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Medical Economics Managing Editor Todd Shryock sits down with Scott Dewey, chief managed care officer at PayrHealth, about the best strategies for payer negotiations.

Music Credits: Gypsy Jazz Swing by tunes2go - stock.adobe.com
COCKTAIL by Mythical Audio - stock.adobe.com
The Joy of Being by Duke Herrington - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.


Overview of the podcast and introduction of the speakers discussing payer negotiations.

Starting Preparation for Negotiations (00:01:03)


Importance of having a strategy and understanding leverage before entering negotiations.


Advice on how far in advance physicians should prepare for payer negotiations.

Contract Length Considerations (00:05:11)


Discussion on the pros and cons of long-term versus short-term contracts.

Negotiating Power of Smaller Practices (00:06:47)


Insights on how smaller practices can find leverage against larger payer organizations.

Dealing with Non-Negotiable Contracts (00:08:54)


Advice for practices facing contracts labeled as "not negotiable."

Prior Authorizations in Contracts (00:09:53)


Strategies for negotiating limitations around prior authorization requirements.

Unilateral Amendments in Contracts (00:12:31)


Discussion on the commonality of unilateral contract amendments by payers.


Overview of frequent mistakes made by physicians in contract agreements.


Differences between value-based care contracts and traditional fee-for-service agreements.


Importance of getting all agreements in writing and understanding contract updates.


Wrap-up of the discussion and thanks to the guest for sharing insights.

Podcasts

Scott Dewey, chief managed care officer at PayrHealth, joins the podcast to discuss the best strategies for negotiating with payers.

Ep 39: Negotiating with payers with Scott Dewey, chief managed care officer at PayrHealth

Choice is up to Congress, but plan presents a raise for 2026, with additional money for primary care.

MedPAC recommends tying Medicare physician reimbursement to Medicare Economic Index

Company aims to make claims appeals easier and quicker for physicians by having AI do much of the work

New AI can autonomously help physicians generate appeal letters for denied claims

How proactive legal strategies can protect providers and support access to advanced diagnostic testing.

The importance of mounting a robust response to urine PCR testing denials and clawbacks

Opting out of Medicare might be your only choice

What you need to know about the Medicare reimbursement cuts for 2025

MGMA: Late 2024 legislation had some help for health care, but House, Senate need to act now.

New Congress plays ‘dangerous game’ as Medicare cuts to physicians could hurt patient access to care

2025 health care agenda: The IRA 9/13 rule

The Inflation Reduction Act included policy on how 

. It’s a “pill penalty” that creates a disincentive for pharmaceutical makers to develop new drugs and bring them to market, said 

Videos

Rep. Greg Murphy, MD (R-North Carolina), discusses reforms he hopes Congress will consider this year.

2025 health care agenda: Medicare Advantage abuses

Medicare Advantage needs reform because some insurance companies are upcoding patient conditions to get more money from the federal government. That is wrong and 

Congress and health care in 2025: Diversity, equity and inclusion in medical schools

Instead of focusing on the science of medicine and creating 

, pushing diversity, equity and inclusion in 

 is a travesty that will cause patient harm in coming years, said 

 (R-North Carolina). It is the highest honor to care for patients and they deserve the highest quality physicians available, he said.

Congress and health care in 2025:  Medicare cuts in physician pay

 (MPFS) has been cutting reimbursement to doctors. That has to stop and 

 because doctors are trying to survive and they can’t raise their rate. 

 (R-North Carolina) said doctors need a limit to cuts or they will limit care for seniors.

Congress and health care in 2025: Medicare cuts in physician pay

Value-based payment: An introduction to a study

Value-based payment: Sources and a summary

Value-based payment: Will it cover the cost of doing business?

Value-based payment: Or is it fee-for-service? Or both?

Value-based payment: Not all insurers are on board

Value-based payment: Health systems don’t support doctors

Value-based payment models: Workforce shortages are a problem

Value-based payment models: Problematic performance measures 

Value-based payment models: Too much documentation

Value-based payment models: Potential solutions, part 1

Value-based payment models: Potential solutions, part 2

Value-based payment models that focus on patient health sound like a great idea.

So why don’t more physicians use those programs instead of fee-for-service 

 that remain a substantial part of the health care economy?

 were not participating in value-based payment models. Researchers from Mathematica wanted to find out why, so they went to the source: a dozen primary care physicians, primary care management experts and focus groups with 17 frontline physicians and other clinicians. None of them had any prior participation in value-based payment models.

Their responses were compiled for the study, 

“Why Primary Care Practitioners Aren’t Joining Value-Based Payment Models: Reasons and Potential Solutions,”

In this video series, co-author Ann S. O’Malley, MD, MPH, discusses the findings. Lessons from 14 years of value-based payment models could shape how physicians adopt them in the future – and ultimately improve patient health.

Co-authors are Rumin Sarwar, MSPH, Cindy Alvarez, MPH, and Eugene C. Rich, MD, of Mathematica.

Value-based payment models, designed to enhance patient health, are not widely adopted by primary care physicians, who predominantly use fee-for-service models. A study by Mathematica, involving primary care physicians and management experts, explored the reasons behind this reluctance. The study, published by The Commonwealth Fund, highlights insights from 14 years of value-based payment models and suggests potential solutions for increased adoption. The findings, discussed by co-author Ann S. O’Malley, MD, MPH, aim to guide future implementation and improve patient outcomes.

Researchers asked doctors why they continue with fee-for-service payment. There are many reasons, as a study co-author explains.

Why more physicians don’t participate in value-based payment models

 would help attract greater participation in value-based 

. Current doctors also need more training and support in integrating value-based care principles into their practices. Ann S. O’Malley, MD, MPH, a researcher for Mathematica, discusses potential workforce solutions suggested in the study, 

“Why Primary Care Practitioners Aren’t Joining Value-Based Payment Models: Reasons and Potential Solutions.”

Increasing the number of primary care physicians could enhance engagement in value-based payment models. Existing practitioners require additional training and support to effectively incorporate value-based care principles into their practices. Ann S. O’Malley, MD, MPH, from Mathematica, explores workforce solutions in the study "Why Primary Care Practitioners Aren’t Joining Value-Based Payment Models: Reasons and Potential Solutions." The study emphasizes the need for strategic workforce development to overcome barriers and foster greater participation in these models, ultimately improving healthcare delivery and outcomes.

A physician researcher discusses why primary care physicians do not participate in value-based payment models.

Prospective payments, fewer metrics and less distortion in reimbursement for primary care all would 

. Ann S. O’Malley, MD, MPH, a researcher for Mathematica, discusses potential solutions suggested in the study, 

Primary care doctors spend so much time logging patient data that they don’t have time to care for patients, and 

. Ann S. O’Malley, MD, MPH, a researcher for Mathematica, discusses findings about physician and patient documentation in the study, 

Primary care physicians face significant challenges in adopting value-based payment models due to the extensive time required for patient data documentation, which detracts from direct patient care. This administrative burden is a key barrier to participation in these models. The study by Ann S. O’Malley highlights the need for solutions to streamline documentation processes, allowing physicians to focus more on patient interactions. Addressing these issues could enhance the adoption of value-based models, ultimately improving healthcare delivery and outcomes.

Value-based payment models: Problematic performance measures

he best way to measure patient outcomes? “Measuring that is very tricky to do, and we don't do it that well,” said Ann S. O’Malley, MD, MPH, a researcher for Mathematica. Here she continues explaining some of the 

Value-based care aims to improve patient outcomes while controlling costs, but measuring these outcomes remains challenging. Ann S. O’Malley, MD, MPH, highlights the difficulties in accurately assessing performance in value-based models. The study "Why Primary Care Practitioners Aren’t Joining Value-Based Payment Models: Reasons and Potential Solutions" explores these challenges, emphasizing the complexity of outcome measurement and the reluctance of primary care practitioners to adopt these models. Potential solutions are discussed to address these barriers and enhance the effectiveness of value-based care.

 does not have enough doctors, clinical staff and support for primary care. Ann S. O’Malley, MD, MPH, a researcher for Mathematica, discusses some of the workforce implications of the study, 

The U.S. healthcare system's shortage of doctors, clinical staff, and primary care support hinders participation in value-based payment models. Ann S. O’Malley, MD, MPH, highlights workforce challenges and potential solutions in her study. The study identifies barriers such as inadequate staffing and support, which deter primary care practitioners from engaging in these models. Addressing these issues is crucial for enhancing participation and improving healthcare delivery. Solutions may include increasing workforce capacity and providing better support systems to facilitate the transition to value-based care.

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