The future of American healthcare relies on insurance plans and healthcare providers working together, and America’s Health Insurance Plans (AHIP) is one association facilitating that cooperation. Elizabeth Goodman, Vice President of Government Affairs and Innovation at AHIP, argues that the sharing of information between providers and insurance plans — what is called a value-based arrangement — allows for the best quality of care for patients. “We firmly believe that the best care is delivered to patients when the plan and the provider’s incentives are aligned,” she said. “If you’re in the industry and you’re not operating or unwilling to share with the plan and move to a value-based care model, you’re not delivering the best care you can for your members.”
The magic number
The aims of value-based arrangements are threefold, as Danielle Lloyd, Senior Vice President of Private Market Innovations and Quality Initiatives at AHIP, explained. “The intent of value-based arrangements is to improve the quality of care, reduce the cost of care, and improve the patient experience of care,” she said. “So, consumers will see distinct benefits from being in these programs in terms of the quality, cost, and patient experience.”
Lloyd outlined how the shared goals of providers and plans are often negotiated in value-based arrangements. “There is frequently something called a joint operating committee, where the plans and providers sit down and talk about what needs to be done and determining what the plans need to do, what the providers need to do, and what they want to share,” she said. “From the provider perspective, one thing is to reduce the burden associated with clinical practice and administrative tasks.”
Behind the scenes
“Usually the plan and the provider will get together annually,” Goodman said. “They’ll be able to see how they’re doing against the goals that we’ve jointly set, and what kind of changes they need to make in the way that they deliver care to our members to achieve those goals.”
Typically, insurance plans will share data and analytics with the primary care providers. “The plan, which gets all of the data around prescribing patterns and billing patterns, is sharing that information back with the provider so that they are able to judge their performance relative to quality goals,” Goodman said.
Lloyd elaborated that the sharing of data helps improve the patient’s experience. “The need for data, not just on the individual physician’s performance but what care a patient is receiving outside the office, is very important to them to be able to successfully coordinate the patients care,” Lloyd said. “So, the data analytics piece is very integral to that care coordination.”
In the real world
An example would be if a patient visited an emergency room, that data would be shared with the primary care provider so that they might be advised about how to offer better quality care on the patient’s next visit. “The provider is aware of care gaps because of the data exchange, and the plan is able to assist the provider in closing those gaps in care,” Goodman said.
Aside from quality of care, groups like AHIP can ensure that the cost of care remains affordable. “Costs are controlled so that the patient as a purchaser has more affordable insurance coverage, and as a patient receives higher quality care,” said Goodman. For plans, providers, and patients alike, entering into these value-based arrangements sooner rather than later will benefit everyone. “We’ve reached a tipping point,” Lloyd said, “where it’s clear that value-based arrangements are here to stay and are to some extent the new normal.”