Payer-provider collaboration fosters market strength

June 21, 2017 / By Kristine Daynes

Profitability for a health plan used to be a factor of actuarial skill and efficient operations. Insurers tended to invest in technology to increase the efficiency of call centers, contract management, claims processing and payment. However, internal productivity doesn’t help build brand recognition and market strength when the purchasers of health care—governments, employers and consumers—demand better value, access and customer experience.

There is a different route to financial stability. Insurers can cultivate a value-added role as aggregator and facilitator of health care within regional markets. In this role, smart technology investments support tighter, effective collaboration among payers and providers to the benefit of healthcare purchasers.

What exactly do healthcare purchasers want?

  • Make health care more affordable
  • Make health care more accessible
  • Keep people healthy and functioning on the job
  • Give consumers choices

Tighter, more effective payer-provider collaboration can deliver on these expectations. Health plans are in a unique position of aggregating and distributing information across an entire network of care. As the intermediaries between providers and purchasers of health care, they are in a position to facilitate closer collaboration toward common healthcare goals.

For example, analytics technology can help health plans predict which members have persistent and emerging high-cost needs. But the information alone is not enough to make a difference in costs, outcomes, or patient experience. In the case of Wellmark Blue Cross and Blue Shield of Iowa, what did make a difference was sharing the information directly with physicians and health coaches on the front lines of care delivery. The collaboration helped physicians and their staff avoid the tedium of reviewing every patient profile. Instead they first review the individuals who are at highest risk and those for whom case management could change the outcome (removing catastrophic conditions and malignancies, for example, and excluding high-cost pharmaceuticals). It had the effect of lowering overall costs, improving patient outcomes, and fostering stronger payer-patient relationships.

Payer-provider collaboration can take the form of joint teams, shared processes and integrated technology. In all forms, the collaboration requires a level of transparency and data sharing to make sure people are basing decisions on the same data with the same understanding. For example, shared data on physician performance can help identify which providers deliver and best healthcare value (good clinical outcomes at low cost. And it can lead to a discussion about how other physicians can improve their value.

What are the most-promising ways for payers to foster tighter collaboration?

  • Use shared cost and risk-adjusted quality data to set fair prices and reduce patient cost sharing
  • Facilitate care coordination among PCPs, specialists, and hospitals
  • Identify the programs that best manage chronic disease and are most likely to be sustainable
  • Offer a longitudinal, claims-based patient record, giving clinicians better and immediate visibility into their patients’ histories, behavior and clinical needs across the care network
  • Design provider networks that meet consumer expectations for accessible locations and hours
  • Share timely performance information with providers on measures/behaviors they can directly affect
  • Use predictive analytics to identify high-risk individuals and intervene before their chronic conditions become unmanageable or require high-cost care

Payer-provider collaboration can help a health plan lower medical expenses and improve clinical outcomes. The benefits also translate into consumer-centric benefits that purchasers demand.

Kristine Daynes is senior marketing manager for payer and regulatory markets at 3M Health Information Systems.