Health Plans

Minding the gaps: How health plans can improve value-based care execution

By Peter Manoogian, and Shreya Raghuraman

July 9, 2019 | Article | 4-minute read

Minding the gaps: How health plans can improve value-based care execution

To close our series on provider experiences in value-based reimbursements, we are shifting focus to the enablers that support providers in value-based care programs.

Execution matters when it comes to driving lasting success with value-based reimbursement programs. This includes the activities, programs and resources a health plan can invest in to optimize a value-based care strategy. While no enabler is one-size-fits-all, our discussions with providers pointed to three gap areas for health plans to address:  

  1. Educating providers through simple and accessible resources: If provider behavior change is the gateway to true value-based care success, then up-front education is the key. Primary care physicians (PCPs) are trying to manage multiple contracts at a time and can struggle to understand the unique details of each. As a result, they fail to identify and target specific behavior changes that help them meet contract goals.

    PCPs described existing education materials as overly business-focused and difficult to understand. For example, many plans distribute comprehensive, and often lengthy, program manuals. How many PCPs have time to read a 40-page manual? An independent practice PCP summed up his frustrations by saying, “The programs all blend together; you do the best you can and hope you get paid.”

    The dialogue signaled a gap in how health plans partner with providers to deliver the right information about the various programs they launch together. This includes improving the actual program materials: offering laymen’s explanations of each metric and helping PCPs understand the performance-to-payment relationship. Proper education also includes offering details on things physicians care about, such as how medication and referral choices can impact costs. It also means changing how education is delivered. In some instances, it could mean more in-person trainings and health plans using a “train the trainer” approach via practice administrators and/or practicing peers.
  2. Delivering data at the right time, in the right way: Data is a powerful enabler of value-based care. However, data shared by health plans can also be a hindrance rather than a resource. One physician in a large group practice described the data she received: “Each day, I receive ten pages of information from the health plan on a three month lag. I don’t read it because I already have too much to read.”

    Sharing real-time claims data is a hefty and time intensive investment. In the interim, health plans can pursue quicker wins to better equip physicians. Comparison reports can reveal how an individual PCP performs relative to peers in their practice or regionally—both at a metric level as well as at a behavioral level (such as referral patterns) to incite dialogue around best practices. Some PCPs also sought support from health plans in prioritizing patient panels through risk stratification.

    But not every physician engaged in a value-based arrangement needs this information. Many larger provider organizations already have deeply rooted EMR systems and data vendors in place. Investing in data enablers isn’t just about improving the content delivered – it’s also about identifying physicians for which reporting would be the most impactful, like standalone physicians and practices that are beginning to shift into value-based programs for the first time.
  3. Providing clinical resources and support: The third pillar goes beyond training and distributing information. Health plans offering on-the-ground clinical resources with providers are more likely to build sustainable, strong relationships and meet providers where they are.

    An executive at a large provider organization highlighted the importance of this, saying, “The name of the game is more clinical resources. PCPs have been stripped of the ability to do anything other than to see patients in the waiting room.”

    Deploying clinical teams that support case management or serve as clinical consultants can help drive the behavioral changes that lead to value-based outcomes. The key is to also educate those roles on program objectives and align incentives with those of the providers they support.

The good news is that there is plenty of room for plans to launch new and creative education, data and in-clinic enablers. Surprisingly, most providers we interviewed do not receive any support from their health plans today. An independent physician expressed her frustration at the lack of support, saying, “Nobody’s helping us. We’re trying to figure this out ourselves.”


There is no one-size-fits-all approach to designing and deploying value-based care programs, but it starts by engaging with providers as true partners. Health plans that take the time to understand provider needs, design a clear and motivational program and invest in the right enablers are best positioned to deliver value-based care programs that are successful for plans, providers and the patients they serve.

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