Sustainable Solutions for Health Plans


It is clear the past and present models of coordinated care are not sustainable.  Health plans have failed to engage physicians or patients and instead focus on “unit price” strategies. Optimus Healthcare Partners believes a collaborative patient-centered approach between health plans and providers can provide more sustainable solutions.  The key will be integrating the resources and competencies of each entity within new compensation models that align financial incentives.  The fragmented silo approach to healthcare can be replaced with a coordinated accountable direction.  The results will be improved quality, affordable premiums, true value and a sustainable solution for the purchasers and consumers of healthcare.

Accountable Physicians, Hospitals & Health Plans


Prior years have seen negative relationships develop between health plans, physicians and hospitals due to recurring “price-based” negotiations.  Each entity strives to squeeze the maximum amount of dollars from the other, with minimal attention to the needs of patients or purchasers. 



Optimus Healthcare Partners returns “clarity of purpose” to these relationships by holding all entities accountable for patient quality, utilization and experience. This accountability is driven by the Optimus performance management framework that closely follows specific metrics, communicates real-time performance, and outlines needs for improvement over specific time periods. Physicians not willing to improve can be decredentialed from the Optimus network while transparent hospital report cards guides referral patterns to high performing facilities. Health plans are rewarded with superior HEDIS, CAHPS and STAR ratings while maintaining affordable health care premiums.



The Optimus Physician Network


The physicians in Optimus have agreed to redesign daily workflows and incorporate the value-driving elements of a successful accountable care organization. 



For primary care physicians, these elements include the joint principles of the Patient-Centered Medical Home:



A personal physician that is willing to takes responsibility for their Medicare Fee-for- Service patients and Commercial patients and is willing to rebuild the physician-patient relationship


Enhanced access to care for Medicare Fee-for- Service patients and Commercial patients including same day / off-hours / weekends and electronic access


A physician directed medical practice that utilizes all personnel to the level of their licensure in a team approach


Whole person orientation replaces the fragmented silo approach.  The physician and team look to understand and support not just the patient's physical needs but their emotional, social, cultural, mental and spiritual needs.


Care coordination is provided through the use of Optimus clinical coordinators, patient registries and health information exchanges


Quality and safety are improved through compliance with evidence-based guidelines, clinical decision support tools, electronic health records and E-prescribing

  Physician payment model that recognizes value rather than volume of services

For Optimus specialists, the value-driving elements involve adhering to the Optimus PCP-Specialist Care Coordination Agreement. This document is signed by both primary care physicians and the specialists they utilize. The agreement outlines the care coordination responsibilities of each party, including:


Methods of communication for patient referrals

Timeliness of consultations & availability


Level of co-management requested by the PCP

  • Contents of the ideal transaction record to accompany the patient to the specialist

Contents of the consultation to be communicated with the PCP


Consideration of the patient and family during all transitions in care


Together the Optimus PCP's and specialists utilize the Optimus patient registry, health information exchange, analytics and decision support to proactively manage patient populations. 



A Collaborative Patient-Centered Approach


The Optimus organization looks to partner with health plans to redesign the current system of care:



  1.  Identify existing patient programs that could provide improved value and return-on-investment through leveraging physicians and the physician-patient relationship
  2. Eliminate those health plan programs that provide little or no value, thereby lowering health plan administrative costs
  3. Provide physician participation in complex case management utilizing the health plan’s case managers within the Optimus Complex Case Management Program
  4. Work collaboratively on management programs such as care transitions, comprehensive medication management, behavioral health,  and end-of-life care
  5. Coordinate health plan wellness initiatives with employer and physician office programs, thus avoiding duplication of services while leveraging the physician-patient relationship to enhance patient engagement
  6. Work together with health plans, physicians and patients to minimize overuse, misuse, underuse, and out-of-network utilization of health care services
  7. Share information systems, analytics, and new management tools to provide “best-of-breed” resources for all parties
  8. Develop new compensation models that align both parties, drive improved performance, and reward value
  9. Include plan-specific metrics within the Optimus physician performance management framework including HEDIS, CAHPS and STAR ratings
  10. Investigate “co-branded” products with value-based benefit designs for expansion of market share


Optimus Healthcare Partners invites health plans to join Optimus physicians as we develop a new culture for payers and providers.  This will be a culture of change as we manage behaviors, develop new relationships and bring clarity of purpose to the health care system.





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Health Plans

Optimus Healthcare Partners look to collaborate with you to bring value to the health care equation.more