Integrating modeling of logic based theorem applied to psychometric representations of group behavior designed to accomplish shared vision and goals, provides the independent third party professional facilitator with option matrix to determine the maximal benefit outcome for a pareto negotiated conclusion.  This paper reviews the application of logic argument design as it applies to classic modeling of group dynamic behavior coined by scholars promoting consistent successful contractual conclusions between dispositional entities in the healthcare service sector.

 

 

The design of proposed plan calls for facilitation management coordinated between physician leaders and their practice managers partnering in an accountable care organizations (ACO) with a major health insurance carrier regarding lives covered and services included in the ACO reimbursement model.

An ACO is group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.  Blue Cross Blue Shield is designated example of a market dominant third party payer, reimbursing the ACO for contractual services for fixed population of “covered lives”.  Both parties seek to maximize their economic gain for services rendered and both companies are for profit organizations. There are multiple intrinsic issues to discuss regarding reimbursement for services based upon the diagnosis of the patient and the services provided.  For simplicity, the discussion focuses on two sets of reimbursement codes, the ICDM-10 codes which describe a diagnosis and the E/M plus CPT codes which describe the services provided by the healthcare workers.  The negotiations are much more complex than just reimbursement and include additional services expected by BCBS but with little reimbursement, such as preventative and educational care programs, readmission or redundant care following complications or poor outcomes, and maintenance care for diseases that traditionally reimburse poorly to the healthcare providers, but consume considerable time and effort by the providers.  Lastly, there are desired “carve outs” by the healthcare providers for disease management that requires much more time, effort and risk than the current reimbursement structure allows.  For these cases, BCBS would have to cut into their profit margin and even transfer funds from non-Medicare federally funded programs to cover these additional expenses.

Our company, Efficient Healthcare Negotiators (EHN) prepares the template and orchestrates the structural paradigm by which our experts will facilitate stakeholder communication, pre-meeting caucus, intra-meeting group interaction and post meeting negotiations and follow through.  Concentration on common goals, topic discussions, contract negotiations, contract execution and the system tracking function necessary to ensure both the ACO and BCBS comply with the contract specifications, including reporting, error tracking and relationship management. Finally a grievance process will be agreed upon in which both parties will attend to the issues within a preset time frame, investigating resolution and if required, contacting EHN as an intermediary to mediate for dispute resolution.

Model Theory:

This proposed model identifies and invites key stakeholders and decision makers who must participate in this congress to accomplish the contractual tasks required to provide defined medical services and obtain reimbursement for those services.  Both groups are required to submit a brief description of their key personnel necessary to accomplish this task.  Those key persons are requested to submit a letter of intent to negotiate in good faith, participate actively in the activities leading to an acceptable contract and provide a goal statement for public consumption as a pre-meeting introduction of whom they are as participating members of this contracting convention.  Following Stahl’s Model of Collaborative Knowledge-Building (2), our structure in facilitation will be to explore “individual stakeholder perceptions and look at common goals” (2).  The facilitators mission allows for a formulation of a new reality in which both sides arrive at multiple collaborative agreements and the facilitator seeks to support the collective new definition of the relationship between parties as “the collective agreements” (2, 7, 8) which transition to the new socially created knowledge base as the definition of this relationship, accepting the terms of a negotiated agreement as truth. Thus according to Stahl, we are using “social learning models for consensus building when two or more parties claim a position” (2) based upon their desired dispositional perspective.  The discourse (7) and communication objective for the group negotiation is critical to helping multiple perspectives to converge on shared knowledge. The accumulation of negotiated shared knowledge results in the establishment of an accepted group perspective. (2)

EHN believes that a logic based computational model referencing game theory concepts for pareto agreements (1) between these multiple parties presents a unique model for the facilitator to reference and maximize areas of consensus between parties that will drive the Appreciative design model of dynamic collaborative group design and activity to arrive at a successful negotiation between disparate party positions.  According to Ragone (1), “it is possible to have many issues negotiated among many parties” however there will likely be hidden agendas because of “the interplay among shifting coalitions: parties can join and act against other parties involved” (1) Ragone applies the logic behind game theory where bargaining opportunities are defined as either a “cooperative or non-cooperative games” (12).” Theoretically, representatives of each negotiating group are “individually rational” (1,12) and unlikely to accept a deal which involves a loss, i.e., a disadvantageous deal. Practically however, the self-interested agents negotiate over a set of resources in order to obtain an optimal allocation of these resources while maximizing the concessions from their counterpart group (13).  As a facilitator, our model must use logic-based negotiation strategies to discover and delineate the space of possible deals or potential agreements; determine the set of rules and methodology this group will utilize through-out negotiations (the negotiation protocol), and supervise negotiation strategy each agent adopts, within the set of rules specified in the negotiation protocol.  The logic theory of maximal gain simultaneously achieved for optimal pareto negotiation results, dictates that when since several items are being negotiated simultaneously, an integrative conclusion allows each issue to assume a different utility or importance score and as collaborative agents defining a new reality of their relationship, cooperation that provides “more for one party” does not necessarily result in their opponent receiving “less”.(1,12,13)  These are critical ground rules the facilitator for a logic based system must communicate to the participants. Finally, based upon logic driven conclusions defining optimum solutions from each party, the facilitator should be able to proposes agreements mutually beneficial for both parties; an agreement which maximizes the social welfare and one which maximizes individual needs and interests by stakeholder requirements utilizing consensus opinion modeling for integrative contract solution.(1,12,13)
The Third Party Role

In our initial communication brochure to each party, and reiterated throughout our system design, we provide facilitator services, orchestrating a systematic approach to negotiation but not advocating for any one side. The third-party must be defined only as a facilitator, and avoid undo influence or power in the negotiation.(3,4,8,9) EHN recognizes that requests to influence the negotiation by executing an evaluative proposition subjects the neutral intent to functions of arbitration rather than facilitation or conflict mediation.  EHN will recuse itself from any decision making or evaluative influence over any “deal” despite EHN experience and subject matter expertise in these contracting issues.  All party stakeholders are reminded of our role in these negotiation to avoid confusion, bias or prejudice against EHN personnel assisting on this case.

This model mimics complex system software design that requires logic inferences based upon optimal outcomes defined by established positions.(1,2,4,5,6,) The group interaction specifically collaborative knowledge building environments consider learning as a social process incorporating “multiple distinguishable phases that constitute a cycle of personal and social knowledge-building.” (2) The theory, advocated by Gerry Stahl, allows us to replace the computer modeling interface with the facilitator role. The process suggests that the group will effectively manage increasingly complex questions during negotiations as their interaction secures a sophisticated understanding of each theirs needs and interests. This model of collaborative knowledge-building functions equivalent to the social learning model if discourse and communication is “relatively free of hidden agendas, power struggles and un-discussed prejudices.”(2,3,4,6,7,8) Without anticipation that the negotiation from positional perspectives will not result in acceptance of a consensus result, then this new accepted knowledge will be unsuccessful and the negotiations will fail. Logic theory states that failure will occur only when one or more party demands a set of circumstances that their opposite considers extreme and rejects compromise for mutual gain. (1,5)  In addition, this model formulates a communication paradigm that stimulates effective communication by facilitating and demonstrating social interaction skills such as turn-taking, repair of misunderstandings, rhetorical persuasion, and interactive arguing between collaborating parties.(5,7,8)  The knowledge based integrative design calls for support for positional perspectives but facilitates comparison perspectives, “in which one can view and contrast alternative perspectives and adopt or adapt ideas from other people’s perspectives.” (1,2,3,4,5) These comparison perspective aggregates ideas from positional opposite demands and provide the structure to contrast the merits and contentions of each opinion in the form of a discussion forum, an interactive communication dynamic system that allows people to consider and respond to alternative proposals.(2)

 

Collaborative Model Design

The proposition that negotiations directed to create institutional and structural acceptance of a co-dependent business relationship invites key stakeholders to the negotiating table to ascertain over-lapping positional interests that might stimulate concession and ultimately consensus across this multiparty cooperative endeavor.  According to Bryson (4), this model encourages “discourse to introduce both organizations to merge into a new entity to handle problems through their shared authority and capabilities”. Critical to the outcome are coordinated initiatives and shared-power in order to pool their resources and skills to address specific resource and functional needs.  Bryson makes several arguments on the facilitative conditions likely to encourage a successful negotiation environment in the form of propositions.  As an example he points out that stakeholders are subject to hidden pressures or stressors and that collaborators are subject to both “competitive and institutional pressures that significantly affect their formation as well as long-term sustainability” (4) including corporate normative behavior, legal, and regulatory elements that organizations must conform to if they are to achieve the legitimacy that is necessary for survival.  In a hidden way, these rules often influence negotiations disproportionally with positional demands that escape logic to either the facilitator or the opposition party.  In addition, past relationships or collateral relationships sponsor the network effect in that existing networks correlate with the trustworthiness of the partners in this new relationship and the reticent of native contact on the dedication and compliance to a negotiated solution to the problem. (2,3,4,7)

The facilitator considers several critical steps required to orchestrate a successful negotiation structural paradigm for this group. The process demands several pivot points including forging initial agreements (both informal and formal), building leadership amongst group members, building legitimacy for the outcome of the collaborative exercise, building trust between positional future partners in the venture, managing conflict by anticipating current and future sticking points while negotiating immediate and potential solutions, and planning aspects of the research on initial conditions and structure. (4,5,6,8,11) The goals for facilitative intervention include formal agreements discussing broad purpose, mandate, commitment of resources, designation of formal leadership, decision-making structure, and flexibility of the decision makers to adapt to changing conditions that require rapid response and not prolonged bureaucratic delays. (4) Studies of collaboration highlight the importance of a drafting process that requires both key stakeholders and implementer active participation to assure their commitment to agreed upon solutions. (4,8,9,10,11)  These contractual consensus collaborations are more likely to succeed when they have committed sponsors and effective champions in both camps that provide leadership during negotiations and act as resources once agreements are reached but future questions arise.  Between the two camps of dispositional negotiators, the facilitator must investigate opportunities for trust building.  As Bryson points out, “Trusting relationships are often depicted as the essence of collaboration. Paradoxically, they are both the lubricant and the glue.” (4) These relationships facilitate the work of collaboration and bind the design together. Furthermore, a lack of trust can comprise interpersonal behavior, confidence in organizational competence and expected performance, and threaten the common bond and sense of goodwill group consensus offers. (14) Managing conflict is a critical facilitator function, realized from prioritizing agenda items and expectations that parties bring to a collaboration, from perspectives on strategies and tactics to control over the collaboration’s work product. Less powerful partners often require assurance that their interests are being considered and a facilitator who is able to neutralize the power differentials will manage conflict effectively and provide structure to the group for dispute resolution over the longevity of the partnership. (4, 5, 8, 13)

Structural Design

The collaborative consensus design integrates elements of The Dynamics of Collaborative Design with Insights from Complex Systems and Negotiation (5) researched by Mark Klein and the computer logic model proposed by Da Yang in his seminal paper on adaptability of network intelligence utilizing a Wiki Based System for Collaborative Requirements in Negotiation.(6)  The model integrates facilitator goals and interests into a step wise material structure designed to illicit key stake holder participation and dedication.  The facilitator from EHN enforces a sequence of steps and instructions to guide the stakeholders working out mutually satisfactory requirements. During each step, the facilitator offers one or several project tools designed for the group to generate, organize, and evaluate concepts and information. (4,5,6)
Specifically the process is:

1. Identify and engage stakeholders from both camps, recording their contact information, and mapping negotiation roles to stakeholders. The facilitator must hold pre-meeting caucus with each client and develop a high level of understanding of their operational significance to the negotiation and outcome control of the negotiations. Each stakeholder must understand their role as “Shaper and Personal Knowledge Contributor (PKC)”. (5,6)
2. The project continues at the stakeholders inception meeting designed as a collaborative learning process by instituting specific practices: a. the facilitator introduces their role as the learning coordinator; b. meetings begin by defining learning objectives developed by consensus; c. stakeholders utilize appreciative inquiry to discover past successes of collaborative partnership and focus on the methodologies in place that created these successful conditions (win conditions, issues, options, and agreements).and d. assessment, goal review and progress report with accountability objectives defined, summarizing the knowledge learned concerning each learning objective, and identifying future needs. (5,6)
3. Review and expand negotiation topics which are organized according to consensus priority to guide and focus the stakeholder negotiation. This maintains organized information flow between opponents and minimizes tangential conversations that subvert attention form the topic and the goals set for conversation and discourse.  The process of brainstorming ideas and initiatives all converge on win-win conditions for both parties, keeping in mind the ultimate objective – delivery of expert efficient and cost effective healthcare.(5,6,7,8,11)
4. Survey on agreed contracts and conditions. Here, stakeholders will use a multi-criteria polling tool to rate each win condition along two criteria: business importance and ease of realization. This step provides opportunity to challenge or potentially to block an initiative and this encourages open debate and discourse as to the merits of specific argument and its impact on the overall negotiations. (5,6,8,11)
5. Resolution of differences. Conflict will arise and each solution will set the benchmark for a working design of contractual opportunities.  The remaining conditional agreements or outright rejections will be discussed through the funnel theory of discourse, providing circumspect consideration based upon past successful negotiation and consensus agreement which often facilitated stakeholder compromise in favor of the opponents needs based upon good faith environment for productive exchange. (3,4,5,6,11)
6. Lastly, each contract and the execution of the contract will require adaptability by each of the many participants utilizing asynchronous communication and forms of communication that do not “talk” with each other. The continuous refinement stage adapts to the evolving nature of requirements where stakeholders refine the negotiation as the project proceeds. (5,6)

Carlson (8) illustrates key components to the model for improving group’s effectiveness through consensus building including determining a clear and shared vision between group members; generating a supportive culture that suspends judgment and allows free flow of targeted ideas; rewards participants who consistently contribute to the objective analysis and problem solving steps required for consensus opinion identification; open and detailed information sharing, including feedback about performance; training and consultation to secure equi-power participation ; supportive technology, material resources and a comfortable adequate physical environment to stimulate the exchange with facilities and refreshments as needed.  The computational logic theory easily mirrors the collapsed design of the Tuckman (9) and Dimock (10) group dynamic models that provide the facilitator the framework to ensure effective contract negotiations in this business model. Here the facilitator defines the parameters to inspire the vision statement or the “motivating task” that assumes a null hypothesis: “task A cannot be accomplished” with logic and game theory used to disprove the hypothesis through appreciative design that supports algorithms that generate functional data solutions to the tasks, in this case contracting discussions and agreement. (1,5,6)

The computation logic model (1) requires the fundamental interaction using predictability measures assuming that the group acts rationally and that basic human requirements of inclusion, control and connection (Dimock (10)) are met during stakeholder pathway mental mapping.  The psychometric adaption of this model is seen in Tuckman’s (9) stepwise progression through functional group interaction where stages of progressive maturation ensure success.  Thus, mean behavioral human interaction for the “forming, storming, norming and performing stages of group dynamics” (9) can predict aberrant individual interactions that could potentially block consensus opinion ratification. (11) The facilitator will establish a practice pattern in situ which addresses the specific reticence and loops back to group discussion between the principals of consensus and the principals of dissention, during any specific discourse.  As described, the model calls for the progressive compromise between agents, formalized agreements based upon that progress and then delayed negotiation for topics in contention.  Ultimately, the logic pareto agreement model (1) predicts a high percentage of negotiated agreements, contract consensus and a small pool of holdout topics or issues that in this group would contrive the “carve out’ discussions that will be addressed at subsequent meeting.

 

In summary, these integrated models work closely to mirror software networking mind map solutions (1,6) to problems by identifying key stakeholders and creating an organized opportunity to hold discourse and dissect the nature of the issues under a common vision and to create a new knowledge metric that defines the collaborative solution to this groups contractual challenges.  It is anticipated using the pareto solutions model (1) that by pre-meeting caucus, position statement and discussion, investigating areas of common need and solutions through focus target subgroups and general meeting of principals, relying on mechanisms of success through appreciative inquiry, and contracting agreements that filter out the small percentage of polarizing topics and save those discussions for future meetings. The facilitator’s role in system design, conversation and discourse management (3) and solution ratification will create a functional new knowledge set that each party will be compelled through commitment and participation to ratify and hold their respective sub groups and companies to capitulate and attend intently to the four corners of the ratified agreement.

 

 

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