The shift to an outcomes-based model of business you have been reading about for years is real and is finally occurring. We have watched it at the state level in places such as Texas and Tennessee with service-level contracts for specific regions. We also see it at the payer level with programs such as Aim Specialty Health, which focuses more on usage and proving efficacy.
Conversations with payers frequently include discussions about outcomes, yet the term “outcome” by itself is generic and might not mean much if you have not been specifically affected in your organization—or perhaps it means everything because you have been affected. In either case, your approach, preparation and continued engagement with payers are what continue to add meaning to the term “outcomes.” Stated more simply: an outcomes-based model requires having a value-based relationship with your payer.
Preparing yourself for value-based relationships with your payers is something that every company can do, regardless of size or service area. So, what does this mean to you and what can you do about it? Following are five tips to jump-start your payer relationship game plan.
1. Play your highlight reel.
Settling in for the long haul involves being seen and chosen as a partner by your payers. This requires a few concrete steps to fill in the details about why your organization makes a good partner. You will need to offer empirical evidence of your value. It’s fair to say—assuming your company is still helping patients—that you have figured out the first few steps in weathering the storm through this transition to studying outcomes. Start by asking your management team about what you have been doing that works well and why.
Discuss the empirical evidence about the value in the relationship. This will likely be a different point of view than you are used to reviewing for a payer. Typically, we look at metrics such as payment ratios or speed at which the payer pays their claims. When preparing to discuss future contracts, you should be reviewing information on patient satisfaction, examples of condition improvement and clinical use. Use surveys, patient interviews, internal case studies and data downloaded from equipment to tell your story—details that can also be used to justify additional market share and/or competitive advantage in your region.
This can seem like a lot of work to fit into an already bursting schedule. Try this: Ask your teams to collect the information. Next, have a thoughtful conversation with your clinical leader, the person who reviews patient progress notes and your billing leaders to better understand how you want to direct your project.
2. Identify your best contact at the payer.
This seems simple; however, there are many different organizations that provide health insurance to patients and there are several models of decision-making within those companies. First, learn how the organization makes contracting decisions. Asking the right questions will unearth opportunity:
- Does the payer sign managed care contracts?
- When is the application period?
- Are you currently enrolled with the payer?
- What is your current payment ratio with the payer?
- How does your billing team rank the effort to work with the payer?
Then, think about how you will record and aggregate the answers to these questions. The method for documenting this information can range from Excel spreadsheets to slick CRM software systems. Easy access to your research will help your team navigate the value conversation with your payer.
Next, identify your contact. Start with your representative first, but understand that often that person is not the best executive point of contact. When you are able to identify the contact that best matches your level of value, recognize the opportunity to engage in conversations about what you will need from the payer to be successful.
It’s likely at this point (after focusing on Tip 1) that you have uncovered challenges in your organization’s efficiency with the payer. These challenges should absolutely be part of your discussion as you translate those details into contract language. Partnerships require mutual feedback as we transition to these new models. The Lab Tactical team sees as many different models as there are payers across our client base, yet one thing is consistent: shared value exists in the successful person-to-person relationships between organizations.
3. Understand what motivates your payers.
Sure they may take a long time on prior authorizations or “lose” claims from time to time. Get over it. You need to know what a payer is using to define their success. You will need to reflect those bullet points in the details you deliver down the road.
Aligning your strengths with their priorities establishes the value that working with your company brings to the table. (Note: This is also a good time to reference Tip 2 again!)
Reviewing the type of coverage that your payer offers to the consumer is helpful. Some companies, such as United Health Care, are engaged in advanced technologies nationwide, whereas Blue Cross Blue Shield seems to be more focused on evidence of compliance. How does your company and practice match up with what you learn? Is the company moving toward telehealth strategies or wellness initiatives?
Again, this is where alignment of your strengths and their priorities should be highlighted. Increased competitiveness among payers is a byproduct of the Affordable Care Act (Obamacare), and we have watched each of them develop different styles of marketing campaigns to claim their market position. Pay attention to what payers are saying outwardly so you can understand how to present to them internally.
4. Talk to your peers.
Reach out to the HME community and talk with non-competitive colleagues who are able to share their experiences. Dedicating time to informal conversations with colleagues who understand your point of view can help you work through problem solving and keep you accountable to your goals. Remember that health care needs a collaborative approach between providers, patients and payers in order to succeed.
This is a careful balance, and we urge you to treat it as such. Peers can be competitors and vice versa, yet your best resource of knowledge still exists in the professional groups and organizations to which you have access.
5. Be diligent and creative on how you will report back to the payer.
Once you have established a relationship, you can start to schedule in-person or webinar meetings with decision-makers around the table. Take this part of the game seriously. Prepare your presentation as if it were as important as anything else you are doing. Engaging three to five members of your team to collaborate on the proposal details will help you prepare a better presentation than tasking it to an individual.
You can seek professional help, but—and this is a big one—you cannot lose control of your content. After all, it’s your organization that exists in the partnership. We have seen the National Competitive Bidding program bring instability to the industry through misrepresentation. Don’t do the same thing by overselling or compromising the thing you do best.
There is no formula for the content of your presentation; it will be as unique as your organization and should reflect the value alignment we mentioned in Tip 3. Again, people are still behind the decisions. Networking and handshakes (and occasionally personal social media accounts) still work. What you need to be prepared with is data and validated information about why your companies should work together. Your contact will have team members they need to confer with—the easier you make their job, the better.
There are other stories that stem from this article, for example, how to design your workflow around more detailed payer relationships or the negotiation of payer contracts so that profit remains intact. (Perhaps we will write further on those in the future!) If you are not sure how to begin contracting with payers, you can always reach out to a home medical equipment Group Purchasing Organization such as The MED Group or others in the field.
For today, using these steps to prepare and define value-based models in your company will better prepare you for changes on the horizon. We cannot exactly tell where the road will lead us at this point, but we can certainly start the journey and blaze a trail as we go.
