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The Case for Expanding Provider Network Coopetition Among U.S. Health Plans


In my previous blog, I described how, since 2017, Sutherland has created a shared services model that obviates the need for participating California health plans to separately build and update parallel databases to track the availability of providers of nonurgent care for Medicaid recipients.

The company estimates that through its consortium of member health plans it has reduced associated health plan physician data management costs by 75% through elimination of duplicative work and by improvement in survey execution workflow and other areas. For an estimated 80,000 physicians in its CA directory, Sutherland now estimates that it reduces the touch rate on providers related to the Provider Appointment Availability Survey (PAAS) from three to one call per practice. The initiative also improves reporting and other interactions with the California regulatory body (Department of Managed Healthcare, or DMHC) and improves patient access to timely care.

Sutherland’s success with its coopetition/shared services model begs an interesting question: can this model be extended across the U.S. and, if so, how?

Uncovering value from duplicated effort

The coopetition model now proven in California might provide a useful template for future work at the national level. Data from Sutherland’s efforts in California indicate that national health plan provider networks significantly overlap and that much of the work they pursue in building and maintaining their physician databases is therefore duplicative and wasteful. In California, Sutherland reports a 48% overlap of providers between the top three CA health plans. That is, of ~20,000 physicians that are currently contracted to plans managed by one of the top three health plans in CA’s Medi-Cal Medicaid program, over 9,000 are currently contracted with all three health plans. Each health plan in California is required by the DMHC to maintain accurate data on each provider so that patients can gain access to timely care. Each health plan is further required to manage this dataset in order to maintain its own operations. The difficulties in maintaining these parallel datasets result in a myriad of problems for different stakeholders, including wasted effort.

Stakeholders include vendors of business outsourcing services. Prior to Sutherland’s involvement in the shared services initiative, the data collected by the DMHC was of such poor quality that it resulted in a directive to all CA health plans saying that the vendor then in charge of managing the provider data collection effort would no longer be allowed to work in CA.

Sutherland reported that, at that time, 40% of data records contained errors or omissions. The result was that health plans could not confirm members for timely and appropriate access to care, and providers were subjected to unnecessary inconvenience, cost and fatigue. The opportunity for a vendor of business outsourcing services, conversely, was significant. Since two-thirds of data collection efforts by different health plans required the same basic information from providers, Sutherland identified an opportunity in California to generate value by eliminating unnecessary work and collecting a slice of the resulting value, while simultaneously providing value to the regulatory body, providers, and patients.

Geographic & market segment extension of the model

The geographic extension of this model in physician network data management beyond California may be a logical next step. Sutherland itself calls its shared services model for the provider appointment availability survey (PAAS) a “proof of concept”. The fact that Sutherland has successfully united the interests of competing health plans with those of providers, patients, and the state regulatory body lends credence to the idea that other health plans in the U.S. might be convinced to join a similar consortium. Note that some health plans would likely never be candidates, such as Kaiser Permanente, which is based on a vertically integrated model that unifies the management of provision and reimbursement of care. (While Kaiser provides Medicaid services in California, it is not a member of Sutherland’s current shared services model in CA).

However, whether led by Sutherland or another entity (private or public sector), such a consortium could eliminate waste on a state-by-state basis, or even more broadly. The model could be extended to other government healthcare. It could standardize and streamline data collection, present accurate data to a wide range of stakeholders in timely fashion, standardize reporting, reduce provider fatigue significantly, and improve customer/patient access.

Generating leverage

Creating a public utility by mandate may lead to inefficient, unintended consequences, but Sutherland’s success seems to indicate that a market solution can be viable. The CA consortium currently counts 14 health plans, but replicating this success outside CA would require customization to other economic and political circumstances. The mission of the Council for Affordable Quality Healthcare (CAQH) and other associated alliances, non-profits, and government agencies may align with such efforts. Companies that specialize in providing outsourcing services have, as Sutherland proves, many of the capabilities required. Short of a government-sponsored mandate, how can health plans be induced to share proprietary data and data methodologies?

Political leverage might be hard to generate among consumers/patients, but physicians may present a more unified and sharply-focused interest group. If a doctor contracts with a single health plan for multiple products (e.g. Medicare Advantage, Mental Health, etc.) and that doctor’s information needs to be verified for each product, this would require multiple touches, cost, inconvenience, and fatigue. According to Sutherland’s experience in CA, that doctor may, on average, contract with 20 health plan products. The doctor is therefore incentivized to reduce this duplicative and wasteful interaction, and the argument that physician rosters can be harmonized among health plans with minimal interaction (leveraging web portals rather than call centers) is not hard to make. Having thus grasped the challenge, the physicians’ professional organizations may be well-placed to work with health plans to set up more consortia similar to Sutherland’s in California.

Finding allies

An industry alliance designed to introduce blockchain is aimed directly at the challenge of reducing the estimated $2.1 bn in cost associated with maintaining provider data. According to an April 2018 article, Optum, UnitedHealthcare, Humana, others launch blockchain pilot, these industry titans are exploiting the opportunity to reduce waste associated with provider data: “Five healthcare organizations including insurers UnitedHealthcare and Humana, Optum, Quest Diagnostics and MultiPlan are launching a blockchain pilot to help payers tackle mandated provider directories”.

The mission of this alliance may provide a long-term objective to which one or more consortia based on the Sutherland CA model might be mutually supportive. The hype associated with blockchain might create the attention necessary to establish more provider data consortia, while the political clout of physicians’ professional organizations might bring leverage. In combination, private sector players might then find the resources and support necessary to align economic incentives, manage workflows, normalize and de-duplicate data, execute against state and federal regulations, and package provider data in digestible, accurate, up-to-date formats for the constellation of healthcare stakeholders.

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