Limited trust has existed between payers and providers thanks to disagreements over networks, prior authorization and price variation; however, now is the time to change this dynamic, executives from UnitedHealth Group, Anthem and Permanente Medical Group wrote in a JAMA opinion piece.
1. The authors — Lewis Sandy, MD, executive vice president of clinical advancement at UnitedHealth; Hoangmai Pham, MD, vice president of provider alignment solutions at Anthem; and Sharon Levine, MD, former director and senior adviser of the Permanente Medical Group in Northern California — said new payment models are pointing to possible changes.
2. “Perhaps most fundamentally, rigid boundaries between being a payer and being a care provider have begun to blur,” the authors wrote. “While organizations such as [Oakland, Calif.-based] Kaiser Permanente have had decades of experience with the blurring of such boundaries, only recently have large numbers of medical groups taken on risk arrangements for defined populations, stimulated by the opportunities in the Medicare Advantage program and new payment models from [CMS].”
3. The authors continued: “Although this is a long-term journey, evidence of improvement in hospital readmissions, quality metrics, and costs managed by medical groups is beginning to emerge. Payers have realized the need to work collaboratively with physicians and medical groups to have a meaningful influence on costs and quality of care. Both parties may be finally accepting that one cannot succeed without the other.”
4. Opportunities for progress include creating competence across parties, ensuring transparent quality measurement and understanding the motive of each party, according to the executives.
5. “Relationships should change from being based on contracts to relationships built on a shared covenant to patients and to system improvement,” the authors concluded. “The next decade could be transformational, or it could be a missed opportunity. It is the responsibility of each person and organization in the U.S. healthcare system to make transformation real — in care delivery, in payment, and most powerfully, in relationships.”
Date: March 5, 2019