It is widely accepted that, as a patient, I should communicate openly with my doctor for my personal well-being, yet for too long the industry has tolerated a relative lack of dialog between the health plan and the provider in coordinating care for their mutual customer: me. This is not surprising, given that the traditional assumptions are that payers pay and providers provide care (and argue with payers about how much they should be paid). But, as the market moves to value-based healthcare, where true care coordination demands a comprehensive approach to the patient, both medically and as a consumer of care, meaningful payer-provider collaboration is essential to improving patient outcomes, driving down costs, and delivering consumer value.
Historically, the relationship between payers and providers has been somewhat myopically oriented around the financial relationship. Negotiations were typically oriented around rate (providers demanding more, payers looking for less) and administrative complexity (what’s medically necessary and must be authorized). From our view as a trusted intermediary between payers and providers, 99 percent of the abrasion was driven by administrative processes in determining provider payments. And yet, according to a recent Harvard Business School report, over 10 percent of all healthcare “waste” is still attributed to inefficient administrative processes.
Industry-wide reforms have incented these two powerful stakeholders to collaborate differently – and technological advances are making it easier for them to do so. But there’s a long road ahead.
One of the major challenges presented by the shift to “value” is that its approach is often incremental, requiring providers to operate under value- and service-based care models at the same time. This is less a problem within organizations of scale or when providers present a united voice within a larger organization, such as a health system that has organized as an ACO, than it is for smaller, independent provider practices. The goals supported by the value model – keeping chronically ill patients out of hospitals, promoting wellness and prevention visits, continuum-wide care coordination, transparency in consumer decision-making around cost and quality – rub against the grain of a volume-based system, and will increase providers’ financial burdens during the transition.
Trust is essential to building a successful payer-provider relationship. When both parties come to the table with an open mind and a common platform, they can focus on creating alignment in several key areas, including data, workflow, and economic incentives.
- Data sharing. Providers and payers each have their own sets of data. Payers have data on claims, financial analytics, and risk models. Physicians have clinical data that provide patient case histories, as well as powerful evidence of better outcomes, lower readmission rates, and higher satisfaction. In isolation, the value of this data is limited. The key is to forge pathways where these two spheres of data overlap, turning the data into rich, actionable information that benefits both stakeholders and, more importantly, their customers.
- Data and workflow efficiencies. Silos of data housed in legacy systems are not conducive to payer-provider collaboration. Providers need to leverage health plan data, such as claims, benefit, and eligibility information, and yes, even clinical data from payers; and they need to leverage it in their existing workflows, at the point of service, in order to move from episodic care to delivering care focused on the continuum. On that same note, payers with real-time patient information can work more closely with their provider networks to establish appropriate care plans for their members. Tools like self-service portals allow both payers and providers to access complete, actionable information (as opposed to raw data), reducing administrative burdens for both parties, achieving higher performance goals, and identifying coding and care gaps more quickly.
- Timelines. While providers may be tempted to delay implementing value-based care until they see peer results, it’s important not to wait. The market is evolving quickly, and it’s best to start incrementally and make gradual adjustments. By collaborating with health plans now, providers can leverage the experience they have gained with larger organizations and scale accordingly. Likewise, payers have to understand not all providers are the same. A sophisticated health system in Boston, MA, will have different strengths and challenges than a rural health provider in Palatka, FL. Not better or worse – but different and equally important to resolve.
- Reducing administrative burden. Automation is fundamentally changing the healthcare business. With the right technology, health plans can align with providers by offering more efficient administrative processes. At the front desk and in the back office, payers can help provide tools that enable staff members to submit claims electronically rather than manually and to check what is authorized at (or even before) the point of care. This is more critical today than ever to enable capital investments in value-based capabilities.
The transition from fee-for-service to fee-for-value is going to take time. Establishing a transparent and collaborative relationship between payers and providers will ease costly and inefficient burdens for both stakeholders and foster the rich, actionable information needed to ensure that value is achieved throughout the continuum of care. This is the kind of collaboration that I, the patient (more often than I prefer, in fact), am going to demand of my health plan and my healthcare pro.
