Navigating alternative payment models while preserving quality and value

· 6 min to read

Many health care professionals are asking if it is possible to preserve quality and value in our current health care system, especially when the number of alternative payment models seems as varied as the number of stars in the sky. With the understanding of today’s health care system in mind, you may be wondering why physicians focus on quality and value. For most health care providers, it all goes back to why they have decided to pursue this career in the first place.

My journey in health care began as a family medicine physician treating patients from all stages of life – from pediatrics to geriatrics, from house calls to the hospital. Over the course of my career, helping patients overcome and manage illness, manage their health, regain function and take control of their lives has been very fulfilling.

Dr. Melissa Urrea CHCQM, Senior Executive Medical Director, naviHealth
Dr. Melissa Urrea, CHCQM
Senior Executive Medical Director

The challenge was navigating payment for the quality services I provided. I realized that in order to improve the health care system, my role in health care needed to expand. To help patients, payors and providers, I needed to do more than serve one patient at a time. I had to engage in population health to educate and understand populations and utilization management to ensure our fixed and finite resources were used appropriately to be available to everyone. By doing this, I could impact our health care culture for the benefit of more than just one patient at a time.

This career expansion has been girded by certain principles. As a physician, I took an oath to do no harm to patients, but in terms of global health care, not doing harm should be the minimum expected standard; not define the pinnacle of success. It is imperative for me to work for a company that aligns with my Hippocratic oath. In addition, I wanted to work in a culture that helped people thrive and not simply survive. Happily, I can say that during my tenure as an executive physician supporting population health and utilization management, I have had the privilege of working on behalf of hospitals, hospital systems and health care companies and all of them have focused on doing what is right for the patient.

So, let’s return to the topic at hand: How do we navigate toward quality and value in our current health care system regardless of payment model?

Health care providers and payers can utilize a robust clinical model as their north star to guide them to the safe shores of quality and value. From my experience, there are three critical elements necessary for a successful clinical model: technology, talent and relationships.

Why build on these three elements? A clinical model that only utilizes regulatory criteria is like rowing a rowboat with only one ore: there’s a lot of movement, lots of water is splashing, but there is no progress and sometimes you go in circles! Similarly, a clinical model that only focuses on criteria, for example, will transition patients from one location to the next but with no goal or direction it’s impossible to reach quality and value.

Let’s talk about one of these elements in more detail.

Relationships are the key to everything

In my experience, a high level of engagement, education and communication with the patient, health plan and the providers are all crucial to success. In a phrase, relationships are everything. By developing strong relationships with the patient and the facility, we can anticipate challenges and address barriers to discharge.

By developing strong relationships with the patient and the facility, we can anticipate challenges and address barriers to discharge.

These relationships are not only vital at the patient care level, they are also necessary at the partnership level with the health plan. We also leverage our relationships to foster communication between the provider and payor to show where we are aligned; help reach shared strategic initiatives and determine how we can best serve our patients and positively impact health care.

Positive, proactive relationships built on the assumption of positive intent by all parties leads to not only successful collaboration but also improved patient and provider experiences.

Valuing relationships ensures that we don’t operate in a vacuum. We recognize the value providers play in the transitions of care. This is where the talent of our clinicians is engaged to support the providers ensuring the patient receives the appropriate quantity, quality and intensity of services. We also help providers close the gaps in health care by making recommendations to improve health care delivery. For example, placing dementia patients closer to the nursing station or taking daily weights of CHF patients to anticipate potential heart failure exacerbations.

My favorite experience is based on one of our care coordinators who worked with the staff of a skilled nursing facility (SNF) to coordinate a conversation between one of her patients who’d recently been diagnosed with cancer and the patient’s long term care insurance provider. The patient was so overwhelmed by their new cancer diagnosis, they could not fully comprehend the benefits of their long-term insurance policy; but the policy would only speak directly to the patient. Our clinician worked in partnership with the SNF to surround the patient with the support he and his family needed during this very difficult time and successfully helped the patient engage, understand and utilize this policy.

What does all of that mean?

We need to recognize that each patient is an individual and deserves an individualized approach to post-acute placement. This ensures that providers are not only following the regulatory criteria that CMS expects. It also means that the organization is contributing to the quadruple aim of reducing costs, improving the quality of care and improving the patient and provider experience. As we focus on quality and value, regardless of payment model, we directly contribute to the quadruple aim by lowering health care costs (which brings value); and improving the patient experience by factoring in each patient’s unique needs and social challenges to deliver fair, equitable and cost-effective care (which brings quality).

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