Joint venture health plans & value-based care: A Q&A with Tom Grote

As health care claims costs continue to rise, employers and their benefits advisors are always looking for ways to effectively lower spending and help employees adopt healthy behaviors. While value-based care (VBC) promised to address cost and quality issues, many of these models have fallen short of expectations. The question is whether new “payvider” insurance approaches can accomplish what others can’t. Under the joint-venture approach, the payer and provider share accountability for claims costs and profit or losses, which means they both have an equally vested interest in getting patients the right level of care at the right time.

Tom Grote, chief executive officer with joint venture health insurance company Banner|Aetna, recently shared his perspective on joint venture health plans, the “payvider” model and where he thinks value-based care is headed overall.

 What is a joint venture health plan and how does it compare to other “payvider” models?

“Payvider” can refer to a wide range of collaborative models, but a joint venture health plan is the most evolved in terms of accountability and shared responsibility between payer and provider. While there are other models in the market, like health systems with their own health plans, these organizations are attempting to take on operational tasks beyond their natural expertise – typical insurance-based tasks like paying claims, customer service, billing, administration, actuarial and underwriting work. As such, they may struggle to deliver outstanding service to their customers and members.

On the other side of this spectrum, joint ventures can allocate services based on where expertise lies, so the insurance side will manage the operational aspects of the health plan and the delivery system can focus on utilization management, network management and driving care quality.

What are some of the other ways a joint venture health plan can help drive value for employers and employees?

Joint ventures can also present opportunities for cost savings through innovative programs that enhance care management for high-cost claimants and help drive improved employee experiences. While it’s not unusual to hear health insurers talk about collaboration, the joint venture model of shared risk allows care providers and insurers to really work together toward the same goal in an advanced way. Again, because they share equally in the results of the joint venture, there is an implicit trust which drives information sharing and mutual financial interests between both entities that can be the basis for a variety of innovations.

This type of collaboration keeps the clinical expertise in the hands of care providers, where it belongs. Insurers are not experts at caring for and supporting employees, but care providers are, and leaving care decisions to them can lead to more targeted interventions and better health outcomes for patients.

It also leads to the development of initiatives like “frictionless billing.” Frictionless billing is a jointly created program that provides employees with an integrated statement combining the provider billing information and coverage and payment information from the insurer, so they have a complete picture of what has been paid and what is owed.

Within the joint venture model designed to lower costs, are employees limited to a narrow network or can they still easily seek the care they need?

Joint ventures can be designed to offer both cost savings and access to quality care, without limiting care access. A strong network development strategy must take into account unique clinical and geographic considerations for every community it serves.

And of course, incenting providers within the performance network to make the right care decisions is key to controlling costs without sacrificing quality.

 How do joint venture health plans encourage these providers to make the right decisions?

Performance networks often include underlying value-based care incentives for doctors, which encourage them to deliver more efficient care to patients. Things like providing incentives to ensure at-risk employees can connect with necessary care and that all employees receive appropriate screenings and wellness visits. However, this strategy must also give providers the tools needed to do so, which is where today’s most advanced technology and data analytics comes in. This includes real-time information about an employee’s overall health and insights that can help close gaps in care. 

What do employers need to know as they consider whether a joint venture can offer the right benefit strategy for them? What factors should influence their decision?

There are several factors that employers and brokers should consider when looking at products offered via a joint venture. How long has the joint venture been around? Experience in this space really matters like nothing else, because this is still a relatively new model.

Also, what kind of resources can the joint venture access through its parent companies and partners? One of the most exciting opportunities presented by these joint ventures is the pooling of resources from across the health care ecosystem.

In addition, employers will want to consider the network coverage carefully, to make sure that it’s not an overly restrictive narrow network approach, available across all the communities served, including rural areas, if applicable, or national—if the employer has a workforce in a broad geography.

Finally, does the joint venture offer a wide variety of products, including self-funded or level-funded options designed to fit employers of all sizes? Self-funding isn’t just for large employers any longer, and this particular product really aligns with the value proposition of a joint venture designed to control costs.