From Contracting to Collaboration

How to build collaborative muscle and become a trusted risk-sharing partner.

The traditional payer-provider negotiation is often a net-zero-sum game where each approaches the relationship with the mindset that for their team to win, the other must lose. The industry is accelerating the transition from the myriad of discounted fee-for-service models to truly shared financial accountability over a patient population. In our experience, whether these new discussions among payers and providers lead to improved patient outcomes and financial viability (savings or loss) depends on their ability to shift focus away from traditional, siloed contract negotiation and toward forging newly collaborative relationships.

To reach this desired state of shared accountability around clinical and financial outcomes, payers and providers need to define new shared goals that do not resemble traditional contract terms. Rather than focusing on provider process/behavior measures, the new arrangements are focused on patient outcome based measures. In this manner, payers and providers can both begin to align as an integrated team bound to well defined collective results. In this integrated model, the payer and each provider contributes what they do best, is informed by a shared analytics strategy and acts toward joint goals to improve patient outcomes and appropriately reduce costs.

Based on our experience working with several joint payer and provider projects, like Trenton Health Team, we see that highly effective teams recognize and operationalize four principles:

  1. Building trust among the integrated team is foundational to successful long term payer/provider collaboration. Shared goals, improved transparency, and a shared data/analytics approach are critical building blocks of operationalizing and reinforcing this trust. With a shared analytics strategy, teams achieve a common understanding of baseline performance which lets them quickly assess how joint performance is affecting outcomes. Initially, Trenton Health Team found it difficult to integrate behaviors because teams were not speaking the same language; the payers oriented around utilization definitions and providers oriented around clinical outcomes. By centering the discussion on a set of clinical and financial metrics, the conversation and then the behavior shifted. Rather than reviewing quarterly contract performance terms, participants now operate off the same objective patient outcomes measures and receive rapid feedback. With this shared insight, payers and providers focus their combined energies where they wish to have the greatest impact.

  2. Rapid translation of shared insights into targeted actions is necessary to transform outcomes. Without this translation, teams lack clarity about the actions necessary to achieve goals. In the absence of insight driven tasks, traditional care management programs found themselves trying to improve outcomes by increasing the number of patient tasks. Over time the teams drowned in tasks and lost sight of original care goals. Instead, Trenton Health Team relies on analytics to identify patients with modifiable risk factors and then focuses on applying a targeted set of patient goals to adjust these risks, i.e. follow up with your physician, avoid going to the Emergency Room. This approach arms the care team with the insight and time to determine the optimal approach for each patient and targets effort at the highest impact tasks. The joint management team influences this process by adjusting patient selection criteria to find patients who align with the quality goals and the capabilities of the team. This extension of analysis beyond reviewing dashboard charts to the creation of tangible, shared lists of patients who are amenable to specific actions has been transformative. Informed by analysis, the management team quickly modifies the team’s focus while communicating objective performance measures. Informed by objective measures, patient facing teams act with confidence to impact specific patients and benefit overall performance.

  3. Unified care plans act as a playbook ensuring joint efforts are aligned around improving outcomes and reducing costs with specific actions on individual patients. In much the same way that an athletic playbook documents the plan of action to move the ball down the field, unified care plans enable each member of the integrated team to focus on improving shared outcomes. Unified care plans align goals and tasks for each patient such that every member of the care team confidently and consistently performs the role they perform best. Historically, a major challenge facing payer/provider patient management has been that each team is executing disconnected and redundant care plans. Conversely, the Trenton Health Team unified care plans establish the role of the payer for patient identification and stratification while allocating patient goal and action management to the Trenton Health care team. In this model, each part of the team is uniquely responsible for impacting joint goals.

  4. Effective consumer engagement encourages participation in care planning and eliminates the need to mediate between payer and provider. Too often consumers are caught in the middle with mixed messages and inconsistent directions from various payers and providers involved in their care. Rather than becoming more active in their care, consumers get confused or frustrated and disengage. In collaborative payer and provider relationships, unified care plans direct interventions that provide one integrated approach. As a result, consumers more clearly identify the best ways to engage and start to establish behaviors that positively impact their own healthcare. This has been the case at Trenton Health Team where the efforts of the integrated payer/provider team result in direct consumer engagement in goal setting and action planning. Rather than spending time mediating between payers and providers, each consumer is empowered with a clear path to taking an active role in their care.

Organizations who embrace these principles benefit from having the experience and infrastructure in place to transform care delivery and prepare for ongoing changes in the marketplace. Having strengthened their collaborative muscle, these organizations are prepared to react rapidly and to reliably be a trusted risk sharing partner. By developing these collaborative skills, organizations are positioned to enter many virtual collaborations and, potentially, be more effective in improving care than by being forced into consolidation through merger or acquisition.