Posted: 26 Feb. 2019 6 min. read

Here’s how health plans can break the ice with providers on member experience

By Sarah Thomas, managing director, Deloitte Center for Health Solutions, Deloitte Services LP

A certain level of tension can hang over the negotiating table when health systems and physicians sit down with health plans. This historically adversarial atmosphere is not surprising given the often-tough conversations over payment combined with a health plan’s interest in influencing practice patterns, quality scores, coding, and utilization. While there might not be much romance between providers and health plans, their shared goal of improving patient care and leveraging data could lead to closer and more collegial relationships.

Students of managed care will remember the many versions of health plan–provider alignments, namely group and staff-model health maintenance organizations (HMOs) and provider-sponsored plans. Recently we have seen examples of health plans joining the physician-practice acquisition trend, which is already popular among health systems and venture capital firms. We are also seeing more risk-sharing payment arrangements between payers and health systems. Even outside of such ventures, health plans often look for other ways to enhance the patient experience and improve outcomes.

What do health plans want?

Forging closer relationships with health systems and physicians could help health plans attract customers (i.e., members, patients, and caregivers). Moreover, collaborating with health care practitioners on the frontlines of delivering care could help create superior member and patient experiences, improve outcomes, and lower costs.

Many patients value relationships with their physicians more than other types of interactions (such as cost or convenience), according to a recent Deloitte study that we commissioned to analyze the consumer experience with health plans. Another recent survey of health care consumers validates this point: Consumers trust information from providers more than any other source. Consumers also seek personalized encounters with their providers, and a good “bedside manner” is something the typical health care consumer still demands.

What do physicians want?

While physicians are willing to manage cost—something that both public and private payers want them to do—they often lack the data and tools to do it. The Deloitte 2018 Survey of US Physicians found that two-thirds of physicians receive some quality and productivity information from multiple sources. However, this situation is considerably different when it comes to cost-related information. Our survey found that while 72 percent of physicians see value in cost data (particularly at the point of care), just 28 percent of them said they receive such information from health plans. Cost data might include prices for resources used with their own patients or for the physicians and facilities to which they refer. It also might include estimated out-of-pocket costs. This lack of information can limit a physician’s ability to perform certain tasks. Forty-three percent of physicians said they are not able to find low-cost lab and imaging options, and 36 percent cannot identify high-quality skilled nursing facilities (SNFs), rehab services, or home-health agencies.

Physicians said they would also like to see improvements in some of their insurance-related administrative tasks (e.g., dealing with prior authorizations, verifying a patient’s eligibility and deductible status, handling denials and appeals, and looking up information in formularies). Nearly 20 percent of surveyed physicians said this is one type of activity they prefer to either avoid or optimize.

How might we bring these parties together?

We wanted to find out how to create a closer relationship between health plans and providers. We surveyed health care practitioners (e.g., physicians, nurse practitioners, physician assistants, nurses, and practice administrators) from 300 primary and specialty-care practices. We focused on the following five areas where health plans have existing capabilities and applications—as well as data—that can help improve value (cost and quality) and enhance the patient experience:

  • Care coordination: Aligning care across multiple providers or sites
  • Cost transparency: Knowing the costs associated with the patient’s care
  • Chronic-care management: Caring for patients who have complex or chronic conditions
  • Wellness and prevention: Enabling and ensuring that patients stay healthy
  • Practice performance: Meeting the financial and quality goals of the practice

Physicians are interested in solutions from health plans

Two-thirds of our survey respondents said they are open to using solutions from health plans. They see health plans as having an edge over some other entities when it comes to data and insights. That said, other stakeholders are also offering this type of information, and many physicians would prefer to receive solutions from health systems. Non-physician respondents were more open than physicians to working with different entities. This might point to administrative demands on non-physician staff, which are often underserved and could be addressed by health plan solutions (such as tools that can determine eligibility and out-of-pocket costs).

Health plans that want to forge closer relationships with physicians should consider working more closely—and more boldly—with health systems. As I noted above, many physicians see health systems as preferred partners (a health system might own a physician’s practice). Since health care practitioners prefer to work with health systems, health plans should partner closely with health systems when designing and delivering solutions. After all, disruptors from outside of the industry are threatening the business models of both health plans and health systems.

Improving the patient experience—enhancing quality, providing better information—is an obvious area of alignment for health plans, health systems, and physicians. Each group has an interest in addressing gaps in care to improve both star ratings and Health Effectiveness Data and Information Set (HEDIS) scores, as well as performance measures used for physicians.

But health plans can, and should, be bolder in their collaborations with health systems. Imagine network contract negotiations that bring new voices from both sides for cross-functional care delivery design sessions. Such sessions could identify opportunities for partnerships in data and analytics, which could lead to data- and insight-sharing provisions being incorporated into network contracts. Health plans and health systems, for example, might agree to share cost savings if they also share data and insights that help reduce costs.

Many of the services health care practitioners find valuable are not commonly available today and cannot be developed using off-the-shelf tools. To get value out of their data (and to deliver solutions that seamlessly integrate with physician practice workflows) health plans could consider partnering with electronic health record (EHR) vendors, data integration companies, practice management companies, and public health entities.

Developing new solutions is not the only way to strengthen partnerships. For instance, health plans may start with easing existing administrative requirements on physician practices through process redesign, automation, or analytics. Draft regulations around interoperability would, if adopted, affect health plans, health systems, and physician practices (see the February 19, 2019 Health Care Current). Solutions for data-sharing to meet regulatory requirements can also be explored.

Treat each other as partners

As with any good relationship, meaningful dialogue might be the best place to begin. Health plans, health systems, and providers should acknowledge their differences—and identify common goals. Solutions that address unmet needs, complement existing capabilities, and provide insights that physician practices cannot get elsewhere could be well-received. Health plans should view physician practices as partners in care and develop an intimate understanding of practice workflows, the needs of individual physician practices, and the benefits sought by different users within the practice (such as physicians, care teams, and administrative staff).

Strengthening the relationship between health plans and health care practitioners to form a true partnership might take time, but the goal on all sides—to improve patient experience and outcomes—aligns.


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Sarah Thomas

Sarah Thomas

Managing Director | Center for Health Solutions

Sarah is the managing director of the Center for Health Solutions, part of Deloitte LLP’s Life Sciences & Health Care practice. As the leader of the Center, she drives the research agenda to inform stakeholders across the health care landscape about key trends and issues facing the industry. Sarah has more than 13 years of government experience and has deep experience in public policy, with a focus on Medicare payment policy.