Orthopedic leaders take payer relations and 'flip it on its head'

Practice Management

Payer negotiations have often been tense with physicians and practice leaders. But some orthopedic leaders have explored ways to work with payers from a mutually beneficial standpoint.

Here is how three leaders have approached payers and the positive outcomes that come from that.

Note: These conversations were lightly edited for clarity.

Michael Boblitz, former CEO of Tallahassee (Fla.) Orthopedic Clinic and CEO of Athens (Ga.) Orthopedic Clinic: I'll never forget one of my first meetings in town [after starting at TOC]. I called the CEO of Capital Health Plan, and I was not asking for anything. I was asking for advice. How could TOC be better? We're a 50 year old organization, which is amazing and such a privilege and honor, but sometimes when you're around 50 years you may get stuck in the status quo environment. 

So I was asking the CEO of this health plan, "What can we do better?" He said [the health plan] contracted with our MRI, but the vast majority of members were leaving TOC and going elsewhere. I went back to our director operations, and said "Hey, I need you to expand hours for me." He said the center runs 16 hours a day, seven days a week.

I went back and sat down with the CEO of the health plan again and basically explained that this is a great opportunity for us to really align and partner. You obviously want your members served in our lower cost health center and imaging center, and we want to do that. So we created an agreement where the health plan actually made an investment to allow us to afford the construction and the purchase of a second MRI. That's been operational now for about a year, and it's just been great and able to keep patients in. 

Nicholas Grosso, MD. President of Bethesda, Md.-based Centers for Advanced Orthopaedics: The relationship between payers and physicians has been a long and tumultuous one. I was in the Army for 23 years, and then I went into private practice when I got out. That was a long time ago, back in 2001, and I couldn't get over the animosity and negativeness. They'd come back every year and try to beat you down a few more dollars per CPT code. We were taking less and less every year. It got to the point where it really was a very one-sided relationship with the payers, and the physicians unable to really have any negotiating power. Even if you were in a 10- or 12-physician group back in the early 2000s, it really didn't mean anything to the payers because they would just as soon dump you for anybody else, and they played one against the other. It was a race to the bottom. 

When we formed CAO, it put us in a much stronger position to negotiate. We were able to negotiate better reimbursement rates on our fee-for-service. We tried to build relationships with the payers, and we had better relationships with some because we were really built to get to this value. We saw the writing on the wall. We knew value-based care was going to come eventually and just took a lot longer than we thought it would, and so we kind of built ourselves to do that and leave the talking to the players the whole time saying we're ready, and they really haven't been. Now they're starting to get that way as they update and modernize their systems. 

I really hope going forward it's more cooperative. I mean, there's always going to be that tension there. They're the payer and we're the provider. But as we move toward capitated care, that kind of shifts the dynamic. I'm hoping it's not just an adversarial relationship where we go to the table and try to see who can take advantage of each other, because I think if we work together, we could get to that value-based care. 

Matthew Lavery, MD. President of OrthoIndy (Indianapolis): I'm a big believer in working backwards from your end user. What do they need? What are they looking for? I think there's some interesting things being discussed. One of the things we struggle with, like most medical practices, is how to deal with questions of prior authorization. It comes up all the time from insurance companies. They want you to meet certain criteria before they'll authorize a procedure you're recommending or a treatment. The more we can address those issues on the front end, the more aware we are as a practice of those things and what those payers are looking for and need. But those are things that create huge operational hurdles. 

Physicians don't want to deal with prior authorization. They just feel like it's a questioning of their clinical judgment. But the flip side of it is it's the reality of the world we live in. It's something that I don't see going away anytime soon, and I think the better solution to that is to flip it on its head and go to the insurance companies and saying, "What is it you need from us? What are you looking for?" Then, within reason, tailoring how we provide them information to sort of meet those needs, so that we're getting patients the care they need in a timely fashion and meeting the reasonable criteria of payers and what they're asking for.

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