CAPP Shares Insights of Employer Dialogues at WHCC and SIIA
By Dr. Norman Chenven
Vice Chair, CAPP, Founding CEO, Austin Regional Clinic
In our fragmented healthcare system, providers seldom have the opportunity to speak directly with employers, even though these employers pay for much of the healthcare expenses in this country. Communication between the two parties can often feel like a game of telephone, with health plans playing intermediaries. But communication between the two groups is important and beneficial because providers and employers have a shared, vested interest in higher-value care. This common interest is especially true with CAPP members, who have a keen focus on improving quality, care coordination, and patient outcomes, with a focus on the total health of the patient for the long term. Our vision and values synch up nicely with many employers who are concerned about the cost and quality of healthcare for their employees.
As we explained when our Board Chair Dr. Stephen Parodi recently addressed the World Health Care Congress and when I addressed the Self Insurance Institute of America’s (SIAA) Annual Conference, when employers and providers talk, they find solutions. Last year, CAPP leaders met with a number of employer coalitions in a series of roundtables sponsored by CAPP and the National Alliance for Healthcare Purchaser Coalitions. The National Alliance is an umbrella coalition, reflecting the interests of the many regional employer coalitions across the US. These discussion forums generated many promising and innovative solutions including improving healthcare by integrating behavioral health with primary care, pursuing strategies for reducing low-value care and increasing high-value care, and developing better metrics for measuring performance in alternative payment models. Not surprisingly, these solutions don’t stand well on their own. Each helps reinforce the others.
Integrating Behavioral Health
With a shortage of behavioral health providers and a growing demand for these services, especially during the pandemic, the goal of integrating behavioral health into primary care has been identified as a critical strategy to improve access. As Dr. Parodi shared with the World Healthcare Congress, too often a patient will wait months to see a behavioral health provider. However, if behavioral healthcare is integrated into primary care, the primary care physician (and pediatric, ob-gyn, and chronic care doctors) could start the patient on the right care path immediately simply by asking the right questions. If a concern is identified, the physician can then make a warm hand-off to a behavioral health specialist who is part of the group. In many cases, this person need not be a psychiatrist but can be a counselor or therapist. Integrating behavioral health into primary care serves a secondary function as well: it would also help to reduce the stigma associated with behavioral health which often prevents a patient from seeking help in the first place. By having the therapist as part of the practice, and the doctor introducing them as “my colleague,” there’s no need to find a therapist, to delay care, or to avoid treatment.
Rethinking the Fee-for-Service Model
Of course, this integration works best when the payment model is not built on a fee-for-service chassis. Providing well-coordinated care that focuses on the total health of a patient takes time and it takes a team. Under a fee-for-service model, the payment for “one visit” doesn’t even begin to cover asking the right questions and making the hand-off. But when payers pre-pay for care with a focus on the total health of the patient, it works.
Sometimes employers don’t understand why the dominant payment method –fee-for-service—doesn’t incentivize high-quality care. CAPP members are uniquely positioned to understand why paying for the total health of the patient is critical, and they can play a valuable role in educating employers. Often this process must begin with understanding that, for some employers and consumers, the term “capitation” is like a four-letter word, as I pointed out in my SIIA talk. Explaining why “pre-payment” works can make more sense, thus avoiding this loaded term. With a growing employer interest on narrow networks, many employers are starting to think outside the box when it comes to alternative payment models.
Virtual Care is Part of the Equation
I would be remiss if I didn’t mention that virtual care is part of the equation of quality care. Historically, payment rates for telehealth have been quite poor. Emergency measures taken during the pandemic have begun to change this. But we need payment parity for video and audio-only care so that this delivery mode can become a permanent fixture of our healthcare system to truly meet our patients’ needs and preferences. Spurring the adoption of virtual care is yet another area where employers and providers can be working together.
Finally, providers and employers have an opportunity collaborate on strategies to reduce low-value care and increase high-value care. Integrating behavioral health into primary care is only one piece of this work. Again, CAPP members are well-poised to inform such an effort our focus on accountability, which includes quality measurement of outcomes. The delivery of low-value care often begins when care is not supported by evidence-based medicine. Developing well-understood clinical pathways for specific conditions is a place to start. Low-value care can also occur when the care provided is unnecessary or redundant.
A common concern among employers is the pain their employees experience with balanced billing—when they are referred out of network for tests or care. Once again, with CAPP members focused on pay-for-value models, this is far less likely to happen because the practice is now responsible for the total cost of a patients’ care, a point I underscored at SIIA. And with our use of technology-based decision support aids, CAPP members can help avoid deviating from the evidence-based guidelines and established clinical pathways.
The dialogue we’ve started between providers and employers must continue. It’s already showing promise in identifying common goals and solutions that are most critical, especially considering the impact of the pandemic.