• Aventria Health Group

When FFS Providers Get Locked Out of Referral Flows by Virtual Care Solutions and Providers

What happens when some employers, commercial insurers, or Medicare Advantage plans decide to open up a few virtual front doors that lead only to referrals to providers who are willing to be accountable and offer financial predictability? That’s what the self-insured employers making buying decisions want, after all. They want accountability and financial predictability.

Many employers, or maybe more accurately their benefit consultants, now have access to all-claims databases and other data like the RAND 3.0 report. Coupled with virtual patient navigation solutions cropping up like wildfire, employers can and are steering their plan member populations only to providers who are willing to be accountable for upstream and downstream quality and costs. Further, they are recognizing the power of constructing benefit designs that incentivize patients. Some of these providers will be local, and others will be virtual care delivered by national companies (think Dispatch Health, Livongo, Hinge Health) or Centers of Excellence offering a hybrid model including telehealth.


Given these goings-on, some slower-moving providers could easily find themselves on the outside looking in. So, who are those providers who are or will be getting shut out of referral flows? They’re definitely fee-for-service-centric, but they could be a large health system, an urgent care center, or a hospital-owned primary care physician.

In the Relentless Health Value podcast below, Stacey Richter, co-president of Aventria, speaks with Jeff Hogan, the northeast regional manager for Rogers Benefit Group and also president of Upside Health Advisors. They talk not about what might be theoretically possible but about what is happening right now.

Take a listen:

How does this impact pharma brands?

When health plans steer members only to providers with demonstrably superior patient outcomes and reduced costs of care, then Pharma would be well served to recognize:

  • The market will no longer accept that an expensive branded product is right for everybody, or even everybody within a broad therapeutic category. Your definition of “appropriate” must be narrow based on real-world evidence and/or your label.

Account managers who don’t proactively and clearly define your brand’s niche target patient will likely find themselves in the “No See” zone.
They will be regarded as adding unnecessary costs into patient treatment exactly at a time when the provider has an existential imperative to weed out unnecessary costs.
  • The highest-performing brands pursue a reputation as an authentic collaborator with their provider customers. Providers need Pharma’s therapeutic expertise and knowledge of best practices so their patients get the best possible outcomes. If account managers cultivate a trusted relationship with their customers, everyone wins—most importantly, the patient.

  • The best brand messages are value- and outcomes-based. Helping create an excellent patient/customer experience also could be compelling.

  • Segmentation is growing in importance as is crisply targeting the providers who can offer their brand to the right patients—the patients who will truly benefit from the product.

As payers strive to make health care more cost effective, providers are greatly incented to manage downstream care and costs, including the impact and costs of their prescribing decisions. It all rolls up to being best for the patient, best for the provider, and even best for the payers who are setting up care platforms in the hopes of improving outcomes and bringing cost of care down.

To learn about how Aventria can help you build and strengthen collaborations with employers, their health plans, and the provider organizations in their networks, please reach out to:

Dave Dierk, Co-President, 30-year sales and marketing thought leader in pharmaceutical diagnostics, biomedical, long-term care, managed care, employer, and pharmacy communications, at dave.dierk@aventriahealth.com.


Making a difference in patient care by helping patients, providers, and payers collaborate on shared priorities

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