HE: The tension between health insurers and providers appears to have peaked recently. Do you think that’s the case, and if so, is it necessary to control costs?
Rice-Johnson: The last few years have transformed the world and the health industry alike. I think we are all still adapting to the shock of the pandemic and its long-lasting impact on healthcare.
Many hospitals and health systems across the country are facing challenges in today’s economic climate, from rising labor costs to supply chain issues to recovering from the pandemic. Where, when and how care is delivered is also changing.
We recognize these challenges and have negotiated what we believe are fair and reasonable reimbursement changes with our valued provider partners. We have a responsibility to our members to negotiate terms that do not place an undue financial burden on them and jeopardize access to affordable care. Our goal is to work with providers to balance access to high-quality, affordable care for our members with fair and reasonable payments to providers.
Robbins: Health insurers and providers are all working toward a shared goal—to provide high-quality, affordable healthcare. There’s no question that both are dealing with unique challenges coming out of the pandemic years, but our biggest focus is on our members. The ever-rising cost for delivering care is simply unsustainable. Only when working together can we navigate the many challenges and opportunities that exist in today’s landscape. But, as an industry, we must do things differently than in the past.
HE: Is the recent uptick in claims denials playing a role in how payers and providers can collaborate more closely? How?
Rice-Johnson: When it comes to claims reviews, our goal is to determine appropriate and fair reimbursement for services and to determine the appropriate procedure code for the services provided. That ensures that the cost of care for our members is fair and accurate, that members are not exposed to unnecessary out-of-pocket costs, and that the overall cost of care remains affordable.
I think, broadly speaking, insurers and providers are negotiating and operating in good faith. Philosophically, we’re aligned on quality care and outcomes. And, as more care is delivered under value-based arrangements, financial incentives of payers and providers are aligned. When you incentivize high-quality care and health outcomes, rather than number of services delivered, everyone wins. Providers are rewarded for delivering the best-quality care. Members and patients are healthier and have lower costs through better health management.
HE: What do you say to hospital system CEOs thinking of sponsoring their own health plan to have some leverage in contracting with other payers?
Robbins: We welcome competition. Many of our plans compete with provider-sponsored health plans and have for many years. We have seen many enter the health insurance space with the idea that it is simple to operate a plan, only to leave the market a few years later—which hurts consumers counting on that insurance the most.
Consumers are best served when they have more choices that fit their needs from stable and trusted insurers, which drives down prices and makes healthcare more affordable. Healthcare is not one-size-fits-all, and because local Blue Cross Blue Shield companies are in every ZIP code in the country, we can tailor our health plans to meet local needs of every community.
One essential ingredient in building relationships between payers and providers is trust. We see this work in our Total Care Program, which includes more than 156,000 providers. The program recognizes doctors who focus on healthcare instead of sick care, and it’s based on a shared goal of keeping people healthy and costs down. Whether value-based care arrangements or high-performing networks, Blue Cross and Blue Shield companies are constantly working to collaborate most effectively with providers to serve members.
Rice-Johnson: I can speak to our own experience at Highmark. During my career, Highmark has transformed from a traditional Blue Cross Blue Shield insurer into what we call a national blended health organization—one that brings together a diverse portfolio of businesses that cover a spectrum of essential health-related needs in service to our customers and communities, including health insurance, healthcare delivery, population health management, dental solutions, reinsurance solutions and innovative technology solutions.
As a blended health organization, we’re able to eliminate the fragmentation that sometimes plagues the health industry. As both a payer and provider, we are able to innovate in partnership with our Allegheny Health Network clinicians to deliver better health outcomes and a better experience for our members and patients.
I would also encourage health system leaders to think of partnerships in a broader, more holistic sense. We partner with providers throughout our markets in Pennsylvania, Delaware, West Virginia and New York in a variety of ways. It’s not just about owning or acquiring particular assets. It’s more about finding like-minded, forward-thinking groups and working with them to elevate both the patient and clinician experience.
For example, we have partnered with Penn State Health to create a world-class, community-based network of care in central Pennsylvania. That partnership has expanded critical health access points, improved health equity with culturally competent and bilingual mobile healthcare and education initiatives, and lowered costs for local employers through an insurance product that incentivizes receiving care from Penn State Health and select independent providers.
HE: The price transparency rule for health insurers took effect last year. Has it changed how you operate?
Rice-Johnson: We are supportive of members and patients understanding their bills, their benefits and the cost of their care. The challenge is to ensure that they’re getting the right pricing information—meaning that they know what their actual out-of-pocket costs will be, given their insurance coverage. That kind of pricing information is actionable and useful.
At Highmark, we have price transparency tools that provide members with the information they need to make smart decisions about their healthcare and healthcare spending. By providing quality and cost comparisons along with other practical information, members are offered an integrated suite of tools.
This makes cost and quality not only transparent but meaningful. It helps members across all plan types make educated choices when deciding on medical care.
Robbins: Even before the rule was established, BCBS companies were providing members with easy-to-use tools to estimate the range of costs for specific procedures from providers in their communities. We remain committed to making the entire healthcare industry more transparent—closely working with federal agencies to meet the Transparency in Coverage rule deadlines and make additional resources readily available to the public.
That being said, machine-readable files are not consumer friendly. In fact, they are extremely complex and not likely to be of much use to members who want to understand their personal costs for healthcare services.
That’s why we’re focusing on tools that help people easily access and compare information about out-of-pocket costs and doctors’ ratings and reviews and confirm if their preferred healthcare provider is in-network.
HE: Medicare Advantage is being heavily scrutinized by the Centers for Medicare & Medicaid Services, which promises changes. Is Medicare Advantage the future for the majority of seniors, or will enrollment level off at about 60%, which is where it is today? Are you optimistic, pessimistic or unsure at this point?
Robbins: Medicare Advantage has a proven track record of reducing costs and improving care. Studies show those plans outperform original Medicare on quality measures, including reduced hospital admissions, fewer days in the hospital and fewer emergency room visits.
We believe Medicare Advantage will continue to grow because of the value it brings to members. MA works best when it is member-centered, and care is provided in partnership with providers with a focus on care coordination and management to support preventive and chronic care of our members. We will continue to enhance our capabilities to ensure our Medicare members get the right care, at the right time, in the right setting, and we do that by leveraging data to support clinical decision-making and local investments.
Rice-Johnson: I would say we are optimistic about Medicare Advantage and are investing every year in making our plans better for our members.
Plus, there are lots of exciting things happening in Medicare Advantage. CMS has allowed plans to explore innovative benefits like over-the-counter allowances and Part B givebacks that provide a great deal of value to a lot of MA beneficiaries. The flexibility to go beyond traditional Medicare has become a hallmark of the MA program.
But, at the end of the day, the primary role of your health insurance is to keep you healthy and make sure quality care is affordable and accessible.
The plans that are doing well are doing the basics right—they’re ensuring affordable access to high-quality care and providing their beneficiaries with the best in customer service.
Successful MA plans provide access to doctors and hospitals, both local and nationwide, and a focus on the benefits that matter most to members—robust and affordable medical and pharmacy coverage along with traditional supplemental benefits like dental, vision and hearing. These supplemental benefits aren’t available in traditional Medicare and allow for Medicare Advantage plans to care for the whole person.
It’s clear that older adults see significant value in MA plans. More than half of eligible seniors now choose to enroll in Medicare Advantage, and more than 90% of those enrolled in MA are satisfied with their plan—higher than the satisfaction rate for traditional Medicare.
HE: What is your value-based care strategy? Has it been a success?
Rice-Johnson: We are investing in value-based care to evolve from a fee-for-service model to one in which keeping people healthy and having positive outcomes benefits patients, providers and payers alike.
Our value-based care programs incentivize physicians to work with us toward common care and cost goals. Physicians receive higher reimbursements when those care and cost goals are met and when our members have better outcomes by taking their medications, getting recommended screenings and better managing chronic diseases.
Highmark also works to ensure that physicians have the information they need to meet these goals, including insightful tools, custom reporting and personalized field-based support dedicated to value-based programs.
Since our True Performance VBC program started in 2017, participating primary care physicians have helped to potentially avoid $3 billion in healthcare costs due to lower rates of emergency care and hospital stays.
Data shows that members who receive care from providers in our value-based programs are significantly more likely to complete annual wellness visits, receive recommended cancer screenings and complete recommended diabetes care compared to those in non-value-based programs.
Value-based care is a critical component of aligning incentives among healthcare stakeholders and addressing the rising cost of care in the U.S. We need to reward providers for doing what they do best: caring for patients and helping them improve and manage their health. Getting to a holistic, value-based system of care is a process that is decades in the making. We’re not there yet, but we’re happy with the progress we’re making.
Robbins: BCBS companies are seeing success across our value-based care programs, with better control of chronic conditions, more delivery of preventive care and less utilization of unnecessary services. Through value-based programs, our data shows patients are healthier—with 7% more appropriate antibiotic use, 12% better adolescent wellness care and 13% lower utilization of emergency services for non-emergency needs.
These programs are a true shared risk between insurers and providers—with each of us being equally accountable for patient outcomes, safety and lower costs. Our members rely on us to continue to prioritize value-based care delivery and remove waste from outdated fee-for-service models.
To continue to advance this work, we need to focus beyond primary care. We can only achieve value-based outcomes if specialty care works with the incentives in the primary care value-based care model.
We also need to enhance our measurements to make sure value-based incentives are tied to healthcare delivery that meaningfully improves patients’ outcomes, so they can lead healthier lives.
Highmark covers the insurance needs of approximately 7 million members in Pennsylvania, Delaware, New York and West Virginia.
The Blue Cross Blue Shield Association is a national association of independent, community-based and locally operated Blue Cross Blue Shield companies.