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Provider relations are key when incentives are absent


In lines of care where improved outcomes aren’t paired with bonus payments, motivating providers and members to close gaps in care can be difficult.

When providers earn incentives for closing gaps in care, change can be as easy as providing them with data on the why and how. For commercial lines, however, where incentives are not offered, plans often struggle with ways to engage providers and members to improve outcomes.

Janine A. Sala, associate director of clinical quality-HEDIS Operations at UnitedHealthcare led one of the final sessions on June 30 at Qualipalooza, the second annual RISE quality leadership summit, June 29 to 30, in San Antonio, Texas. The session, “The Commercial and Group Plan Perspective-Provider and Member Engagement,” invited discussion from attendees to learn how difference plans motivate providers to help close gaps in care when incentives, such as bonus payments, are not offered.

Sala says while she was asked to lead the presentation, she was very interested to learn what others had to offer. For commercial plans, the focus on gap in care closure is a fairly new thing. While UnitedHealthcare has built programs for gap closure with its Medicare and Medicaid lines, there is little room for incentive on the commercial side.

Health plans typically tailor interventions for improvement in care gaps based on the plan type. Medicaid focuses on providers because patients can often be difficult to reach. Medicare is tailored for seniors and interventions focus on reaching out to members to improve gaps in care. In commercial plans, it’s more difficult to nail down an intervention that works because members have so many different needs and obstacles.

What UnitedHealthcare has started doing is to focus on running pilot programs with some of the larger employers in the commercial plans, targeting interventions that offer wellness programs and telemedicine. A monthly mobile clinic is offered at one of the largest employer sites, Sala says, and allows employees to stop in without using break time or paid time off to address wellness concerns on-site. The employer offers 30-minute slots to workers and even gives them additional motivation by providing employees who take advantage of the service with a $25 gift card of their choice.

The pilot has been well-received so far, and is being complemented with services like outreach to help employees make appointments, offering weekend appointments reserved specifically for commercial plan members, and utilizing e-visits.

The key, said Sala, is to identify what obstacles the members have in accessing or receiving care, and and working to resolve them.

“Health plans need to focus on what barriers the member has,” Sala said.

UnitedHealthcare is also working to build better relationships with providers groups on the commercial side. While commercial plan members usually aren’t included in programs like STARs or others that are married to state or federal bonus payments, providers still benefit from closing gaps in care in the commercial population.

To do this, UnitedHealthcare sends clinical practice consultants, often a registered nurse, to practices armed with gap in care reports and educational materials, but Sala says the first, often overlooked, step is to build relationships.

“It seems simple, but that’s the first thing we work on,” Sala said. “I think sometimes the health plans miss that piece. We’re all business but sometimes you need to fluff it up a bit.”

Once those relationships are established and providers realize the plan is not trying to do anything beyond help them, improvement comes easier. In fact, Sala says, clinical practice consultants are reporting that providers are not even asking for incentives, but rather are happy that the plan is providing them with education that will improve workflow and outcomes. The changes might be something as small as the verbiage in a note that leads to quicker claim approval and reimbursement, or what information is included in a particular flowsheet.

“We’ve seen compliance increase just with these small tweaks. It’s not making them do extra, it’s changing verbiage or the way they were documenting things,” Sala said.

Providers can then use those same lessons to apply to other lines, including those that offer incentives for closing gaps in care.

“It’s a win-win situation on the health plan side, on the provider side, and on the member side,” Sala said. “It’s a simple concept but that relationship building piece can be very difficult.”


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