The Payer's Perspective
The Payer's Perspective | Aetna, Blue Cross Blue Shield of Tennessee, BCBST, NaviNet, Pay-for-Performance, P4P, Patient-Centered Medical Home, PCMH, Provider Payer Relations

Carriers Share Ideas to Boost Providers' Bottom Lines

A textbook example of a symbiotic relationship, payers and providers need each other to survive. Despite this co-dependent nature, the two groups often find themselves at odds. In today's complicated reimbursement landscape with increasing pressure from all sides to improve quality, eliminate waste and maximize efficiency, payers and providers must find new, sustainable ways to work together to remodel the healthcare delivery system.

Knowledge is Power

What you don't know can absolutely hurt you. Jayna Harley, Aetna's network market head for Tennessee and Arkansas, said unpleasant reimbursement surprises are a major source of frustration for physicians and practice administrators. The Nashville-based executive noted that improper coding, unfamiliarity with payment policies or misinformation about member benefits all impact the bottom line. Effective, real time communication is the solution.
"NaviNet is probably the most exciting connection we have with our providers," she said. "It's an electronic portal that gives them access to an entire suite of administrative tools. It's everything at one point … at one site … on a daily basis to do business with Aetna."
Aetna has been using the HIT solution for about two years with a major push in the last 12 months, and other payers have similar administrative portals to improve workflow and cut down on coding or billing errors. Harley said NaviNet includes Aetna's clinical payment policies so physicians and administrators know what is allowed on the front end. Furthermore, the site includes eligibility and benefit information for each member including co-pays and outstanding deductible, an online directory for referrals, claims status inquiry, and even an option to submit appeals.
"It's also the portal where they can submit electronic claims," she said. "They can enter CPT codes, and Aetna will basically tell them here's how we will pay that claim. They can know exactly what the payment rule is for that code combination. It takes the surprise out of how a claim is going to be adjudicated."
Harley noted providers simply need an Internet connection to use the NaviNet technology, which is available at no charge. With NaviNet's real time capabilities, office staff can determine the patient's payment responsibility for any given visit and collect the full or partial balance on the front end. "That helps significantly with cash flow, which is a concern for every business," Harley pointed out.
She added such technology solutions not only save time, money and resources, but most … including NaviNet … include a clinical component that informs providers of evidence-based best practices.

Reimbursement Enhancement

On the premise that good medicine is good business, BlueCross BlueShield of Tennessee (BCBST) is partnering with physicians to improve the quality of care dispensed. The patient-centered medical home (PCMH) is an example of one such partnership with financial benefits for practices.
"The patient-centered medical home is geared primarily toward primary care physicians," explained Thomas Lundquist, MD, vice president of performance measurement and improvement for BCBST. "The goal from a payer perspective is to help bolster care in the primary care setting."
To do that, BCBST is willing to invest in primary care practices to assist with efficiency and quality. Lundquist said the payer typically provides a stipend to help purchase needed HIT. Additionally, BCBST helps fund the hiring of an additional care coordinator, typically a nurse, to take a proactive outreach approach in the community. Currently, the focus has been on managing six chronic conditions: diabetes, asthma, congestive heart failure, hypertension, coronary artery disease and chronic obstructive pulmonary disease.
Partner practices also receive a higher per member/per month rate for those that sign on to the PCMH because the expectation is there will be more interaction between the patient and provider. Finally, there are semi-annual gainsharing opportunities for physicians who meet quality benchmarks. Lundquist said BCBST believes that partner practices should receive a share of the savings that result from a redesigned, more efficient care delivery system.
"It's really about getting people to rethink their workflow and reach out to patients," said Lundquist of the PCMH model. "It's trying to optimize the delivery system to be more proactive."
Lundquist said the program began in 2008 with three pilot practices across the state. There are now close to 20 sites representing nine practices, and BCBST is in discussion with roughly the same number of practices for future expansion.
Like other payers, BCBST has also embraced pay for performance (P4P) initiatives. "P4P spans not only primary care but specialty care and the hospital setting," Lundquist said. He added that BCBST has started working with just about every medical specialty to set up initiatives specific to the practice's core competency.
"We reward good performance both on the quality metric and cost efficiencies we believe result," he said. "Really, the bottom line here is value creation … both quality and cost efficiency."
Mindful that best practices should decrease hospitalization rates and length of stay, Lundquist said BCBST is working with hospitals to mine patient safety data and reward hospitals that consistently meet quality benchmarks. "We don't want hospitals to lose from doing the right thing," he pointed out.
A smaller subset of the P4P movement is pay for reporting, which is about connecting data sources. "We need clinical data to show that as you improve quality, the cost efficiencies come," Lundquist explained. He added that intuitively payers and providers believe this to be true but noted it's important to prove the working theory.
For each of these programs, Lundquist said, "The bottom line is demonstrating quality and creating value." In a win/win/win scenario, BCBST's clients benefit from lower costs, patients receive higher quality of care, and providers are reimbursed at higher rates.