Strengthening Payer-Provider Partnerships in Medicare Advantage Plans

As Medicare Advantage enrollment rises and traditional Medicare enrollment declines, collaboration between payers and providers becomes essential. However, these relationships have historically been fraught with challenges and various administrative complexities. In this episode of Value-Based Care Insights, we explore the critical need for effective payer-provider partnerships with SueEllen Carroll, Managing Director at AArete, and Darren Ghanayem, a seasoned expert in healthcare and IT. SueEllen and Darren join us to share their insights on building trust between payers and providers, along with strategies for improving governance. Gain insights into fostering payer-provider contract collaboration, improving patient care, and reducing the administrative burden often associated with Medicare Advantage contracts.

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Transcript:

Daniel Marino:

Welcome to value based care insights. I'm your host, Daniel Marino. Well, we have a great topic today, one that is top of mind for many provider organizations, hospitals, health systems, medical groups as well as the payers. In today's discussion, we're going to spend some time talking about how we can build a stronger partnership between our payers and our providers. It is no secret if you're watching the news and a lot of the literature that's out there, the relationship between the payers and providers in a value-based care world is so critical to the performance of these contracts, to how we take care of our patients to really serving basically the needs of the provider community. And it's a different mindset then fee for service versus fee for value as we're thinking about what that relationship needs to look like. And as Medicare advantage starts to become more predominant with our payer provider relationships, and in particular how we're taking care of, say, the Medicare population. It's critical that we work through some of these challenges that we focus a lot on collaboration. We focus a lot on reducing the administrative burdens. It's been enormous for providers. It's so critical that we improve our communication and frankly, build the trust factor. 

Well in in today's conversation I have 2 wonderful guests. From a consulting firm called Are these 2 individuals work very closely with payers and bring a great perspective to our conversation today in terms of how they can really support the payer provider relationship. One of our guests is Darren Ghanayem, managing director of Arete. Darren. I don't think I got your name right, but I'll let you kind of chime in and SueEllen, Carrol and SueEllen is also a managing director, and she focuses on a lot of pair provider relationship. So Darren, SueEllen, welcome to the program. 

 

Darren Ghanayem:

Thanks, Dan. Good to be here. 

 

SueEllen Carroll:

Thanks for having us, Dan. 

 

Daniel Marino:

So maybe we could start with you. You know you do a lot of work with working with the with the payers, and I know one of the big focuses that you have is it's kind of creating that that new relationship, that collaboration kind of breaking down some of the historical challenges that obviously have been in place for years. As we focus a lot on fee for service, what are you seeing right now as some of the big challenges within the pay or provider collaboration. 

 

SueEllen Carroll:

Thanks, Dan. yeah, I think I think you kind of hit on it right over, especially the last 15 years or so. We've kind of built into this adversarial relationship and the groundwork of that is a lack of teamwork, a lack of trust. I think a broad challenge that that both parties are facing is workforce shortages, which is just exacerbating the issues that we're that we're seeing. 

 

Daniel Marino:

Yeah, I couldn't agree with you more. And you know, Darren, when you. when you think about what's driving the payers. especially the commercial carriers in the Medicare advantage space, and really would love to kind of focus on that.  You know, they're responsible for managing or kind of assisting the Medicare community, the Medicare population. But they also have a lot of new financial drivers. Right? How does that come into play? 

 

Darren Ghanayem:

Yeah, I mean, look, Dan, I think I think the past and the history has been very transactional, right? So the providers clearly have been incentivized, based on the contracts to focus on the elements of the member interactions that are reimbursable via the fee for service arrangement and the payers are trying to catch fraud, Catch abuse catch maybe over billing situations so that that just feeds into yen and yen and basically a relationship that's based on I'm going to do this transaction of vacuum. And then I'm going to interpret that transaction of vacuum. And that really has led to. You know, the way that these teams work together, or in some cases don't work together. 

 

Daniel Marino:

Right. 

 

Darren Ghanayem: So what value based payments and CMS as the Federal Government is trying to do is to really say, let's focus that energy on the member and health improvement, and not so much on your transactions. And I think that's really driving the difference. 

 

Daniel Marino: Yeah, I agree with you. That's a good point. And I, it's really a paradigm shift, right? Moving past that that transactional based model to one of really more of a collaborative based model. But you know, we do a lot of work on the provider side. And you know, as we start to think about restructuring their kind of the thought process, In in terms of how to collaborate one of the questions that that constantly comes up is alignment around the star ratings. Star ratings are critical for the MA plans. I know it's a huge incentive for the payers. Frankly, a lot of the providers that we work with yhey don't fully understand the value of the star ratings, and frankly, how the star ratings benefit them. How do you get through that? 

 

Darren Ghanayem:

I'm going to start that one still, and it's not an easy answer. But it's almost like you've got to start chipping away at this, and you know how we advise our clients is. you know, data is the universal language of business. So make sure your data tells the story, and make sure you are communicative to your provider partners on this is the quality program. It's not my particular company's interpretation of it. It is what it is. So we have a concept and a theme here that is, teach to the test. You know, this is how that you're going to be graded. This is how you're going to be scored on the members, wellbeing and health. So it's not a payer, grade or provider grade. It's a really collaborative outcome and the data can normalize that conversation and take the emotion out, while just the last comment on that being respectful that a provider is not just dealing with one payer. They're dealing with dozens, so you know, and everyone has their own rules and processes. So you got to have some empathy with that make it realistic. So that's also a challenge. 

 

Daniel Marino:

So SueEllen, when you're when you're working with the pair providers, we? How do you get through some of the data transparency issues? I mean exchanging of the data working together around the data. Is critical. Yet it seems to me everybody is very protective of their data. 

 

SueEllen Carroll:

Yeah, absolutely. And just to highlight what Darren was saying, I think we've seen the most success with truly achieving patient-centered care, delivery and collaboration through data transparency. And most success achieving data transparency through good governance between the pair and the provider. So that includes making sure that we're talking about the same things, agreeing on definition for our data, and then moving forward from there. Right? The big thing, the first big thing that we always see is. Payers come, and they talk about their members. Providers come and they talk about their patience, and it's important to remember those that's the same person. 

 

Daniel Marino:

Oh, and that's such a good point, too. The terminology. There has to be an alignment there. Right? Members versus patients, I think, even when you talk about the cost to care right? There is such a an a different interpretation of what cost is. So yeah, I agree with you. I think the aligning on that vocabulary and the definitions around it is certainly important. But you made another interesting point, and that's really around governance. How does the governance structure? How should it come into play to foster this environment of collaboration, Darren? Any thoughts. 

 

Darren Ghanayem:

Yeah, I do have some thoughts on that. I think that generally you've got to normalize your vocabulary when you talk about governance. So you know, when you're talking about quality, you mentioned quality a bit ago, and I would say the same thing applies to concepts like risk adjustment. And coding, medical coding. I mean that those words sound the same, but having different interpretations by some people on what they really mean, and some of our clients we work with really, we need to start at the beginning with a very basic foundation of here's what comprises quality stars. Here's the metric. Here's how it's measured. Here's how often and what the process is we're putting the providers through. This is why we're doing it. So that levels the playing field a little bit. If that is a common. you know, kind of vocabulary or nomenclature. And then, you know, you have to be open. Some people like reports. And I'll look at the report offline. Some people react better to portals and dashboard views. Technology can be used as a communication tool. But it can't just be, here's a link. Go figure it out, you know. It's got to be more than that, and it's got to be bi-directional. So. 

 

Daniel Marino:

Yeah. 

 

Darren Ghanayem:

Cannot be just. I'm going to show up. And I'm going to jam what I want in my 30 min with you. It has to. It has to really be a collaboration, and both sides have got to come prepared to that conversation. 

 

Daniel Marino:

Yeah, I absolutely agree. And you know, one of the things that we say a lot of times when we're helping organizations with kind of thinking about their data. Any information that you get has to be actionable, and it has to translate to really that audience. So if information is coming from the payers to the providers, It needs to translate in such a way that providers can do something with it. And vice versa. You know, I think, as we think about the data that that I mean, let's face it. The providers have all the clinical data, right? The payers have claims and the cost utilization data. So you know again, as we start to share that, it needs to be shared in a way that actually creates a lot of strong insights and a lot of lot of strong value out of it. 

 

Darren Ghanayem:

Yeah, and it. And then it has to pass this. So what test? You know? So just because you've got a bunch of data. Okay, so what? And I think that that's really the intent of some of these. Some of these lever pulls that that I think CMS is doing with the quality program, the stars program. And you know, even mandates like interoperability. I really think they're trying to emphasize that collaboration, making it somewhat simpler. But it really. the cultural part of this is a challenge. Because, you know, a lot of times we see people having their interactions, their precious interactions together talking about the past. What happened in the past? You sent these claims, you denied these claims. And while that's important. I really think sometime needs to be carved out, saying, How can we do better in the future with our our present? So I think that's part of our governance challenge as well. Dan. 

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino, and you're listening to value based care insights. We're having a wonderful discussion on building the Payer provider partnership. I'm here today with Darren Ghanayem and SueEllenl Caroll from Arete. Darren, I want to build off one other thing that that you mentioned. And it is around, you know, building of that of that relationship. And obviously having that information, that helps to drive some change, I think, is really important. I feel like the other area that really become is critical is building that trust factor. Right? So we're collaborating and focusing on the things that need to occur going forward. We need to have that strong, that communication. But we need to build the trust and the and a lot of times that trust comes from establishing credibility and being able to see some real results. How, in your opinion, how does the payers have they started to build, and how they formulated that trust with it with the providers, because I think in in a lot of cases providers are very skeptical. 

 

Darren Ghanayem:

Yeah, yeah, I think so, too. And deservedly so. It's look I think we've started right. I think we're in. In all candidness. I think it's in its infancy when it comes to trust, because you've got to change behaviors and the behaviors that have traditionally led to mistrust has been the fact that there are unilateral decisions on both sides, and that does impact the flow of money, and that that has a an emotional impact. But one of the tools is that you know, we have as an industry is a very clear definition on what is the betterment of the patient or member? And what does comprise of health improvement? And how are those measures applicable when you start changing a measure? When will that credit of that improvement be seen? You know, good quality programs within a payer can predict this and can be a very clear. Here's what you do. And if you do this, if you close that care gap, if you code to the risk adjustment diagnosis that we know is important for reimbursement. You will see change. And here's how we're going to measure that. That's you know, not magic science. But I think that's a really good place to start Dan. 

 

Daniel Marino:

Yeah, I agree with you. You know. The as you were talking reminded me of a an engagement we had a couple of years ago we were working with a it was a shared savings agreement. On a on a small cohort of patients, and we're only about 5,000 and boy up until this point the provider and the payer had a really, you know, was not a very good relationship. They there was a lot of distrust there. And so we were brought in to kind of help to facilitate that, and working on behalf of the providers. One of the areas that we started with, though, was collaborating around care management on the provider side, with case management on the payer side. And I'll tell you, bringing those folks together as well as them, bringing the medical directors together. It was a game changer. I don't know if you guys have done any of that work. But it was a real game changer in terms of being able to move that culture towards collaboration.  

 

Darren Ghanayem:

It's a great method. Yes, Suellen, once you go ahead and start with this one. 

 

SueEllen Carroll:

Yeah, absolutely. Dan, that's actually what I was going to say earlier is that the easiest way we have found to establish trust based governance is to focus on that that care management, that utilization management, because it helps reset the payer and the provider and remind them that we're talking about the same person in the end. Right? So, going back to something that Darren said earlier, it's always good for both sides to bring empathy to these discussions to help kind of reset that relationship. And from there you can. You can see the light at the end of the tunnel. It doesn't feel like you're just chipping away something that you'll never see, the pay that the provider won't feel like. They're chipping away something that they will never see the end of the payoff for is so if you can focus on one area, I would focus on care coordination first. that will also help alleviate some of the administrative burden that I know both sides are feeling, especially with the workforce shortages in in healthcare today. 

 

Daniel Marino:

I agree with you, and I'll tell you this kind of gets back to, you know a comment that you made Darren. When you bring in the clinical folks who are really focused on the patient. They don't get involved in any of that administrative stuff, right? They're really focused on the outcomes of the patient, you know, when you bring 2 RNs together, one from the provider and one from the payer, you know they focus on, how do we need to work together? And as long as they're aligned on the clinical philosophy, in my mind that that tends to work. And I really feel like, at least in in the work that we had done with this one client, It really made a difference on bringing and really building a sense of collaboration. 

 

Darren Ghanayem:

Yeah, yeah, I mean, look. Agreed sharing some of that transactional information, whether it be considered burden or insight. You know, opening up those traditional boundaries where, like medical coding happens on both sides, so let's maybe talk to one another about what we're how we're coding. You know pretty common sense idea, I think, but also realization that you've got to incent providers so that they see some light at the end of the tunnel as a payer. You can't just say, once you receive 4 stars, you're going to get some benefit. It? I mean, okay, so that's maybe the end game objective, but, you know, incentivize for improvement, incentivize for trying to remove some of the burden of the reason that authorizations are universally hated across the board, so no one likes authorizations. The patients don't like it. The payers don't like it and the providers, but it's there for a reason. So let's talk about delegation and other arrangements where we can ease that burden and still get the objective met which is getting the right gear for the right action, and I keep going back to and the clinical philosophies and the providers are very well trained and educated on how to treat and how to identify clinical situations. But that's not always directly lined up with how the quality Stars program programs work. And it just has to be understood. 

 

Daniel Marino:

Well, and it has to be understood. And then you have to build on top of that to your point where you have to create aligned incentives. You know that time and time again, and the program. And we practice that a lot of the in the work that we do. If you have the aligned incentives, it's much easier for you to create the right level of behavior that you want and see the right level of results in that. 

 

Darren Ghanayem:

Absolutely. And back to back to your point. I think the delegation opens up the door of Okay. and you've got a system challenge. We've got a system challenge. We, you know. Let's figure it out together.  I think that's a good step. You know. It's it doesn't have to be, you know, fully delegated model, but sharing some of that transactional responsibility is a good you know, kind of icebreaker for this relationship. 

 

Daniel Marino:

So one thing I do want to touch on real quick. And it's kind of the elephant in the room. But it's the it's the administrative challenges that that we're seeing as a result of certainly the MA products and the commercial plans. You know, many, many hospitals, many health systems. Have either considered dropping out of MA, or you know some of a few of them have already. I you know I I think all in all  If you align the incentives, it's actually a good thing for the patience and a good thing for our industry. But these administrative burdens that we're seeing is really. it's creating a lot of costs and a lot of challenges. And, as you said before, Darren, you know, not just on the hospitals and on the payers, but on the patients as well, too. How do we get past that? 

 

Darren Ghanayem:

You know. This is another tough question. I for a couple of ideas to throw out there, you know, one of which may not be popular, but Medicare advantage over the last couple of years, especially with Covid and some of the loosened controls, I think it's become a benefit game. So you add more and more benefits to your to your package, and you try to do that at a low premium or no premium offering. Are those benefits that require administration? Are they really helping? Are they helping turn the knob, or, or, you know, change the cost curve? I really think that that requires some deep, deep review to make sure that the benefits are really providing an overall win for the provider, the patient, and the payer. So that's one thing administratively, you could take a look at, and other than that, you know it. It really is the duplicative nature of some of these functions where I mentioned earlier medical coding, it happens on both sides, and it's not a cheap function. So you know the reason for that is  kind of a head scratcher to me. 

 

 Daniel Marino:

Well, and I go ahead SueEllen, and you have a comment. 

 

SueEllen Carroll:

Yeah, I think interestingly. if you really look at the incentive for both parties, sometimes they are very aligned. Both parties, for instance, are incented to encourage primary care or preventative care. However, the approach and the kind of different perspectives lead to real differences and can lead to administrative burden as we keep talking about right? So one thing that we've seen really help in that is through collaboration and discussion around, you know, making sure that if there's a technological solution or a vendor, for instance, that the payer is bringing in as part of one of their benefits, for instance, they're engaging with their provider partners to ensure that that there's not already a program and initiative going on with their partners, or that, you know, it's going to actually affect their patients their members, the way that everybody wants it to. 

 

Daniel Marino:

I agree with you. I think I think just building on that. It has to come down to the to communication, you know. And I've said this to a number of our provider clients. If you have a big issue with a lot of the administrative challenges, the presets, you need to have some conversation. You need to have some communication around it. That's the only way to get to get past this. Well, Darren and SueEllen, and this has been great. I love this conversation. We clearly have a lot of work to do as an industry, bringing our payers and our providers closer together. Certainly, as we start to engage in even more value-based contracts and performance outcomes on behalf of our patients. The success of this is going to be dependent upon how well our payers and our providers work together. I I'm sure you know, there's a lot of probably a lot of a question by our audience, and many of them struggle with this. Real quick. You know any final thoughts that maybe pieces of advice you might want to give to any of our listeners. Darren, maybe start with you. 

 

Darren Ghanayem:

Yeah, I think that today's the best day to start looking at the future. I mean, that don't need to wait for perfection. I really think that starting this dialogue, which we do with a lot of our payers and provider partners. You know they come to us and say, Let's we're ready to start ready to really start this and not just throw out an incentive program. So I think there's no better day that than today. And what I see CMS doing and a lot of other areas are following with those lines of business. How CMS acts is they're trying to tighten this up. They're trying to tighten up the reimbursement and make it so that it is much more about outcome based and not so much serve fee for service based. I really do feel that way. So today's a good news start. 

 

Daniel Marino:

I agree with you, I think, starting sooner than later, and have those conversations. Well, SueEllen, maybe I'll turn to you, you know, if any of our listeners are interested in learning more about are about you and Darren. How a  where can they get a hold of you? 

 

SueEllen Carroll:

Absolutely thanks, Dan. you can. You can check out our website, AArete.com. or feel free to send me an email. scarroll@aarete.com 

 

Daniel Marino:

Great. Well, guys, I really want to thank you for this. I think it's a great start, you know, as we, as I mentioned, I think we've got a lot of work to do, but I commend you on the work that you're doing on the on the payer side. I as I've said time and time again, I'm a huge proponent of value-based care. I think it's the best thing for our industry. So thanks again for coming on the program. 

 

Darren Ghanayem:

My pleasure. Thanks, Dan. Good talking to you. 

 

SueEllen Carroll:

Thank you. 

 

Daniel Marino:

And a special thank you to our listeners for tuning in. Until our next insight, I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners