How to Build Trust and Collaboration Between Health Plans and Physicians

Mike Grodus, Director, Healthcare Transformation Healthcare Consulting

health plans

One of the best ways to maximize revenue under value-based care arrangements is for health plans and physicians to team up and work collaboratively on health care transformation. By building a strong and meaningful partnership, health plans and physicians can achieve higher quality, provider better care and improve patient satisfaction. However, sometimes this is easier said than done. There are many obstacles and barriers to collaboration that must be addressed in order for a successful partnership to evolve. Ultimately, it all boils down to communication and trust.

From a physician’s perspective, the health plans may be viewed in a negative light due to cumbersome prior authorization processes and other medical management policies. It is hard for physicians to partner with health plans on quality improvement if they feel that the health plans are limiting their ability to provide the member with necessary medical care and services. On the other hand, the health plans may be frustrated that physicians don’t follow the specified rules and are continually requesting exceptions or special treatment. Despite their differences, with the right level of support and infrastructure, health plans and physicians can work together to achieve their shared goals under value-based care arrangements.

Today, many physicians are connected to larger organizations, such as physician organizations (POs), physician hospital organizations (PHOs), and independent physician associations (IPAs), or they are employed by a health system. Typically, a formal PO structure includes some level of staffing to perform the necessary practice transformation services. The existing physician organization structure can be used as a foundation to set up the infrastructure needed to enable success. Health plans can leverage these organizations to communicate with physicians and provide additional support and resources to create meaningful relationships.

Strategies for Health Plans to Engage with Physicians

There are many actions that health plans can take to initiate contact, build trust, and maintain ongoing positive relationships with physicians and POs. Here are a few strategies that have proven successful for Medical Advantage Group’s clients:

  1. Initiate quarterly Joint Operating Committee (JOC) meetings with POs. This forum will greatly enhance the communication between both parties. Some key components of a successful JOC meeting include:
      Bring “value added” information to the meeting, including quality and utilization performance reports at the physician group level and at the individual physician level.
    • Define and jointly agree on the areas needing the most improvement and agree upon the strategies and action steps.
    • Decide how the health plan and the PO staff can work in conjunction with each other to educate the physician practices. For example, the PO staff agrees to visit the physician practice monthly and the health plan would supplement that with a visit of their own.
    • Share itineraries and information covered at the practice visits, in order to allow reinforcement of practice objectives and focused areas of improvement.
    • Develop and share reporting and analytics among the organizations to monitor progress and identify barriers.
    • Meet on a regular basis to review results and desired outcomes which will provide a checkpoint to ensure success or to modify joint strategies, as needed.
  2. Properly incentivize physicians.
    • Make it financially worthwhile for the physicians to focus on quality measures, utilization management, or cost containment. Physicians need to feel that their efforts are being rewarded. Appropriate payments to incentivize physicians are one of the more significant drivers of physician participation with the health plan.
  3. Provide coding education.
    • Educate physicians and billing staff on the importance of appropriate medical condition coding and how hierarchical condition category (HCC) coding impacts their patient’s risk scores. The PO staff can also be informed and serve as advocates to encourage physicians to focus their efforts on the coding initiatives.
  4. Initiate physician leadership meetings.
    • Schedule periodic medical leadership meetings with participation from key POs or physician groups to gather physician input on the health plan’s processes, procedures, medical treatment protocols, etc. Involving physicians in the decision making will give them a sense of ownership and commitment to what is ultimately implemented. If larger forums are not possible, scheduling one-on-one medical director meetings can also produce positive communication and improved relations.

There are many positive benefits to health plans from the activities described above, including improved quality scores, improved risk scoring through proper coding education, and medical cost management. The improved results will reflect positively on the health plan’s NCQA ratings, Medicare STAR ratings, and other quality ratings. It will also enable competitive premium pricing due to lower medical costs, which will ultimately lead to increased membership.

There are many positive benefits to health plans from the activities described above, including improved quality scores, improved risk scoring through proper coding education, and medical cost management. The improved results will reflect positively on the health plan’s NCQA ratings, Medicare STAR ratings, and other quality ratings. It will also enable competitive premium pricing due to lower medical costs, which will ultimately lead to increased membership.

Strategies for Physicians and POs to Engage with Health Plans

There are many actions that physicians and POs can take to create and maintain open communication and positive working relationships with health plans. Here are a few strategies that have proven successful for Medical Advantage Group’s clients:

  1. Invite the health plans to attend large PO meetings. This will allow the health plans to explain their programs and the benefits of participation directly to the physicians. It also allows for health plans to answer questions and resolve any issues or problems. By bringing health plans to the table, POs can improve communication and help physicians to see the value of the relationship.
  1. Establish strong working relationships between the PO’s staff and the health plan’s staff to leverage actionable reporting, resource use, and issue resolution.
  1. Clearly communicate and set expectations about what is needed from the health plan for the physicians to be successful. This can include requests for technical support, data feeds, staff augmentation and support, analytics and reporting, etc.

Close working relationships with health plans will promote improved communication, which will translate into more timely issue resolution, joint agreement on contract terms needed for a productive long-term relationship, health plan program support, and improved financial performance.

Building Communication and Trust Yields Positive Benefits

Physicians and health plans that want to maximize success under value-based care arrangements need to overcome barriers and leverage each other’s knowledge and resources.

In today’s complex health care environment, there are continued pressures on both health plans and physicians due to regulatory changes, as well as price, cost and quality demands from purchasers. In addition, there are emerging threats from new competitors and less costly plan structures, including limited or narrow network plans that may shut out some physicians entirely.

It is in the best interest of health plans and physicians to find ways to work more closely to achieve their shared goals. The key to success lies in building trust through improved communication and collaboration.