Downshifting Risk Through Payer-Provider Partnerships on the Road to Value-Based Care


COVID-19 forced providers and health plans to hit the brakes on traditional approaches to managing care—and then continue the journey in another vehicle, at a pace that seemed to approach 100 miles per hour.

COVID-19 forced providers and health plans to hit the brakes on traditional approaches to managing care—and then continue the journey in another vehicle, at a pace that seemed to approach 100 miles per hour.

Regulatory changes designed to increase access to care were issued at a frantic pace. Coding guidelines changed frequently as clinicians dealt with a virus never before documented. Meanwhile, the pandemic reshaped consumers’ healthcare purchasing behavior, with up to one third of patients delaying needed care due to safety concerns or financial fears.

Health plans saw claim volumes drop significantly as in-person visits were limited to the sickest patients and preventive care was postponed. Suddenly, payers found that the data they relied on to identify and manage risk—claims data that could indicate changes in health status—slowed to a trickle. Major payers began to consider: “How can we work with healthcare providers to ensure members receive the right care and that provider relationships remain intact during the pandemic?”

Healthcare organizations’ experiences during year one of the COVID-19 pandemic point to four ways to strengthen payer-provider collaboration and reduce risk—lessons that can be applied during the pandemic and beyond.

1.) Work with providers to develop a longitudinal view of members’ health history.
Research shows that comprehensive population health initiatives for managed care patients decreased COVID-19 mortality rates, even among high-risk members. When providers participating in managed care programs use data to determine which patients are most at risk for contracting COVID-19, they become better able to monitor these patients closely and treat them early—ideally, in outpatient settings. This reduces patients’ risk for life-threatening complications. More frequent contact with high-risk members also helps optimize care for existing chronic conditions and increases member engagement.

Health plans can empower providers to improve health outcomes and reduce risk for their most vulnerable members by sharing data that can provide a 360-degree view of members’ health history, such as treatment that takes place across multiple sites of care. Access to data not only informs clinical decisions at the point of care, but also helps predict members’ risk of COVID-19 infection, their likelihood of experiencing an adverse event and their COVID-19 mortality risk. With this information in hand, payers and providers can jointly develop interventions that keep members healthy and support better COVID-19 outcomes.

2.) Bolster providers’ response by sustaining the financial health of those in shared-risk contracts.
Fee-for-service providers took a financial hit during the pandemic, when in-person visits came to a sudden halt. Unless providers had the capability not only to launch virtual visits, but also to engage at-risk members in telehealth and e-visits, they struggled to stay afloat during the early months of the pandemic. Even now, some have struggled to regain pre-pandemic volumes for patient visits. Some payers offset financial risk for providers by advancing incentive payments for providers in shared-risk contracts based on prior-year performance. They also collaborated with providers to identify members who faced increased likelihood of contracting COVID-19. These included not only members with comorbidities, but also those with chronic conditions that might not be well-controlled during the pandemic, such as hypertension.

For example, a review of pharmacy claims data can pinpoint which members are not keeping up with prescriptions for hypertension, cholesterol, and more. From there, health plans and providers can work together to engage members and overcome barriers to optimal health behavior, such as by making medications easier to afford and access. The goodwill demonstrated through advance payments and information sharing helps solidify payer-provider relationships, establishing a foundation for value during the pandemic and afterward.

3.) Make it easy for providers to improve population health.
During the pandemic, health plans communicated with providers more frequently around ways to improve the health of specific populations. Some plans gave providers curated lists of members who would benefit from follow-up. These payers then facilitated connections between providers and members so members would continue to receive the right care at the right time, despite the obstacles the pandemic presented.

For example, Highmark Health found that the use of secure texting with members, rather than phone calls, resulted in higher member engagement. As a result, two-way texting between this health plan and its members rose 450% year over year, connecting members with transportation for health appointments and COVID-19 testing or vaccinations; home health support for members with chronic conditions; and basic necessities, such as groceries, to maintain members’ health. The health plan also arranged weekly calls with 100 providers across the nation that enabled providers to share best practices in care during the pandemic. Collaborative approaches such as these deepened the impact providers and payers had on members’ health during a public health crisis.

4.) Be vigilant around fraud, waste, and abuse prevention—but don’t let a small group of bad actors influence yourentire approach.
The pandemic underscored the need for payers to have a strong fraud, waste, and abuse program: The Office of Inspector General conducted a nationwide healthcare fraud takedown in September 2020, which identified more than $6 billion in alleged loss including $4.5 billion related to telefraud schemes. Certainly, health plans saw unusual instances of telefraud and other forms of abuse during the pandemic, such as a telehealth surgery claim or a claim for a hip replacement procedure for an intubated COVID-19 patient. But while establishing a program to eliminate waste is essential, payers should be careful to do so while protecting relationships with the majority of providers that are committed to following the rules.

One way to accomplish this is by establishing a “gold card” approach in which COVID-19 claims from providers that have a strong track record for payment integrity are automatically pushed through for reimbursement. This ensures that providers have the financial footing to continue to expand access to care for vulnerable populations, such as by bringing mobile COVID-19 vaccination clinics to rural, inner-city and suburban communities where residents struggle to sign up for appointments due to lack of internet access, transportation and more.

A New Road for Payer-Provider Partnership

The COVID-19 pandemic thrust payers and providers into unexplored territory, but those that teamed up to meet members’ care needs and eliminate disparities in care were better positioned to reduce risk—both clinical and financial. In 2021 and beyond, applying these lessons in collaboration will deepen payer-provider relationships and accelerate the move toward value and better member outcomes.

Emad Rizk, M.D., is president and CEO of Cotiviti. Brian Setzer is executive vice president of Enterprise Planning and Operations at Highmark Health.

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