How Health Reform is Changing Payer, Provider Relations

We don’t need to tell you that health care reform is ushering in many changes for physicians. From EHRs to new healthcare delivery models, you are encountering change on a daily basis.

But one reform-related change flying slightly more under the radar is the shifting dynamic between providers and payers.

During the HIMSS13 Conference in New Orleans, emergency medicine physician Tricia

Nguyen, chief medical officer of Arizona-based Banner Health Network, a large multi-site health system with 37,000 FTE physicians and one of Medicare’s 32 Pioneer Accountable Care Organizations (ACOs), touched on this change and how it’s affecting her healthcare system.

“Who here isn’t going through tremendous change at their organization on a daily basis?” she said during her session: “Lessons/Insights from a Pioneer ACO’s Journey to Value-Based Care.” “This is a transformative period in healthcare.”

In addition to participating in the Medicare pioneer program, Banner Health is also an Aetna ACO, meaning it will share in a portion of the savings with Aetna if it manages to improve care quality while reducing care costs. “We have to have a high-value network of physicians and manage limited resources very well,” said Nguyen.

Before forming this ACO partnership with Aetna, Banner Health and “limited interaction” with the payer, said Nguyen, noting that the interactions they did have tended to focus on things like rate negotiations and fees for service, as is typical of payer/provider relationships.

“Over the last three years we have gone down this journey of having negotiation be very different,” she said. “... There’s a true partnership, a sharing of resources across Aetna and Banner to make this [ACO] relationship work.”

In fact, to help Banner succeed as an ACO, Aetna is providing the health system with full technology support for population health management. That includes Health Information Exchange technology to enable patient health information to be shared across a patient’s entire care team, technology to merge clinical data and claims data so that it can be fed back to Banner Health physicians in a timely and relevant way, and technology to identify gaps in care.

“When you think about the value and the ability to work together, it really represents a revolution in how plans think about how they work with delivery systems,” Charles Kennedy, CEO of Aetna Accountable Care Solutions and Nguyen’s co-presenter, said during the presentation. Banner and Aetna are sharing information and working together “to figure out how can we both be successful.”