Dealing with the health care system bureaucracy can sometimes be maddening. When you’re in the hospital for a procedure or need a prescription your physician orders, you simply don’t want your care to get caught in a back-and-forth entanglement between your doctor and your health insurance company.

Luisa Charbonneau, the CEO of Braven Health, has made it her mission to take patients out of the middle of these scrums, and create a seamless experience in which doctors and insurers work as one. Behind that mission is a mechanism that – one year after Braven Health was formed – is already creating new lines of communication and making genuine headway to provider/payer harmony.

Voice of the patient and doctor

The mechanism is a “Provider Council” – a 14 member group of doctors, specialists and physician office managers deputized to work with the company’s business leadership and guide how Braven Health serves its 17,000 members. The membership is comprised of professionals from practices that are large and small, as well as owned independently or through a health system. Created when Braven Health was formed in 2020, council members have been meeting quarterly since February 2021 are sharing common experiences and best practices to make the company better.

“Our provider council is not only the voice of the doctor, it’s a channel for the voice of the patient,” said Charbonneau, who also chairs the council. “Braven Health is getting first-hand insights into pain points of care delivery – unvarnished and honest – which helps us diagnose and correct problems that get in the way of a positive patient experience.”

The council is a reflection of what Braven Health is – New Jersey’s first and only Medicare Advantage company owned in partnership between Horizon and two of the state’s major health system leaders – Hackensack Meridian Health and RWJ Barnabas Health. The plan operates in eight New Jersey counties - Bergen, Essex, Hudson, Middlesex, Monmouth, Ocean, Passaic and Union.

Process improvements

Charbonneau notes that as much as health care and health insurance are connected, the lines of communication often don’t intersect. The complexity of the health care system as a whole, its framework, and the volume of professionals involved in the patient’s journey can create a perfect storm of uncoordinated care. The best way to untangle the complexity, Charbonneau says, is to improve communication.

“Creating a better patient experience and outcome starts when the doctor and the insurance company are on the same page at every touchpoint of the health care continuum. That means regular communication and replacing a ‘them and us’ process with a ‘we’ process to help the patient.”

It didn’t take long for that process to start working once the lines of communication opened in earnest.

At the first meeting earlier this year, a council member brought a patient complaint about a medication that required an extra approval hurdle for the prescribing doctor – prior authorization. The doctor was frustrated because he believed the medication was part of the Braven Health formulary, and therefore not subject to the additional insurance approval step.

Charbonneau said Braven Health investigated the problem and found a solution – the same medication was available in capsule form, at a fraction of the cost of the pill version and did not require Braven Health’s prior authorization. “The solution was fairly simple: educating the provider about the differences in cost between the two versions, and instructing pharmacies to reach out to providers when this medication was being prescribed so doctors knew that a capsule substitute could save both time and money. So, through the give and take of the council, we eliminated a pain point and made drug costs more affordable to our Braven Health members. The improvement started by listening to the member, then working together to make it happen.”

The Horizon ripple effect

Charbonneau called the pharmacy workaround a small step in a long journey toward a collaborative and coordinated health care experience for the patient. But, she also emphasized this and other improvements have a wider benefit, well beyond the 17,000 members of Braven Health.

Braven Health plans use Horizon’s existing Medicare Advantage managed care networks, and Horizon performs most of Braven Health's administrative services, such as enrollment, claims management, Medical Policy, provider management, and customer service. That means that Horizon can apply learnings, improvements and innovations that emerge from the Braven Health Provider Council to the benefit of all of Horizon’s provider networks and its 3.7 million members.

Charbonneau called the council “a laboratory for system improvements” and emphasized that the focus is about to shift to raising the bar on the quality of care. “To improve outcomes, we’re looking for ways to get patients more engaged in their care, particularly preventive medicine that keeps them on schedule with health screenings, and on track with treatments and therapies that maintain good health,” she said.

“I cannot thank the physicians and office leaders enough for not only their willingness to devote time and their expertise to the council but for their honesty about what’s working and what can be improved. We’re just getting started on this journey but we’re doing it together, and that’s the kind of collaboration patients expect and deserve,” she said.