Payer and provider organizations face new territories with value-based care imperatives, social risk, and health equity drivers, shifting consumer expectations, and mounting pressure from employers. As new models of care emerge, and means of collaboration take shape, can health plans and health systems achieve more by combining efforts?
By joining forces, payers and providers can leverage common quality and clinical outcomes goals while tapping into each other's unique strengths and value in the patient-member experience.
Building new, synergistic payer-provider partnerships
In 2019, a survey of 80 provider and payer organizations revealed that 94% believed that collaboration between the two is now a key determinant of success. And, while many payers and providers are successfully partnering to deliver value, a 2022 survey by the Healthcare Financial Management Association (HFMA) found that 50% of health system chief financial offers and other executives say that strategic partnerships with payers is their top external challenge.
However, the emergence of payviders is evidence that both payer and provider organizations see the value of collaboration. Nearly 60% of health systems had plans to become a payvider in 2022. As health systems take on more risk and contract directly with employers, and health plans continue to buy provider practices and launch healthcare delivery services, partnerships between payers and providers become even more critical.
Payers and providers can address challenges from common ground
One strategy for payers and providers is to build anew through their commitment to common goals -- improving patient outcomes, optimizing finances, achieving quality care, and the best patient-member experience. More specifically, both types of organizations want robust data and analytics, more efficient operations, and sound technology that supports future growth and innovation.
How health plans and systems align or diverge will have a long-lasting impact on healthcare in the U.S. Some choose mergers or acquisitions, while others partner with digital-first companies.
As half of health systems say that strategic partnerships with payers are their top external challenge, 10% say legal and trust issues with payers, 21% say local competition, and 6% point to new entrants and disruptors. Changing this trajectory will require a new approach. Taken from the HFMA survey, "The one-size-fits-all, 'I-win-you-lose' approach is no longer a good business model."
Payer and provider interdependence: Value-based care, PHM, health equity
Value-based care (VBC) is one area where payer-provider collaboration is critical. Research by HFMA's Value Project uncovered several value-based and population health-related areas where partnering could reap the most significant rewards:
- Shared savings models like accountable care organizations (ACOs)
- Bundled payments where one episode of care is paid for through one payment and providers have negotiated that price for all related services
- Reference pricing where providers agree to offer services at a price that has a maximum
- Patient-centered medical homes where care management services are included
While VBC models may harken back to managed care of the 1990s, payer-provider collaboration is different today when primary focus is placed on quality and a commitment to best patient outcomes rather than utilization. Data capture, sharing, and analysis provide a level of quality and performance measurement and reporting not possible at that time. When partnerships build on this foundation, benefits may be realized, including transparency, greater trust, and more remarkable evidence-based outcomes.
As a physician and former CEO of McKesson, Dr. Emad Rizk shared in his book, The New Era of Healthcare Practical Strategies for Providers and Payers, "The fundamental need in today's healthcare system is for the two largest constituents – payers and providers – to work together in alignment. We need a change in thinking and actions to shift the dynamic of how payers and providers work and interact with each other."
Understand the other's roles, goals, processes, and pressures
Effectively collaborating and aligning care and business objectives will require payer and provider leaders to understand the other's way of carrying out their mission. While both work in healthcare, many misconceptions exist about the other's roles, goals, processes, and unique pressures.
Even integrated delivery and financial systems (IDFS) that contain both payer and provider sides struggle to align when they are part of the same entity. Here, again, honoring their common goals of the best patient health outcomes and experience is a starting place. Identifying strengths to leverage – as well as weaknesses that the other can boost – can enhance trust and partnership.
Payers want to mitigate risks and costs associated with unplanned care and costs resulting from delayed and suboptimal treatment and unnecessary and inappropriate care. They seek to optimize appropriate system access and take a more population-based approach, holding claims data, risk and severity information, and quality information across providers.
Providers have built a presence in their community and a direct connection with clinicians. They hold clinical data, research work, evidence-based care and pathways, and quality metrics. Working with individual patients, clinical decisions and care are based on the patient's unique characteristics and risks, the best evidence for care innovations that are the most effective. They want to offer options to their patients based on data and evidence when making care recommendations.
Ways to improve the payer-provider relationship
Dr. Rizk's book points to three types of alignment that are required to create a modern, value-based payer-provider collaboration. These include economic, quality, and administrative. Since its publication, a fourth area of alignment to consider is patient-member experience and engagement.
Across all of these areas, there are ways that payers can help providers do their job better and more efficiently together around common quality and outcome goals. There are also ways that provider organizations can help payers achieve their goals. Once the two partners have revealed more of their top-line patient care, operations, and business objectives, they can work to identify ways to support each other toward specific performance outcomes.
What can payers do to become better partners?
Take a data-driven approach to partnership: Identify common quality outcomes goals. Then, build further trust and synergy through sharing clinical, quality, and cost data on goal-related conditions. Share which quality requirements each are working towards. And, let the data identify areas for collaboration and improvement.
Help relieve the administrative burden on providers: Physicians spend 15-20% of their time on administrative tasks. Payers have access to technology and solutions that can support greater delivery efficiency.
Chronic disease management: Payers might offer access to their care managers and coordination software so that physician practices can more easily refer and avoid setting up their care management program.
Data sharing: Health plans can provide infrastructure and technology to bring together financial and clinical information through their repository of claims data, laboratory values, and benefit and eligibility information. Information like de-identified quality metrics across physicians is very beneficial to provider organizations.
Population analytical capabilities: Payers can support providers through advanced analytical support, which physicians could use to aid in clinical care and decision support.
Workflow efficiencies: Provider organizations and practices that are good partners would benefit from more manageable and less burdensome pre-authorization and referral steps.
What can providers do to become a better partner?
Data-sharing: Clinical and patient information are vital for health plans to meet their objectives. Sharing sensitive clinical information is the lifeblood of the partnership as best care revolves around timely, accurate clinical data. Partnering at the technology level by engaging CIOs and Chief Data/Analytics Officers at both organizations can expedite success and is key to maximizing the value of the partnership.
Physician adoption and support: First, identify standard quality and outcomes goals, use data to learn baseline performance, and then look for areas that are not meeting common goals to implement change. Collaborative accountability can only be achieved if physicians commit to collaboration and adopt mutually agreed-upon strategies and initiatives.
Measuring quality: While payers like to set the standard, it takes providers to collaborate to achieve robust performance measurement and reporting. Flexibility in agreeing upon measures and commitment to track and share is paramount.
Commit resources to partnerships with payers: Ongoing communication and timely action demonstrate commitment to the partnership. Surveys show that this is an area where payers and providers have made the most extensive improvements. Assigning staff to manage the partnership will help keep it a priority long-term.
Should your payer or provider organization collaborate?
Partnering is challenging. However, tapping into the hard-won strengths of a payer or provider counterpart may be the fastest and most valuable route to achieving care, financial, and market goals.
RTI Health Advance provides quality, operational, strategic, and analytics experts who can support partnering decisions, implementation, and operations. Schedule an initial discussion with RTI Health Advance.