Conversations in hospital circles have been dominated by discussion of Centers for Medicare & Medicaid Services-sponsored accountable care organizations. Meanwhile, another trend gradually has gained traction throughout the health care industry: partnerships between hospitals and commercial payers. Collaborative partnerships between Eastern Maine Medical Center in Bangor and CIGNA and between Sharp Rees-Stealy Medical Centers in San Diego and Anthem Blue Cross Blue Shield provide some early takeaways in this brave new world.
Both hospitals and commercial payers recognize the need to increase value within the health care system. Dick Salmon, M.D., national medical director for performance measurement and improvement at CIGNA, notes that the current environment encourages providers to search for value beyond physician alignment strategies and traditional payer relationships, and to collaborate on informatics and clinical programs. "We want very much to be more than a payment partner," Salmon says. "We believe very strongly in our ability to be more."
Though the organization and payment models of these types of partnerships differ, in a successful relationship both parties must display an institutional commitment to improve population health. Describing CIGNA's decision to partner with EMMC, Salmon says the company looked for one main thing: C-suite passion in pursuing the Institute for Healthcare Improvement's triple aim — better care for individuals, better health for populations and lower per capita costs. From Salmon's perspective, leadership buy-in creates the foundation to make the relationship successful.
Hospital-payer partnerships have many benefits. Some benefits are not realized immediately and require a significant time commitment and up-front financial investment from both parties. Donna J. Mills, senior vice president and CEO at Sharp Rees-Stealy Medical Centers, points to ongoing efforts to coordinate data analysis with Anthem. The first year has been spent arranging the information systems to better link the two groups, reducing duplicate analyses. Already advanced in their analytics, Sharp is capitalizing on the new partnership benefits to dive deeper into prospective data, even employing physicians as data analysts to provide another level of analysis beyond typical clinical capacity.
CIGNA furnishes several data reports to partners, including patient-specific utilization of out-of-network providers, quality performance metrics and high-tech usage rates. Patient-level analytics are provided daily, while performance analytics — comparing providers within the same market — are released semiannually. For example, evaluating emergency department usage by CIGNA patients at EMMC to other CIGNA patients in the same market showed that EMMC's figures were statistically higher. In response, EMMC opened urgent care centers with extended hours, reducing the number of medically unnecessary ED visits.
Increasing care coordination may involve a significant up-front investment to hire more employees. A majority of hospitals in payer partnerships receive either a financial grant or additional reimbursement per member per month to employ these new coordinators in the provider setting. EMMC care coordinators contact any patient who has visited the ED three or more times within a six-month period to provide follow-up care sooner.
While large up-front costs and the lack of proven results may deter some payers and hospitals from forming partnerships, Mills believes the current economic and regulatory environment demands a change in care to improve population health. Mills emphasizes, "This is a different way of doing business. … Consumers, employers and payers need to pay for outcomes and value, and we need to demonstrate it."
Jill Seidman, MPH, is a program manager at the Health Research & Educational Trust. Visit Hospitals in Pursuit of Excellence at www.hpoe.org to explore these and other topics.