Team Work

June 24, 2011
Healthcare is no longer about payor or provider, it’s about payor and provider THE REASONS SURROUNDING managed care’s rise to fame (160 million

Healthcare is no longer about payor or provider, it’s about payor and provider

THE REASONS SURROUNDING managed care’s rise to fame (160 million members in the United States) vary from employers cutting costs to government agencies (Medicare and Medicaid) contracting directly with capitated payors.

Cutting healthcare costs and improving the quality of care have been managed care’s goals. And many experts, including those at The Economist, would agree that "thanks to HMOs, America’s healthcare system works better than it used to. The advantages of managed care outweigh the drawbacks."

There is, however, little time for healthcare organizations to revel in lower costs and higher quality. Change is inevitable.

"The tradition of managed care is beginning to shift to what some people, like Jeremy Nobel of the Harvard School of Public Health, are calling ’the era of post-managed care,’" explains Tom Morrison, a partner at Firepond Partners, Inc., Boston. "Exactly what this will be is unclear."

What is clear, according to Morrison and others, is that better communication and integration of information systems across the healthcare enterprise will grow in importance in the next few years. Providers and payors--though their objectives remain somewhat separate--must learn to work together.

"Health plans will need to implement information systems that allow them to communicate with members, employer groups and large numbers of loosely affiliated providers," Morrison says.

Simmi Singh, vice president at CNA Consulting Group, Chicago, agrees. She cites clinical information systems as a necessary area of IT convergence. "Payors analyze the information for payment adjudication and medical management purposes. Providers use it to make real-time decisions related to episodes of care."

But the fact remains that managed care is healthcare, and as such, payors and providers must stop competing with similar ideas. "I believe that the relationship between payors and providers is going to go from competitive to cooperative--not just because we are all one big happy family, but because it is going to be essential to maintain care quality, access and profitability," Singh says.

Roy Ziegler, vice president at First Consulting Group, Long Beach, Calif., adds that the more seamless healthcare becomes the more satisfied consumers will be. "If a member calls up a health plan and the health plan has delegated a lot of responsibility, as well as risk, the health plan administrators might say ’you have to call your provider,’" Ziegler says. "The more [payors and providers] can collaborate, the less fragmented they will seem to the consumer."

Information systems and the engineers that design the software can help both sides pool their resources to completely integrate the healthcare industry.

Paul Smolke, healthcare managed care/payor industry marketing manager at Microsoft, Redmond, Wash., says that the most pressing technological need for both payors and providers is integration of information. It seems, as some traditionally provider-focused vendors begin exploring the payor market, that Smolke is not alone in his assumption. While a few vendors persist in seeing managed care as a passing fad, more and more companies (HBOC, IBM, Microsoft and Siemens, for example) are setting up divisions focused solely on the payor market.

Other vendors, such as Rothenberg Associates, are partnering their traditional financial systems with clinical IT companies. In this case, Rothenberg officials are forming a strategic alliance with InterQual--experts in clinical decision support.

As providers and payors begin working together to collect data, information technology can help provide the expertise and resources necessary to move healthcare into the next millennium.

Lisa Paul is senior editor at Healthcare Informatics.