Health plans play key roles in integrating care for people eligible for Medicare and Medicaid. One of the most critical is engaging providers (i.e., physicians, hospitals, nursing facilities, home- and community-based services providers) in order to ensure that the needs of their dually eligible members are met. This is true regardless of the integration mechanism — financial alignment demonstrations, Medicare Advantage Dual Eligible Special Needs Plans, or Medicaid managed long-term services and supports (MLTSS) programs. Because the accelerating changes in the organization of care for Medicare-Medicaid enrollees can lead to uncertainty for providers and potential tensions with managed care, health plans should develop well-considered approaches to provider engagement.
Over the last year, Independent Care Health Plan (iCare) has worked with six other health plans to advance integrated care for dually eligible beneficiaries through PRIDE (PRomoting Integrated Care for Dual Eligibles), a project directed by the Center for Health Care Strategies (CHCS) and supported by The Commonwealth Fund. During a recent conversation with CHCS and other PRIDE members, iCare explained how health plans can better engage providers.
How Can Health Plans Better Demonstrate Value to Providers?
To engage providers, health plans must prove their value. Potential strategies include:
1. Helping providers to explain integrated care programs
Beneficiaries typically have two questions about integrated care programs when they are deciding whether or not to enroll: Will I be able to keep my providers? and Will I still be able to receive the same care and services? Health plans need to move beyond marketing jargon to give providers clear information about the integrated care program that can be relayed to patients. Health plans can work with states to develop educational materials to help providers respond to such questions. For example, California has a Physician Toolkit on its demonstration website; Massachusetts maintains a list of providers’ frequently asked questions; Virginia holds town hall meetings to bring together health plans and providers; and Wisconsin supports a website that allows plans to access and send state-vetted information to providers who may have questions about the program.
2. Extending providers’ reach
Providers serving people with complex needs, including dually eligible individuals, are often frustrated by their inability to see what’s happening in their patients’ lives beyond the walls of their offices or facilities. The assessments performed by health plans for integrated care enrollees are often done in the person’s home and are more extensive than in-office provider assessments. The health plan’s in-home assessment can identify fall risks, inadequate food resources, and expired or untaken medications — all things that most providers would otherwise never see. Health plans should share these comprehensive assessments with providers, alerting them of unmet patient needs, change of condition, treatment reactions, and other potential concerns. Health plan assessments can give providers a more complete view of patients, minimize the need for repeated time-consuming and burdensome assessments, and promote better communication between plans and providers.
Health plans can also offer providers access to care management resources that can extend the reach of office-based primary care, encouraging appropriate utilization, and extending the physician’s ability to observe or follow-up in the home. Under its Fully Integrated Dual Eligible Special Needs Plan contract with providers, iCare’s web-based care planning system enables them to access the care plan remotely. This not only gives them access to important contextual information about their patients, it also enables providers to insert and/or upload case notes and alerts, thereby enriching the information available to all concerned about the patient’s care.
3. Leveraging integrated care activities to improve quality measures
Serving dually eligible individuals with complex care needs may make it more difficult for providers — physicians, hospitals, nursing facilities, home health agencies — to score well on certain quality measures. However, many of the activities that health plans perform in integrated care programs (e.g., conducting functional assessments, coaching members on medication adherence, etc.) can directly impact provider quality measures. By participating in integrated care programs, providers can potentially improve their performance on quality measures and, in the future, may fare better in value-based payment arrangements. For example, iCare’s advance practice nurses are assigned to work on-site at select skilled nursing facilities (SNFs). The nurse practitioners develop familiarity with the SNF’s capabilities and staff, allowing iCare to appropriately deliver the correct services during a SNF stay (e.g., flu shots that improve scoring on quality measures).
How Can Health Plans Build Relationships with Providers?
Traditionally, a health plan’s primary point of contact with a provider practice or facility is a contract/ business manager. A contract manager’s primary focus, however, is not on improving the quality of care or facilitating the integration of a broader array of supportive services. Instead, health plans can collaborate with provider-based quality “czars” — becoming more and more common in larger provider organizations because of star ratings and value-based purchasing initiatives — who oversee quality measurement and improvement.
For example, in working with Aurora Health Care, a major provider organization in Wisconsin, iCare realized the benefits of identifying and partnering with a provider-level quality champion. iCare now has bi-weekly meetings with Aurora staff in which they review care planning and utilization management information on their patients with complex care needs. With other provider organizations, iCare has recruited providers to participate on its board committees, thereby allowing providers to understand iCare’s strategic approach and have input into iCare’s decision-making processes.
Provider Engagement is Key to the Success of Integrated Care
Integrated care plans need providers not just to build networks that meet the diverse needs of enrollees, but also to inform and counsel individuals contemplating their enrollment options. For health plans, provider engagement means advancing the mission and purpose to which the provider is also dedicated — connecting with the right people and demonstrating how the plan can provide value to the beneficiary, the provider, and the plan itself.
