Show Coverage: Align products with care models

Providing the right care at the right place at the right time at the right price has plagued the healthcare industry for decades. While the mantra isn’t new, integrating innovative products, reimbursement and the care model holds promise as a solution, said Sam Muppalla, executive vice president, chief strategy and marketing officer, Portico Systems. He spoke during a Thursday presentation on aligning these three elements.

“The integration needs to be easily administered, enable payers to react quickly and include a network with incentives, while lowering administrative costs,” said Robert Kritzler, MD, deputy chief medical officer, Johns Hopkins Healthcare.

“Developing dynamic products and networks, transforming reimbursement from fee–for–service to shared savings or bundling and moving from individual provider care to a team approach should fuel better relationships between patients and providers,” Muppalla added.

Dr. Kritzler challenged the benefits of capitation by questioning its lack of information on quality. While information technology may be expensive, he is confident that the result will be a sufficient return on investment as technology nimbly coordinates all processes needed to deliver care.

Among the products are flexible designs, such as tiered, narrow and client– or patient– specific networks, which not only serve as opportunities to stand out among the competition but also to provide the right value to the right population, decrease administrative costs and enable affordable and accessible care.

“Consumers do not react well to restrictive choice, such as fewer providers,” Dr. Kritzler said, “but will be more accepting if the options provide value. If they want more choice, they have to be willing to pay for it.”

To create incentive–based reimbursement, Dr. Kritzler recommends provider incentives for managing care on the front end with gain share at the back end–away from piecework and payment for volume of care.

Muppalla’s reimbursement model is not so simple. It is a studied game of mix and match, a hybrid model combining fee–for–service, capitation and other methodologies to provide collaborative and accountable care, he said.