Requirements for Success
Setting the Stage for Collaboration
In todays competitive health care industry, both payers and providers are experiencing rising medical and administrative costs amidst revenue pressures. Benefits are becoming increasingly expensive to distribute as paper-intensive processes create administrative backlogs. In addition, employers are encouraging self-service benefit offerings, creating a disturbing shift in benefit- management responsibility. As patients are left to choose their own benefit plans, comparison shopping increases as consumers seek health plans and providers that will deliver the quality, convenience, access, and accountability that they expect at a price they can afford.
Although these business imperatives are equally important to both payers and providers, it is often difficult to get these diverse groups together to resolve issues. Problems of this magnitude are difficult enough to resolve without the added burden of uniting two groups from opposite ends of the health care delivery spectrum.
A collaboration project sets the stage for increasing levels of cooperation and communication between payers and providers to improve customer service levels and streamline business processing. The collaborative process is also a mechanism for payers and providers to leverage existing systems and processes to reduce costs and improve performance.
From experience with past payer-provider collaborations, Capgemini understands that a blend of creative problem solving balanced with business metrics can smooth the collaboration process. Fixing the claims management process requires the greater challenge of changing payer-provider interactions and the way the process occurs across both organizations.
A Critical Mass
Collaboration projects work best when there is a geographic market concentration of payers and providers. This promotes executive sponsorship in two ways: The relative size of the book of business makes the collaboration important to the participating organizations, and limiting the number of players facilitates organization of the work effort. For example, Capgemini recently completed a payer-provider collaboration project in Michigan involving seven of the largest health care systems in Detroit and encompassing over 75 percent of the Detroit market. These providers included Beaumont Health System, Detroit Medical Center, Henry Ford Health System, Oakwood Healthcare System, St. John Health System, Trinity Health, and University of Michigan Health System.
The major payer involved in the project was Blue Cross Blue Shield of Michigan. BCBSM members comprised approximately 50 percent of the nongovernmental market, and 75 percent of these members were serviced by the provider participants of this project. By having a critical mass of providers and payers, collaboration projects quickly gain visibility and gather momentum in both the payer and provider organization.
Executive Sponsorship
Sponsorship from C-level personnel is critical to the success of a payer/provider collaboration project. High-level executives can marshal the resources, finances, and people needed to make a large-scale project succeed, so they must endorse the project from the beginning. It is important to maintain executive commitment, ensuring that the collaborative process receives the appropriate guidance, support, and motivation needed to stay on track and maintain morale.
Payer-provider collaboration transcends an organizations functional areas, so the CEO, CIO, COO, and CFO must all demonstrate a strong commitment to the project. With endorsement from the top, a trickle-down effect inevitably occurs, so payer and provider management teams must also be on board. These managers help support the new rules of engagement, enforce specific project milestones, and ensure that key personnel are dedicated to specific projects or are available as needed.
Resource Commitments
With executive sponsorship behind the collaboration, securing the monetary and personnel commitments to launch the project is much easier. Configurations for funding payer-provider collaboration projects differ, but the main concern is ensuring that the funding will be available for ongoing expenses.
In the Michigan project, for example, a stipend was advanced at regular intervals by the hospitals and BCBSM throughout the course of the collaboration. Contrast this with the collaboration between Highmark Inc. and the University of Pittsburgh Medical Center Health System in which Highmark committed to investing $20 million for joint information technology initiatives focused on consolidating and integrating operations, decreasing costs, and improving patient care. Collaboration projects are sometimes a joint investment between payers and providers, sometimes funded through the payers budget, or sometimes a function of grants. In any case, the degree to which an investment fund can be developed so that the focus is on the allocation rather than the funding itself provides a collaboration platform from which both groups can work. This places all participants on the same page to sustain project focus.
Commitment of human resources is just as important as the financial obligation. Key personnel must be assigned to the project, since they have a vested interest in making sure that processes work correctly. Capgemini finds that the best workgroup members are people who work intimately with the processes being addressed.
By committing financial and staffing resources to the project, both payers and providers declare their full endorsement, providing the foundation for a productive working relationship throughout the collaboration process.
Removing Barriers
A poor understanding of each others expectations, processes, policies, and capabilities often must be resolved before payers and providers can collaborate. Early in the collaborative process, the provider may believe that the payer organization is trying to make it difficult to be compensated for services rendered on a timely basis. This occurs because the provider does not realize the complexity of what the payer must do to verify that claims are being paid appropriately.
For example, increasingly complex contracts are becoming more difficult to administer on both sides, creating financial adversities for both payers and providers, resulting in rising accounts receivables (for providers), increasing claim resolution costs, higher manual intervention rates, and unwanted duplicate claims.
In addition, a significant number of members change their benefits annually, making it easy for inaccurate and volatile information to confuse all the players and create barriers to true communication. Changes in benefit design may lead to inconsistent interpretation of payer clinical criteria for scheduling services and inconsistent levels of precertification authorization, which only compound communication problems. A perception of interference in clinical decisions can also arise as the payer attempts to control medical costs for customers.
Traditionally, resources have been deployed to address the symptoms of these problems rather than the systemic causes. Consequently, claim denials have been handled on a oneoff basis, often one claim at a time. By breaking down the barriers of mistrust, payers and providers can come together to share data and shift the internal emphasis from win-lose to win-win.
Building Trust
Although it sounds elementary, a can-do attitude is imperative to the success of a collaboration project. Payers and providers must be committed to achieving positive results and must stay open-minded to address mutual areas of conflict.
Trust and common respect must also be instilled during the first meetings between payers and providers. Because these groups have an adversarial history, it is important first to establish a common ground. In Capgeminis experience, payer and provider representatives often express initial concern that they will be unable to come together to face common issues. In fact, a history of failed attempts serves to reinforce this belief. Capgemini has found that third-party facilitation is essential to creating a new platform for working together. The Capgemini facilitation techniques employed through the collaboration focus on finding the common problems to be solved in the collaboration. Inevitably, the collaborations reveal that there is enough return in areas of common ground to warrant an investment, and trust is built through achieving success in these areas.
Defined Roles and Responsibilities
Capgemini uses knowledge transfer sessions and interactive workgroups to establish project objectives. Next, Capgemini establishes workgroups assigned to create a series of tasks to achieve an objective. Capgemini recommends staffing the workgroups with a small number of people who are closest to the areas of focus.
For example, in the Michigan project, workgroups were assigned around five solution sets, including coordination of benefits issues, Medicare issues, denial tracking, best practices, and training. Each workgroup included eight to 10 people, with payer representatives who understood claims processing and provider representatives who were knowledgeable about hospital policies and practices.
Capgemini supported the workgroups with data analysis, facilitation, and various levels of project management in order that the payer-provider team members could focus on the important work of bringing expertise in their own work processes and critical thinking on redesign.
A Fact-Based Approach
Payer-provider collaboration requires a fact-based approach to help establish the rationale and remove the emotion from decisions that need to be made. In addition to helping the groups make better, fact-based decisions, a fact-based approach provides additional advantages, including:
Improved performance monitoring; Empowering staff at all levels to make timely, accurate decisions; Improved quality and increased member and patient loyalty through better information exchange; and Enhanced predictive capabilities.
A fact-based approach, supplemented by observation, requires payers and providers to continually track and report project successes. This strategy keeps the collaboration project focused on the defined business case and targeted financial results.
In the Michigan project, for example, project participants used benchmarking data to track AR (see Figure 1). The results of the benchmarking data clearly showed progress and helped move the project along.
Figure 1. Detroit Area Hospitals Benchmarking Survey
Milestones and Progress Reporting
Capgemini emphasizes the importance of deadlines and established timeframes for the completion of every step of a payer-provider collaboration project. Once a project milestone has been reached, results are measured and reported to project sponsors and executives. This feedback mechanism keeps the collaboration on track and the executives engaged in understanding team and organizational progress toward hard results and improved working relationships.
Capgemini encourages both payers and providers to continually track and report on the efforts of the collaboration process. By measuring results with data-driven reporting, each workgroup is held accountable for completing its portion of the project.
Progress reporting also ensures that project victories are recorded for all to witness. Capgemini often recommends that a steering committee be established to perform regular reporting for the workgroups. This encourages accountability and keeps the project moving toward established goals.
Another important aspect of milestone and results tracking is the ability to recognize the point at which a workgroup or project team has achieved objectives and can be sunsetted to free up resources. Many attempted collaborations have suffered due to ill-defined objectives and teams left to flounder without clear milestones and end points. This saps both energy and momentum from collaboration efforts.
Results Orientation With Quick Wins
At project ramp-up, it is imperative to establish realistic objectives and boundaries. A focus on desired outcomes helps workgroup participants outline specific items that need to be accomplished.
During large-scale payer-provider collaboration projects, Capgemini advocates that participants work in manageable segments. This helps increase the probability that early results will be achieved and prevents the group from getting trapped into trying to solve problems that are too large. Working in manageable segments helps, especially during multiyear projects, because incremental success is more easily measured. Without these mini-victories, project participants often lose sight of the goal or simply lose interest. In the Michigan project, Capgemini purposely kept the groups focused on early wins to propel later efforts and build a basis of confidence that was critical to creating buy-in from project participants.
One of the early recorded wins of that project was reducing the number of claim denials. Providers were experiencing an unacceptable number of denied claims, causing significant rework and resulting in frustrated patient inquiries. BCBSM was also experiencing pain from claim denials, with an increasing call volume from both providers and members.
By working through the process to correct initial billing practices, denials were greatly reduced. The Michigan providers saved an estimated $27 in administrative costs per rebilled claim and significantly reduced the number of accounts previously written off because of inaccurate eligibility or benefit information. This early win excited project participants and helped set the stage for solving other problems.
The Leverage Model Sharing Results
One of the most valuable aspects of the payer-provider collaboration project is the ability to leverage the people involved in the process. In this way, only a few key personnel are required to participate from each organization, saving a great deal of time and resources.
Typically, not all providers have a representative on each task force. Instead, Capgemini recommends using knowledge-sharing exchanges in which the task forces present their findings and materials to the group as a whole. During the Michigan project, knowledge-sharing forums were held at a universitys outreach center, where the groups had access to various rooms to hold a general session and breakouts.
The Michigan project represented 18 hospital systems made up of two to 10 hospitals each. If each hospital had assigned a representative to each task force, the commitment of provider personnel would have been overwhelming. Instead, by sharing task force results with the whole group, both payers and providers achieved a major impact with a minor commitment of personnel. In this way, Capgemini helps both payers and providers maximize their investment in the collaborative process.
Summary
To succeed, a payer-provider collaboration requires commitment, organization, trust, and leverage. By securing executive sponsorship, a critical mass of participants, and the appropriate resource commitments, Capgemini helps payers and providers break down barriers of mistrust and miscommunication to lay a foundation for collaborating on a host of important future initiatives. By keeping the project on track with defined roles and responsibilities, milestones, progress reporting, and an orientation to quick wins, incredible gains in efficiency can contribute to the shared success of both payers and providers.
