Why PCPs Are Key to Coordinating Patient Engagement with Payers, ACOs

Coordinating payer, provider patient engagement efforts

Foerster said that the first step to orchestrating care management is hammering out the details between payer and provider partners. In the case of his ACO, stakeholders need to be clear about whether the payer or the provider will be spearheading patient engagement efforts.

“An ideal scenario is the payer and the provider group together setting expectations of rules and responsibilities from the start,” he said. “We try to establish that from the start because I think that creates the accountability down the way in terms of, okay, the provider is responsible for this, so let's see what that provider is up to. How many patients have you engaged? What has been your success? What type of clinical outcomes have you been seeing?”

Or, on the flip side, how many patients has the payer engaged? What is their success rate?

Right now, those insights are pretty opaque and data from Insights by Xtelligent Healthcare Media shows that payer-provider communication is elusive. Measuring patient engagement efficacy will require opening up those conversations between payers and providers and enabling some transparency.

Collaboration should also touch on the financial side of things.

“How are we funding those efforts?” Foerster posited. “It might be the payer because of funding through premiums from the employer or the patient themselves. Or, if we've identified opportunities where the provider should be responsible for roles and responsibilities, there should be some funding around that, such as a care management fee or something to really compensate for that service.”

Certain value-based care models are more conducive to incentivizing and helping providers enable patient care management. Simple pay-for-performance models can be more restrictive in enabling providers to lead patient engagement, while global risk or capitated arrangements can allow for more flexibility. However, those details need to be part of the larger conversation between payer and provider.

“But even in the middle, what are the division of roles and responsibilities between the organizations?” Foerster said. “If the payer is delegating specific services that the provider group should be responsible for, then there needs to be an appropriate level of funding for those services.”

Third, payers and providers must set expectations, or at least a plan, for health data exchange. Providers and ACOs will want to see patient claim histories, who is attributed, and how that changes over time. Insights into care gaps and the clinical record outside of the ACO is also essential, Foerster said.

“And on the flip side, the payer probably wants to see our full picture,” he pointed out. “We've got a very rich clinical record because we're interacting with patients on a day-to-day basis. So, can we send over supplemental file feeds for the payer to understand what we're doing?”

The mechanisms for achieving that data liquidity—and the ability to make sense of and use that data—is going to vary from provider to provider, Foerster emphasized. An ACO like Privia Health has a big IT team that can digest large amounts of data from its payer partners, but Foerster acknowledged that small and medium ACOs or provider groups can’t.

Support on the health IT side of things could help, he added. Right now, EHR vendors can exchange clinical data between the provider and the payer, but it would be helpful to have quality gap data, diagnosis gaps, and even network tiering interoperable across organizations.

“You're going to have a lot of variability in terms of the technical skill sets of physician organizations,” Foerster reiterated. “And so, if EHRs really can help solve this problem at an EHR-to-payer level and then turn it on really, for lack of a better word, for provider groups, I think that can really up a lot of the ways in which we can work together with payers.”

At the end of the day, that data liquidity is going to empower provider groups to do what they do best: care for the patient.

Leading with the primary care provider

At Privia Health, the primary care provider is at the center of patient engagement and care management efforts.

“We believe in PCP access almost above all else, really,” Foerster said. “For any organization trying to engage patients in care management—good luck getting that done if you can't engage your patient through your primary care doctor.”

When doing patient outreach, for instance, Privia Health avoids doing cold outreach on its own. After all, most patients are only familiar with the name of their doctor’s office, not some nebulous Privia Health entity, Foerster said. Routing emails through the primary care office and signing off from the patient’s doctor instills trust and frames patient engagement from the provider’s lens.

“The second thing we do is try and enable our physicians really to have some of the tools and resources to better be able to identify and then refer patients into applicable programs that might be available,” he added.

Take, for example, an in-house behavioral health program that Privia developed with some of its physicians. The ACO introduced that to the rest of its provider organizations by reviewing what the program does, what types of patients it will and won’t help, how to screen patients for the program, and who does and doesn’t qualify.

Foerster emphasized that Privia Health was the conduit between the behavioral health program and the provider; from there, the provider could spearhead the referral process.

Of course, there’s that fourth element of the quintuple aim: provider burnout driven at least in part by the onslaught of activities necessary for good care management.

“You've really got to try and create a payer agnostic approach as much as possible, which can be hard,” Foerster acknowledged.

In managing some 80 value-based contracts, Privia knows the myriad clinical quality measures to which providers are beholden. The organization works to simplify on the provider side by detecting common threads across different contracts.

Maybe A1C is a consistent measure across different programs, as well as medication adherence. Giving that kind of guidance to providers, who don’t want to treat patients differently based on their payer attribution, helps them lead care management.

Where payers—and, Foerster admitted, groups like Privia—come in is by providing the resources and creating an environment in which providers can conduct patient care management.

“Payers should take the role of enabling the ecosystem of their physician network, not micromanaging the care of patients in that physician network,” Foerster concluded. “That entails all the things I'm talking about, give physicians data, give them incentives and funding to run programs, sometimes provide some of those supplemental tools and resources that they're not going to be able to have access to easily inside their office.”

Correction 12/13/2022: A previous version of this article stated that Privia Health was located in Pennsylvania. It is actually based in Virginia.