Bridging the Gap Between Healthcare Payers and Providers

Healthcare payers and providers are still fighting along the borders that separate one another. Initiatives such as pay-for-performance—a payment model that rewards clinicians, hospitals and medical groups for meeting certain performance measures for quality and efficiency—drive massive gaps between payers and providers. Providers religiously cling to patient health information as they strive to make financial gains as a reward for a patient’s health outcome. Payers, in the meantime, are defending patient finance records as pay-for-performance can hurt the bottom line when a patient’s reimbursement process is not properly handled. Aggressive defense of key data sets, lack of communication and minimal collaboration hurts both sides—most of all, it hurts patients.

A clear, collaborative model must be adopted for payers and providers to deliver a better patient experience

When payers and providers don’t collaborate, the patient needs to take the extra initiative and burden of forcing the communication between both sides—dealing with multiple bills, different opinions on their outcomes and, sometimes in extreme cases, dealing with hidden costs payers or providers were unaware of. This is unacceptable. As time goes on, payers and providers must be united. Once aligned, this hybrid of information will lead to better health outcomes, an enhanced care mode and clear financial wins for both sides. A clear, collaborative model must be adopted for the two sides to join together to deliver a better patient experience.

According to Andrew Underhill, a chief technologist at Systems Made Simple:

This strategy enables informed care decisions and also reduces the likelihood of duplicative or unnecessary tests. It also limits the reliance on patient memory and perspective, ensuring care decisions are based on facts rather than educated guesses.

Andrew Underhill, chief technologist at Systems Made Simple, on creating a clear collaborative model

Payer and Provider Collaboration Is a Necessity

Payer and provider collaboration and vertical integration model from BCG

An integrated system that allows payers and providers to collaborate without barriers is becoming a necessity. Many payers and providers do not share the same infrastructure, identity information or mobile strategies—yet both sides may share the same patients. A secure, integrated hub for real-time collaboration, analytics, secure messaging, and communication over health outcomes builds a strong bond between payers and providers, helping to structure governance and lead to streamlined payment arrangements.

Collaboration at this level will benefit providers who can now share critical information to payers. And, in reverse, payers can provide ways to improve the overall quality of a patients health long-term. Creating a singular entity for each side of the healthcare model to work cooperatively supports an ideal alliance to advance the quality and cost of care.

In a recent study completed by HealthAffairs, “Collaboration between Aetna (payer) and NovaHealth (provider) focused on shared data, financial incentives, and care management to improve health outcomes for approximately 750 Medicare Advantage members. The patient population in the pilot program had 50 percent fewer hospital days per 1,000 patients, 45 percent fewer admissions, and 56 percent fewer readmissions than statewide unmanaged Medicare populations. NovaHealth’s total per member per month costs across all cost categories for its Aetna Medicare Advantage members were 16.5 percent to 33 percent lower than costs for members not in this provider organization.”

Accessibility and Transparency Is Critical

Payers and providers need a plan for ensuring transparency. The targeted quality measures that providers and others are performing against must be made available to all participants involved.

The accessibility of this information and shared transparency among all entities ensures:

  • Performance measures are met and that everyone gets paid appropriately in value-based systems
  • Both sides get their proper financial returns and satisfaction scores
  • Payers and providers have an open dialogue and share critical information that would be lost in other forms of digital communication
  • Silos come down, creating trust among organizations that have been blind to each other
  • Cross-collaboration in each stage of patient care, providing returns that improve population health

Improving Patient Health Outcomes

Using aligned data from both payers and providers allows communities to be created around a patient’s chronic disease or illness. Many times, support groups are built around these ideals but are disconnected from both the provider and patient. Due to a lack of social resources, patients are unable to fully comply with treatment plans, follow provider instructions, return for a follow-up visit, and ultimately, experience good health outcomes.

Patients will refuse to join these groups as they are just “another patient portal” that they need to participate in. Using data leveraged from the provider, however, payers can create strong social communities that address a patient’s issues before they join. Places like MyMedicareAnswers drives improvements in patient satisfaction, availability of information and treats the patient with respect.

Payer, provider and patient collaboration is key to improving patient satisfaction and delivering better health outcomes

A New Era

The time has passed where payers and providers can work independently from one other. Both sides must unite digitally in a socially collaborative space—a space that connects clinicians to their patients’ payers. Healthcare providers can find peace and mutual understanding after a long war over fragmented policies and reimbursement measures. Payer, provider and patient collaboration is key to improving patient satisfaction and delivering better health outcomes.

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