Payers and providers are the captains of two different ships sailing in similar waters. Both oversee incredibly relevant aspects of the healthcare system. Both the providers and payers are administering care from a quality perspective while keeping a sharp eye on the cost. Cost, quality, and care experience are essential elements that make up the entire landscape of the 21st century US healthcare. The significant disruptions in healthcare are a direct result of recent innovations brought in by the payer-provider dynamics. A lot has been accomplished, and a lot remains to be done.
What is the objective?
Before getting down on the nitty-gritty of the situation, let us analyze the common goals of payers and providers that can push them to join forces. Improving patient outcomes and optimizing finances have to be the two most fundamental focus areas that payers and providers can accomplish by jointly working together. What’s better? They both can significantly reduce time-consumption and resources needed to achieve that goal. After narrowing down the precise nature of their objectives, we encounter 3 crucial ones which are also centrally aligned with the IHI Triple Aim:
- Improving clinical outcomes
- Improving financial outcomes
- Improving the patient experience
The Triple Aim requires providers to take on the attributes of payers such as ﬁscal responsibility and expects payers to act more like providers by emphasizing on the patient’s experience of care. Lately, some providers and payers are beginning to form new partnerships to chip away at years of built-up distrust and the adversarial nature of their relationship. Five significant outcomes that such collaborations have been leading to are:
“How can shared clinical data be used to create administrative efficiencies and improve quality?”
While payers have access to claims data, they lack complete access to clinical data. Once providers start sharing clinical data with payers, payers can have a more holistic picture of patients, and that can enable as well as enhance price transparency, quality metrics, evidence-based care, among others.
Electronic Health Records (EHRs) have been critical in accelerating this collaboration as they aggregate almost all of the patient’s clinical information at one place. While challenges around interoperability remain, EHRs have usually been a critical component of a value-based strategy. However, it is important to keep in mind that true collaboration is not possible without the right information at the right time.
“How would it impact healthcare if both payers and providers are made aware of each other’s roles with respect to the patient population?”
Transparency means payers must engage providers in their quality measures to ensure that they understand, while providers who have access to valuable information regarding their patients’ medical history should share it with payers to enable better care coordination and maintain a patient-centered focus.
Providers need to know how they are performing in comparison to other providers of the state or nation. On the one hand, the benchmarks, risk-adjustments, and others need to be crystal clear to providers to get the true value for the care they deliver. On the other hand, providers need to be updated about their members and the health status of the at-risk population. This will increase trust and promote transparency that can eventually deliver better clinical and financial outcomes.
“Will shared responsibility lead to more accountability?”
Since aligned incentives are designed to reduce conﬂicts of interest in value-based care, payers and providers need to take their responsibilities towards each other sincerely for value-based results and consequent success. Accountability is crucial in a value-based setting, and a collaborative effort ensures that each member is held accountable for their actions as any dereliction directly or indirectly affects the outcomes of others.
That is why sharing responsibilities as well as being responsible for each other’s progress will go a long way in making each stakeholder increasingly accountable in their respective roles.
4. Care and cost outcomes
“Can a collaboration significantly improve health and cost outcomes?”
Through sharing quality measurement expertise and partnering for better healthcare delivery, payers and providers can meet their individual goals more efficiently. On the one hand, payers need to mitigate risks, lower costs, and minimize inappropriate system access while on the other hand, providers require efficient workflow, lower utilization rates, closed care gaps, patient satisfaction, and timely reimbursement. Once both stakeholders begin integrating their operations, it can lead to more savings and better patient outcomes.
5. Patient engagement
“Will the coming together of payers and providers complete the healthcare trio by enhancing patient engagement?”
Payers and providers need to cultivate a kind of mutualism as it provides a balance that can only be achieved by working together. By adopting a mindset of collaboration, both stakeholders can engage patients more effectively than either could alone. Payers can increase patient satisfaction through incentivizing physicians to focus on placing the patient at the center of care experience.
As is commonly believed, the key to value-based success is patient engagement and it will ultimately bring together the three stakeholder groups with personalized information that will initiate positive actions and produce meaningful outcomes. Therefore, the payer-provider partnership, along with the transparency it brings, can truly lead to a sustainable healthcare system.
The road ahead
Value-based care was introduced along with a promise of affordable and equitable healthcare. More importantly, it can only be driven if all healthcare stakeholders are in it together. A growing number of provider-payer collaborations have been gaining traction across the US. ACOs are turning out to be a driving force for better partnerships between payers and providers. As more and more commercial ACOs are coming up, we see much more balanced dynamics between payers and providers.
Healthcare is in a place where it is ripe for innovation. Payers and providers have a great opportunity to disrupt the space with value-based care being viewed as a critical part of healthcare transformation. With the operations aligned with organization goals, patients are at last being drawn to the center of care, and improving their experience has become a priority.
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