Physicians, Payers, and Patients: Partnering for Success

Fee-for-service initiated a healthcare system that led to skyrocketing prices, which eventually undercut the ultimate goal of medicine: providing patients with high quality care at the best cost, for the optimal patient outcome. Physicians and payers often feel at odds in their sometimes competing methods of arriving at the same goal of patient well-being. These challenges have ushered in the era of value-based care, presenting a new set of obstacles, along with significant opportunities for success for both physicians and for payers.
I’ve spent my career working at the nexus of payers and providers.  This work has included years of working in the trenches of payer-provider contracting negotiating large, complex fee for service contracts, leading national cost of care programs designed to implement initiatives to control the rise in medical costs piece by piece, and later working to implement a nationwide primary care value-based incentive model as an effort at more comprehensive cost and quality improvement.  Today I lead a large innovative independent physician organization in Georgia. It is clear to me that while both parties (providers and payers) want the same end goal for patients — better care at the best cost — the optimal tools and incentives have not been in place to facilitate a complementary relationship.

Success Requires Discipline

We are unquestionably in the midst of a significant financial transformation within the healthcare delivery system. While many payments still come in the form of fee-for service, changes are already taking place, moving payments and future opportunities towards risk, oriented around performance. The migration of Medicare programs has set the stage for commercial payers to follow suit, and the market is quickly transforming to a model that requires managing and assuming risk.

The harsh reality is that the skillset required to be successful in these models does not come to any individual or organization overnight. Success requires a disciplined process of building capabilities over time. Care coordination, technology integration, revenue cycle management, and narrow networks are a few capabilities with which physicians must engage.

Many fear that participating in the evolution happening right now within healthcare will involve a lot of wasted money and effort with no reward. That fear is warranted. The correct, pragmatic approach providers can take is to partner with an organization that is evolving to manage those risks and outcomes in a measurable manner.

Why A Wait and See Approach Won’t Pay Off

Organizations that have an eye towards the future of managing risk, and are accountable for the totality of cost wrapped up in managing a population, are moving in the right direction. Contrary to what some may believe, the wait and see approach is really not the safe bet. The risk of waiting to see how value-based incentive models play out is embracing the risk of falling behind, as the pace of financial changes within healthcare accelerates.
I liken not preparing for value-based incentive models to telling friends you’re going to run a marathon in two years, and then waiting to train until you can win the race. You can’t do that. You have to work hard, in advance, to achieve future success.
The reality is that financial rewards will take time to materialize. The crucial idea for independent physicians to understand is that payer partnerships provide the opportunity to ramp up and prepare for financial rewards in the future. It goes back to planning and preparing so that you can get out there and finish the marathon.

The Ultimate Goal: Provide Better Care at a Better Cost

Ultimately, I believe that physicians need to give thought to ways they can partner with payers for the benefit of the end consumer; the patient. The reality is that the healthcare system is fragmented and unaffordable for everyone, payers, physicians, and patients alike. Our goal is to increase positive outcomes and reduce costs through a model that will produce a winning solution over time.  As you consider what the future will look like for your practice, consider the risks of inaction, the opportunities for financial success, and the pragmatic approach necessary in any successful physician-payer partnership. You can retain your independence while engaging in partnerships that equip you for the future. Seek them out and know that your decisions today will influence not only your success, but your patient’s success, in the future.
Interested in learning more about how you as an independent physician can partner for success with payers? Attend this live Web Seminar on what it takes to be a successful independent physician and navigate the transition to value-based care. Tune in on Nov. 30, 2017 at 2 pm ET/11 am PT. Featured presenters include Amy Cheslock, President of Privia Medical Group – Georgia, Dr. Jim Sams, Physician Executive of First Georgia Physician Group, and Shalini Wittstruck, Regional VP of Provider Solutions, Anthem Blue Cross and Blue Shield of Georgia.