4 Payer Responses to Primary Care Challenges

4 Payer Responses to Primary Care Challenges

Primary care providers are the foundation of the healthcare system. With the pandemic putting its future at risk, health plans can take 4 steps to address this challenge. 

It’s been said that the coronavirus pandemic hasn’t created any new problems; it’s just escalated existing ones. This maxim seems especially true for primary care providers. Primary care practices have really struggled during the pandemic – at a time when their role has never been more important. Patient volumes are down by more than half, which makes it difficult for them to stay afloat in largely fee-for-service arrangements. But even under ordinary circumstances, independent practices tend to operate at an unsustainable net loss of 20 to 30 percent a year. 

Primary care providers are the keyholders for our healthcare goals: improving the health of populations, enhancing the experience of care for individuals, increasing health equity and reducing the cost of healthcare. How can payers support primary care in a way that helps improve the clinician experience so they can better fulfill their role’s potential? Let’s explore the landscape around primary care, including how it has been impacted by COVID-19, how consolidation and other factors are affecting its future, and steps health plans are taking. 

Role of Primary Care  

Even before the novel coronavirus, Americans in an increasing number of “provider deserts” suffered from lack of reliable access to care. As a result, they experience some of the worst issues in our healthcare system: poor healthcare outcomes and increased healthcare costs due to complex conditions exacerbated by lack of management and overuse of emergency rooms. These vulnerable populations are more likely to experience adverse effects of COVID-19, and the difference comes down to primary care. 

2019 report found that Americans with dedicated primary care received significantly more “high-value” services, such as recommended cancer screenings, diagnostic and preventive testing, diabetes care and counseling. Those with primary care also reported better healthcare access and experience, compared to those without. These results are intuitive, but their significance can’t be overstated. 

A primary care provider is often termed the “quarterback” of the healthcare system. It’s usually the longest-term relationship a patient has and, especially in the current environment where interoperability is lacking, primary care often has the most comprehensive health information available. They know the patient health history and social determinants of health, and they understand how the healthcare system operates. 

Conversely, a person without a primary care provider – due to poor proximity, healthcare coverage, schedule availability, or a combination of these factors – may have access to a specialist or two, but they are likely largely relying on a cobbled together arrangement of emergency care and walk-in urgent care. None of which is designed for whole-person care and can lead to complicating events like dangerous medication interactions. 

Pandemic Impact 

With the patient volumes at primary care practices down significantly, revenues have also been cut in half. Even with CARES funding, small business loans and telehealth payment parity made available, it has been a struggle for this group of providers. Recently, the HHS provided nearly $6 million in funding for COVID-19 training and technical assistance activities to 52 state and regional Primary Care Associations (PCAs), which support non-profit and safety net primary care providers. While this is certainly a welcome lifeline, it covers only a small segment of providers and services and doesn’t address the administrative burden that is particularly onerous for primary care.  

A recent survey indicated in May that many practices are at risk of closing in a matter of weeks. Specifically, 45% report layoffs and furloughs, 28% skipped or deferred salaries and 14% have temporarily closed – numbers that have remained constant. In fact, one tool projects a catastrophic loss of family medicine physicians by the end of June – almost 60,000 fewer, leaving over 1,800 shortage area counties. 

Mixed telehealth success

While many providers have rapidly deployed telehealth and virtual care to continue to serve patients and minimize their financial impact, reimbursement  hasn’t always followed and some patients struggle with accessibility. The survey previously cited further revealed 84% of providers report patients struggle with virtual care, and only 57% say more than half of the care they provide is reimbursable while 18% have been denied reimbursement for virtual and telehealth. 

Patient care delays

While the current phase of reopening holds out hope for improving these issues, there continue to be areas of concern. Particularly, patients have been and continue to delay essential preventive and maintenance care due to financial issues. This situation has been growing along with the proliferation of high-deductible health plans. And, once again, the pandemic has aggravated it into a potential crisis. 

One recent survey indicated a third of consumers plan to reduce their healthcare spending. And, unfortunately, “consumers with complex chronic illness and those in healthy families were more likely than other groups to say they would adjust their spending on healthcare visits or medications.” 

Burnout

Altogether, these concerns are worsening a perennial challenge for primary care providers: burnout. A survey conducted last year indicated 79% of primary care physicians experience burnout, compared to 68% of physicians overall. A study published this year explains why the current crisis is intensifying the burn: too little time with patients, overwhelming paperwork, emphasis of profit over patient care. 

Researchers expressed concern about the extraordinary burden COVID-19 has placed on these professionals. “These findings tell us that we need to prioritize understanding and addressing clinician burnout at a system level and at a local level. The human cost, as well as significant physician shortages expected in the future, make this a critical public health concern.” 

Threats to the Future of Primary Care 

Demand for primary care providers is increasing more rapidly than supply, and provider availability is seen as one of the top barriers to meeting the healthcare needs of patients in this country. In 2013, 53% of states were already experiencing primary care physician (PCP) shortages. By 2025, experts expect that shortage will include 72% of states. 

The number of doctors going into primary care continues to decrease in favor of better-paying specialties. And consolidation – in the form of doctors employed by health systems or payers, or joining larger practices – continues to increase, which further decreases provider access and drives up healthcare costs. 

Another factor contributing to the primary care shortage is our rapidly aging population. For one, physicians themselves are growing older. Fully one-third of currently practicing physicians will be over retirement age in the next decade. In addition, seniors are a rapidly growing segment of the population, increasing by 50% over the next decade, and tend to require two to three times more healthcare than their younger counterparts. At the same time, there continue to be reports of primary care physicians exiting Medicare, due to lower reimbursement combined with higher administrative burden to participate.  

In fact, there is some evidence of primary care providers dropping out of onerous reimbursement arrangements entirely in favor of more predictable compensation models. So-called “membership medicine” like concierge or direct primary care (where patients pay upfront fees for access to doctors) is a small segment of how these physicians practice but is growing in popularity, especially in affluent areas.  

What providers encompass “primary care”?

When you think of “primary care” you may be only thinking of your family doctor. But primary care includes a broad spectrum of credentials – doctors, nurse practitioners, nurses, pharmacists – and a range of specialties that fulfill the general medical needs of patient populations: 

  • Family medicine 
  • Internal medicine 
  • Pediatrics 
  • General OB/gyn 
  • Gerontology 
  • Behavioral health 
  • Community health 
  • Optometrists 

How Health Plans Can Respond to Primary Care Challenges 

The future of primary care stands to impact all areas of quality and satisfaction in healthcare but, perhaps most relevant and impactful for health plans, are the ways it affects short-term and long-term healthcare costs. According to an expert on the intersections between public health, primary care, and health care policy, “If you think that investing more significantly in primary care and preventive public healthcare is expensive, try not investing. That’s way more expensive. And not just economically, you’re also ignoring the suffering that goes on as well.” 

In addition to the potential increased costs, consolidation is also not preventing a loss of primary care providers. As the new president of the AMA relates, “The recent issues during the pandemic with physicians who are employed by large health systems not being able to get the PPE that they need, being disciplined for wearing PPE in certain situations, being furloughed, being laid off, being disciplined just for doing what they thought was best for their patient, I think, highlights the importance of physician autonomy.” 

In the face of these challenges – impacting payer bottom lines, member satisfaction and health, and provider networks – health plans have a few avenues to pursue in shoring up this cornerstone of the healthcare system. Here are 4 ways that payers can respond to primary care challenges: 

 1. Extend telehealth

Health plans providing leeway on virtual care has been a real boon for providers and their patients. But, along with extending telehealth payment parity, effectively communicating those changes and appropriate education really makes this benefit useful. The leader at a technology provider for clinician practices noted, “Most physicians don’t even know how to code correctly for the phone call or virtual visit to take advantage of the changes Medicare (and other payers) have made during the pandemic to increase phone call reimbursement and pay for telehealth visits at the same rate as in-person visits.”

2. Promote value-based care contracts

We wrote before how those providers who were already engaged in alternative payment models were better prepared to weather the patient volume dips associated with the pandemic. Primary care providers seem especially suited to this model because of their role in preventive care and unique ability to screen for social determinants of health and impact overall patient care outcomes. For health plans positioned with advanced technology to offer real-time communication, two-way data exchange, and telehealth flexibility, their primary care provider networks should be better prepared to withstand perceived risks and more open to these modern arrangements.  

CMS is already piloting the Primary Care First project with similar structure and goals. The program covers a variety of providers – MD, DO, CNS, NP and PA – and will be active in 26 regions across the U.S. With a simple flat fee payment structure plus upside revenue sharing, it aims to reduce primary care practitioners’ administrative burden to allow them to focus on effective care and the doctor-patient relationship. 

 3. Continue prepay payment integrity efforts

When it became clear how seriously the pandemic was affecting providers, health plans fast-tracked their plans to transition more payment integrity efforts prospective. Because post-pay audits increase the provider administrative burden and increase costs for payers as well, this move to prepay is a trend that’s here to stay. Especially when combined with provider education and two-way communication, supported by an engagement platform like Pareo Provider, this activity should increase engagement with valuable network providers.

4. Support and engage providers

With the understanding that without providers, there is no effective healthcare system, health plans have been directly supporting providers financially. While this effort is admirable and well-intentioned, it is a short-term solution. But extending technology and policy to reduce providers’ administrative burden promise to offer long-term relief. 

The work providers have to perform in EHRs is particularly burdensome, with primary care providers particularly hard hit among specialties. With around 20 minutes per patient visit, on average, dedicated to this administrative task, it’s an outsized contributor to burnout and minimizes primary care availability. And this time doesn’t even include pulling medical records for health plans’ payment integrity needs. With real-time communication and seamless data exchange – supported by advanced technology platforms like Pareo – health plans can promote interoperability and reduce cumbersome administrative tasks. 

One health plan has launched a new partnership with this intent. This arrangement consolidates all necessary medical records and administrative processes like prior authorizations into one place. By allowing for a quicker and more structured view of patient information, it should reduce documentation time in favor of patient care.  

Pareo Transforms Engagement in Healthcare 

Even before the global pandemic hit our shores, the healthcare industry had been focusing on innovating in the face of coming disruption. Pareo was created with this initiative in mind, supporting health plans at the top of this chain to transform engagement in healthcare. The integrative technology platform may start with payment integrity, but it extends to real-time communication with providers – including primary care – to reduce their administrative burden and add to the time they spend caring for members. It’s an effort with real implications in reducing healthcare costs and improving outcomes. 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Health Plans Return to Payment Integrity

Health Plans Return to Payment Integrity

Now that the crisis-volume of COVID-19 cases has started to ease across the country, delayed elective procedures and in-person provider visits are beginning to resume. While providers return to some semblance of normalcy, health plans are returning to business as usual as well. Our health plan clients are making moves to resume retrospective payment integrity audits they paused in order to relieve the provider administrative burden. What does “back to normal” look like for the healthcare industry, and how can health plans do a health check on the lingering symptoms of the pandemic to ensure their return to cost containment operations goes smoothly?  

The “Great Pause” Brings Clarity for Health Plans  

While providers have borne the brunt of the pandemic, health plans appear to have weathered the first months of COVID-19 relatively unscathed – or have they? Even in the short-term, there have been significant changes for health plans. Changes such as receiving more telehealth claims than ever before, heightened data security challenges, and facing rapid upheaval of processes in an already administratively complex environment. What’s more, they have risen to the occasion to support their network providers and members, who have suffered significant hardships during this time.  

In addition, with the dramatic reduction in healthcare encounters, overall claim volumes have dropped as well, especially for those insurers whose populations reside outside of virus hotspots. Taken alongside pledges to accelerate payments to providers and reduce their administrative burden by minimizing claims recovery efforts to only the most egregious cases, this situation has left payment integrity departments with more breathing room in their day-to-day than usual. And it couldn’t come at a better time. 

During periods of great uncertainty like the industry is experiencing now, the most critical skill is adaptability: being able to focus on surviving in the current moment while also building toward thriving in a future that will look different. Increasingly for health plans, innovations to survive in the short-term and thrive long-term look like technology – including both novel uses for existing tools and new solutions to address new (and old) challenges.  

These were trends before the coronavirus pandemic, and the urgency of the situation has only magnified technology’s importance in supporting members, offering work environment flexibility and reinforcing relationships with providers. As the chief medical officer at one large regional health plan explains, “We need to be more open to change, step out of our comfort zones and embrace the unfamiliar. Barriers that have stymied innovation in healthcare aren’t as insurmountable as we once thought.” 

Increased Healthcare Utilization Results in 3 Claims Trends 

Now that health plans have navigated through the short-term impacts and are putting plans in place to position for long-term success, they are better prepared to adjust to the new normal of healthcare. A recent survey indicated that 80% of payer respondents expect a sharp increase in claims over the next few months. For payment integrity departments, that signals a return to processing claims as before, even as some changes in healthcare utilization are expected to continue for a while. Here are 3 claims trends health plans can look out for in the next phase of reopening. 

1. Resumed elective procedures, ER and outpatient visits

The state bans on elective procedures relaxed at the end of April, and patient activity is responding accordingly, albeit slowly. One survey indicates 70% of patients have rescheduled procedures for the second or third quarter of 2020, which holds true across all regions of the U.S. With that resumption, though, sites of care are changing with patients less willing to visit inpatient hospitals. Hospital outpatient settings, ambulatory surgery centers and a physician’s office were preferred. 

In addition, emergency department use and physician visits best conducted in-person are also rebounding. ER visits, which dropped 42% during April, have recovered 21-32% of volume, depending on patient age. Outpatient volumes recovered over 50%. 

As procedures and face-to-face encounters resume there is a concern that the delay may have caused conditions to worsen, resulting in more complex and costly claims. In one survey, “more than one in ten of those who skipped care reported that their condition declined because of their decision to postpone care.” 

2. Continued telehealth, home health claims

For the rest of patients whose maladies can be managed and addressed remotely, telehealth and other modes of virtual care are still a popular option. Its use increased more than 4,000% over the last year, growing from 0.17% of medical claim lines to 7.52%. Now that consumers – and their providers – have been prompted to try it, they have found telehealth lives up to its promise of convenience, without unduly limiting the effectiveness or person-to-person connection of the visit. It also comes at a lower cost, and a new report estimates at least 20% of care could be offered digitally. 

Home health, too, has found its moment for patients who, for instance, regularly receive infusion treatments, need dialysis or require post-operative care. These trends have accelerated due to advances in at-home technology along with payers temporarily relaxing restrictions. However, whether these prove to be temporary changes or a permanent shift remains to be seen. 

3. Increased behavioral health utilization

The stresses of living during a global pandemic, along with increased social isolation due to stay-at-home orders, have negatively impacted mental health conditions for many Americans. Prescriptions for antidepressants, anti-anxiety and insomnia medications spiked in the first months, many for first-time use. At the same time, while inpatient mental healthcare capacity and utilization has dropped, many patients have taken advantage of virtual mental health visits.  

One technology vendor executive attributes this increase to reduced stigma associated with telehealth, along with greater availability. That is a hopeful sign for wellness initiatives, and because counseling is one of the specialties more readily covered by telehealth even before the pandemic, this trend may continue indefinitely. 

How Health Plans Can Improve Payment Integrity Agility 

With the understanding that healthcare may be in flux until a reliable vaccine and/or treatment for COVID-19 is available, health plans are returning to their claims recovery efforts with sensitivity to how this activity affects providers and members. This transition requires agility, which is a cultural initiative and skill. As a leader at a large state-based health plan says, “We put these skills into action during the COVID-19 pandemic, making decisions rapidly to respond to the needs of our members and providers.” 

Responding to member and provider needs with tech innovations 

Adjusting to the rapid changes in healthcare to be responsive to member and provider needs may start with a culture shift, but technology is the enabler. Providers and members both are still reeling from the coronavirus impact, and health plans are best positioned with real-time data to promote seamless communication and continue the shift to prepay. 

Real-time data provides the insights needed to determine how and when to adjust the response. Health plans can leverage an integrative platform like Pareo to ingest data feeds from multiple sources for a fuller view of the claims environment. It’s a first step towards interoperability, which supports both members and providers. 

Seamless digital communication follows. At some point, health plans will begin to roll back the financial relief they have been extending to members and providers. The waived copays and cost sharing for coronavirus testing and treatment. The relaxation of prior authorization requirements. To ensure members and providers don’t end up holding the bag due to lack of knowledge, seamless two-way digital communication is key. Both internally with payment integrity departments and externally with members and providers.  

Pareo Provider includes a web-based portal designed to engage with providers on claims status, education, medical records exchange, data sharing and other relevant two-way communication to foster this valuable partnership. Request a Sell Sheet

Prepay claims processing has come into its own during the healthcare crisis to reduce abrasion with providers. It’s more sustainable than accelerating payments and CARES funds, which have many strings attached, and reduces the costs associated with reworking claims – for both payers and providers. While post-pay payment integrity audits will never cease entirely (combating healthcare fraud, in particular, is largely a post-pay activity), minimizing the administrative burden of “coming from behind” to adjust payments in favor of more prepay work is a trend that’s here to stay.  

Pareo Prepay supports this shift from pay-and-chase to working claims before payment with a concepts repository accessible across the payment continuum and configurable workflows that easily accommodate tight prepay timelines.  Request a Sell Sheet

The Bigger Picture 

Innovations in payment integrity have long been a goal at health plans. Health plans that we speak with continue to drive home the importance of data at this crucial time, to provide a measure of predictability during a situation that’s far from certain. Yet, connecting data from disparate streams and collapsing it into usable insights – insights which can be drilled down into – is still far from available to many health plans.   

Imagine a platform in which your entire payment integrity operations are fluid, accessible, operational – in real time. Imagine accessing configurable reporting that offers actionable insights, tracks KPIs, and connects previously disparate data streams.  

Advanced technology platforms like Pareo put this goal within reach for more payers – not just those with vast resources at their disposal. Pareo now more than ever has the chance to revolutionize the healthcare industry. Are you ready to learn more? 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.