The biggest question payers face when they decide to get into the business of primary care delivery is whether they will build the care delivery system from scratch or buy it by working with an experienced partner.
Building and buying both come with their own challenges. The right approach will depend on the capabilities of the payer and the speed at which they want to launch a primary care solution to their members.
This post unpacks four questions payers should ask to determine whether building or buying is the right approach for them.
1. Do we have the infrastructure needed to build and operate a primary care system?
Building an integrated primary care model isn’t for the faint of heart. It’s a significant undertaking that strains even the most sophisticated organizations.
In many cases, it requires building completely new capabilities that do not exist within your organization. We recommend creating a detailed plan that outlines the people, resources, and processes that will be required to both build and then operate the primary care solution to determine, first, if the project is feasible and, second, if it can be accomplished in a reasonable amount of time.
Another key consideration is how much you will separate the effort to build and operate the primary care model from your core plan administration business model. The best option for efficiency and reduced disruption is to completely separate the two operationally, requiring you to effectively run two separate businesses.
2. Do we have the budget to develop a care delivery system?
Developing a care delivery system will take significant time and budget. Once you have an understanding of your existing infrastructure and processes to support the effort, we recommend creating a detailed financial projection to determine if you have the financial capacity to complete the project.
Your projections must include both the costs of building actual care centers and budget to develop the care model, processes, and systems necessary to ensure that your primary care system can deliver positive health outcomes while reducing the total cost of care.
Any projections should be compared against the cost to work with a partner with experience implementing a primary care solution. While there is no guarantee that a built solution will perform, many partners will guarantee their model will achieve certain HEDIS quality scores or star ratings if you work with Medicare Advantage populations. These guarantees significantly reduce the risk to the payer.
3. What level of control do we need? And can we achieve that with a partner?
Different primary care partners are going to offer different levels of control. You need to decide what level of control and customization your organization needs. If you’re willing to cede some control, a payer can likely find efficiencies with a partner as well as the level of customization needed.
The best partners will balance the needs of payers to customize their care delivery without sacrificing proven best practices that allow them to improve member experience and quality of care.
4. If a partner could effectively serve the needs of our population, would we still build?
There is no doubt that building a primary care solution will be more expensive, take longer, and cause more disruption to a payer’s existing business model. The other main argument beyond control (addressed in the question above) is the argument that you know your member panels better than anyone else and therefore should be able to build the model that serves them best. But what if this wasn’t true?
Experienced primary care partners can create a model that can serve the specific needs of your population and more, without the significant effort required to build. For example, Vera’s advanced primary care model:
Addresses the needs of each population and supports continuous innovation: The partner’s model should create a single provider network that can quickly adopt new technologies or pilot new care delivery approaches without waiting for the rest of the healthcare system to catch up.
Aligns incentives: Alignment on goals and financial incentives between those providing the care and the payer will allow everyone to collaborate on the best ways to serve member panels.
Allows quick responses to emergent needs in a crisis: In situations like COVID-19, a primary care model should be capable of quickly pivoting to solutions like video and phone appointments because the revenue model isn’t dependent on members coming into the care center.
Exceeds member expectations because of the strength of the provider-member relationship: When providers focus on member social, mental, and physical well-being, patients consistently provide the feedback that they have never felt so heard or motivated to own their health.
Ready to buy? What now?
Developing and building a primary care system is challenging. Our advanced primary care model is the ideal solution for payers. Its ability to serve any population, using insights from advanced informatics, creates a system that can drive true outcomes. That, combined with aligned incentives, ensures that all care will focus on improving outcomes for your populations.