3 Tips for synchronizing provider and health plan relationships
How health systems are working together to improve care outcomes
July 20, 2021

As of July 1st, 2021, the Centers for Medicare and Medicaid Services Interoperability and Patient Access Rule went into effect—attempting to reduce friction in care delivery by improving ease of access to health records between stakeholders in the care community. 

While policies like this are a step in the right direction, there are many additional ways health plans and providers can better work together to achieve synergy and make long-term progress in improving patient and population outcomes. 

Background: The existing challenges in today’s healthcare system

Tensions between systems and providers are the result of a number of variables and misunderstandings that have emerged from a long-siloed healthcare system. This lack of communication can prove costly—not only in redundancy of efforts but also in a lower quality of care which ultimately results in increased high cost utilization. 

Improving interoperability breaks down barriers through improving communication and information sharing. Combining this with efforts that help healthcare providers not only communicate with health plans, but work in tandem to improve care, can move us closer to achieving the ultimate aims of a unified, value-based healthcare system.

Here are three ways to get started...

Tip 1: Work together to improve care plan adherence

An individual’s ability to successfully adhere to their care plan impacts both provider and health plan performance. 

Stakeholders can work together to improve care plan adherence by improving the transition from the clinic—where a patient first receives information about the care plan from the provider—to self-management at home. As health plans are able to implement programs to change behavior and improve adherence between provider visits, medication and care plan self-management improves. 

For example, when Desert Oasis Healthcare medical group implemented Wellth’s digital health platform to improve adherence with daily app check-ins, member and patient care plan adherence reached an average of 95 percent adherence—as well as a 52 percent reduction in ED utilization and other high cost utilization and a 1.31 average HbA1c reduction for individuals with type two diabetes. 

Read the full case study

Tip 2: Work together to support social determinants of health

The World Health Organization suggests that social determinants of health account for 30-55 percent of an individual’s health outcomes. As a result, identifying and addressing these social determinants becomes an important part of successful care management. 

While many providers have begun asking questions about food and housing security as part of clinic visits, depending on the frequency and cadence of these in-person visits, months or more may pass before the provider becomes aware of a problem. Health plans can help by screening for social determinants more regularly and between provider visits. 

By conducting social determinant assessments through channels of communication that patients are already using on a daily basis—such as digital health check-in or tracking apps—providers and health plans can identify potential social determinants early on, and work together through assigned network social workers and case managers to address challenges before they create long-term repercussions on the individual’s health. 

Tip 3: Tag team preventative care reminders and outreach 

Studies have shown that 90 percent adherence to prescribed preventative care can reduce care costs by $53.9 billion annually. Understanding this, many health plans offer little-to-no-cost preventive care for members, yet only 8 percent of individuals actually receive all of the preventative care they need. 

When providers call and remind their patients—whether personally or through an automated telephone system—appointment scheduling and attendance reaches an average 34 percent. While this is helpful for some populations, it will likely not be enough for members with established patterns of nonadherence or chronic conditions. 

Manual telephone calls often come during work hours, making it difficult for members to answer or remember to call back after work. Instead, sending these reminders through a platform that members are using regularly can improve likelihood of the patient scheduling and receiving those preventative care visits. 

In addition, if health plans are willing to offer incentives for this preventative care—such as a reward for an annual eye check-up for members with diabetes—providers are more likely to see their patients as often as necessary for condition management. 

We’re all in this together

As health plans and providers partner in addressing social determinants, preventative care, and self-management, everyone wins. 

Providers win as patients thrive and feel more satisfied with their care as their ability to successfully self-manage their conditions improves. Health plans win as better condition management leads to fewer member readmissions, less inpatient and ED utilization, and better quality scores. 

And, finally, member and patient outcomes improve as they take medications regularly, have their food and shelter needs met, and receive the necessary preventative care to thrive.