The relationship between health systems and payers has strained as inflation grows faster than reimbursement rates. Some health systems cut ties with certain payers amid contentious negotiations while others dropped Medicare Advantage plans. WVU Medicine took a different approach.
About 18 months ago, the 24-hospital academic health system launched its own health plan for more control over coverage. The health system had tried population health and risk-bearing programs in the past, but weren't able to yield long lasting results.
"It works until it doesn't," said Nick Barcellona, CFO of WVU Medicine, during an interview with the "Becker's Healthcare Podcast" at the CEO+CFO Roundtable in November. The conversation was supported by R1.
In the typical cycle with health plans, the system takes on risk and focuses on population health. But the health plan raises benchmarks every year until they become unachievable in the provider's view and physicians become frustrated. Why the disconnect?
"A lot of times you're not focused on the right quality measures. You're not even talking about those quality measures; you're much more focused on cost and looking at the per member per month trends," said Mr. Barcellona. "Those trends are nine months old, 12 months old, 18 months old and you're telling a physician to change their behavior based on old data."
WVU Medicine's leadership team wanted to change that dynamic to become more forward-thinking about their population health and risk-bearing strategy.
"No offense to my insurance friends, but a lot of great ideas about how we can change care pathways, deliver care more effectively, and drive population health come from guess who? The providers," said Mr. Barcellona. "The folks who are actually sitting across the bedside or exam room from the patients. That's where we want to give them a voice and let them help us come up with ideas of what we can do differently."
There are also administrative and back office opportunities to become more efficient and integrated. The health system has a payer-provider committee led by the system's CIO, who also leads population health initiatives in partnership with the health plan CEO and other provider leaders. The cohort gathers around the same table every month to identify and solve population health pain points.
"How can we try to improve the relationship between these two sides of the spectrum that historically have fought," said Mr. Barcellona. "I'm not here to tell you we have that all figured out, but I think having that dialogue and being able to work toward the future state is what we're focused on because ultimately that's how we're going to improve the trajectory of healthcare for the patients we serve in West Virginia and beyond."
Since developing the health plan, Mr. Barcellona and his team have had more informed and candid conversations with other health plans to outline what they need to strike an in-network deal. WVU Medicine works with six other health plans right now, but not all will stay.
"In the future state, there aren't going to be that many health plans," he said. "We're going to be able to take what we learn and our expectations from doing it ourselves and have tough conversations with those payers."
The health system aspires to have relationships with two to three other payers and grow revenue as a payer-provider.