Football season may be over for the year. But for payers, the idea that “as goes the quarterback so goes the team” has never resonated as loudly as it does now — and will in the future — in the new world of Sustainable Health Communities.
Historically, payers have had an important, yet somewhat fundamental role: to select and manage risk, to negotiate favorable provider contracts, ensure its network is comprehensive, design appropriate benefit plans, manage care and provide appropriate customer service. Now, as we enter the era of Sustainable Health Communities, payers take on a new and even more critical function as the enabler — the head coach of the team where the primary care physician (PCP) is the “quarterback” in the local health care delivery system.
While the PCP will be in charge of care coordination when it comes to the patient, the payer will be providing (in other words, in large part, funding and bringing to the table) all the information, intelligence, connectivity, work flow and supporting services that will lead the community to improved and sustained outcomes in the local health care community.
The flow of information from the payer to all community constituencies — and the technology, connectivity and workflow that enables it to happen — is invaluable within a Sustainable Health Community and fundamental to reaching its lofty goals. To successfully support the physician, the payer needs to ensure not only that best-practice data reaches the point of care, but also that the physician can better communicate with and engage the patient during and after the visit. This means everything from supplying tools such as EMRs to extending the physician’s reach through email, video, social media, etc. Payers also need to empower the patient by facilitating health programs and disseminating information that actually reaches the patient and makes them act on their own behalf. Easier access to information, intelligence and knowledge can help patients across the board — from better management of chronic illnesses to understanding which diagnostic tests/preventative medicine may be the most appropriate to which providers have better outcomes.
In the Sustainable Health Community model, physicians are incented not by how many tests they run or procedures they perform. Instead, the payer awards physicians for keeping the patient healthier overall, and for meeting certain quality care metrics. For example, if an overweight patient complaints of joint pain, the physician doesn’t simply run a few tests, prescribe an NSAID and schedule a follow-up appointment for a few months later. The patient also receives information on programs about weight loss, and has several regular touch-points with the physician (through email, social media networks, etc.) to encourage better health outcomes. And, when those metrics are achieved, and the patient has lost weight, has less severe pain (reduces or stops all medications, etc.), the payer rewards the physician. Payers pay for quality not quantity, value not volume.
Within the Sustainable Health Community, the payer serves as an enabler, teaming with and supporting all the constituents including employers, consumers and patients and sharing in the risks and rewards. In fact, in this new model, the leverage game of the past is over for payers/providers (leveraging membership or geography or services) – and those that focus less on price points and more on partnering, driving efficiencies, facilitating programs and improving patient care and overall population health will come out the winners. And, most importantly, we’ll have a healthier health care system and population.