Working with Payers: An Interview with Torrie Fields

Private health insurance plans continue to be the dominant payers in America. Increasing numbers of Medicare beneficiaries are relying on private Medicare Advantage plans, totaling nearly eighteen million and more than 40% of total Medicare beneficiaries in some states. At the same time, the majority of states have privatized Medicaid coverage to Medicaid managed care organizations. These populations, along with some families buying insurance individually, join the traditional employer-based populations among the more than 155 million lives covered by health plans.

Private health insurance gives providers an opportunity to develop mutually beneficial partnerships, and palliative care is garnering increasing interest.  To explore payer-provider partnerships further, CAPC’s Allison Silvers (AS) sat down with Torrie Fields (TF), Senior Manager for Palliative Care at Blue Shield of California, one of the early pioneers in health plan palliative care innovation.

AS: How have you seen palliative care payer-provider partnerships evolve over time?

TF: It’s been very exciting to see palliative care placed in the context of the larger continuum of care. More and more, palliative care is simply part of population management and not a parallel service. Originally, my conversations with other health plans were more on the business case for palliative care, but now they “get it,” and are working on their own strategies and implementation.

At the same time, there are more palliative care programs available, and they are beginning to sustain themselves. That means they have been able to articulate their service in a way that adds value.

AS: So articulating your value well is one key to success, step one of  CAPC’s An Introduction to Working with Payers infographic. On that note, what are some of the mistakes you see palliative care providers making in their discussions with health plans?

TF: One of the more common mistakes is that palliative care providers focus on cost savings, and not on care delivery. Health plans are seeking optimal care for our members with serious illness, which is not the same thing as seeking cost avoidance. We need to learn about your palliative care services. What types of patients do you serve, and how do they find you? What is your clinical model? How do you respond to patient and family needs after hours? Health plans are beginning to understand that palliative care improves quality and lowers cost of health care, but only for those patients able to access it. We are just as interested in the outcomes as we are the process of ensuring providers are able to identify and care for those with serious illness.

AS: In other words, value is quality/cost, and palliative care services are an important part of the quality side of the equation?  How do you ensure that you’re getting quality?

TF: We look at staffing models, and the skills and credentials of the program staff. Also, we ask what the quality metrics are that the program uses, i.e., what are their satisfaction results, depression assessment, and follow-up, etc. As a larger organization, we track gaps in patient care, and we’re able to look at the previous care gaps patients have, organized by provider. If a provider has fewer patients with care gaps, that is an indicator of quality. Most often, these care gaps are seen in patients with palliative care needs. We also seek to rely on quality certifications and accreditation offered by The Joint Commission and others. Programs that come to us without certification are expected to get it by the time their contract is renewed, or at least be able to show progress toward that certification.

AS: While there are local palliative care programs meeting with health plans, it seems there is also tremendous growth in national palliative care programs working with health plans.  How does this all play out at the plan level?

TF: The national programs are spearheading interest among health plans, and can fill a great need. At the same time, the existing local relationships between the treating providers and the palliative care providers are quite effective, and we should be working to shore these up. For example, some palliative care programs are embedded in our network oncology practices and these arrangements have been serving the patients well.

The palliative care programs really shouldn’t divorce themselves from the treating providers and community resources with whom they work. Our case managers and hospital discharge planners look for natural referral relationships and sustainable structures for our members, and palliative care should work collaboratively within our accountable care organizations and health systems. In order to ensure the continuum of care is sustained, we work to honor and strengthen the naturally occurring relationships between inpatient, outpatient, and community providers for those with serious illness.

AS:  That makes sense, as health plans rely on their network health systems, and a health system with well-integrated palliative care is best suited to care for the seriously ill regardless of prognosis.  But how do health plans know what palliative care programs and clinicians are available to their systems?

TF: Identifying palliative care providers is a major challenge. The provider-credentialing systems that we rely upon list palliative care physicians by specialty, not sub-specialty. We were lucky in California because the California Health Care Foundation undertook a project to identify palliative care providers in the state, and that was how we found the palliative care providers in our existing network.

AS: A few other states have also worked to create palliative care program directories, but you’re right, policymakers need to do more in this area.

TF: Yes, policymakers have a stronger role to play, as do quality organizations. We need to be able to identify clinicians with the right credentials and also programs and services that adhere to quality standards.

To hear more thoughts and join the discussion on working with payers and related topics regarding palliative care, join us at CAPC National Seminar 2017.