The relationship between payers and providers has come a long way over the last decade, as the push toward value-based care has shifted the dynamic between the two healthcare stakeholders. Working together effectively, and with common, aligned goals, is increasingly linked with the ability to provide high-quality, cost-effective care.
A recent SPH Analytics survey of more than 100 directors and managers representing 86 healthcare organizations (two-thirds health plans, one-third providers) demonstrates this. According to the findings, 94 percent of respondents said collaboration is now a key factor to success. In addition, 72 percent of payers and providers report having prioritized efforts to drive closer payer/provider collaboration.
These developments are indeed promising, although most payers and their provider partners still indicate they could do a better job of aligning on quality. Notably, more than one out of three payers (35 percent) cited “willingness to collaborate” as their top challenge in working with payers, while most providers cited “technology,” followed by “willingness to collaborate” and “value-based payments/contracts.”
In the future, a practice’s ability to collaborate effectively with its payer partners will be linked to sustainability and financial solvency. In recent years, the industry has witnessed the evolution of vertical integration partnerships, often characterized by a large payer having a majority financial stake in a primary-care practice with direct influence on care decisions. But successful collaboration is not contingent on these strategies alone. When payers and providers agree to share common tools and tactics, they can still reap the benefits of collaboration.
The good news is that healthcare is moving closer to meaningful interoperability between technology systems. While greater connectivity lays the foundation for better collaboration, providers and their partners don’t always see eye to eye when it comes to quality improvement.
Case in point: A primary-care physician may want to focus on improving outcomes for patients with chronic conditions like diabetes and/or hypertension, but its payers only support — and pay for — limited clinical interventions. This may lead to resentment among physicians, who feel they are the stewards of quality care and in the best position to make decisions that are linked with positive outcomes.
Payers, meanwhile, don’t always see the value of certain best practices and clinical interventions across the continuum of care. For example: Patients with chronic comorbidities may need more frequent engagement with providers to achieve desired outcomes, but utilization issues sometimes create barriers: Is it medically necessary to achieve a desired result? Do patients significantly benefit from more frequent engagement, even when such engagement costs payers more up front to cover?
One of the reasons for this mismatch in expectations is that providers aren’t always sharing quality data with their payer partners. According to the SPH Analytics survey, 70 percent of payers and providers already participate in payer-provider collaborative partnerships, but 20 percent are still not sharing data to support patient-centered collaboration.
A lack of transparency hinders both partners: In order for payers to optimize their members’ experiences, they need data that can help them gauge the patient experience and shape health plans to meet population health needs. When healthcare organizations don’t share quality data, payers don’t have the benchmarking tools they need to adjust or refine coverage.
Meanwhile, physician practices and other healthcare organizations are frustrated when payers aren’t clear about how they measure quality, or express differences in coverage that can result in fragmented care (e.g., different care plans for patients with the same underlying conditions). As providers strive to improve population health management, the ability to follow consistent guidelines across the board will drive outcomes and cost savings.
Moving forward, payer and provider partners can take a number of steps to improve collaboration. These include:
- Aligning clinical goals. Payers and providers should identify the quality measures that necessitate specific healthcare goals and objectives, such as HEDIS reporting, for a given year. Once goals are aligned, the provider group can then make specific plans to meet those goals. For example, if a certain percentage improvement in patients with A1C levels > 9.0% is a goal, the provider group may choose to step up its engagement with diabetic patients, such as using electronic communication between visits to ensure medication adherence.
- Addressing communications technology obstacles. If payers aren’t sharing data that’s easy to integrate with a provider’s EHR, providers won’t be able to leverage the data to make meaningful change. Likewise, if providers aren’t sharing data in a useable format with payers, they won’t have the information they need to drive improvements and adjust coverage decisions. Tools to integrate data between both organizations, preferably in a way that doesn’t impede the provider’s workflow, should be assessed. Many regions already have data sharing networks in place, such as health information exchanges, and in other cases, health plans often initiate sponsorship of a data sharing hub that allows data to be shared with many provider organizations at once.
- Use standard quality measurement tools. 47 percent of payers in the study report and 81 percent of providers report they do not have population health technology tools in place that can be used by both payer and provider. The best way to measure and demonstrate quality across the healthcare system is by using standardized data-aggregation tools to isolate trends (e.g., the risk factors associated with acute exacerbations of heart disease or hypertension) and measure the effectiveness of interventions (e.g., scheduling a visit when a patient exhibits one or more clinical thresholds). With this said, if payers and providers were to leverage the same quality measurement tools, they could to compare apples to apples, which eliminates the time and waste associated with comparing and accepting the others’ results.
While collaboration may not feel natural to payers and providers, who have different perspectives on quality and cost, every step healthcare partners take to align on common objectives benefits patients. And as healthcare providers push deeper into value-based care, the organizations that can make collaborative partnerships work will see the greatest financial and clinical rewards.