer, did not think about that the provider did think about. I’ve not found any of them that are dead set against a value program if it is something they feel like the deck’s not stacked against them. 

Conversely, we can also have conversations about, “Well, what do you think the genuine disincentive should be if this, this, and this doesn’t happen?”

We have very robust conversations. It helps to get to the resolution of, “What are we trying to do together?” And it also gives us that very valid outside perspective that we put into our calculus when we’re coming up with these very complicated programs. Right, Malia? 

The other thing I would say is consistent quality metrics across your programs. I am all in favor of pushing value-based program participants to another level, but I’m in favor of doing that through efficiency metrics. I would like for them to be focused on universal quality metrics because, number one, it’s helping the payer with stars, and number two, it’s not giving them multiple moving targets to aim at. But I think that is a level of consistency, and granted, these things change every year. I mean, I was really excited. In 2023, now we have something called SNS, which is a social needs screening. Hey, that’s something we can all use. But I think that a lot of times, we get really eager to include too many quality metrics. And then, they’re so overwhelmed trying to get all of them that they lose interest or they lose excitement.

The third thing I would say is, back to Malia’s comment about workflows, I am actually master’s trained as a patient safety specialist, which really is human factors engineering in the healthcare space. We got to stop talking about workflows. That whole workflow thing for me is such a sore spot because I don’t know the realities of what happens in that practice. And by the way, from practice to practice, it’s a different thing. What we need to be talking about is clinical practice habits, the habits that the practice has around how they approach documentation, or how they approach diabetes care management, or whatever it is. What do you, as a practice, have as a habit around that particular thing? Because, at its core, a value program is intended to change habits. Right, Keith? That’s your thing with incentives.

Keith:
Now you’re speaking my language.

Lisa:
We are trying to change their habits, and that’s not an easy get. So the more that we can talk about changing their thought process, instead of changing their workflow in their office, or, “Does this drop into their EMR?” or whatever, I think that’s where we pick up yardage because we are helping them think a different way that ultimately helps them be successful. You are stifling a smile so hard right now, Keith.

Keith:
In my world, it’s all about designing the right choice architecture that puts the right cues and nudges in place to change those patterns but doesn’t get in the way.

Lisa:
Yep.

Keith:
Doesn’t feel like utilization management, doesn’t feel like prior authorization, and, to Michelle’s point, feels like sticks rather than carrots. And I think that all bubbles up towards creating trust, right? You are not trying to, as the payer, out-doctor your doctors. You’re trying to convince them of what is the best evidence-based paths to go forward that are hopefully going to reduce the burden for your members as well. You say you did, though. You mentioned Medicaid. You mentioned stars. When you look across lines of business, would you say that there’s anything really important to your success, things you might have to change, or how you align quality measures so that my full panel … even within one payer that has multiple lines of business … feels like a consolidated unit and I can make real strides across the board?

Lisa:
Yeah, it’s interesting. There’s been so much focus on Medicare, Medicare Advantage, and Medicaid over time.

Keith:
Stars.

Lisa:
But the vast majority of our membership at my Single-State Blue was commercial. And that’s what the aggregators are really good at, too, is MA. They can knock it out of the park with MA. But so many of the aggregator partners that I had, or was talking to, commercial is a new thing for them. I think the winning formula is when you can have something do double or triple or quadruple duty. Meaning, you’ve got a list of those quality metrics that we already know on the government program side … because I’ve had all of those.

We already know on the government program side, “This is what we need to focus on to advance our stars for the payer to achieve these X, Y, Z things,” but creating a pathway so that the providers don’t have to think of them separately. Because back to Malia’s earlier point, they don’t look at their panel and go, “Oh, well, this is an Elevance member, and this is a CareSource member.” They don’t think about that. And so the more we can feed into that sort of holistic thinking, the better we move the needle on some of these habit changes.

Malia:
Keith, I just want to jump onto that for a second because commercial can be a challenging piece of this. If you look at the way commercial healthcare is going, particularly across generations, more and more people don’t even have a PCP. So we assign them. We assign the member to a PCP, and that PCP may never see them. Now, they may go to a minute clinic, they may go to an urgent care, they may use doctor-on-demand or some other on-demand telehealth. And so I think part of the payer’s job – and nobody’s really doing this right now, so please don’t ask me how well we’re doing it – is how do you take all of that data that is not attributed to the provider, but is attributed to the member? So I go to Walgreens and get my flu shot. I didn’t go to my PCP to get my flu shot.

The PCP, in Malia’s opinion, should still get credit that my member got their flu shot. It shouldn’t matter where the site of service is. It should matter that the things that we want them to do to be healthy are occurring. So PCPs, understandably, will argue, “I maybe see a member once a year if I’m lucky, and that’s because they’re sick.” And so we’ve got to start thinking about how do we take this data in a very different way that allows the PCP who’s not going to see Bob … because Bob is 24 years old and thinks he is immortal … “But I did go get my flu shot.” So commercial becomes super complicated, and I think we’ve got to think about that from a data standpoint in a very different way.

Keith:
Yeah. And in my mind, a lot of it comes down to how are you managing and incentivizing the attribution model that you’ve designed. And how are you doing it based on what components of spend? What are you encouraging versus what are you putting into a risk for a cap payment and things like that? 

When developing incentive and value-based programs, how do you consider the profile of patient panels to ensure equity and assessment? Things like social and environmental risk factors, Medicaid eligibility, disabled, et cetera?

Michelle:
This is a great question, and it really depends on what you’re trying to measure. You definitely have to risk adjust for your population, so you have to be well aware of what your patient panel looks like. And that’s really important because of different social determinants of health and the ability of members to be able to seek care. We do a lot of different things in the Blue Cross of Michigan space where we try to account for that. Sometimes, it’s something as simple as reaching out to the POs and asking them to attest. We have safety net practices, which is a federally qualified health center, so FQHCs. So there are different ways that we can identify that there are practices that have more social determinants of health-type issues that are present in that population.

From a utilization perspective, you can risk adjust away all sorts of things. You can get into all sorts of debates about which sort of modeling you use and the accuracy of that risk adjustment. But there are lots and lots of different papers that you can read, peer-reviewed papers to look through that kind of stuff. So it really depends on what you’re trying to do. I think another important venue right now is that enablement piece and making sure that you are supporting practices in the right way. That’s something that we’ve been working towards more and more of different provider outreach. Do you need food banks? When you’re filling out an assessment … So as a member, going in and you’re filling out some sort of assessment for if you need food or if you’re in an unsafe living environment, what kind of support can we give those practices, as a payer, so that they can then support their members better? That’s something that we’re actively doing, and rolling out a couple of different programs this summer. Thank you.

Keith:
Malia or Lisa, anything you would want to add to that from your perspective?

Malia:
I’m not a mathematician, nor am I a scientist. MBA by training, so I don’t do hard math. But one of the things we haven’t talked about is the importance of case-mix adjustment. So if you go to a provider and say, “if you just lower your MLR…” Well, if my MLR is 94% because almost all of my members have chronic conditions, then it doesn’t matter what metric I put in place. I can’t get it any lower. So risk adjustment is important, but then so is case-mix adjustment in terms of how we think about a market. If we’re going to have market benchmarks, as an example, as one of our scoring devices, you’ve got to be able to say to a provider, “Yes, you’re above benchmark. But you’re above benchmark in the way that you need to be because you’re managing the population the absolute best that anybody can ask you to.” So I think there’s this weird mix that we haven’t figured out yet, but I think we’ve got to do that.

Is there anything that you’re doing in the commercial VBC space to help PCPs with referral management and understanding the highest quality and efficiency providers to refer members for the best outcomes and impacting total cost of care?

Lisa:
Now, this is one of those big black boxes, especially if this patient that this PCP is trying to manage is going to a specialist that’s not within their health system, or they have no correlation to it whatsoever. It has been an interesting experience to start to give the PCPs that kind of information that they didn’t have before. And it depends. The funny dynamic is we had very similar responses, whether it was an independent PCP or a PCP that was within a health system. Because they still have similar goals but slightly different spins. So we would talk about, “Hey, there’s a preponderance of your patients that are going to this particular ophthalmologist. We want you to understand that this ophthalmologist, on a case-mix adjusted basis, is not doing as well as these three others, and this is why,” and we paint the full picture for them.

Nine times out of 10, they’re gobsmacked and saying, “Oh my gosh, I had no way of knowing any of this before. This is great. Now I have better information to refer on.” That also pokes them on something that I refer to as active versus passive referrals. You have the docs that’ll say, “You need to go see an orthopod,” and that’s the end of the conversation. And then, you have the docs that say, “You really need to go see an orthopod. Here are three top orthopods that we’ve had a really great experience with. They do a really great job. You might want to talk to the three of them first or one of the three of them first.” Those activated referrals are an entirely different thought process for a lot of providers, and I think I’m convinced that it has to do with the fear of Stark laws. Oh my god, steerage. The horrible steerage word.

But that’s really what we’re asking them to do – partner with the very best performing specialists who are treating their patients that they are responsible for. Interestingly enough, when you have this conversation with a multi-specialty practice, that maybe their PCPs are in your value program, suddenly, the multi-specialty practice is also able to see a couple of things. Number one, “Where am I losing domestic spend? Where do I have patients that are going somewhere else for cardiology when they’re attributed to my PCP?” Number two, “How are my specialists performing in the market on a case-mix adjusted basis against the other specialists, and why?” Because they all want to up their game. They’re competitive by nature.

Keith:
Creating those competitive partnerships is absolutely critical.

Lisa:
That’s right.

How do you assign specialists responsibility for things like blood pressure, HbA1C, while also holding the PCPs responsible for repetitive care?

Malia:
Yeah, I think that goes back to something that we said earlier when we were talking about the commercial space. You can give credit to two people, right? It’s that whole thing of two things that can be true at the same time. So in my experience, anytime you see a specialist, most of them are going to do a blood pressure check. I mean. My dentist does it. So if my dentist discovers that I have high blood pressure and then says something to me about it, and my PCP gets credit, that’s great. And if that dentist somehow is in some wacky value-based care contract, he or she should get credit for that too. So I think we have to get out of this mindset that it’s an all-or-nothing event. We’ve got, I think, 46 lines on a claim. So if I put in there that I took Malia’s blood pressure, I should be able to pull that information and populate it into my overall record so that however my program is designed, that credit is going to multiple places.

Now, again, I don’t do the math, so I don’t understand the financial implications of that. But in my simple world, that’s going to lead to a better outcome regardless. And I know one of the questions out there was, “In a utopian world, how would this all work?” For me, it’s that we stop viewing this as an actuarial formula to drive behavior and more of a partnership designed to change outcomes. And if we do that in a really authentic way, the member only wins. They only get better. Any woman who goes to see their gynecologist, or their obstetrician is going to have her weight done, she’s going to have her blood pressure done, she’s going to go have some other tests done. All of that comes together. That is general health, and this is supposed to be about health. I’m about to get on my soapbox, so I’m going to stop myself there and back way up. But to the utopian question, the specialist question, there’s my answer.

Keith:
Hallelujah. I love it. And in my mind, too, healthcare economics is a massively important part of the answer, right? And so the provider engagement around those answers is so incredibly important. I think that’s been a theme that we’ve heard throughout this entire conversation. It’s finding the right levers of engagement, knowing that one size does not fit all. And I’m not just talking about specialists versus PCPs. I’m talking about the different types of practices that are out there and what they need to actually be able to perform if they’re in aggregation or they’re in their onesies-twosies. Having the data case-mix adjusted on aligned metrics that are simple, that just allow you to build that partnership on the known things that need to change. Having those specialist programs that are aligned with the more mature PCP models that are in your markets. And then having all the great processes in place to bring them to the table.

We talked a lot about the operating models that include providers or joint advisory committees, or joint operations committees and advisory boards, to kind of create the shared agreement on what do we need and how you can even share that across the other programs or contracts that they’re in. I learned a lot. Thank you, all. You were incredible panelists. You shared a great wealth of information. Thankfully, you all mostly agreed with each other on the things that are really important to go forward. I’m looking forward to using some of this and figuring out how we really shift the market to a lot more value. 

Note: We made some slight edits to this transcript to improve readability.