Catalyst for Payment Reform

2023 Health Plan User Groups: No dog and pony shows allowed

2023 Health Plan User Groups: No dog and pony shows allowed

Once upon a time, I used to work for a health plan (I won’t name it here, but it’s obvious if you look me up on LinkedIN) and a part of my job entailed presenting to CPR and its members at quarterly health plan user group (HPUG) meetings.  I won’t lie and pretend that this was my favorite part of my job: CPR members held my feet to the fire, asking tough questions and demanding accountability for the promises and commitments the health plan had made in years prior.  All the happy little platitudes that the sales team coached me to recite at client meetings?  They flew like tired lead balloons at the HPUG.  CPR members have seen far too many dog and pony shows, and their patience for cherry-picked statistics and images of happy doctors in swimming pools runs thin.[1],[2]  

But here’s the thing: to get things done in health care, sometimes you need to make some noise.  And when CPR members make noise, health plans listen.  

I can attest to this first-hand.  True story: my health plan/employer did not see the value of measuring patient experience in its value-based payment programs.  They believed (sincerely I think) that none of the operational changes or quality improvement efforts that ACOs incentivized would be visible to patients, and therefore a report comparing member experience in an ACO versus a fee-for-service practice was wasted effort.  CPR members didn’t buy it.   When I returned from that (very uncomfortable) meeting in Chicago, I let our VP and our head of national accounts know that I’d been taken to the proverbial woodshed at an HPUG meeting.  Suddenly, the conversation changed from “explain to them why it doesn’t matter” to “we need to talk to the people who own our CAHPS data and put up the funds for a new extract.”

Granted, most HPUG meetings veer more toward “engaged conversation” than “heated debate” but this is how CPR moves the Overton Window.  CPR members don’t just ask health plans for updates on how many dollars they’ve dedicated to their bundled payment program: we push them to respond to tough questions in new territory like data sharing, health equity and their post-COVID payment reform strategies.  We make them all take the same test through our program evaluation tools so they can’t cherry-pick statistics or hide behind shiny marketing materials.  And because CPR members set the agenda for the HPUG meetings, the discussions focus on what matters most to you, purchasers, and what keeps you up at night.  It’s OK if the health plans squirm a little; it’s what helps them grow.

With these tenets in mind, here is the agenda that CPR and its purchaser members set for 2023: 

Data TopicDiscussion Topic
Q1: February/March 2023
Health Plan Progress ReportThe Health Plan Progress Report requires plans to document their spend in alternative payment models, quantify the impact of benefit design and payment reform on maternity outcomes, and report on utilization of behavioral health services.APMs with Downside Risk: Health Plan Goals and Progress COVID-19 may have compelled health plans to hit the pause button on APMs with downside risk, but now that we’ve returned to something resembling normalcy, it’s time to revisit health plans’ strategies to introduce shared financial accountability for cost and care quality into their provider contracts.  CPR members want to understand which downside risk models health plans intend to pursue and why, what their goals are, and how they are holding themselvesaccountable for achieving their targets.
Q2: May/June 2023
Comparison of Virtual-First to Traditional Health Plan Product Given the relative novelty of virtual-first health plans, CPR will allow participating plans to provide their own reporting this quarter.  Plans will report on outcomes for patients enrolled in traditional products compared to the plan’s virtual-first product, including the following: Cost of care outcomes and trend dataClinical quality and care experience measuresUtilization across sites of service (i.e., primary care, specialty care, ER, hospital, readmissions, etc.) Virtual-First Product Overview  Although there is no universal archetype of a virtual-first plan, their commonality is that they encourage patients to seek primary care in a virtual setting, progressing to in-person care only as needed.  These plans differ from traditional PPO or HMO products that may include virtual care, but do not encourage/mandate its use as a point of entry into the delivery system.  These plans have grown in popularity, but questions remain regarding their quality, cost-savings potential, care coordination and interoperability.  CPR members want to understand how virtual-first plans work, how they select providers, criteria for in-person care, recommended benefit design, and their roadmap for product evolution.
Q3: September 2023
Health Disparities ReportingAddressing health disparities across demographic groups must begin with understanding the nature and scope of the problem.  Purchasers need data from their health plan partners to formulate strategies and adopt programs to improve health outcomes across their covered populations.  In 2023, the National Committee for Quality Assurance (NCQA) identified 13 HEDIS measures to be stratified by race and ethnicity.  Health plans are asked to report on outcomes for these 13 measures by race and ethnicity for their Commercial and Medicaid books of business.Data Sharing and TransparencyData is the currency of today’s health care economy.  All purchasers need access to timely, accurate and complete individual claims and clinical data to administer a high-value benefits strategy.  But questions of access, ownership, and the transfer of information from health plans to purchasers and their contracted business associates have become increasingly fraught.  CPR members would like health plan to discuss its approach to data sharing, its strategies to encourage price transparency, and its stance toward anti-tiering/steering clauses in provider contracts.  

I will say that it’s gratifying to sit on CPR’s side of the fence; in this job, I get to facilitate the tough questions instead of trying to tap-dance around them.  I don’t believe that health plans are villains, but they are big and they move slowly and cautiously; without consistent nudging (sometimes gentle, sometimes a little more forceful) they struggle to find a signal in the noise.  My story about CPR convincing a health plan to measure patient experience in an ACO is just one small drop in the ocean of change that CPR and its members effected over past decade.  HPUG meetings are available exclusively to CPR members and their contracted health plans.  If you’re not a member, we hope you’ll join us and jump on the bandwagon.  No dogs, ponies, or doctors in swimming pools allowed. 

[1] The health plan’s marketing team once had slide featuring a photo of a doctor in a white coat, floating in an inner tube in a swimming pool.  To this day, I have no idea what it meant, and I refused to use that slide. 

[2] And just to be clear, selective statistics and glossy sales slides are ubiquitous across all health plans.  I can testify to this now that I work for CPR.

CPR’s Director of Projects and Research, Julianne McGarry, MPP, wrote this blog post.

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