A keen focus on innovation has helped David Nefussy successfully navigate the ever-shifting dynamics of the health care business. As Spectrum Health’s Vice President of Payor Relations, he is responsible for crafting agreements and negotiating reimbursement with insurance companies, managed care organizations, and third-party payors to ensure the company grows its provider network while maintaining its focus on delivering highest quality patient care.
“I look for possibilities to participate in new initiatives that will differentiate us from other providers,” Nefussy said. “I think as an organization, you want to be on the front line for any new innovations and be an active participant in things that meet our mission to try to help people. If we can find new ways to work with partners to help finance that, it improves outcomes for everyone.”
Taking A View from Both Sides
Nefussy joined Spectrum in 2017, bringing more than two decades’ experience on the payer side of managed behavior healthcare with companies like OPTUM, Magellan, Beacon and others. He credits being on both the payor and payee sides of the equation with his success in serving as a liaison to the provider community.
Under Nefussy’s leadership, Spectrum’s subsidiary services at the New England Recovery Center (NERC) have garnered significant recognition from insurance providers, including earning the Blue Star distinction from Blue Cross Blue Shield of Massachusetts as well as accolades from Cigna’s Center of Excellence and Tuft’s Center of Innovation. These programs each independently rated NERC’s services as being of the highest quality in the industry based on a wide range of applied criteria.
“I have that education on both sides, and I’ve maintained very good relationships” he notes. “So, I’m able to look at things from both perspectives and recognize the impact changes will have, and approach things in an honest way. It gives us a chance to do some things that are really unique.”
A Hand in Shaping Better Outcomes
A unique opportunity for the future is unfolding now as Nefussy works with Tufts Health Plan and Harvard Pilgrim Health Care to finalize preparations for their 2023 merger into Point 32 Health. The combined managed care organization will insure more than two million subscribers across the northeast.
“I’ve worked with the medical directors over there in the past, and they recognize that we’ve been a center of innovation,” Nefussy said. “I’m glad to have a seat at the table as they work through this. We’re helping them develop pay for performance metrics that we can pilot and shape for success on both sides.
“Our focus is finding ways to balance metrics that keep individuals engaged in treatment that results in a positive outcome,” he continued. “Reimbursement methodologies have changed significantly over the years, from straight fee-for-service to pay-for-performance, which has a lot of upside. But while that model has become common on the medical side, behavioral health has been slower to adopt it, so we have to make sure we’re developing the right measurements.”
Dedicated to Saying Yes
Through his involvement with payment models, credentialing, and network management, Nefussy plays an influential role in shaping Spectrum’s broad accessibility to patients, as well as making it a trusted partner for insurers and other payors.
“I continue to be inspired by the valuable work I see all around me at Spectrum,” he reflects. “I’m proud that we’re an organization that can work with all payors, and that we never have to say no to providing services. We can always say yes, and that’s so important to me and, I think, everyone that works here.”
For more information about working at Spectrum Health Systems, visit the careers page on our website.