Every member of a value-based care organization has a role to play to deliver the right care at the right time. Leadership team members have even more specific roles to ensure that things run smoothly, and this fact got us thinking it would be beneficial to offer a snapshot of how each of these individuals’ work complements each other to accomplish a value-based care vision.
So, over the next several weeks, Lightbeam subject matter experts will discuss the many responsibilities organizational leaders perform to protect their patients, advocate for quality care, and improve long-term outcomes. As Chief Medical Officer of Lightbeam, I have the pleasure of kicking off this series by sharing the role of CMOs in value-based care organizations.
What Payer and Provider CMOs Share
The role of the CMO varies depending on whether the organization is payer or provider-led. However, both individuals will be persons of influence in the organization; they ensure high-quality care is delivered to their patients, provide clinical guidance to the leadership team, align care delivery initiatives with the organization’s strategic goals, and other similar functions.
Both want to maximize opportunities, earn high marks for quality, and generate the optimal reimbursement rate for their value-based care efforts. Lastly, payer and provider CMOs are experts in healthcare policy and regulatory trends. They focus on the needs of their communities to be the best advocates, locally and legislatively, if need be.
How They Differ
Provider CMOs are closer to the actual delivery of care and have a significant role in promoting safety and quality. They are concerned with other essential care metrics like access and patient satisfaction. In terms of cost and utilization, they are responsible and mindful of the critical business elements that come with performing value-based care effectively and efficiently and help guide the efforts to identify opportunities to deliver high-quality care at a lower cost.
Provider CMOs are often heavily involved in hiring new provider staff, verifying their credentials, and managing performance. Depending on the organization’s size, they may also be intervening if there is a conflict or a serious clinical or personnel matter. If the organization is reasonably large, they may help address the issue, but will not take a lead role in an investigation or resolution.
Payer CMOs, while focused on obtaining the same outcomes, have a different role to play in value-based care. Management consulting firm McKinsey & Company provides a lengthy overview of how the payer CMO has evolved. Again, while there is overlap, payer CMOs are more of “strategic business partners” whose efforts affect a broad group of stakeholders, including the end-user of their care offerings—patients.
With the responsibility of making the most appropriate business decisions, payer CMOs have several key priorities, including but not limited to:
- Beneficiary engagement
- Collecting and evaluating patient satisfaction data
- Creating unique payer and provider partnerships
- Evaluating evolving trends, especially those that address social determinants of health (SDOH) and other care inequities
Payer CMOs are also heavily involved with the rest of the management team in setting policies related to things like prior authorizations, provider contracts, and quality benchmarks.
Despite the differences in focus and responsibility, one thing is clear when evaluating the role of the provider and payer CMOs: it is critically important they have talented leaders in this position if the healthcare industry continues to move away from the traditional fee-for-service models and realize the potential of value-based care.
Learn more about the population health management solutions that help CMOs by visiting our Chief Medical Officer page. If I can answer any questions about our CMO solutions, email me at email@example.com.
Kent Locklear, MD, MBA is Chief Medical Officer of Lightbeam.